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Br J Dermatol. 2019 Jan 12. doi: 10.1111/bjd.17632. [Epub ahead of print]

Healthcare utilization and management of actinic keratosis in primary and secondary care: a complementary database analysis.

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Erasmus Medical Centre Cancer Institute, Department of Dermatology, Rotterdam, The Netherlands.
Netherlands Comprehensive Cancer Organization (IKNL), dept. Research, Utrecht, the Netherlands.
Erasmus University Medical Centre Rotterdam, Department of Public Health, Rotterdam, The Netherlands.
National Health Care Institute, Diemen, the Netherlands.
Erasmus Medical Centre, Department of General Practice, Rotterdam, The Netherlands.
Erasmus University Medical Centre, Department of Medical Informatics, Rotterdam, The Netherlands.
Beth Israel Deaconess Medical Centre, Department of Dermatology, Harvard Medical School, Boston, USA.



The high prevalence of actinic keratosis (AK) requires optimal use of healthcare resources.


To gain insight in health care utilization and management of AK, by describing the healthcare utilization of people with AK in a population-based cohort and in a primary and secondary care setting.


A retrospective cohort study using three complementary data sources was conducted to describe the use of care, diagnosis, treatment, and follow-up of AK patients in the Netherlands. Data sources consisted of a population-based cohort study (Rotterdam Study, RS), routine general practitioner (GP) records (Integrated Primary Care Information, IPCI), and nationwide claims data (DBC Information System, DIS).


In the population-based cohort (RS), 69% (918/1,322) of participants diagnosed with AK during a skin screening visit had no prior AK-related visit in their GP record. This proportion was 50% for participants with extensive AK (i.e.,≥10 AKs; n=270). Cryotherapy was the most used AK treatment by both GPs (78%) and dermatologists (41-56%). Topical agents were the second most used treatment by dermatologists (13-21%) but was rarely applied in primary care (2%). During the first AK related GP visit, 31% (171/554) was referred to a dermatologist, with likelihood of being referred comparable between low and high-risk patients, which is inconsistent with the guidelines. Annually, 40·000 new claims representing 13% of all dermatology claims were labelled as cutaneous premalignancy. Extensive follow-up rates (56%) in secondary care were registered, while only 18% received a claim for a subsequent cutaneous malignancy in 5 years.


AK management seems to diverge from guidelines in both primary and secondary care. Underutilization of field treatments, inappropriate treatments and high referral rates without proper risk stratification in primary care, combined with extensive follow-up in secondary care result in inefficient use of healthcare resources and overburdening in secondary care. Efforts directed to better risk differentiation and guideline adherence may prove useful in increasing the efficiency in AK management. This article is protected by copyright. All rights reserved.


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