How well do family physicians manage skin lesions?

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Applied Evidence

How well do family physicians manage skin lesions?

J Fam Pract. 2007 January;56(1):40-45

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References

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FAST TRACK

With the more common diagnoses, agreement between FPs and dermatologists was above 80%

Overall, patients were very satisfied with the dermatologic care provided by their family physician. On a 5-point satisfaction scale, 55% of patients reported 1, the highest satisfaction level and 34% reported 2, the next highest level at day 7. At days 28 and 84, 93% of the patients reported the 2 highest levels of satisfaction. These data exclude patients lost to follow-up. Including all participants in the denominator, the rates of either the 2 highest levels of satisfaction at day 7 was 78%, at day 28 was 76%, and at day 84 was 70%.

The overall agreements in diagnosis and treatment, respectively, between the family physicians and the dermatologists were 72% and 80%. We examined only the aspects where both of the dermatologists agreed. Interestingly, for the more common diagnoses, the agreement rates were above 80%; however, for less common diagnoses, the rates were 62%. This trend was not observed in the treatment agreements, primarily due to dermatologists recommending steroids much more often than family physicians prescribed steroids. See Table 4 and Table 5.

TABLE 1
Characteristics of study sample

CHARACTERISTIC	N (%)*
Age of participants (years)
0–17	42 (17)
18–35	80 (33)
36–64	107 (44)
≥65	15 (6)
Gender
Male	112 (46)
Female	131 (54)
Race/ethnicity
Hispanic^†	27 (11)
Non-Hispanic
White	186 (77)
African american	13 (5)
Asian	13 (5)
American Indian/Inuit	2 (1)
Highest education level (older than 18 years)
High school or less	26 (13)
Some college/college grad	111 (56)
Graduate school	63 (31)
Employment status (older than 18 years)
Employed	163 (82)
Unemployed	35 (18)
Insurance status
Insured	228 (94)
Uninsured	15 (6)
Skin lesion primary reason for visit
Yes	189 (73)
No	70 (27)
* Totals may no always equal 244 due to missing data.
† Hispanics may be of any race.

TABLE 2
Skin lesions seen in study sites

DURATION OF LESION PRIOR TO VISIT (N=258)	N (%)
30 days or less	161 (62%)
31–60 days	15 (6%)
61–90 days	9 (4%)
91 days or longer	73 (28%)
TEN MOST COMMONLY DIAGNOSED SKIN LESIONS (N=257)	N (%)
Eczema	73 (28%)
Dermatophyte infection	28 (11%)
Benign nevus	26 (10%)
Bacterial infection	14 (6%)
Seborreic keratosis	11 (4%)
Bites	11 (4%)
Herpes	10 (4%)
Warts	10 (4%)
Viral exanthem	8 (3%)
Actinic keratosis	7 (3%)
FREQUENCY OF REPORTED TREATMENT ELEMENTS	N (%)
Prescription	158 (59%)
Recommended over-the-counter medication	63 (24%)
Reassurance with no other treatment	43 (16%)
Recommended prevention	29 (11%)
Removed lesion	28 (11%)
No treatment but arranged follow-up	15 (6%)
Degree of certainty with diagnosis*	Mean: 8.4 (SD: 1.7)
Referred to another provider (n=263)	23 (9%)
Unless otherwise noted, the sample size is 267 lesions.
* 1=Not at all certain, 10=Very certain.

TABLE 3
Patients reported high satisfaction

	NUMBER OF PATIENTS REPORTING OUTCOME (%) FOR PATIENTS WITH LESIONS EXPECTED TO IMPROVE BY FAMILY PHYSICIAN (RESOLUTION SCORE ≥ 7)*
Day 7 (n=234)	(n=181)
Much better or better	152 (84%)
The same	24 (13%)
Much worse or worse	5 (3%)
Day 28 (n=220)	(n=169)
Much better or better	150 (89%)
The same	15 (9%)
Much worse or worse	1 (2%)
Day 84 (n=203)	(n=157)
Much better or better	147 (94%)
The same	6 (4%)
Much worse or worse	1 (2%)
* Totals not identical with Table 2 due to loss to follow-up.

Acknowledgments

The views expressed are those of the authors. No official endorsement by the Agency for Healthcare Research and Quality is intended or should be inferred. We would like to thank the following medical students who played an integral role in recruitment, Aaron Baker, Richard Sisson and Giovina Lara Bomba. We would like to thank Haewon Park for editorial assistance. We would like to that the following practices for participation, Potomac Physician Associates of Kensington, La Clinica del Pueblo, Community of Hope, Fort Lincoln, Fairfax Family Practice of Vienna, Fair Oaks, and Prince William.

CORRESPONDENCE
Dan Merenstein, MD, 215 Kober Cogan Hall, 3750 Reservoir Road, NW, Washington, DC 20007. E-mail: djm23@georgetown.edu