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Types of Skin Lesions Referred by PCPs at VA

by U.S. Medicine

December 5, 2016

MINNEAPOLIS—Skin lesions sent to dermatology by primary care physicians (PCPs) represent a significant proportion of VA healthcare visits, according to a new study.

The report in the Journal of the American Academy of Dermatology noted that, according to previous research, the per-person incidental (i.e., lesion was not mentioned in consult) malignancy detection rate of 6.9% and an incidental melanoma detection rate of 0.5%.1

This study, which was led by researchers from the Minneapolis VAMC and the University of Minnesota Medical School characterized lesions identified by PCPs by using chart review of more than 30,000 consults.

Data presented included lesions referred to the Minneapolis VA Dermatology Service over an eight-year period characterized by location, confirmation by diagnostic test and diagnosis.

Results indicate that nearly all (99.5%) malignant lesions were confirmed by a diagnostic test, compared with 23.9% of benign lesions. In addition, lesions described as suspicious by the referring provider were 2.5 times more likely to be confirmed by a diagnostic test than lesions described as not suspicious, regardless of final diagnosis, according to the report.

Of malignant lesions, the most common diagnosis was basal cell carcinoma (60.4%) followed by squamous cell carcinoma (SCC) (33.1%) and melanoma (5.3%). Although the majority of basal cell carcinomas and SCCs were considered suspicious (98.7% and 95.8%, respectively), referring providers were significantly more likely to consider SCCs not suspicious compared with basal cell carcinoma.

Of the 9,939 benign lesions referred to dermatology, the most common diagnoses included benign keratosis (28.3%), actinic keratosis (21.0%) and benign melanocytic lesions (8.6%). Study authors pointed out that all three categories were significantly more likely to be characterized as suspicious in the referring provider’s note, but that cysts (5.1%) and warts (4.0%) were significantly more likely to be described as not suspicious.

“There are several important findings of this study,” according to the study conclusion. “A disproportionate number of consult lesions were located on exposed body areas, easily visualized by the referring provider, likely secondary to time constraints.”

Researchers said there were a variety of reasons for the high number of benign lesions that were considered suspicious by the referring provider:

  • Studies demonstrate a lower diagnostic accuracy of PCPs compared with dermatologists for skin conditions.
  • The wording practice used by referring providers could be misleading. Lesions described with worrisome language are generally scheduled. Training PCPs in recognition and management of benign dermatologic lesions, particularly benign keratoses, may improve cost-effective care and better use of dermatologic resources.
  • Difficulty in recognition of SCC as suspicious for malignancy may be attributed to the diagnostic continuum from actinic keratosis to SCC.

 

1Grey KR, Kingsley-Loso JL, Warshaw EM. Lesions referred to dermatology in the Department of Veterans Affairs (VA) health system: A retrospective chart review. J Am Acad Dermatol. 2016 Aug;75(2):430-4. doi: 10.1016/j.jaad.2016.02.1233.


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