Healthcare utilization and management of actinic keratosis in primary and secondary care: a complementary database analysis
2019
textabstractBackground The high prevalence of actinic keratosis (AK) requires the optimal use
of healthcare resources.
Objectives 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.
Methods 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).
Results In the population-based cohort (Rotterdam Study), 69% (918 of 1322) of
participants diagnosed with AK during a skin-screening visit had no previous AKrelated 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.
Conclusions 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.
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