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An Observational Pilot Study

Susan M. Swetter, MD; Seaver Soon, MD; Cynthia R. Harrington, MD, PhD; Suephy C. Chen, MD, MS

Arch Dermatol. 2007;143(1):30-36.

Objective  To compare the effect of differing health care delivery models, specifically, gatekeeper (GK) vs direct access (DA) routes, on melanoma outcome as measured by tumor thickness and cancer stage at diagnosis.

Design  Retrospective medical record review of patients previously diagnosed as having cutaneous melanoma who were referred to a university-based clinic from January 1, 1996, through December 31, 2000.

Setting  Stanford Pigmented Lesion and Cutaneous Melanoma Clinic, Stanford, Calif.

Patients  Two hundred thirty-four patients with primary melanoma stratified according to health care access route (GK or DA).

Main Outcome Measures  Differences in Breslow thickness, American Joint Committee on Cancer stage, histologic features, patient delay in seeking medical attention, and physician delay in diagnosis (time between initial physician visit and diagnostic biopsy procedure).

Results  Of 234 patients, 168 (72%) were referred through the DA route and 66 (28%) through the GK route. A significant association was found between physician delay and access route; patients in the DA group underwent biopsy sooner (3 months vs >3 months) than those in the GK group (P<.001). No significant difference was observed in stage at diagnosis (predominantly stage IA), proportion of nodular melanoma (DA 4% vs GK 2%), patient delay, or median tumor thickness between DA and GK routes (0.42 mm vs 0.50 mm, respectively). A trend toward a greater proportion of histologically ulcerated melanoma was observed in the DA group compared with the GK group (12% vs 5%, respectively; P = .06).

Conclusions  This pilot study demonstrated no difference in outcome between GK and DA routes as measured by melanoma thickness and stage, although patients in the DA group underwent diagnostic biopsy sooner than those in the GK group. The potential effect of health care models on melanoma outcomes merits further study.

Author Affiliations: Dermatology Services, VA Health Care Systems, Palo Alto, Calif (Dr Swetter), and Atlanta, Ga (Dr Chen); Health Services Research and Development, Veterans Affairs Health Care System, Atlanta (Dr Chen); and Departments of Dermatology, Stanford University Medical Center, Stanford, Calif (Drs Swetter and Harrington), and Emory University School of Medicine, Atlanta (Drs Soon and Chen).

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