Department of Dermatology, Erasmus University Medical Centre, Rotterdam, the Netherlands.
Department of Research, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands.
Br J Dermatol. 2019 Sep;181(3):544-553. doi: 10.1111/bjd.17632. Epub 2019 Apr 19.
The high prevalence of actinic keratosis (AK) requires the optimal use of healthcare resources.
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.
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).
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.
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 efficiency of AK care.
光化性角化病（AK）的高患病率要求优化医疗资源的使用。
深入了解基于人群的队列中 AK 患者的医疗保健利用情况，以及初级和二级保健机构中 AK 的管理情况。
使用三种互补数据源进行回顾性队列研究，以描述荷兰 AK 患者的护理、诊断、治疗和随访使用情况。数据源包括基于人群的队列研究（鹿特丹研究）、常规全科医生记录（综合初级保健信息）和全国索赔数据（DRG 信息系统）。
在基于人群的队列（鹿特丹研究）中，在皮肤筛查就诊期间被诊断患有 AK 的 69%（1322 名参与者中的 918 名）在全科医生记录中没有之前的 AK 相关就诊。对于广泛 AK（即≥10 个 AK；n=270）的参与者，这一比例为 50%。冷冻疗法是全科医生（78%）和皮肤科医生（41-56%）最常使用的 AK 治疗方法。局部药物是皮肤科医生第二常用的治疗方法（13-21%），但在初级保健中很少应用（2%）。在首次 AK 相关的全科医生就诊中，31%（554 名参与者中的 171 名）被转介给皮肤科医生，低风险和高风险患者被转介的可能性相似，这与 2017 年荷兰全科医生关于“可疑皮肤病变”的指南不一致。每年，有 40,000 份新的索赔代表所有皮肤科索赔的 13%被标记为皮肤前恶性肿瘤。在二级保健中记录了广泛的随访率（56%），而在 5 年内只有 18%的患者因随后的皮肤恶性肿瘤获得了索赔。
初级保健和二级保健中的 AK 管理似乎与指南不符。在初级保健中，场治疗利用不足、治疗不当以及转诊率高而没有适当的风险分层，再加上二级保健中的广泛随访，导致医疗资源利用效率低下和二级保健负担过重。针对更好的风险分层和指南依从性的努力可能有助于提高 AK 管理的效率。
关于这个话题已经知道些什么？光化性角化病（AK）的患病率很高，特别是多发性 AK 是皮肤癌的一个强烈预测指标。AK 的高患病率要求优化医疗资源的使用。然而，（基于人群的）AK 医疗保健利用和管理数据非常罕见。这项研究增加了什么新内容？尽管 AK 相关的护理已经消耗了大量的资源，但大约 70%的 AK 患者从未接受过护理。初级保健中的 AK 管理表现出对局部治疗的利用不足和转诊率高，而没有适当的风险分层，而在二级保健中则采用了广泛的随访计划。这种医疗资源利用效率低下突出表明需要更好的协调和风险分层，以提高 AK 护理的效率。
