Ching Allison, Pedula Kathryn, Devere Theresa, Aruga Cheryl, Honda Stacey, Ching Karen
Kaiser Permanente Hawaii, Honolulu, HI, USA.
Hawaii Permanente Medical Group, Honolulu, HI, USA.
J Prim Care Community Health. 2024 Jan-Dec;15:21501319241306298. doi: 10.1177/21501319241306298.
Patients with a primary cutaneous melanoma (PCM) are at increased risk of developing a second primary melanoma (SPM). Earlier stage at diagnosis is associated with better 5-year mortality, yet low compliance with recommended follow-up after treatment for PCM and high rates of patients lost to follow-up are reported in the literature. Strategies to enhance population-based surveillance for SPM have not been well described.
To determine whether the implementation of a systematic automated population-based program (SAPP) to ensure dermatologist total body skin exams (TBSEs) in the PCM population compared to the pre-automated period and pre-database periods improves compliance with follow-up, detects more SPMs, or affects mortality?
Quality Improvement Study.
Large integrated health care system with internalized Dermatology services.
Members with a PCM prior to, or during the study periods of interest, were included in this quality improvement study. There were 6317 eligible individuals with PCMs in 3 study periods: pre-Database (1/1/2005-11/1/2009), pre-Automation (11/1/09-7/31/15), and post-Automation (8/1/15-12/31/2021), respectively.
INTERVENTION(S) OR EXPOSURE(S): Manual registry for melanoma patients (pre-Automation) and systematic automated population-based program for PCM patients (post-Automation).
MAIN OUTCOME(S) AND MEASURE(S): Mean number of TBSE per person-year. Time Between TBSE. Incidence of SPM detection. Stage of SPM at diagnosis. Melanoma Death and All-Cause Mortality.
In patients with PCM, a SAPP to ensure dermatologist TBSE, reduces median time (months) between TBSEs from 12.3 pre-Database to 8.2 post-Automation (stage 0-2a PCM) and from 10.3 to 6.8 (stage 2b-4 PCM; < .0001), improves number of TBSEs per person-year with each successive study period (pre-Database mean [SD] 0.56 [1.07]; pre-Automation 0.80 [1.25]; post-Automation 1.78 [4.17]; < .0001), and improves SPM detection rates per 1000 person-years (pre-Database 20.2 [95% CI 12.2-30.9]; pre-Automation 27.5 [18.2-39.9]; post-Automation 27.5 [26.6-51.8], < .0001 for trend) at earlier cancer stages. There is an associated annual reduction in all-cause (1.4 per 1000 person-years, = .0004) and melanoma-cause mortality (0.2 per 1000 person-years, = .0197).
Implementing a systematic, automated population-based Melanoma program to ensure dermatologist TBSEs improves compliance with follow-up in patients with PCM. More patients received at least annual dermatologist TBSEs and more SPMs were detected at earlier stages. Improvements were sustained and there were significantly lower all-cause and melanoma-cause mortality. The system facilitates prioritization of higher risk patients for intervention and is a unique strategy enhancing patient safety, efficiency, and timeliness of care.
原发性皮肤黑色素瘤（PCM）患者发生第二原发性黑色素瘤（SPM）的风险增加。诊断时处于早期阶段与更好的5年死亡率相关，但文献报道PCM治疗后推荐随访的依从性较低，失访率较高。尚未充分描述加强基于人群的SPM监测的策略。
确定实施系统性自动化人群项目（SAPP）以确保皮肤科医生对PCM人群进行全身皮肤检查（TBSE），与自动化前时期和数据库建立前时期相比，是否能提高随访依从性、检测到更多的SPM或影响死亡率？
质量改进研究。
拥有内部皮肤科服务的大型综合医疗保健系统。
在感兴趣的研究期间之前或期间患有PCM的成员被纳入本质量改进研究。在3个研究时期有6317名符合条件的PCM患者：数据库建立前（2005年1月1日至2009年11月1日）、自动化前（2009年11月1日至2015年7月31日）和自动化后（2015年8月1日至2021年12月31日）。
黑色素瘤患者手动登记（自动化前）和PCM患者系统性自动化人群项目（自动化后）。
每人每年的TBSE平均次数。两次TBSE之间的时间。SPM检测发病率。诊断时SPM的分期。黑色素瘤死亡和全因死亡率。
在PCM患者中，确保皮肤科医生进行TBSE的SAPP将两次TBSE之间的中位时间（月）从数据库建立前的12.3个月缩短至自动化后的8.2个月（0 - 2a期PCM），从10.3个月缩短至6.8个月（2b - 4期PCM；P <.0001），随着每个连续研究时期的推移，每人每年的TBSE次数增加（数据库建立前平均[标准差]0.56 [1.07]；自动化前0.80 [1.25]；自动化后1.78 [4.17]；P <.0001），并且在癌症早期阶段每1000人年的SPM检测率提高（数据库建立前20.2 [95%置信区间12.2 - 30.9]；自动化前27.5 [18.2 - 39.9]；自动化后27.5 [26.6 - 51.8]，趋势P <.0001）。全因死亡率（每1000人年1.4，P = 0.0004）和黑色素瘤导致的死亡率（每1000人年0.2，P = 0.0197）每年都有所下降。
实施系统性、自动化的基于人群的黑色素瘤项目以确保皮肤科医生进行TBSE可提高PCM患者的随访依从性。更多患者至少每年接受一次皮肤科医生的TBSE，并且在早期阶段检测到更多的SPM。改进得以持续，全因死亡率和黑色素瘤导致的死亡率显著降低。该系统有助于对高风险患者进行干预优先级排序，是提高患者安全性、效率和护理及时性的独特策略。
