Hypothesizing that geographic variation in the county-level density of dermatologists may affect melanoma-associated mortality, Aneja et al,1 in a recent issue of the Archives, show that the presence of 1 or more dermatologists per 100 000 people is associated with an approximately 30% or greater reduction in the corresponding age-adjusted mean melanoma mortality rate compared with counties with no dermatologists. Accordingly, they argue that this result “reflects that access to a dermatologist allows for an accurate and earlier diagnosis of melanoma, more appropriate therapy, or a combination of these factors.”1(p176) The magnitude of this effect size—in concert with the reported lack of significant association with sociodemographic parameters that have hitherto repeatedly been linked with worse outcomes across many diseases, including melanoma2—should prompt reconsideration of potentially unrecognized confounders. For example, the County Health Rankings database recently developed by the Robert Wood Johnson Foundation3 highlights the importance of myriad factors contributing to county-level health outcomes that extend well beyond the usual suspects of race, income, education, and insurance to include the physical environment, community safety, family and social support, employment, diet and exercise, unsafe sexual practices, tobacco and alcohol use, and others. Estimating the contribution of such factors to the variance of county-level melanoma outcomes may help avoid errors in consequent policy prescriptions advocating “more dermatologists.” This is particularly important, given the large body of research, acknowledged by Aneja et al,1 that suggests an inverse relationship between density of specialists and overall health care outcomes. Reasons for this inverse relationship include deteriorating coordination of care among primary and specialist physicians, unnecessary treatment by specialists, and further marginalization of vulnerable populations secondary to cost-sharing with more expensive specialty providers. Conceivably, melanoma deaths might be prevented by the addition of more dermatologists but at the price of increased all-cause morbidity and mortality, a possible unintended consequence warranting further investigation. Finally, the results reported by Aneja et al1 should be interpreted in the context of standard dermatologic care. It has been recently calculated that the number of patients needed to be screened to prevent 1 melanoma-related death using total body skin examinations is roughly 25 000.4 It is also known that most dermatologists in the United States see 150 or fewer patients per week.5 Suppose then that we conservatively estimate that the average dermatologist spends 60% of her time each year performing only total body skin examinations. Then, over the 4-year study period reported by Aneja et al,1 1 dermatologist will have performed approximately 19 000 total body skin examinations and, on average, prevented 0 melanoma deaths through screening. This simple (but limited) thought experiment perhaps offers a contrasting view as to how small the effect size of a single dermatologist may actually be in reducing melanoma-related mortality. Back to top Article Information Correspondence: Dr Lott, Department of Dermatology, Yale University School of Medicine, 333 Cedar St, PO Box 208059, LCI 501, New Haven, CT 06520-8059 (email@example.com). Financial Disclosure: None reported. References 1. Aneja S, Aneja S, Bordeaux JS. Association of increased dermatologist density with lower melanoma mortality. Arch Dermatol. 2012;148(2):174-17822351816PubMedGoogle ScholarCrossref 2. Pollitt RA, Swetter Sm, Johnson TM, Patil P, Geller AC. Examining the pathways linking lower socioeconomic status and advanced melanoma [published online December 16, 2011]. . Cancer;22179775PubMed 3. Robert Wood Johnson Foundation. County Health Rankings. http://www.countyhealthrankings.org. Accessed March 5, 2012 4. Gelfand J. Behind the numbers: number needed to screen. J Watch Dermatol. 2012;20(1):3Google Scholar 5. Kane L. Medscape dermatology compensation report: 2011. http://www.medscape.com/features/slideshow/compensation/2011/dermatology. Accessed March 5, 2012
Archives of Dermatology – American Medical Association
Published: Sep 1, 2012
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