title: Delay of Surgery for Melanoma Among Medicare Beneficiaries.
abstract: OBJECTIVE
  Timely delivery of surgery for cancer affects health care quality and outcomes. However, population-based studies characterizing the delay of surgery for melanoma in the United States have not been performed.
  
  
  OBJECTIVE
  To assess the delay of surgery for melanoma by tumor-, patient-, and physician-level characteristics.
  
  
  METHODS
  We performed a retrospective cohort study of Medicare beneficiaries diagnosed as having melanoma from January 1, 2000, through December 31, 2009, using the Surveillance, Epidemiology, and End Results-Medicare database. We included all patients undergoing surgical excision of melanoma diagnosed by means of results of skin biopsy.
  
  
  METHODS
  Anatomic location and stage of the tumor, patient sociodemographic characteristics, prior melanoma, Elixhauser comorbidities, and the specialties of the physicians who performed the biopsy and surgery.
  
  
  METHODS
  Surgical delay, measured as the time from the biopsy to surgical excision. We estimated risk-adjusted odds ratios (ORs) and marginal probabilities of delay with 95% CIs for each covariate using mixed-effects logistic regression.
  
  
  RESULTS
  Our cohort consisted of 32 501 cases of melanoma. Most of the patients were white (95.4%), male (63.1%), married (47.9%), and 75 years or older (60.8%) and did not have a prior melanoma (93.7%). Melanomas were most frequently located on the head and neck (40.5%) and staged as in situ disease (48.2%). More than three-quarters of cases (25 269 [77.7%]) underwent excision within 1.5 months of biopsy. Among those treated after 1.5 months (7232 [22.3%]), 2620 (8.1% of all cases) experienced a delay of longer than 3 months. The incidence of a risk-adjusted surgical delay longer than 1.5 months was significantly increased among patients 85 years or older compared with those younger than 65 years (odds ratio [OR], 1.28 [95% CI, 1.05-1.55]; P = .02), those with a prior melanoma (OR, 1.20 [95% CI, 1.08-1.34]; P = .001), and those with an increased comorbidity burden (OR, 1.18 [95% CI, 1.09-1.27]; P < .001). Melanomas that underwent biopsy and excision by dermatologists had the lowest likelihood of delay (probability, 16% [95% CI, 14%-18%]). The highest likelihood of delay (probability, 31% [95% CI, 24%-37%]) occurred when the biopsy was performed by a nondermatologist and excised by a primary care physician. Similar findings were observed for a delay longer than 3 months.
  
  
  CONCLUSIONS
  Approximately 1 in 5 Medicare beneficiaries experience a delay of surgery for melanoma that is longer than 1.5 months. Those patients undergoing biopsy and surgery by dermatologists have the lowest risk for delay, highlighting potential opportunities for improved access to and coordination of dermatologic care.
authors: Robert Wood Johnson Foundation Clinical Scholars Program, Yale University School of Medicine, New Haven, Connecticut2Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut3Section of Dermatology, Veterans Affairs Conne.
authors: Jason P
authors: JP
authors: Lott
authors: Department of Surgery, Yale University School of Medicine, New Haven, Connecticut.
authors: Deepak
authors: D
authors: Narayan
authors: Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut5Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University School of Medicine, New Haven, Connecticut.
authors: Pamela R
authors: PR
authors: Soulos
authors: Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut5Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University School of Medicine, New Haven, Connecticut.
authors: Jenerius
authors: J
authors: Aminawung
authors: Robert Wood Johnson Foundation Clinical Scholars Program, Yale University School of Medicine, New Haven, Connecticut2Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut5Cancer Outcomes, Public Policy, and Effectiven.
authors: Cary P
authors: CP
authors: Gross
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D001706:Biopsy / Q000706:statistics & numerical data; D015897:Comorbidity; D003880:Dermatology / Q000706:statistics & numerical data; D005121:Extremities; D005260:Female; D006258:Head and Neck Neoplasms / Q000473:pathology / Q000601:surgery*; D006801:Humans; D008297:Male; D006278:Medicare / Q000706:statistics & numerical data*; D008545:Melanoma / Q000473:pathology* / Q000556:secondary / Q000601:surgery*; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000473:pathology / Q000601:surgery*; D009367:Neoplasm Staging; D016609:Neoplasms, Second Primary / Q000473:pathology / Q000601:surgery*; D011320:Primary Health Care / Q000706:statistics & numerical data; D012189:Retrospective Studies; D012307:Risk Factors; D018426:SEER Program; D012867:Skin / Q000473:pathology; D012878:Skin Neoplasms / Q000473:pathology* / Q000556:secondary / Q000601:surgery*; D013518:Surgery, Plastic / Q000706:statistics & numerical data; D061665:Time-to-Treatment / Q000706:statistics & numerical data*; D060726:Torso; D014481:United States