title: Effect of health care delivery models on melanoma thickness and stage in a university-based referral center: an observational pilot study.
abstract: OBJECTIVE
  To compare the effect of differing health care delivery models, specifically, gatekeeper (GK) vs direct access (DA) routes, on melanoma outcome as measured by tumor thickness and cancer stage at diagnosis.
  
  
  METHODS
  Retrospective medical record review of patients previously diagnosed as having cutaneous melanoma who were referred to a university-based clinic from January 1, 1996, through December 31, 2000.
  
  
  METHODS
  Stanford Pigmented Lesion and Cutaneous Melanoma Clinic, Stanford, Calif. Patients Two hundred thirty-four patients with primary melanoma stratified according to health care access route (GK or DA).
  
  
  METHODS
  Differences in Breslow thickness, American Joint Committee on Cancer stage, histologic features, patient delay in seeking medical attention, and physician delay in diagnosis (time between initial physician visit and diagnostic biopsy procedure).
  
  
  RESULTS
  Of 234 patients, 168 (72%) were referred through the DA route and 66 (28%) through the GK route. A significant association was found between physician delay and access route; patients in the DA group underwent biopsy sooner (< or =3 months vs >3 months) than those in the GK group (P<.001). No significant difference was observed in stage at diagnosis (predominantly stage IA), proportion of nodular melanoma (DA 4% vs GK 2%), patient delay, or median tumor thickness between DA and GK routes (0.42 mm vs 0.50 mm, respectively). A trend toward a greater proportion of histologically ulcerated melanoma was observed in the DA group compared with the GK group (12% vs 5%, respectively; P = .06).
  
  
  CONCLUSIONS
  This pilot study demonstrated no difference in outcome between GK and DA routes as measured by melanoma thickness and stage, although patients in the DA group underwent diagnostic biopsy sooner than those in the GK group. The potential effect of health care models on melanoma outcomes merits further study.
authors.affiliation: Dermatology Services, VA Health Care Systems, Palo Alto, CA, USA. sswetter@stanford.edu
authors.forename: Susan M
authors.initials: SM
authors.lastname: Swetter
authors.forename: Seaver
authors.initials: S
authors.lastname: Soon
authors.forename: Cynthia R
authors.initials: CR
authors.lastname: Harrington
authors.forename: Suephy C
authors.initials: SC
authors.lastname: Chen
mesh_terms: D000328:Adult; D000368:Aged; D001706:Biopsy; D002140:California; D003695:Delivery of Health Care / Q000379:methods* / Q000592:standards; D005260:Female; D006801:Humans; D008297:Male; D008545:Melanoma / Q000175:diagnosis / Q000473:pathology*; D008875:Middle Aged; D009367:Neoplasm Staging; D010865:Pilot Projects; D012017:Referral and Consultation; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D012867:Skin / Q000473:pathology; D012878:Skin Neoplasms / Q000175:diagnosis / Q000473:pathology*; D014495:Universities