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

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.