Inclusion/exclusion criteria
A lesion was considered new if patients presented to a family physician with one or more skin lesion that had not been previously treated or examined by another physician.
Patients were ineligible if they: 1) had a lesion with unknown duration; 2) had no telephone for follow-up; 3) did not speak English or Spanish; or, 4) had a lesion resulting from trauma.
Interventions
The initial intervention consisted of 2 parts: 1) after examining a patient, family physicians completed a 10-question survey, recording diagnosis, treatment plan, and resources used in treatment; 2) research assistants completed a 14-question survey, consisting of general patient and lesion information. Follow-up patient surveys were completed by telephone on days 7, 28, and 84.
Two university-based dermatologists helped develop the photography protocol. They specifically requested 3 digital photos of lesions under incandescent light, specific information for diagnosis, and direction for how photographs should be taken. The photographs were taken using Olympus C-5000 5MP Digital Camera w/3x Optical Zoom and were developed with HP photo glossy paper. The dermatologists separately reviewed the photographs blinded to the family physician’s diagnosis and treatment. The dermatologists commented on diagnosis and treatment plan for the first 99 patients enrolled in the study.
Outcomes
The primary outcome was dichotomous: whether skin lesions improved or not at day 7. Secondary outcomes were measures of improvement at days 28 and 84. We also examined patients’ satisfaction on a scale of 1 to 5 (“How satisfied were you with your skin care provided by your family physician?” 1=very satisfied, 5=very unsatisfied).
The categorization of acute skin lesions was developed by a modified delphi process in order to classify the lesions into groups. The principal investigator initially categorized all diagnoses and treatments. Next, 3 other members of the study (AK, BP, and DM) individually reviewed and guided categorizations. The 2 dermatologists gave the final input. This resulted in 41 categories for diagnosis and 9 for treatment.
Statistical analysis
Descriptive statistics provided baseline characteristics for the group. Frequencies were computed on patient, visit, and lesion characteristics, including patient improvement at days 7, 28, and 84. We also computed patient satisfaction with the care provided by their physician at 7, 28, and 84 days. Agreement rates between the family physicians and the 2 dermatologists were obtained for the subset of cases where both dermatologists agreed on the diagnosis. Similarly, the agreement rates were computed for recommended treatment using only those cases where the 2 dermatologists agreed on treatment. All descriptive statistics were computed with SPSS (SPSS, Inc, Chicago, Ill).
RESULTS
A total of 244 patients with 267 skin lesions were recruited by 53 family physicians during the study period. The 7-day follow-up patient survey was completed for 234 lesions (88%), the 28-day survey was completed for 220 lesions (82%), and the 84-day survey was completed for 203 lesions (76%). Study participants ranged in age from 3 months to 86 years; adults were predominantly college-educated, non-Hispanic, and white (TABLE 1). The majority of study participants (73%) reported that their skin lesion was the primary reason for their appointment.
Characteristics of the clinical encounters are presented in TABLE 2. While most skin lesions were present for 30 days or less (62%), over one quarter had been present for more than 90 days. The family physicians made 40 general dermatologic diagnoses. Only 3 lesions (1%) were considered malignant (data not shown). Family physicians reported relatively high confidence with their diagnoses (mean confidence score of 8.4, with range 1 to 10, 1=not at all certain, 10=very certain).
Other characteristics of the clinical encounters not shown in TABLE 2 are the family physicians’ judgment on resolution of the lesions and diagnostic steps used in treating the lesions. In most cases, family physicians believed the lesion would resolve within 12 weeks (203 lesions received a score of ≥7, 0=no improvement expected, 10=complete resolution expected). There was a bimodal distribution with 144 lesions receiving a 10, while 36 received a grade of 0. To make their diagnosis, most family physicians examined other parts of the skin (70%), consulted a colleague (14%), or consulted an electronic resource (6%). Laboratory tests, skin scrapings, diagnostic cultures, Woods lamp exams, or skin biopsies were performed in a total of 10% of encounters.
TABLE 3 reports the primary outcome, patient-reported resolution of skin lesions. These data were restricted only to lesions that were expected to improve (defined as a clinician assigned resolution score ≥7).