Dermatological surgery: a comparison of activity and outcomes in primary and secondary care

Abstract

BACKGROUND: Dermatological surgery is carried out by a variety of practitioners in primary and secondary care. OBJECTIVES: To explore the activity and histopathological outcomes among different groups of dermatological surgeons dealing with skin cancers. METHODS: Reports for all new skin tumour specimens processed by our histopathology department over a continuous 3-month period were reviewed retrospectively. RESULTS: One thousand, one hundred and eleven new skin tumour specimens were identified. General practitioners (GPs) were least accurate in clinical diagnosis, with 42.8% (59/138) of their request forms including the eventual histological diagnosis, compared with 69.5% (328/472) for dermatologists (odds ratio, OR 0.33, 95% confidence interval, CI 0.22-0.48). Inappropriate procedures were most often performed by plastic surgeons, usually involving large excision biopsies for benign lesions in elderly patients [6.6% (20/305) of their specimens vs. 0% for dermatologists, exact P < 0.001]. Excision biopsies performed by GPs had the highest rate of margin involvement by tumour of any specialty [68% (15/22) of such specimens vs. 8% (9/116) for dermatologists; OR 25.47, 95% CI 8.26-78.53]. As per National Institute for Health and Clinical Excellence guidance, 13.8% (19/138) of tumours operated on by GPs should instead have been referred to secondary care for initial surgical management. CONCLUSIONS: This study presents a strong case for dermatologists to continue to provide the lead in diagnosis of skin lesions, and in selection and execution of dermatological surgical procedures.