Is the quality of skin cancer screening in Germany related to the specialization of the physician who performs it?: Results of a nationwide survey among participants of skin cancer screening

Skin cancer screening (SCS) is an important measure for secondary prevention of skin cancer, which is the most common cancer type worldwide. This study aimed to describe patient‐reported quality of SCS in Germany according to the specialization of the performing physician and different patient characteristics.

Germany as a standard benefit for individuals with statutory insurance. The nationwide SCS program was controversially debated both before and after its introduction in 2008. 4,5 A recent literature review showed that after the implementation of SCS in Germany, the incidence of skin cancer (in situ and invasive) and rates of thin melanoma increased while rates of thick melanoma decreased. 6 Only limited evidence on the impact of SCS on skin cancer mortality could be observed. 6,7 In Germany, statutory health insurance funds, which insure the majority of the population (88%), 8 cover the costs for biennial SCS for all members >35 years of age. Some private health insurance funds also bear the costs for this preventive service. SCS comprises a standardized, visual, full-body examination for malignant melanoma and non-melanoma skin cancers that is performed with naked eye. Additionally, physicians are mandated to counsel patients on the risks of ultraviolet radiation and on sun-protective measures during the SCS. 9 Moreover, patients with a high risk for developing skin cancer should be educated about how to perform self-examination of their skin. 9 SCS can be provided by dermatologists, and general practitioners who have been trained for this examination. The SCS is generally free of charge for those who are entitled to this preventive service. However, some physicians use aids during the SCS (eg, dermatoscope, photographic documentation of the pigmented moles).
For these extra services, which are not included in the coverage of SCS by health insurance funds, additional fees may be charged by physicians.
In the past, several studies have explored the use of SCS within the German population, both from the perspective of those who underwent SCS and based on evaluation of data from health insurance companies. These studies reported SCS participation rates to range between 28% and 40%. [10][11][12][13][14] In addition, regional differences in access to SCS have been revealed. 15 One study focused on the provision of preventive counseling for skin cancer during SCS; however, the results were based on a relatively small sample size. 16 To date, little is known about the quality of SCS provided by physicians. Therefore, the present study aimed to explore differences in patient-reported quality of SCS according to the specialization of the physician who performed the most recent SCS, and to patient characteristics using a large, representative sample.

| Study setting
The present study was based on cross-sectional data from the fifth wave of the representative National Cancer Aid Monitoring.
Overall, 4000 individuals 16-65 years of age participated in the survey (response rate, 28.9%). Interviewers, who were trained by the study team, collected data from October to December 2019 using computer-assisted telephone interviews. The multistage sampling procedure used for the random sampling of participants is described in more detail elsewhere. 17 The study design and sampling procedures were approved by the Ethics Committee of the Medical

| Instrument and measures
All outcome variables regarding the most recent SCS and covariates used in this study are described in detail in the following sections. All questions and items were pretested in 15 cognitive interviews and slightly revised according to the results before the survey.

| Aspects of SCS regarded as outcome variables
First, participants were asked about their waiting time for an appointment to undergo their most recent SCS. Participants could report waiting time in days, weeks, or months. For analysis, however, all responses were converted to days. Second, detailed information regarding the service participants received during the most recent 4. Information about how to perform a self-examination of the skin (yes/no), which should be a part of SCS in at-risk patients according to the German guideline on skin cancer prevention. 9 Third, consistent with the study by Braun et al, 18 2 items were used to assess participant satisfaction with their most recent SCS: "How satisfied are you with waiting time for the appointment to undergo SCS?", "In general, how satisfied are you with your physician regarding the time he has devoted to you during SCS?" (very satisfied, rather satisfied, rather dissatisfied, or very dissatisfied).
Fourth, participants were asked whether they had to pay extra for some additional services during the most recent SCS, consistent with the study by Augustin et al 10

| Variables regarded as covariates
In the present study, covariates included the following: 1. Specialization of the physician who performed the most recent SCS (dermatologist versus [vs.] general practitioner/other specialist); 2. Study participants provided sociodemographic information including sex, age, and characteristics needed to define their immigrant background. In accordance with established indicators, participants were defined as having an immigrant background if their mother and father were born abroad, if one parent was born abroad, or if the participant's mother tongue was not German. 19 In addition, information regarding the highest level of education was collected and categorized as low (still at school, without school-leaving qualification or general school), medium (secondary school), and high (high school graduate).
3. The interviews also addressed information about different skin characteristics to enable a description of individual skin cancer risk. According to the World Health Organization, risk factors for skin cancer include pale skin (type I or II, according to the skin classification system described by Fitzpatrick), 20 large number of naevi (> 40), frequent sunburn during childhood, and a (family) history of malignant melanoma. According to the number of risk factors, participants were subcategorized as: "those without any risk factors"; "those with one risk factor"; and "those with two or more risk factors". 4. Additionally, information regarding insurance status was also assessed during telephone interviews (insured via statutory or private health insurance).

| Statistical analysis
Data were weighted by age, sex, education, and federal state of residence to ensure a nationally representative sample. Descriptive analyses and the chi-squared test were used to explore and compare the distribution of covariates. Additionally, t tests were performed to reveal potential differences in waiting times according to the specialization of the physician; differences with P < .05 were considered to be statistically significant. Statistical analyses were performed using SPSS version 25 (IBM Corporation).

| RE SULTS
Overall, 54.4% of the subsample was female, and it was approxi-  (Table 1). Participants had to wait significantly longer for an appointment with a dermatologist (31.1 days) than for an appointment with another specialist (15.7 days; P <.001).
Participants who underwent SCS in a dermatological practice were more likely to be dissatisfied with the waiting time for an appoint- Dermatologists examined all body sites that should be inspected during SCS significantly more frequently than other specialists  (Table 2). Individuals 35-45 years of age were more likely to receive preventive counseling than older participants (76.9% vs. 66.1% among those 56-65 years of age; P = .002). Participants with an immigrant background reported to receive all of these services slightly more frequently than their counterparts; however, this difference was statistically significant only for written information (57.9% vs. 42.9%; P = .001). Private insurance policyholders received significantly more frequent additional services than those with statutory insurance (eg, 80.5% vs. 70.7% for preventive counseling; P = .002). Participants with no risk factors and with >2 risk factors for skin cancer were significantly more likely to receive oral and written information about prevention than those with only one risk factor (P < .001 and P = .002, respectively).

| D ISCUSS I ON
The aims of the present study were to describe the quality of SCS as perceived by participants with regard to the specialty of the performing physician; and according to patient characteristics.
Results revealed that patients had to wait significantly longer for an appointment to undergo SCS at a dermatological practice Longer waiting times for an appointment with a dermatologist were also reported in a previous survey of 359 individuals who underwent SCS 15 and mirror the generally longer waiting times for an appointment in a specialized practice than at general practitioner. 21 A study involving 681 dermatologists reported that other more acute reasons for presentation (eg, acute eczema, assessment, and excision of suspicious nevus) had a higher priority when setting appointments in dermatological practices. 22 For these reasons, the longest waiting times, with an average of 5.7 weeks, were identified for SCS. Because waiting times among our data were shorter, we cannot exclude that some patients reported an alteration in a current nevus when they scheduled the appointment, which would make their need for an appointment more urgent. However, we did not get any information on how the appointments for SCS were scheduled.
In our study, we explored the provision of services during SCS in detail. Overall, 71.1% of participants reported receiving advice regarding skin cancer prevention during SCS. This figure is comparable to that recently reported by Krensel et al 16 Written preventive information and advice regarding self-examination of the skin were provided less frequently to approximately 40% of participants.
Although there are guidelines specifying which body sites should be examined during a standardized visual examination, 9 our results revealed that the feet, scalp, and genital area were examined much less frequently during SCS.
In our large study sample, we explored patient-reported provision of services during SCS according to the specialty of the performing TA B L E 1 Perceived quality of the most recent skin cancer screening (SCS) according to the specialization of the physician who performed it of receiving information about self-examination in older participants. This is somewhat concerning because the importance of selfexamination increases with age due to higher risks for developing skin cancer later in life. 2 We also noted that privately insured patients were more likely to receive all additional services we examined in our study. One possible explanation for these differences is the different ways in which physicians charge for patient consultations. For privately insured patients, higher fees can be charged for SCS than for those with statutory insurance. This finding contributes to the ongoing debate regarding social inequality in medical care in Germany. 27,28

| Limitations
In our large representative study, we explored differences in ser-

| CON CLUS ION
A detailed analysis of SCS was performed using a nationally representative sample. Although the majority of SCS participants received counseling on skin cancer prevention during an SCS, we found differences in the provision of counseling, written preventive information, and information regarding self-examination of the skin, as well as in the quality of visual examination between dermatologists and other specialists. These findings highlight the need for the implementation of quality assurance measures.

ACK N OWLED G EM ENTS
The authors wish to thank Aylin Evin, BA (Mannheim Institute of Public Health), for her assistance in preparing the manuscript.

CO N FLI C T O F I NTE R E S T
The authors declare no conflicts of interest.

AUTH O R CO NTR I B UTI O N S
TG, KD, SS, and EWB designed the research study. TG, KD, and SS performed the research. TG analyzed the data. TG, KD, SS, and EWB interpreted the data. All authors contributed to the drafting, reviewing of the article, and have approved the final article.

DATA AVA I L A B I L I T Y S TAT E M E N T
Research data are not shared due to guidelines of funder.