Graells J, Espinola A, Barrio C, Muñoz M D, Román A, Parellada N
Servicio de Dermatología, Hospital Comarcal de Sant Boi de Llobregat, Barcelona, España.
Actas Dermosifiliogr. 2007 Apr;98(3):171-7.
Lack of diagnostic skill in cutaneous surgery may lead to erroneous and potentially detrimental therapies. This study compares the diagnosis and treatment in cutaneous surgery, including cryotherapy, between a dermatologist and family physicians.
It is an observational, prospective study on a random sample of patients that consulted the dermatologist for candidate lesions. Each lesion was independently evaluated by a dermatologist and a family physician, both of whom assigned the clinical diagnosis and therapeutic advice. Concordance for diagnosis, recommended treatment and indication for cryotherapy was calculated by Cohen's kappa coefficient.
Six hundred forty-six lesions were evaluated. Global kappa indexes were 0.69 (95 % CI, 0.65-0.73) for diagnostic concordance, 0.62 (95 % CI, 0.56-0.67) for recommended treatment and 0.73 (95 % CI, 0.67-0.78) for indication of cryotherapy. Diagnostic concordance was significantly better for melanocytic nevus, achrocordon and for lesions with multiple and monomorphous presentation, and worse for isolated pigmented lesions. For recommended treatment concordance was better for multiple and monomorphous lesions and worse for skin cancer and seborrheic keratosis. For indication of cryotherapy concordance was worse for skin cancer, melanocytic nevus, acrochordon and seborrheic keratosis. Family physicians made an erroneous indication for cryotherapy in 5.88 % of cases, including 3 non melanoma skin cancers.
Concordance between dermatologists and family physicians for minor cutaneous surgery is generally good. Family physicians should be more careful in evaluating solitary pigmented lesions and patients at risk for skin cancer.
皮肤外科诊断技能的欠缺可能导致错误且潜在有害的治疗。本研究比较了皮肤科医生和家庭医生在皮肤外科（包括冷冻疗法）方面的诊断和治疗情况。
这是一项对因可疑病变咨询皮肤科医生的患者随机样本进行的观察性前瞻性研究。每位皮肤科医生和家庭医生对每个病变进行独立评估，两人都给出临床诊断和治疗建议。通过科恩kappa系数计算诊断、推荐治疗及冷冻疗法指征的一致性。
共评估了646个病变。诊断一致性的总体kappa指数为0.69（95%CI，0.65 - 0.73），推荐治疗的kappa指数为0.62（95%CI，0.56 - 0.67），冷冻疗法指征的kappa指数为0.73（95%CI，0.67 - 0.78）。黑素细胞痣、皮赘以及表现为多发性和单形性的病变，诊断一致性明显更好；孤立性色素沉着病变的诊断一致性则较差。对于推荐治疗，多发性和单形性病变的一致性更好，皮肤癌和脂溢性角化病的一致性较差。对于冷冻疗法指征，皮肤癌、黑素细胞痣、皮赘和脂溢性角化病的一致性较差。家庭医生在5.88%的病例中给出了错误的冷冻疗法指征，其中包括3例非黑素瘤皮肤癌。
皮肤科医生和家庭医生在小型皮肤外科手术方面的一致性总体良好。家庭医生在评估孤立性色素沉着病变和皮肤癌高危患者时应更加谨慎。
