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Increasing supplies of dermatologists and family physicians are associated with earlier stage of melanoma detection,☆☆

https://doi.org/10.1067/mjd.2000.106242Get rights and content

Abstract

Background: Physicians are important in the early detection of melanoma. We investigated whether primary care physician supply and the supply of dermatologists were related to stage at diagnosis for malignant melanoma. Methods: From the state tumor registry in Florida in 1994, we identified incident cases of malignant melanoma for which stage at diagnosis was available (N = 1884). Data on physician supply was obtained from the 1994 American Medical Association Physician Masterfile. Logistic regression determined the effects of physician supply (at the ZIP code level) on the odds of early-stage diagnosis controlling for patients’ age, gender, race/ethnicity, marital status, education level, income level, comorbidity, and type of health insurance. Results: Each additional dermatologist per 10,000 population was associated with a 39% increased odds of early diagnosis (odds ratio = 1.39, 95% confidence interval [CI] 1.09-1.70, P = .010). For each additional family physician per 10,000 population, the odds of early diagnosis increased 21% (odds ratio = 1.21, 95% CI 1.09-1.33, P < .001). Each additional general internist per 10,000 population was associated with a 10% decrease in the odds of early-stage diagnosis (odds ratio = 0.90, 95% CI 0.83-0.98, P = .009). The supplies of general practitioners, obstetrician/gynecologists, and other nonprimary care specialists were not associated with stage at diagnosis. Conclusions: Increasing supplies of dermatologists and family physicians were associated with earlier detection of melanoma. In contrast, increasing supplies of general internists were associated with reduced odds of early detection. Our findings suggest that the composition of the physician work force may affect important health outcomes and needs further study. (J Am Acad Dermatol 2000;43:211-8.)

Section snippets

Sources of data

We identified all 1994 incident cases of melanoma occurring in Florida for which stage at diagnosis was available (N = 1884) using the Florida Cancer Data System (FCDS), Florida’s population-based statewide cancer registry. The year 1994 was the most recent for which all relevant data were available. The FCDS was created in 1978 and has been collecting cancer incident data since 1981. The FCDS has well-established methods to ensure complete case finding including cooperative arrangements with

Results

Table I describes the demographic characteristics for the 1884 study subjects.

. Characteristics of patients diagnosed with malignant melanoma in Florida, 1994 (N = 1884)

CharacteristicsNo.*%
Gender
 Male111759.3
 Female76740.7
Race/ethnicity
 White, non-Hispanic176393.6
 Black, non-Hispanic150.8
 Hispanic623.3
 Other442.3
Education
 High school education65034.7
 More than high school education122565.4
Marital status
 Never18210.2
 Current126870.8
 Divorced/separated1196.7
 Widowed22412.5
Payer
 Medicare66943.7
 Medicare HMO644.2
 

Conclusions

Physician supply was a significant predictor of stage at diagnosis for patients with malignant melanoma. Most striking was the relation between the supply of dermatologists and stage; each additional dermatologist per 10,000 population was associated with 39% greater odds of early diagnosis. An increasing supply of family physicians was similarly associated with earlier diagnosis. Unexpectedly, an increasing supply of general internists was associated with greater odds of late stage diagnosis

References (55)

  • B Miller et al.

    Cancer Statistics Review:

    (1973-1989)
  • RJ Friedman et al.

    Malignant melanoma in the 1990s: the continued importance of early detection and the role of physician examination and self-examination of the skin

    CA Cancer J Clin

    (1991)
  • S Landis et al.

    Cancer statistics, 1998

    CA Cancer J Clin

    (1998)
  • A Girgis et al.

    Screening for melanoma: a community survey of prevalence and predictors

    Med J Aust

    (1991)
  • M Berwick et al.

    Screening for cutaneous melanoma by skin self-examination

    J Natl Cancer Inst

    (1996)
  • National Center for Health Statistics et al.

    National Center for Health Statistics: Health

    (1988. 1989)
  • AC Geller et al.

    Use of health services before the diagnosis of melanoma: implications for early detection and screening

    J Gen Intern Med

    (1992)
  • D Epstein et al.

    Is physician detection associated with thinner melanomas?

    JAMA

    (1999)
  • R. Marks

    Prevention and control of melanoma: the public health approach

    CA Cancer J Clin

    (1996)
  • J. Austoker

    Melanoma: prevention and early diagnosis

    Br Med J

    (1994)
  • GP Runkle et al.

    Malignant melanoma

    Am Fam Physician

    (1994)
  • CJ Cockerell et al.

    Think melanoma

    South Med J

    (1993)
  • D Kamath et al.

    Florida’s undeclared epidemic: malignant melanoma

    J Fla Med Assoc

    (1997)
  • J Ayanian et al.

    The relation between health insurance coverage and clinical outcomes among women with breast cancer

    N Engl J Med

    (1993)
  • T Hofer et al.

    Use of community versus individual socioeconomic data predicting variation in hospital use

    Health Serv Res

    (1998)
  • N. Krieger

    Overcoming the absence of socioeconomic data in medical records: validation and application of a census-based methodology

    Am J Public Health

    (1992)
  • N Krieger et al.

    Social class: the missing link in U.S. health data

    Int J Health Serv

    (1994)
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    Dr Roetzheim was supported through a Generalist Physician Faculty Scholars Award from the Robert Wood Johnson Foundation.

    ☆☆

    Reprint requests: Richard Roetzheim, MD, MSPH, University of South Florida, Department of Family Medicine, 12901 Bruce B. Downs Blvd, MDC 13, Tampa, FL 33612.

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