Healthcare utilization and management of actinic keratosis in primary and secondary care: a complementary database analysis

Abstract

Summary Background The high prevalence of actinic keratosis (AK) requires the optimal use of healthcare resources. Objectives 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. Methods 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). Results 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. Conclusions 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 ...

Insight into the management of actinic keratosis: a qualitative interview study among general practitioners and dermatologists

“…This qualitative study confirms the previously found quantitative variation in AK management within and between primary and secondary care 12 and reveals the underlying motives reported by GPs and dermatologists. In contrast to dermatologists, GPs reported limitedly conducting proactive clinical assessment of cutaneous photodamage, mainly due to a perceived lack of value.…”

“…either in a face-to-face setting (n = 28) or by telephone (n = 12). A predefined topic guide based on prior experiences of the authors 12,19,20 was used for the interviews and included the following main themes: AK care in general, diagnosis of AK, treatment of AK and follow-up care of AK (Appendix S1; see Supporting Information). Participants were asked to complete a short questionnaire to provide demographic information.…”

“…10,11 Although AK is considered to require low-risk care that can be provided by the GP, a rather substantial proportion of patients are referred to secondary care, resulting in 40 000 new dermatology consultations annually. 12 Dermatologists, who have been equipped with national AK guidelines since 2010, still have a prominent role in the diagnosis and treatment of AK. 1,3,10 As AK is a high-volume condition, it requires an optimal use of resources.…”

“…A previous study showed that AK management varies within and between primary and secondary care. 12 However, an in-depth understanding of healthcare providers' management of AK is currently lacking. The aim of this qualitative study was therefore to gain insight into the management of AK by exploring the underlying motives of current practices regarding the diagnosis, treatment and follow-up of AK among GPs and dermatologists.…”

A study on healthcare utilization for actinic keratoses in the Netherlands highlights a global issue

“…In this issue of the BJD , Noels and colleagues report on their study of healthcare utilization for AKs in the Netherlands . They highlight large differences in practice among primary care services and dermatologists.…”