Summary
The purpose of this article is to improve skin assessment by establishing the standard of having patients don gowns during their annual wellness exam, to increase dermatology referrals when skin assessment is abnormal, and to improve integumentary documentation to include more precise descriptions of abnormal skin findings.
Original Article
Dermatological screening in primary care
By Brittany Wheatley, DNP, FNP-BC
Skin cancer has become the most prevalent type of cancer in the United States, with over 2 million individuals diagnosed each year.1 Newly diagnosed cases of skin cancer account for more than breast, lung, colon, and prostate cancer combined.2 Within the last 30 years, melanoma rates have nearly tripled while the mortality has increased by 33%.1 According to the Skin Cancer Foundation, one person dies every hour from melanoma, and annual treatment cost for melanoma and nonmelanoma skin cancer in the United States is $977 million dollars.1,3 The best strategy to reduce morbidity and mortality associated with skin cancer includes early detection and treatment.4
The American Academy of Dermatology (AAD) recommends annual skin cancer screening as well as self-skin exams by the patient.5 The American Cancer Society (ACS) recommends that individuals between the ages of 20 and 40 be screened every 3 years and those 40 and older screened annually.6 The U.S. Preventive Services Task Force (USPSTF) did not find sufficient evidence to support routine skin cancer screening; however, they do agree that it is beneficial to screen individuals considered to be at high risk for melanoma.7 The ACS also supports the recommendation to screen high-risk individuals.6 High-risk patients as defined by the USPSTF include the following: fair-skinned men and women, those over age 65 especially men, those with a family history of skin cancer, those who report sunburn(s), those who have exposure to indoor tanning beds, those who have atypical moles, and individuals with more than 50 moles.7
Primary care providers (PCPs) have more opportunities to implement early detection because patients often seek their counsel first when health issues arise, including skin issues.2 According to the CDC, 55.5% of all medical visits are to PCPs, which puts PCPs in a strategic position to perform adequate skin inspections during wellness visits.8 However, largely due to the conflicting guidelines and time constraints, most PCPs do not provide adequate skin inspections.9
Significance
Over 3.5 million skin cancers are diagnosed in the United States annually, and approximately one out of every five individuals in the United States will develop skin cancer within their lifetime.2 Based on the USPSTF’s criteria of high-risk individuals, it is estimated that approximately 104.7 million adults are considered high risk for skin cancer, which is over half of the U.S. adult population.7 The majority of patients with melanoma claimed to have had a visit with their PCP the year prior to being diagnosed; however, only 20% of the patients reported that their PCP performed a skin exam.4
When PCPs neglect to perform skin assessments, they miss the opportunity to detect concerning lesions and, ultimately, to offer treatment. Without timely treatment, skin cancer can spread, causing disfigurement, increase in tumor size, larger scaring, metastasis, and even death.10 In contrast, if detected early, skin cancer is treatable and curable.4 Therefore, to produce the best patient outcomes, PCPs should include skin inspections during physical exams. In particular, because of the limited number of dermatologic specialists and long waiting periods to see these specialists, there is an increasing need for PCPs to ensure they are adequately inspecting their patients’ integumentary systems.2
In a small primary care practice in the southeastern United States, little importance has been placed on having patients gown for physical exams; therefore, skin inspections are not being performed during visits. A lack of gowning is not only the biggest deterrent of performing a skin inspection; it also limits the quality of the entire physical exam.5 Without clear visibility of the integumentary system, adequate skin inspections cannot be performed. As a result, lesions that should be referred can be overlooked, and integumentary documentation is limited to default descriptions (for example, skin is clean, dry, and intact).
The purpose of this article is to improve skin assessment by establishing the standard of having patients don gowns during their annual wellness exam, to increase dermatology referrals when skin assessment is abnormal, and to improve integumentary documentation to include more precise descriptions of abnormal skin findings.
Evidence review and synthesis
The review of the literature suggests that skin inspection is safe, cost-effective, and easy to perform. According to the AAD, skin inspections are best performed when the skin is exposed via gowning, makeup and nail polish is removed, and adequate lighting is used.5 Detection of a melanoma during skin inspection may add years to a patient’s life.2 Kingsley and colleagues demonstrated an increased need for PCPs to perform skin inspection because over 50% of malignant lesions were missed by PCPs simply because an inspection was not performed.10
Kingsley and colleagues discovered that the most common location to detect a melanoma was on the back, and the most common location for nonmelanoma skin cancer was the face and neck.10 PCPs should have visualization of these cancer-prone areas while performing auscultation of the heart and lungs as well as the head, eyes, ear, nose, and throat exam, therefore making it easier to examine the skin.
In a randomized control trial, Argenziano and colleagues noted that earlier detection and treatment of skin cancer led to better patient outcomes.4 Argenziano and colleagues argued that not only should PCPs perform skin inspections but also that no one should die from malignant melanoma.4 Oliveria and colleagues stated that 76% of all melanomas discovered were found by PCPs and discovered that only 60% of PCPs in the United States routinely perform skin exams on patients.11 They reported that lack of time was the major barrier for PCPs to overcome closely followed by a lack of guideline consensus.11
Studies show that PCPs are now more than ever relied upon to manage a multitude of issues, which makes referrals the easy option.12 However, a skin inspection should be a standard component of the physical exam. Skin inspections allow for early detection of skin cancer and give providers the opportunity to provide patient education in regards to skin cancer. This ultimately affects patient outcomes and resources within the healthcare system.13
Tsao and colleagues found that more commonly, the initial presentation of skin cancer is to PCPs.14 They also stated that melanomas are often further progressed and thicker when diagnosed in the primary care setting because they have gone unnoticed for longer periods of time.14 Tsao and colleagues recommended the use of the Asymmetry, Uneven Boarders, Color, Diameter (greater than 6 mm or the size of a pencil eraser), and Evolving (ABCDE) mnemonic, noting that it has been very useful in helping providers identify lesions suspicious of melanoma.14 This classification tool not only provides mnemonic explanations but also includes pictures comparing normal and abnormal lesions, making it easier for patients to understand and providers to explain. Although the ABCDE mnemonic has been a cornerstone for practice, it does not apply to all melanomas.14
The evidence indicates that the majority of PCPs are not performing adequate physical exams, resulting in delayed diagnosis and treatment of skin cancer.2,9 As indicated in the evidence and systematic reviews, performing skin inspections leads to early detection of skin cancer, timely treatment of skin cancer, increased dermatology referrals, and increased patient education. This ultimately results in higher rates of skin assessment, skin cancer detection, and skin cancer prevention.10 Although there is a need for more randomized control trials to help establish universal guidelines for performing skin exams, it is clear that skin inspection is standard when a head-to-toe exam is performed.15 The reported evidence represents current, relevant literature that supports the implementation of the project.
Setting and sample
This quality improvement (QI) project was implemented in three primary care offices located in the Southeastern United States. Each office has approximately 20 to 25 primary care patients per day. On average, two to five of the patients in each office were presenting for a wellness exam. The project sample included all patients presenting for their annual physical/wellness exam. All patient data were deidentified and therefore was exempt from institutional review board approval.
Theoretical framework and intervention
The framework chosen for this project is the Plan-Do-Study-Act (PDSA) cycle developed by Dr. William Edwards Deming. The PDSA cycle provides learning by temporarily putting a planned change into effect to determine its impact.16 This framework follows four step-by-step transitions that allow for easy organization and successful implementation of change.16 The “plan” phase is where one determines what needs to be done and how to accomplish it.
During the planning phase, the need for thorough skin assessment during wellness exams was established. Having patients don gowns was determined to be the best intervention for skin exposure. Provider buy-in was important in the execution of this intervention; therefore, education was provided on the importance of a proper skin assessment as well as appropriate documentation of abnormal skin findings.
The goal was for documentation to move from the default skin description to more of a customized description of what the provider assessed based on the ABCDE criteria for skin lesions. This change would require the provider to manually enter in the descriptive information. The “do” phase is the actual implementation of the planning phase and collecting the data from the outcomes. During the do phase, each of the project sites was provided with an educational in-service on the importance of providing skin inspections and the dangers of skin cancer.
Patient gowning reminder posters were hung in the lab room of each office as a visual aid for the medical assistants. Custom Post-it notes were developed for the front office staff to place on the chart of each individual presenting for their wellness exam. The Post-it notes provided an area for the provider to circle if the patient was gowned and if the patient received a dermatology referral. Once completed, the Post-it notes were then placed into a drop box for collection. Lastly, weekly phone calls were placed and office visits (once every 2 weeks) were conducted to identify any issues with the protocol and to answer staff questions.
The “study” phase consisted of collectively analyzing the data to determine if the plan was successful and to identify what was learned from the process. During this phase, data were collected from the Post-it notes as well as the electronic medical record (EMR) system. Data were entered into an Excel spreadsheet, and graphs were developed to display results. The “act” phase involved determining if any further changes needed to be made and how the process could be further improved.14 In this phase, project limitations were identified, and additional recommendations for practice were given.
Outcome measurement
The primary outcome measure for this project was to increase the number of skin inspections performed during wellness exams by gowning patients, which would improve detailed documentation of the integumentary system, including suspicious skin lesions, and in turn, increase dermatology referral rates. These outcomes were measured by collection of Post-it notes and by reviewing EMR data and documentation.
Data collection and analysis
Preintervention data of the total number of wellness visits within a 3-month timeframe (September to December) were collected from the EMR. Data were collected from a password-protected EMR system with assistance from the office coding and billing specialist. Wellness visit information was obtained from the EMR by an audit on specific ICD10 codes corresponding with these visits. Detailed integumentary system documentation and dermatology referrals were then tallied.
Postintervention data were similarly collected for 3 months to assess if gowning increased, if integumentary system documentation expanded beyond default options, and if dermatology referrals increased. The two sets of data were compared to determine if there was an increase in skin inspection, detailed integumentary documentation, and dermatology referral rates. Custom Post-it notes were also collected and totaled monthly to determine adherence to patient gowning.
Confidentiality
Confidentiality was maintained by avoiding the use of patient-specific identifiers during data collection. The EMR program requires authorization and is password-protected; only office staff members had access to this patient information system. Patient confidentiality was maintained throughout the process; all office staff members had completed Health Insurance Portability and Accountability Act training.
Results outcome A: Skin exposure via patient gowning
A total of 67 patients fit the postintervention inclusion criteria (presenting for a wellness visit) in this review. Baseline data were obtained during the period of June to August 2016. Preintervention data indicated that 24 of 60 (or an average of 39% of patients presenting for a wellness visit) were placed in gowns. The implementation of having patients don gowns for wellness exams took place during the months of September to November 2016. During those months, 63 of the 67 (or an average of 93% of patients who came for total wellness visits) were gowned for the visit. Gowning significantly increased during the postimplementation months, and by the month of November, patient gowning for wellness exams was at 100%.
Results outcome B: Dermatology referrals
Baseline data for dermatology referrals were also gathered during the same timeframe as patient gowning. Preimplementation data yielded only one dermatology referral between the months of June and August. Postintervention data collection showed a 24% increase in dermatology referrals for the month of September, had a 10% decrease in the month of October, and finished out with an additional 6% decrease for November. Despite referral rates spiking and decreasing, there was an 8% overall increase by the completion of the project. The majority of the dermatology referrals were for total body skin exams rather than for specific lesions of concern.
Results outcome 3: Skin documentation
Skin documentation data were gathered during the same timeframe as gowning and referrals. Preimplementation documentation was almost 100% via the default description of “clean, dry, intact, and no lesion of concern.” Postimplementation data collection showed that despite having patients gown up for wellness exams and provider education, customized documentation did not increase.
Summary and interpretation
This QI project resulted in some important changes within this primary care practice. The most prevalent change was establishing the standard of having patients gown when presenting for a wellness visit to allow for better skin inspection for skin cancer detection. The project also yielded results of increased dermatology referrals; however, despite the interventions, skin documentation was relatively unchanged, and providers continued to use the default descriptive text. This was likely related to the providers having to manually enter findings into the EMR, which takes more time and is more cumbersome than simply checking a box.
The results from this QI project reflected positive outcomes from the interventions that were implemented. The providers within these practices have gained a new appreciation for skin exposure and will hopefully continue to have patients gown for wellness visits to provide the patient with an adequate skin inspection and dermatology referral if indicated. This QI project took place on the coast of Florida; therefore, results—especially pertaining to referrals—were expected to be significantly higher. Residents in this particular area tend to have higher levels of sun exposure, which leads to increased risk for skin cancer; however, this was not represented in the data.
Limitations
Throughout the duration of the postimplementation period, employee turnover presented as an issue. One office suffered the loss of a provider, and two of the offices experienced multiple medical assistants and front office staff turnover. This resulted in a repeated in-service in those offices as well as having to complete at least two follow-up phone calls per week to ensure the interventions were being executed.
Employee turnover, as well as the hiring of a new provider, may have limited this project’s results, as the level of involvement by new employees and providers may not have been as high due to the demands of learning a new job and going through a period of orientation. Providers were also limited due to the time constraints of their daily patient load, which made it easier and faster to use the default text option when completing patient skin assessments. An exhaustive literature review was not completed; therefore, this QI project is based on a limited review.
Implications for practice
For future improvements, further educational interventions geared toward PCPs regarding skin cancer may increase skin exams as well as more detailed skin documentation. The development of a standardized guideline for skin exams may also prompt PCPs to make skin assessment more of a priority, and in turn, decrease negative patient outcomes related to skin cancer. Providing check box options within the EMR following the ABCDE criteria would allow for more detailed integumentary system documentation.
Conclusion
In the primary care setting, a few simple changes can make a significant difference. The utilization of gowns for wellness exams is a standard of care that should already be established. Adequate integumentary system documentation should also already be an important aspect of the physical exam. Additionally, dermatology referrals and patient education on skin cancer are important health promotion aspects that will take minimal efforts to provide. Additional provider education along with reinforcement of appropriate skin assessment and documentation would be beneficial for future improvements. Skin cancer rates are increasing, the treatment costs are rising, and now more than ever, PCPs are in a position to help prevent these increasing rates. PCPs are in an ideal role that can help fill the gap between dermatology and primary care.
REFERENCES
1. Lakhani NA, Saraiya M, Thompson TD, King SC, Guy GP Jr. Total body skin examination for skin cancer screening among U.S. adults from 2000 to 2010. Prev Med. 2014;61:75-80.
2. Gordon R. Skin cancer: increasing awareness and screening in primary care. Nurse Pract. 2014;39(5):48-54.
3. Skin Cancer Foundation. Skin cancer facts. 2017. www.skincancer.org/skin-cancer-information/skin-cancer-facts.
4. Argenziano G, Puig S, Zalaudek I, et al. Dermoscopy improves accuracy of primary care physicians to triage lesions suggestive of skin cancer. J Clin Oncol. 2006;24(12):1877-1882.
5. American Academy of Dermatology. How to perform a skin exam. 2015. https://www.aad.org/File%20Library/Main%20navigation/Education/Basic%20Derm%20Curriculum/PDFs/The-Skin-Exam.pdf.
6. American Cancer Society. Skin exams. 2017. https://www.cancer.org/cancer/skin-cancer/prevention-and-early-detection/skin-exams.html.
7. U.S. Preventative Services Task Force. Skin cancer: screening. 2016. https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/skin-cancer-screening2?ds=1&s=skin%20cancer%20screening.
8. Centers for Disease Control and Prevention. National Ambulatory Medical Care Survey: 2010 summary tables. 2010. www.cdc.gov/nchs/data/ahcd/namcs_summary/2010_namcs_web_tables.pdf.
9. Garg A, Wang J, Reddy SB, et al. Curricular factors associated with medical students' practice of the skin cancer examination: an educational enhancement initiative by the integrated skin exam consortium. JAMA Dermatol. 2014;150(8):850-855.
10. Kingsley-Loso JL, Grey KR, Hanson JL, et al. Incidental lesions found in veterans referred to dermatology: the value of a dermatologic examination. J Am Acad Dermatol. 2015;72(4):651.e1-655.e1.
11. Oliveria SA, Heneghan MK, Cushman LF, Ughetta EA, Halpern AC. Skin cancer screening by dermatologists, family practitioners, and internists: barriers and facilitating factors. Arch Dermatol. 2011;147(1):39-44.
12. Awadalla F, Rosenbaum DA, Camacho F, Fleischer AB Jr, Feldman SR. Dermatologic disease in family medicine. Fam Med. 2008;40(7):507-511.
13. Rourke L, Oberholtzer S, Chatterley T, Brassard A. Learning to detect, categorize, and identify skin lesions: a meta-analysis. JAMA Dermatol. 2015;151(3):293-301.
14. Tsao H, Olazagasti JM, Cordoro KM, et al. Early detection of melanoma: reviewing the ABCDEs. J Am Acad Dermatol. 2015;72(4):717-723.
15. Swartz M. Textbook of Physical Diagnosis: History And Physical Exam. 7th ed. Philadelphia, PA: Elsevier; 2014.
16. Melnyk BM, Fineout-Overholt E. Evidence-Based Practice in Nursing & Healthcare. 2nd ed. Philadelphia, PA: Wolters Kluwer; 2011.
Brittany Wheatley is an RN, BSN, and DNP graduate.
The author has disclosed no financial relationships related to this article.