The association of physician-specialty density and melanoma prognosis in the United States, 1988 to 1993

doi:10.1016/j.jaad.2008.08.040

Journal of the American Academy of Dermatology

Volume 60, Issue 1, January 2009, Pages 51-58

https://doi.org/10.1016/j.jaad.2008.08.040 Get rights and content

Background

Studies suggest physician workforce may influence cancer outcomes.

Objective

We sought to quantify the effect of physician-specialty density on melanoma prognosis.

Methods

Data from 17,702 melanoma cases reported to the Surveillance, Epidemiology, and End Results program from 1988 to 1993 were merged with sociodemographic data (1990 US Census) and dermatologist, family practitioner, and internist density data (Area Resource File). Linear and logistic regression analyses were used to model prognosis (melanoma mortality to incidence ratio).

Results

A higher density of dermatologists was associated with better prognosis (lower mortality to incidence ratio) (β = –50 × 10⁻⁴; SE 8 × 10⁻⁴). Internist density was also a significant predictor of better prognosis whereas increased family practitioner density was associated with worse prognosis. Controlling for sociodemographics, physician density remained a significant predictor of the mortality to incidence ratio.

Limitations

Socioeconomic factors were estimated. Physician density was examined by county.

Conclusion

Controlling for sociodemographic factors, physician-specialty density predicted melanoma prognosis. This suggests that specialist health care availability may affect melanoma outcomes.

Section snippets

Methods

This was a population-based ecologic analysis of a cohort of patients in the melanoma cancer registry using data from the SEER-9 program, which was linked to the US Census data (socioeconomic estimates) and Area Resource File (ARF) (physician provider data). Sponsored by the National Cancer Institute (NCI), the SEER program provides the broadest system of cancer registration in the United States, and represents approximately 10% of the US population in the original 9 population-based cancer

Results

The density of providers in SEER counties was examined for dermatologists, family practitioners (FPs), and internists. The median density of dermatologists was 3.4 dermatologists per 100,000 population (range: 0-27 dermatologists/100,000 population). The median density of FPs was 13.9 FPs per 100,000 population (range: 0-87 FPs/100,000 population) and the median density of internists was 33.7 (range: 0-161 internists/100,000 population). The density of dermatologists was highly correlated with

Discussion

This study, which examines multiple operational definitions of prognosis that are relevant to melanoma, illuminates the potential role of access to health care in melanoma outcomes, an area in which there has been limited study. In this study, we examined the provider density and specialty type, factors that may reflect potential access to care. Findings from this study suggest that access to specialty care may explain some differences in melanoma prognosis. Alternatively, unmeasured factors

References (23)

RG. Roetzheim et al.
Increasing supplies of dermatologists and family physicians are associated with earlier stage of melanoma detection
J Am Acad Dermatol
(2000)
J.S. Resneck et al.
Short wait times for patients seeking cosmetic botulinum toxin appointments with dermatologists
J Am Acad Dermatol
(2007)
A. Jemal et al.
Cancer statistics, 2006
CA Cancer J Clin
(2006)
Ries LAG, Eisner MP, Kosary CL, Hankey BF, Miller BA, Clegg L, et al. SEER cancer statistics review, 1975-2001....
A. Jemal et al.
Cancer statistics, 2007
CA Cancer J Clin
(2007)
A. Jemal et al.
Cancer statistics, 2003
CA Cancer J Clin
(2003)
A.C. Geller et al.
Cutaneous melanoma mortality among the socioeconomically disadvantaged in Massachusetts
Am J Public Health
(1996)
R.M. MacKie et al.
Incidence and thickness of primary tumors and survival of patients with cutaneous malignant melanoma in relation to socioeconomic status
BMJ
(1996)
C.A. Reyes-Ortiz et al.
Socioeconomic status and survival in older patients with melanoma
J Am Geriatr Soc
(2006)
Ries LAG, Eisner MP, Kosary CL, Hankey BF, Miller BA, Clegg L, Edwards BK. SEER cancer statistics review, 1973-1999....

R.D. Cress et al.

Incidence of cutaneous melanoma among non-Hispanic whites, Hispanics, Asians, and blacks: an analysis of California cancer registry data, 1988-93

Cancer Causes Control

(1997)

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Utilization, cost, and provider trends in patch testing among Medicare beneficiaries in the United States from 2012 to 2017
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Citation Excerpt :
Our data show that nearly 99% of nonmetro counties in the US do not have a provider offering patch testing for the Medicare population. Indeed, although overall physician density has been associated with a variety of clinical outcomes in dermatology and other medical specialties, the greatest improvement in outcomes occurs in counties having any physician offering the relevant services versus those that have no such physicians.8-11,22-24 In these counties, barriers such as travel to a different county or physicians in the county being less likely to recommend patch testing because of decreased familiarity with the procedure likely preclude patients who may benefit from patch testing from receiving it.22,25-28
Patch testing is the best diagnostic test for allergic contact dermatitis. However, there is presently a lack of data on the test's geographic availability and the characteristics of the providers offering this test across the United States.
To evaluate the geographic variation in the availability of patch testing for the Medicare population and to characterize the temporal trends of patch testing cost, use, and provider specialty from 2012 to 2017.
Retrospective cohort study of the Medicare Provider Utilization and Payment Data from 2012 to 2017.
As of 2017, patch testing was available in 20.3% of metropolitan counties and in 1.1% of nonmetropolitan counties. From 2012 to 2017 in metropolitan regions, the number of beneficiaries tested by dermatologists grew by an average annual growth rate of 1.84%, whereas those tested by allergists grew by an average annual growth rate of 20.31%. Most providers that averaged use of 80 or more patches per beneficiary were dermatologists (76.3%).
Analysis was restricted to Medicare Part B claims; data were unavailable on individuals with commercial insurance.
Most of the increase in patch testing utilization from 2012 to 2017 has been in metropolitan regions. Although growth was especially prominent among allergists in metropolitan counties, the majority of providers performing comprehensive patch testing were dermatologists.
Geographic Distribution of Hand Surgeons Throughout the United States
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The purpose of this study was to evaluate the geographic distribution of hand surgeons in the United States. We assessed the states and congressional districts (CDs) for optimal numbers of surgeons, determined whether there is an even distribution, and identified factors influencing practice location. Hand surgeon practice location data from the American Association for Hand Surgery and American Society for Surgery of the Hand (2015) and both state and CD population data from the US Census (2014) were assessed. CDs each contain approximately the same population. Furthermore, select hand surgeons were asked to fill out a survey to identify how 6 factors influence practice location. A total of 2,707 American Association for Hand Surgery active and American Society for Surgery of the Hand active and candidate US members were included. The mean number of hand surgeons per state was 53 (range: 3–298). The most hand surgeons were in California, Texas, New York, and Florida and least were in Wyoming and Alaska. There were 16, 11, and 24 states with suboptimal, optimal, and greater-than-optimal density, respectively. There were 436 CDs. We found 231, 30, and 175 CDs with suboptimal, optimal, and greater-than-optimal density, respectively. There were weak correlations between hand surgeons and CD populations and between CD population densities and CD hand surgeons per capita. Twenty hand surgeons were included in the survey resulting in no difference of any 1 factor compared with the other 5 factors. There was a difference in the factor “population size” between hand surgeons from greater-than-optimal and suboptimal CDs. The findings of our study indicate that hand surgeon proportions do not correlate with population proportions, and distribution is not skewed toward areas of higher population density. Many areas are not optimally served, and hand surgeons may be choosing where to practice based on a combination of factors beyond population need.
The role of spatially-derived access-to-care characteristics in melanoma prevention and control in Los Angeles county
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Citation Excerpt :
Because a greater percentage of HW (9%) than NHW (1%) used Medicaid to pay for diagnostic services, the service shortage for Medicaid enrollees may disproportionately affect HW and may result in increased rates of thick melanoma among this population, especially as people gain coverage but struggle to find providers or have difficulty accessing those designated to them. Consistent with previous studies, our study showed that a greater supply of dermatologists decreased the risk of advanced melanoma (Aneja et al., 2012; Eide et al., 2009a; Roetzheim et al., 2000). Moreover, risk reductions were only significant, albeit marginally, among NHW and in low-poverty areas, suggesting that an increase in the number of neighborhood dermatologists may not necessarily improve access to dermatological care and may not successfully impact melanoma mortality among HW and high-poverty areas.
Among 10,068 incident cases of invasive melanoma, we examined the effects of patient characteristics and access-to-care on the risk of advanced melanoma. Access-to-care was defined in terms of census tract-level sociodemographics, health insurance, cost of dermatological services and appointment wait-times, clinic density and travel distance. Public health insurance and education level were the strongest predictors of advanced melanomas but were modified by race/ethnicity and poverty: Hispanic whites and high-poverty neighborhoods were worse off than non-Hispanic whites and low-poverty neighborhoods. Targeting high-risk, underserved Hispanics and high-poverty neighborhoods (easily identified from existing data) for early melanoma detection may be a cost-efficient strategy to reduce melanoma mortality.
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Access to dermatologists is an ongoing concern for Medicaid enrollees. Understanding current use is a key step toward designing and implementing policies to improve access.
We sought to quantify how often Medicaid enrollees visit dermatologists and receive treatment for skin-related conditions compared with patients with other coverage or without health insurance.
We conducted a retrospective cross-sectional analysis of multiyear federal survey data (Medical Expenditure Panel Survey). The sample included Medical Expenditure Panel Survey respondents younger than 65 years from 2008 to 2012.
In unadjusted comparisons, we found that 1.4% of Medicaid enrollees had an ambulatory visit to a dermatologist annually, compared with 1.2% of uninsured individuals and 5.5% of individuals with private coverage. In adjusted models, we found that health insurance source, age, sex, race/ethnicity, and geography are associated with the likelihood of having visits to a dermatologist. Compared with individuals with private coverage, Medicaid enrollees are less likely to receive a diagnosis for a skin condition by any provider and are less than half as likely to have skin-related diagnoses made by dermatologists.
We have relatively few Medical Expenditure Panel Survey respondents for a subset of specific diagnoses.
Our findings emphasize the need for efforts to reduce disparities in access to dermatologists.
National utilization patterns of Mohs micrographic surgery for invasive melanoma and melanoma in situ
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We sought to determine national utilization patterns for MMS in the treatment of invasive melanoma and melanoma in situ.
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: Supported by a Dermatology Foundation award and a Surdna Foundation award (Dr Eide); grants CSP 402 from the Department of Veterans Affairs, Office of Research and Development, and CA 106592 from the National Cancer Institute (Dr Weinstock); and the Agency for Healthcare Research and Quality Institutional Training grant, HS00011-16 (Drs Clark and Eide).

: Conflicts of interest: None declared.

View full text

Original articleThe association of physician-specialty density and melanoma prognosis in the United States, 1988 to 1993

Background

Objective

Methods

Results

Limitations

Conclusion

Section snippets

Methods

Results

Discussion

J Am Acad Dermatol

J Am Acad Dermatol

Cancer statistics, 2006

CA Cancer J Clin

Cancer statistics, 2007

CA Cancer J Clin

Cancer statistics, 2003

CA Cancer J Clin

Cutaneous melanoma mortality among the socioeconomically disadvantaged in Massachusetts

Am J Public Health

Incidence and thickness of primary tumors and survival of patients with cutaneous malignant melanoma in relation to socioeconomic status

BMJ

Socioeconomic status and survival in older patients with melanoma

J Am Geriatr Soc

Incidence of cutaneous melanoma among non-Hispanic whites, Hispanics, Asians, and blacks: an analysis of California cancer registry data, 1988-93

Cancer Causes Control

Original article
The association of physician-specialty density and melanoma prognosis in the United States, 1988 to 1993