Complex skin cancer treatment requiring reconstructive plastic surgery: an interview study on the experiences and needs of patients.
Archives of dermatological research
To provide patient-centered care, it is essential to explore what patients consider important and to adjust care accordingly. This may specifically be relevant for patients with complex skin cancer, for whom the care process is often more complicated and psychological and social problems may play a larger role. The objective was to explore the experiences and needs of patients who had undergone surgical treatment by a dermatologist for a complex skin cancer with a subsequent reconstruction by a plastic surgeon. An interview study was conducted among 16 patients who had undergone surgical treatment by a dermatologist and reconstruction by a plastic surgeon for basal cell carcinoma, cutaneous squamous cell carcinoma, or lentigo maligna. The interviews focused on patients' experiences and needs regarding care using a predefined topic list. All interviews were audio-taped, transcribed verbatim and inductively analyzed using Atlas.ti. Patients reported a need for a skilled and friendly physician who tailors information and communication to their individual situation. A need for continuity of care and improved collaboration between healthcare providers was also emphasized. Furthermore, patients experienced complications and unmet expectations and expressed a need for shared decision-making at various steps throughout the treatment process (depending on age). Patients also considered completeness of tumor removal, follow-up visits with multiple specialists to be planned the same day and recognition of the psychological impact of the disease on the partner important. To improve patient-centered care for complex skin cancer patients, more efforts should be directed towards improving continuity of care and collaboration. Furthermore, it is advocated for physicians to be sensitive to the individual needs of patients and their partner and adjust information, communication and (supportive) care accordingly.
View details for DOI 10.1007/s00403-021-02204-3
View details for PubMedID 33611719
Practice Variation in Skin Cancer Treatment and Follow-Up Care: A Dutch Claims Database Analysis.
Dermatology (Basel, Switzerland)
BACKGROUND: Quality indicators are used to benchmark and subsequently improve quality of healthcare. However, defining good quality indicators and applying them to high-volume care such as skin cancer is not always feasible.OBJECTIVES: To determine whether claims data could be used to benchmark high-volume skin cancer care and to assess clinical practice variation.METHODS: All skin cancer care-related claims in dermatology in 2016 were extracted from a nationwide claims database (Vektis) in the Netherlands.RESULTS: For over 220,000 patients, a skin cancer diagnosis-related group was reimbursed in 124 healthcare centres. Conventional excision reflected 75% of treatments for skin cancer but showed large variation between practices. Large practice variation was also found for 5-fluorouracil and imiquimod creams. The practice variation of Mohs micrographic surgery and photodynamic therapy was low under the 75th percentile, but outliers at the 100th percentile were detected, which indicates that few centres performed these therapies far more often than average. On average, patients received 1.8 follow-up visits in 2016.CONCLUSIONS: Claims data demonstrated large practice variation in treatments and follow-up visits of skin cancer and may be a valid and feasible data set to extract quality indicators. The next step is to investigate whether detected practice variation is unwarranted and if a reduction improves quality and efficiency of care.
View details for DOI 10.1159/000513523
View details for PubMedID 33503632
What do patients and dermatologists prefer regarding low-risk basal cell carcinoma follow-up care? A discrete choice experiment.
2021; 16 (3): e0249298
BACKGROUND: Follow-up after low-risk basal cell carcinoma (BCC) is being provided more frequently than recommended by guidelines. To design an acceptable strategy to successfully reduce this 'low-value' care, it is important to obtain insights into the preferences of patients and dermatologists.OBJECTIVE: To determine the preferences and needs of patients and dermatologists to reduce low-risk BCC follow-up care, and the trade-offs they are willing to make.METHODS: A questionnaire including a discrete choice experiment was created, containing attributes regarding amount of follow-up, continuity of care, method of providing addition information, type of healthcare provider, duration of follow-up visits and skin examination. In total, 371 BCC patients and all Dutch dermatologists and dermatology residents (n = 620) were invited to complete the questionnaire. A panel latent class model was used for analysis.RESULTS: Eighty-four dermatologists and 266 BCC patients (21% and 72% response rates respectively) completed the discrete choice experiment. If the post-treatment visit was performed by the same person as treatment provider and a hand-out was provided to patients containing personalised information, the acceptance of having no additional follow-up visits (i.e. following the guidelines) would increase from 55% to 77% by patients. Female patients and older dermatologists, however, are less willing to accept the guidelines and prefer additional follow-up visits.LIMITATIONS: The low response rate of dermatologists.CONCLUSION: This discrete choice experiment revealed a feasible strategy to substantially reduce costs, while maintaining quality of care, based on the preferences and needs of BCC patients, which is supported by dermatologists.
View details for DOI 10.1371/journal.pone.0249298
View details for PubMedID 33780499
Insight into the management of actinic keratosis: a qualitative interview study among general practitioners and dermatologists.
The British journal of dermatology
2019; 181 (1): 96–104
The increasing incidence of actinic keratosis (AK) is causing a large burden on healthcare systems. The current management of patients with AK seems to vary within and between primary and secondary care; however, an in-depth understanding of healthcare providers' management of AK is currently lacking.To gain insight into the management of AK by exploring the underlying motives of current practices among general practitioners (GPs) and dermatologists in the Netherlands.A qualitative study was conducted consisting of semistructured individual interviews with 22 GPs and 18 dermatologists focusing on the underlying motives regarding AK management. A predefined topic list was used. All interviews were audiotaped, transcribed verbatim and inductively analysed by two researchers drawing on elements of grounded theory.GPs reported conducting limited proactive clinical assessments of cutaneous photodamage due to a perceived lack of value, varying in their method of diagnosing AK. They mainly applied cryotherapy or referred to secondary care due to lack of experience, varying in their applications and providing mostly patient-driven follow-up care. They also reported a great need for guidelines due to a lack of knowledge of AK management. Dermatologists indicated pursuing proactive clinical assessments of cutaneous photodamage and the goal of providing guideline-driven AK care. However, patient preferences still largely influence both treatment choices and follow-up regimens. Furthermore, dermatologists reported the need to improve AK and skin cancer management in primary care.For AK care to become more standardized and uniform in Dutch primary care, the implementation of guidelines and (continuing) education are needed to address the commonly reported barriers of lack of value, experience and knowledge among GPs. For efficient use of care among dermatologists, shared decision-making tools along with adequate (framing of) patient information may be useful.
View details for DOI 10.1111/bjd.17818
View details for PubMedID 30801664
View details for PubMedCentralID PMC6849726
Factors influencing current low-value follow-up care after basal cell carcinoma and suggested strategies for de-adoption: a qualitative study.
The British journal of dermatology
2019; 180 (6): 1420–29
Providing follow-up to patients with low-risk basal cell carcinoma (BCC) can be considered as low-value care. However, dermatologists still provide substantial follow-up care to this patient group, for reasons not well understood.To identify factors influencing current BCC follow-up practices among dermatologists and suggested strategies to de-adopt this low-value care. In addition, views of patients regarding follow-up care were explored.A qualitative study was conducted consisting of 18 semistructured interviews with dermatologists and three focus groups with a total of 17 patients with low-risk BCC who had received dermatological care. The interviews focused on current follow-up practices, influencing factors and suggested strategies to de-adopt the follow-up care. The focus groups discussed preferred follow-up schedules and providers, as well as the content of follow-up. All (group) interviews were transcribed verbatim and analysed by two researchers using ATLAS.ti software.Factors influencing current follow-up care practices among dermatologists included complying with patients' preferences, lack of trust in general practitioners (GPs), financial incentives and force of habit. Patients reported varying needs regarding periodic follow-up visits, preferred to be seen by a dermatologist and indicated a need for improved information provision. Suggested strategies by dermatologists to de-adopt the low-value care encompassed educating patients with improved information, educating GPs to increase trust of dermatologists, realizing appropriate financial reimbursement and informing dermatologists about the low value of care.A mixture of factors appear to contribute to current follow-up practices after low-risk BCC. In order to de-adopt this low-value care, strategies should be aimed at dermatologists and GPs, and also patients.
View details for DOI 10.1111/bjd.17594
View details for PubMedID 30597525
View details for PubMedCentralID PMC6850416
Opportunities for improving the efficiency of keratinocyte carcinoma care in primary and specialist care: Results from population-based Dutch cohort studies.
European journal of cancer (Oxford, England : 1990)
2019; 117: 32–40
High incidence rates of keratinocyte carcinoma (KC) in Western countries put pressure on healthcare systems. The aim of this study was to describe clinical practice in order to identify areas for improvement.A random selection of patients from the Integrated Primary Care Information database who consulted their general practitioner (GP) for suspicious or confirmed KC (n = 1597) was made in the analysis. For secondary care, 1569 patients with histologically confirmed KC were randomly selected from the Netherlands Cancer Registry. All patients were diagnosed between 2009 and 2013 and followed up until 2016. Details on diagnosis, treatment and care during follow-up were described.Among 942 patients who consulted their GP, KC was included in the working or differential diagnosis, but two-thirds (629) were not KC. If the GP suspected KC, the GP directly referred to a medical specialist in most cases (548 of 942). In half (470 of 967) of all confirmed KCs, a skin malignancy was not described in the initial working or differential diagnosis of the GP. The medical specialist treated the first primary KC in 86% (1369 of 1596) by excision, 4% (69 of 1596) by Mohs surgery and 10% (158 of 1596) by another treatment. Although follow-up is not recommended for low-risk basal cell carcinoma, 83% (29 of 35) received follow-up care. In contrast, 82% (60 of 73) patients with squamous cell carcinoma received less follow-up than recommended.Strengthening the diagnostic pathway for KC in primary care and reduction of low-value follow-up visits in secondary care seem potential areas for improving the efficiency of KC care.
View details for DOI 10.1016/j.ejca.2019.05.010
View details for PubMedID 31229947
Healthcare utilization and management of actinic keratosis in primary and secondary care: a complementary database analysis.
The British journal of dermatology
2019; 181 (3): 544–53
The high prevalence of actinic keratosis (AK) requires the optimal use of healthcare resources.To gain insight in to the healthcare utilization of people with AK in a population-based cohort, and the management of AK in a primary and secondary care setting.A retrospective cohort study using three complementary data sources was conducted to describe the use of care, diagnosis, treatment and follow-up of patients with AK in the Netherlands. Data sources consisted of a population-based cohort study (Rotterdam Study), routine general practitioner (GP) records (Integrated Primary Care Information) and nationwide claims data (DRG Information System).In the population-based cohort (Rotterdam Study), 69% (918 of 1322) of participants diagnosed with AK during a skin-screening visit had no previous AK-related visit in their GP record. This proportion was 50% for participants with extensive AK (i.e. ≥ 10 AKs; n = 270). Cryotherapy was the most used AK treatment by both GPs (78%) and dermatologists (41-56%). Topical agents were the second most used treatment by dermatologists (13-21%) but were rarely applied in primary care (2%). During the first AK-related GP visit, 31% (171 of 554) were referred to a dermatologist, and the likelihood of being referred was comparable between low- and high-risk patients, which is inconsistent with the Dutch general practitioner guidelines for 'suspicious skin lesions' from 2017. Annually, 40 000 new claims representing 13% of all dermatology claims were labelled as cutaneous premalignancy. Extensive follow-up rates (56%) in secondary care were registered, while only 18% received a claim for a subsequent cutaneous malignancy in 5 years.AK management seems to diverge from guidelines in both primary and secondary care. Underutilization of field treatments, inappropriate treatments and high referral rates without proper risk stratification in primary care, combined with extensive follow-up in secondary care result in the inefficient use of healthcare resources and overburdening in secondary care. Efforts directed to better risk differentiation and guideline adherence may prove useful in increasing the efficiency in AK management. What's already known about this topic? The prevalence of actinic keratosis (AK) is high and, in particular, multiple AKs are a strong skin cancer predictor. The high prevalence of AK requires optimal use of healthcare resources. Nevertheless, (population based) AK healthcare utilization and management data are very rare. What does this study add? Although AK-related care already consumes substantial resources, about 70% of the AK population has never received care. Primary care AK management demonstrated underutilization of topical therapies and high referral rates without proper risk stratification, while in secondary care the extensive follow-up schedules were applied. This inefficient use of healthcare resources highlights the need for better harmonization and risk stratification to increase the efficiency of AK care.
View details for DOI 10.1111/bjd.17632
View details for PubMedID 30636037
View details for PubMedCentralID PMC6850060
Needs and preferences of patients regarding basal cell carcinoma and cutaneous squamous cell carcinoma care: a qualitative focus group study.
The British journal of dermatology
2019; 180 (1): 122–29
Despite the high and rising incidence rate of keratinocyte cancer (KC) and the importance of incorporating patient values into evidence-based care, few studies have focused on the perspectives of patients with KC.To identify the needs and preferences of patients with basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) regarding care.A qualitative study was conducted consisting of three focus groups with patients with BCC and three focus groups with patients with SCC. In total 42 patients participated. In each focus group, the patients' needs and preferences regarding treatment and follow-up were discussed, using a predefined topic list. All sessions were transcribed verbatim and analysed by two researchers.The following needs and preferences were identified: (i) the need to receive all relevant, tailored information; (ii) a physician who takes you seriously and communicates well; (iii) a short waiting period and the best treatment with direct results; (iv) to be seen by the same physician; a preference for a dermatologist during (v) treatment and (vi) follow-up; (vii) a general need for structured follow-up care and (viii) a full-body skin examination during follow-up. Patients with BCC additionally expressed the need for openness and transparency and wanting to participate in shared decision making.It is advocated to organize skin cancer care that is better tailored to the needs of patients with KC, providing patient-centred care. This should include investing in the patient-physician relationship, and personalizing the type and form of information and the follow-up schedules. Adding the patient's perspective to current guidelines could facilitate this process.
View details for DOI 10.1111/bjd.16900
View details for PubMedID 29927480