The study's lead author said delays in melanoma surgery were more common than expected, and the team at Yale School of Medicine is looking into explanations. Right now, there is no "gold standard" for how long it should take between a diagnosis and excision.
As Medicare presses ahead with greater emphasis on value-based care, a study published today in JAMA Dermatology reveals an opportunity: creating standards for getting those diagnosed with melanoma into surgery.
The study, led by Jason P. Lott, MD, MHS, MSHP, found that 1 in 5 Medicare beneficiaries with newly diagnosed melanoma had a delay of more than 45 days before having surgery. Delays were more common among the very old and those with other health problems. Having a dermatologist perform the biopsy, instead of a primary care physician, decreased the likelihood of surgery being delayed, the researchers found.
“Delay for melanoma surgery in this population is more common than we expected,” said Dr Lott, a postdoctoral fellow in the Robert Wood Johnson Foundation Clinical Scholars Program at Yale School of Medicine. We are working to identify reasons for delay in the time it takes for patients to get surgery. That information will help ensure that we are delivering more prompt and patient-centered surgical care.”
An accompanying editorial in JAMA Dermatology by Elaine Lin, BS, and Jerry D. Brewer MD, noted the importance of the findings, given the rise in melanoma cases. “Early detection of and treatment aids in identifying less advanced tumors, plus prompt surgical treatment could alleviate stress and anxiety,” they write.
However, both the study’s authors and the commentators acknowledge that, thus far, there is no precise standard for how long it should take for a patient to have surgery. This persists, the study authors note, even though “minimization of delay is an important patient-centered objective of high-quality dermatologic care.”
Researchers examined 32,501 Medicare cases from the Surveillance, Epidemiology, and End Results (SEER) Medicare database from January 1, 2000, to December 31, 2009. Most patients were white (95.4%) and male (63.1%), married (47.9%) and age 75 years or older (60.8%). Most patients did not have a prior melanoma (93.7%).
The vast majority of the cases, 77.7%, underwent excision within 1.5 months of biopsy. Among those treated after 1.5 months, 2620 cases, or 8.1%, saw their surgery delayed beyond 3 months. Delays of more than 1.5 months were more common among patients older than 85 years, compared with patients younger than 65 years (the odds ratio [OR] was 1.29 with a CI of 95%, P = .001) and among those with an increased comorbidity burden (OR of 1.18 with a CI of 95%, P < .001).
Delays were least likely when melanomas underwent both biopsy and excision by a dermatologist (probability, 16% [95% CI]). The highest likelihood of delay occurred when a biopsy was performed by a nondermatologist and excised by a primary care physician (probability 31% [95% CI]). Findings were similar for delays longer than 3 months.
In their commentary, Ms Lin and Dr Brewer suggest that care gaps could be closed through better coordination and communication, and perhaps through the use of electronic medical records, which could “flag” when a diagnosed patient must be scheduled for surgery. Medicare is encouraging and, in fact, increasingly connecting reimbursement to the ability of physicians and health systems to coordinate care for beneficiaries.
Guidelines and training are needed, however. “Further research aimed at substantiating the consequences of surgical delay in the setting of melanoma may also improve a movement toward a standard of care and possible guidelines among all medical subspecialties,” the write. “Medical training should emphasize heightened communication skills and the importance of multidisciplinary teamwork as an essential element to establishing solid surgical follow-up.”
Lott JP, Narayan D, Soulos PR, Aminawung J, Gross CP. Delay of surgery for melanoma among Medicare beneficiaries. JAMA Dermatol. [published online April 8, 2015]. doi:10.1001/jamadermatol.2015.119.
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