Article Figures & Data
Figures
- Figure 1. MelaNOma Participant Flowsheet.
Notes: A flowsheet of participant training and data collection. Those who participated in MelaNOma Intervention were trained. Two participants from the trained group and fourteen participants form the control group were excluded due to insufficient number of months of practice for EHR analysis.
Abbreviations: Electronic Health Record (EHR), Federally Qualified Health Center (FQHC), Rural Health Clinic (RHC)
- Figure 2. MelaNOma Study Intervention and Data Collection Timeline.
Tables
Training Program Purpose Content/ Learning Objectives Mode of delivery Primary Training Session:
Enhancing Skin Cancer Early Detection and Treatment in Primary CareImprove the screening and identification of melanoma and how to diagnose and triage in primary care
Improve the use of existing systems of care to enhance skin cancer careIdentify normal versus abnormal lesions
Recognize patients with elevated skin cancer risk
Practice hands-on smart phone dermatoscope use
Demonstrate how to take photos with EHR
Describe preferential biopsy techniques
Discuss the different ways patients can receive skin cancer care outside of the traditional referral system
Live in-person; virtual Booster Training: Case-based “Snackable” via E-mail Deliver small bite-sized case-based questions with information to reinforce learnings and promote application in practice Identify normal versus abnormal lesions
Review melanoma risk factors
Identify workflows for suspicious lesions
Weekly emails with a quiz question, 5 emails in total. Second Live Training: Dermoscopy Skill Booster Build further skills for identification, dermatoscope and EHR tool use Review of abnormal lesion characteristics
Practice hands- on photography and dermoscopy
Illustrate how primary care doctors and dermatologists visualize and triage skin lesions
Live in-person; virtual Abbreviation: Electronic Health Record (EHR).
Variable/ Definition Data Source Data Collection / Analysis Compare changes in knowledge Clinician Knowledge - Clinicians’ knowledge of risks, lesion identification and management of melanoma Assessed via survey using 27 items. 17 lesion identification and biopsy items are drawn from prior study. The study team wrote the remaining 10 items. Clinicians completed a web survey prior to and after the first training session. Surveys are matched by unique study identifier such that an individual change score can be computed.
An overall knowledge score (all 27 items), Risk Assessment Knowledge (6 items), Knowledge of EHR tools (4 items) and Lesion Identification & Biopsy (17 items). Items are scored correct or incorrect and the score for total and subscores are represented as percent correct, ranging from 0-100%.Compare changes in process of skin cancer assessment, referral and documentation Dermatology assessment – use of screening tool Electronic Health Record (EHR) data abstracted through manual and automated methods Operationalized at the clinician level representing the number per 1000 patients. Indicators are measured pre- and post-training. Dermatology e-consult, reason for e-Consult Documentation - Use of Dot phrase* Dermatology referral, reason for referral Use of Medical photography for dermatology - binary variable indicating whether medical photography image was made. Compare Changes in Number of Melanomas Identified by Biopsy Number of biopsies and biopsy findings – counts and rates per 1000 patients indicating average biopsies per clinician and biopsy findings number of biopsies per 1000 patients EHR data abstracted through manual and automated methods Operationalized at the clinician level. Assess the feasibility, appropriateness and acceptability of Melanoma Training Acceptability – Extent to which the training is agreeable, palatable, satisfactory Assessed via semi-structured interview. Qualitative Interviews with clinicians exposed to the training
Appropriateness – Extent to which the training fits and is compatible for addressing issue or problem Feasibility - Extent to which the training can be successfully used or carried out * AVS-After visit summaries: SKINCANCERAVS - adult, SKINCANCERAVSPEDS - pediatrics; Skin cancer physical exam phrase SKINCANCERPE. Biopsy phrases: SKINCANCERPUNCHBX and SKINCANCERSHAVEBXS. Screening tool: SKINCASCREEN.
Total
n=44Training exposure
n=15No Training exposure
n=29Characteristics Sex, female 28 (63.6%) 10 (66.7%) 18 (62.1%) Degree MD/DO 37 (84.1%) 10 (66.7%) 27 (93.1%) PA/NP 7 (15.9%) 5 (33.3%) 2 (6.9%) Resident (vs attending) 11 (25.0%) 0 (0.0%) 11 (37.9%) Rural site (vs urban FQHC) 27 (61.4%) 10 (66.7%) 17 (58.6%) Abbreviation: Federal Qualified Health Clinic (FQHC)
Survey Content Pre-Training Survey
N=16Post-Training Survey
N=12Pre-Post Change
N=10P Total Score (27 items/survey) 72.1 (7.2) 80.8 (9.6) 8.1 (9.1) 0.02 Risk Assessment Knowledge (6 items) 66.7 (18.3) 79.2 (12.6) 11.7 (20.9) 0.11 Knowledge of EHR tools (4 items) 68.8 (22.7) 66.7 (24.6) -3.3 (29.2) 0.73 Lesion Identification & Biopsy (17 items) 74.6 (10.7) 83.8 (11.3) 8.8 (12.5) 0.05 Abbreviation: Electronic Health Record (EHR)
- Table 5. Rate of Referrals, e-Consults and EHR Tool Use at Baseline and Post-MelaNOma Training for Clinics 1 & 2 by Training Exposure Group*.
Training Exposure No Exposure Group by time interaction Baseline
(N = 15)Post-Training (N = 15) Baseline
(N = 29)Post-Training (N = 29) P-Value Total Number of Visits 7972 7339 9888 10432 Dermatology Referral 16.9 11.4 13.8 14.1 0.02 Reason for Referral Biopsy proven skin cancer that needs surgery 0.1 0.1 0.0 0.2 <.01 Concern for skin cancer 3.1 3.5 2.9 2.7 0.57 Routine skin check 4.8 2.1 2.5 4.6 <.01 Skin lesion not cancer concern 1.2 0.7 1.1 1.1 0.39 Other 6.7 5.0 5.4 5.6 0.04 Unknown 1.1 0.0 1.9 0.0 0.99 Dermatology e-Consult 5.5 7.8 5.1 7.2 0.50 Lesion (evaluate for skin cancer) 1.6 4.8 0.9 2.1 0.05 Atypical Skin Ulcer/Wound 0.3 0.5 0.6 0.1 0.46 Inflammatory Skin Rashes 0.0 0.1 1.5 0.6 <.01 Unknown 1.2 0.3 1.0 1.5 0.06 Dot phrases SKINCANCERAVS** 0.0 0.7 0.0 0.3 0.01 Medical photography (photo taken during primary care clinician visit) All photographs (any) 33.6 36.7 47.1 55.8 0.99 Photographs specific to skin lesion concern 10.8 11.9 8.8 11.9 0.84 Notes: *All rates are calculated based on per 1000 patients. **SKINCANCERAVS: Skin cancer after visit summary.
Abbreviation: Electronic Health Record (EHR).
Training Exposure No Exposure Group × time interaction Baseline Post-Training Baseline Post-Training P-Value ** (N = 15) (N = 15) (N = 29) (N = 29) Number of Biopsies 4.197 4.712 1.853 3.65 0.391 Biopsy finding Lesion-specific 3.353 4.175 1.335 3.573 0.286 Benign lesions 3.353 3.746 1.113 2.847 0.303 Malignant lesions 0 0.429 0.222 0.726 N/A Melanoma 0 0.109 0 0 N/A SCC 0 0.32 0.128 0.498 N/A BCC 0 0 0.053 0.088 N/A Other skin cancers 0 0 0.041 0 N/A Rashes / Inflammatory 0.844 0.537 0.519 0.077 0.094 Notes: *All rates are calculated based on per 1000 patients. **P values with N/A indicate where models were not run due to small counts or models did not converge.
Abbreviations: BCC- Basal Cell Carcinoma, SCC- Squamous Cell Carcinoma
- Appendix 1a.
- Appendix 1b.
- Appendix 2.
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