Dermatology: Practical and Conceptual Research | Dermatol Pract Concept 2021;11(1):e2021118 1 Dermatology Practical & Conceptual General Practice Registrars’ Management of and Specialist Referral Patterns for Atopic Dermatitis Anneliese Willems1,2, Amanda Tapley3,4, Alison Fielding3,4, Vivian Tng5, Elizabeth G. Holliday3, Mieke L. van Driel6, Jean I. Ball7, Andrew R. Davey3,4, Kristen FitzGerald8, 9, Neil A. Spike1, 2, Parker J. Magin3,4 1 Eastern Victoria GP Training, General Practice Training Organisation, Melbourne, VIC, Australia 2 The University of Melbourne, Department of General Practice, Melbourne, VIC, Australia 3 The University of Newcastle, School of Public Health and Medicine, Callaghan, NSW, Australia 4 GP Synergy, Regional Training Organisation, NSW & ACT Research and Evaluation Unit, Newcastle, NSW, Australia 5 Department of Dermatology, John Hunter Hospital, Newcastle, NSW, Australia 6 The University of Queensland Faculty of Medicine, Primary Care Clinical Unit, Brisbane, QLD, Australia 7 Hunter Medical Research Institute, Clinical Research Design, IT and Statistical Support Unit (CReDITSS), New Lambton, NSW, Australia 8 University of Tasmania, School of Medicine, Hobart, TAS, Australia 9 General Practice Training Tasmania (GPTT), Regional Training Organisation, Hobart, TAS, Australia Key words: atopic dermatitis, eczema, referral and consultation, general practice, dermatologist Citation: Willems A, Tapley A, Fielding A, Tng V, Holliday EG. Van Driel ML, Ball JI, Davey AR, FitzGerald K, Spike NA, Magin PJ. General practice registrars’ management of and specialist referral patterns for atopic dermatitis. Dermatol Pract Concept. 2021;11(1):e2021118. DOI: https://doi.org/10.5826/dpc.1101a118 Accepted: July 26, 2020; Published: January 29, 2021 Copyright: ©2021 Willems et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License BY-NC-4.0, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: The ReCEnT project was funded from 2010 to 2015 by the participating educational organisations: General Practice Training Valley to Coast, the Victorian Metropolitan Alliance, General Practice Training Tasmania, Adelaide to Outback GP Training Program, and Tropical Medical Training, all of which were funded by the Australian Department of Health. From 2016-2019, ReCEnT was funded by an Australian Department of Health commissioned research grant and supported by GP Synergy Regional Training Organisation. GP Synergy is funded by the Australian Department of Health. This project has ethics approval through University of Newcastle’s Human Research Ethics Committee: H-2009-0323. Competing interests: The authors have no conflicts of interest to disclose. Authorship: All authors have contributed significantly to this publication. Corresponding author: Parker J. Magin, MBBS, PhD, School of Medicine and Public Health, The University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia. Email: parker.magin@newcastle.edu.au Background: Atopic dermatitis (AD) is a common presentation in the general practice (GP) setting. Implementation of appropriate referral pathways is instrumental for best patient care and is an essen- tial skill for Australian GP registrars .  Objectives: We aimed to explore the prevalence and associations of GP registrar referrals to special- ists for AD management. Methods: A cross-sectional analysis utilizing data from the Registrar Clinical Encounters in Training (ReCEnT) project, an ongoing cohort study that documents in-consultation clinical and educational AbstrACt 2 Research | Dermatol Pract Concept 2021;11(1):e2021118 Introduction Atopic dermatitis (AD) is associated with psychological, social, and quality-of-life effects in patients and their fam- ilies [1,2]. AD has a 12-month prevalence of 16%-17% in childhood and is characterized by chronic inflammation and pruritus [ 3]. While AD is predominantly a childhood illness [4], an estimated 50% of those affected by AD in their early years go on to have symptoms into their teenage years and adulthood [5]. Given its prevalence, AD represents a common presenta- tion in the primary care setting. The majority of AD is mild and may be managed in primary care, rather than in specialty practice [6]. Skin presentations represent 11% of all problems encountered by GP registrars. Of these, 12% are “dermatitis,” including AD [7]. AD is generally a straightforward clinical diagnosis [8,9], and the treating clinician must first exclude other conditions [6]. Patient education underpins treatment and all cases should be treated with emollients [8]. Topical corticosteroids and, when appropriate, antimicrobial and antiseptic mea- sures, comprise the next level of therapy [8]. This manage- ment can be appropriately delivered in primary care. In mod- erate-severe disease, referral may be necessary for access to additional therapies such as narrowband UVB phototherapy or oral immunosuppressive therapies [10]. Additionally, a specialist’s opinion may occasionally be needed for clarifica- tion of diagnosis or for exploration of exacerbating factors, such as allergy [6]. With a breadth of management options available accord- ing to severity of AD disease, it is important for clinicians to have confidence in diagnosis and early stages of man- agement [9]. Similarly, clinicians should be competent in recognizing disease severity and have a good understanding of the indications for referral [6]. This may be problematic in primary care. Some studies have suggested that GPs may lack confidence in diagnosis [11,12] and management of skin disease [11,13,14]. GPs and vocational trainees in specialist general practice (GP registrars) have limited formal training in managing skin disease [7,13,15]. There is relatively little teaching of dermatology during medical school [16,17]. Der- matology placements are infrequent in junior doctor rotations and, as such, the bulk of dermatology learning takes place in-practice during postgraduate terms [16]. Consequently, skin disease remains a learning-need for GP registrars, and GP registrars find skin consultations problematic compared to non-skin consultations [7]. There is also a lack of evidence regarding appropriate circumstances for a GP referral of skin diseases [18,19]. Given the historical challenges of GP registrar management of skin disease, the frequency of AD in Australia, and the challenges in providing appropriate referrals, we sought to address an evidence gap. In this study we sought to explore the nature, frequency, and associations of GP registrar specialist refer- rals for AD. Materials and Methods We performed a cross-sectional analysis of data within the Registrar Clinical Encounters in Training (ReCEnT) project. ReCEnT documents the in-consultation educational and clinical experiences of GP registrars. GP Vocational training GP training in Australia operates under an apprenticeship-like model wherein registrars are supervised by senior accredited GPs within an accredited practice environment. Training experience of Australian GP registrars. Registrar, patient, and consultation factors associated with referrals for AD were established using logistic regression. Results: A total of 2,783 registrars (96% response rate) provided data from 381,180 consultations from 2010 to 2019. A total of 3,285 (0.55%) of 595,412 diagnoses managed were AD, of which 222 (6.8%) resulted in referral. Of these referrals, 70% were to dermatologists, 17% to allergists/immu- nologists, and 10% to pediatricians. Associations of referral included registrar female gender, patient age, longer consultation duration; an established (rather than new) AD diagnosis; supervisor advice being sought; and learning goals being generated.  Conclusions:  Both registrar and patient factors influence AD referral patterns. Registrars referred established rather than newly diagnosed AD, suggesting a level of comfort in initial management. Re- ferral was associated with longer consultations, seeking supervisor advice, and generation of learning goals—suggesting these are more complex presentations and, possibly, registrar learning opportuni- ties. A significant proportion of referrals were to non-dermatologist specialists. The implication of this for optimal patient care is a subject for further study.   Research | Dermatol Pract Concept 2021;11(1):e2021118 3 entails at least 3 6-month, full-time-equivalent, community -based general practice terms. reCEnt Registrars complete 3 cycles of ReCEnT data collection dur- ing training, once each term. Details of 60 consecutive con- sultations are collected on paper-based Case Report Forms. From these consultations, problems managed and referrals made are coded according to the International Classifica- tion of Primary Care (second edition) classification system (ICPC-2 Plus) [20]. Registrar and practice variables are also collected every 6 months. ReCEnT was conducted in up to 5 Regional Training Providers (RTP), across 5 states, during 2010-2015, and in 3 Regional Training Organisations (RTO), across 3 states and 1 territory, from 2016, following a major restructuring of Australian GP vocational training. this study Data from 2010-2019 is included in the current study. For this study, our analyses were confined to consultations coded as “dermatitis, atopic,” “eczema,” and “eczema, infantile.” See Supplementary Table 1 for a complete list of inclusion and exclusion ICPC-2 Plus codes. Outcome Factor The outcome was “specialist referral made.” Independent Variables Independent variables included in these models included registrar, practice, patient, consultation and educational fac- tors. Patient factors were: patient age group, patient gender, Aboriginal or Torres Strait Islander status, and non-English speaking background status. Registrar factors were: registrar age and gender, full-time or part-time employment status, the term of GP training, whether the registrars had worked at their current practice previously, and whether they had qual- ified as a doctor in Australia. Practice factors were: the size of the practice, whether the practice was fully bulk-billing (that is, no fee charged to the patient), the rurality of the practice, the RTP or RTO the registrar was enrolled with (hereafter “region”), and the socio-economic index for areas,-index of Table 1. Demographics of Participating GP Registrars and Their Practices Registrar Variables (n=2783) n (%) Registrar gender Male 1,055 (37.9) Female 1,728 (62.1) Qualified as doctor in Australia Yes 547 (19.8) No 2,223 (80.3) Pathway registrar enrolled in General 1,930 (70.0) Rural 826 (30.0) registrar round/Practice Variables (n=6414) Registrar age (years) Mean ± SD 32.6 (6.3) Registrar works Full-time or Part-time Full-time 4,770 (77.1) Part-time 1,420 (22.9) Registrar training term Term 1 2,640 (41.2) Term 2 2,091 (32.6) Term 3 1,683 (26.2) Practice rurality Major city 3,983 (62.7) Inner regional 1,633 (25.7) Outer regional remote 732 (11.5) Practice SEIFA-IRSD Mean ± SD 5.5 (2.8) Practice routinely bulk bills Yes 1,784 (28.1) No 4,566 (71.9) Registrar worked at practice previously Yes 1,343 (21.2) No 4,988 (78.8) Practice size Small (1-5 GPs) 2,371 (38.4) Large (6-10+ GPs) 3,811 (61.6) GP = general practice; SD = standard deviation; SEIFA-IRSD = socio-economic index for area – index of relative socioeconomic disadvantage. 4 Research | Dermatol Pract Concept 2021;11(1):e2021118 relative socioeconomic disadvantage (SEIFA-IRSD) in which the practice was located. Consultation factors were: the dura- tion of consultation, number of problems managed within the consultation, whether AD was a new problem, whether the registrar sought assistance for diagnosis or management of the problems managed, whether pathology was ordered, whether follow-up was ordered, whether learning goals were generated, and which medications, if any, were prescribed. Statistical Analyses Statistical analysis was at the level of problem/diagnosis. The proportion of problems/diagnoses that were atopic dermatitis and, of those, the proportion that were referred were calcu- lated with 95% confidence intervals (CI) and were adjusted for repeated measures within registrars. Descriptive statistics included frequencies for categorical variables and mean with standard deviation for continuous variables. The frequencies of categorical variables were com- pared between outcome categories using chi-square tests for all variables, except when Fisher’s exact test was used (due to an expected count less than 5 in 25% or more cells). For continuous variables, means were compared using a t test. Logistic regression has been used within the general- ized estimating equations (GEE) framework to account for repeated measures within registrars. An exchangeable work- ing correlation structure was assumed. Univariate analyses were conducted on each covariate with the outcome. Covar- iates with a univariate P value < 0.20 were considered for inclusion in the multiple regression model. Once the model with all significant covariates was fitted, model reduction was assessed. Covariates that were no longer significant (at P < 0.2) in the multivariable model were tested for removal from the model. If the covariate’s removal did not substantively change the resulting model, the covariate was removed from the final model. A substantive change to the model was defined as any covariate in the model having a change in the effect size (odds ratio) of greater than 10%. Diagnostic tests were conducted to assess goodness of fit, using the Hosmer-Lemeshow test for logistic models. Predictors were considered statistically significant if the P value was < 0.05. Statistical analyses used STATA 14.1 (StataCorp, College Station, TX, USA) and SAS V9.4 (SAS Institute Inc., Cary, NC, USA). This project has ethics approval through an appropriate Human Research Ethics Committee. results In total, 2,783 registrars (96.1% response rate) provided data from 381,180 consultations from 2010-2019, including 595,412 problems managed. Table 1 shows the demographics of participating registrars. Of all problems, 3,285 (0.55% [95% CI: 0.53, 0.57]) were AD. Of all AD problems, 222 (6.8% [95% CI: 6.0, 7.7]) were referred. Of these referrals, 70% were to dermatologists (Table 2), 17% to allergists/immunologists, 10% to pediatri- cians, and 3% to a clinic without specifying the specialist. The characteristics associated with specialist referral are presented in Table 3. As well as the associations with referral, overall findings of note are that for 9.7% of AD problems, supervisor advice or assistance was sought and for 18% of AD problems learning goals were generated. The results of univariate and multivariable logistic regres- sion are presented in Table 4. Statistically significant multivariable associations of an AD problem being referred to a specialist included registrar female gender (OR 1.49 [95% CI: 1.05, 2.12]) and being Aus- tralian-trained (OR 2.02 [1.18, 3.48]); patient age (patients aged 0-1 year less likely to be referred [OR 0.58 [0.34, 0.98] compared to patients aged 2-12 years); AD being an existing problem (OR 0.28 [0.18, 0.43] for a new problem); pathol- ogy being ordered (OR 2.48 [1.08, 5.69]); and learning goals being generated (OR 2.57 [1.69 3.90]). Also significant in multivariable analyses, less non-AD problems, on average, were addressed in consultations result- ing in referral (OR 0.57 [95% CI: 0.43, 0.75]), and these con- sultations were longer (OR 1.05 [95% CI: 1.02, 1.07] for each additional minute of consultation duration). In univariate analysis (Table 3), referral was associated with an estimated average increase of 3 minutes in AD consultation duration. In AD consultations resulting in referral, supervisors were more likely to provide the registrar with advice or assistance (20% versus 9%), which was significant on multivariable analysis (OR 1.73 [95% CI: 1.06, 1.83]). Discussion The associations of GP and GP registrar referrals for AD have not been well investigated. To our knowledge this is the first analysis exploring Australian GP registrars’ (or GP trainees in other countries) referrals for AD. This study Table 2. referrals for Atopic Dermatitis (n=222) Specialist Frequency Percentage Dermatologist referral 153 70 Allergist/immunologist referral 38 17 Pediatrician referral 21 9.6 Referral to clinic/center 4 3.2 Other 3 1.4 total 219 100 Note: Three referrals were excluded, as they did not specify the referral type and hence have been removed from analysis. Research | Dermatol Pract Concept 2021;11(1):e2021118 5 Table 3. Characteristics by referral status in Atopic Dermatitis Consultations (n = 381,180)   Referral for Atopic Dermatitis Factor Group Variable Class No Yes P value Patient factors                           Patient age group 0-1 years 655 (22%) 32 (15%) 0.12   2-12 years 834 (28%) 67 (31%)     13-24 years 542 (18%) 49 (23%)     25-44 years 541 (18%) 38 (18%)     45+ years 441 (15%) 30 (14%)   Patient gender Male 1,318 (44%) 93 (43%) 0.89   Female 1,677 (56%) 121 (57%)   NESB No 2,589 (90%) 187 (88%) 0.40   Yes 290 (10%) 25 (12%)   Patient/practice status Existing patient 1,009 (34%) 88 (40%) 0.12   New to registrar 1,722 (57%) 111 (51%)     New to practice 272 (9%) 20 (9%)   Aboriginal or Torres Strait Islander No 2,826 (99%) 210 (99.5%) 0.52   Yes 38 (1%) 1 (0.5%)   Registrar factors                       Registrar gender Male 1,131 (37%) 69 (31%) 0.078   Female 1,932 (63%) 153 (69%)   Registrar full-time or part-time Part-time 733 (25%) 57 (27%) 0.48   Full-time 2,249 (75%) 156 (73%)   Term Term 1 1,194 (39%) 94 (42%) 0.39   Term 2 1,122 (37%) 71 (32%)     Term 3 747 (24%) 57 (26%)   Worked at practice previously No 2,383 (79%) 180 (82%) 0.33   Yes 631 (21%) 40 (18%)   Qualified as doctor in Australia No 503 (16%) 29 (13%) 0.18   Yes 2,547 (84%) 192 (87%)   Registrar age Mean (SD) 32 (6) 32 (6) 0.74 Practice factors                           Practice size Small 1,069 (36%) 76 (36%) 0.90   Large 1,906 (64%) 138 (64%)   Practice routinely bulk bills No 2,132 (71%) 151 (69%) 0.49   Yes 879 (29%) 69 (31%)   Rurality Major city 2,075 (69%) 164 (76%) 0.090   Inner regional 685 (23%) 41 (19%)     Outer regional remote 262 (9%) 12 (6%)   Region Region 1 518 (17%) 28 (13%) 0.37   Region 2 139 (5%) 14 (6%)     Region 3 374 (12%) 22 (10%)     Region 4 1,300 (42%) 97 (44%)     Region 5 28 (0.9%) 3 (1%)     Region 6 506 (17%) 44 (20%)     Region 7 198 (6%) 14 (6%)     SEIFA-IRSD Mean (SD) 6 (3) 6 (3) 0.098 (Table 3 continues) 6 Research | Dermatol Pract Concept 2021;11(1):e2021118   Referral for Atopic Dermatitis Factor Group Variable Class No Yes P value Consultation factors                         New problem seen No 1,791 (65%) 166 (85%) <0.001   Yes 959 (35%) 30 (15%)   Sought help any source None 2,367 (77%) 138 (62%) <0.001   Supervisor 274 (9%) 45 (20%)     Other sources 422 (14%) 39 (18%)   Pathology ordered No 3,004 (98%) 211 (95%) 0.004   Yes 59 (2%) 11 (5%)   Follow-up ordered No 1,963 (64%) 131 (59%) 0.13   Yes 1,100 (36%) 91 (41%)   Learning goals generated No 2,339 (82%) 128 (61%) <0.001   Yes 523 (18%) 81 (39%)   Consultation duration Mean (SD) 17 (8) 20 (9) <0.001 Number of problems Mean (SD) 2 (1) 2 (1) <0.001 NESB = Non-English speaking background; SEIFA-IRSD = socio-economic index for areas – index of relative socioeconomic disadvantage; SD = standard deviation. Table 4. Characteristics Associated With a referral being Made for Atopic Dermatitis    Univariate Adjusted Factor Group Variable Class OR [95% CI] P value OR [95% CI] P Value Patient factors       Patient age group Comparator 2-12 years   0-1 years 0.61 (0.39, 0.95) 0.027 0.58 (0.34, 0.98) 0.0417 13-24 years 1.13 (0.76, 1.67) 0.55 1.02 (0.63, 1.63) 0.9444 25-44 years 0.87 (0.58, 1.32) 0.52 0.91 (0.55, 1.50) 0.6988 45+ years 0.85 (0.54, 1.32) 0.47 1.23 (0.73, 2.05) 0.4358 Registrar factors   Registrar gender Female 1.30 (0.97, 1.74) 0.078 1.49 (1.05, 2.12) 0.0269 Qualified as doctor in Australia Yes 1.31 (0.88, 1.93) 0.18 2.02 (1.18, 3.48) 0.0110 Practice factors SEIFA-IRSD   1.04 (0.99, 1.10) 0.098 1.03 (0.98, 1.10) 0.2550 Consultation factors               New problem seen Yes 0.34 (0.23, 0.50) <.001 0.28 (0.18, 0.43) <.001 Sought help any source Other sources 1.57 (1.09, 2.27) 0.016 1.19 (0.73, 1.97) 0.48  Comparator: None Supervisor 2.82 (1.97, 4.03) <.001 1.73 (1.06, 2.83) 0.030 Pathology ordered Yes 2.65 (1.36, 5.17) 0.004 2.48 (1.08, 5.69) 0.031 Follow-up ordered Yes 1.24 (0.94, 1.64) 0.13 0.75 (0.52, 1.09) 0.13 Learning goals generated Yes 2.83 (2.10, 3.82) <.001 2.57 (1.69, 3.90) <.001 Consultation duration   1.03 (1.02, 1.05) <.001 1.05 (1.02, 1.07) <.001 Number of problems   0.69 (0.58, 0.83) <.001 0.57 (0.43, 0.75) <.001 sEIFA-IRSD = socio-economic index for areas – index of relative socioeconomic disadvantage Table 3. Characteristics by referral status in Atopic Dermatitis Consultations (n = 381,180) (continued) Research | Dermatol Pract Concept 2021;11(1):e2021118 7 provides several significant findings pertaining to registrar engagement and confidence with AD, frequency of referral, and specialist choice. summary of Main Findings Registrars referred 6.8% of AD cases. The dermatologist was the preferred specialist to manage AD, with 70% of cases referred to this specialty, but a relatively high percentage of cases (17%) were referred to allergists/immunologists. Prominent associations of referrals included longer con- sultations, a preexisting AD diagnosis, and consultations in which fewer issues were managed. There was increased supervisor involvement for consultations in which AD was referred and considerably increased learning-goal generation for these consultations. Interpretation of Findings and Comparison With Previous Literature The context for our finding of referral of 6.8% of AD prob- lems is that GPs have previously been shown to refer 10.3% of all problems managed [21]. In an earlier analysis of this Australian registrar population, we found a referral rate for skin problems of 8.0%. This earlier analysis also found that registrars were 38% (odds ratio [OR] 0.62) less likely to refer skin problems compared with non-skin problems. Our results, though, suggest AD remains a significant learning-need for GP registrars. Compared to all problems seen (in previous analyses from ReCEnT), when presented with a diagnosis of AD, a GP registrar is more likely to seek supervisor advice or assistance (9.7% compared to 6.9% for all problems [22]), and generate learning-goals (18.4% compared to 16.6% for all problems [23]). This is consistent with previous evidence that diagnosing skin diseases (includ- ing AD) is an area that receives less attention throughout undergraduate, postgraduate, and specialist training for GP trainees [7,16,17,24]. Qualified GPs are also reported to have some difficulty with AD management [13]. The relative frequency of referrals of an existing rather than a new AD problem/diagnosis suggests that, while reg- istrars may need considerable training to manage AD, they may nevertheless be comfortable with AD diagnosis and ini- tial management. Despite presenting some challenges for the early-career GP, AD is most often a straightforward diagnosis, is mostly of mild or moderate severity, and can be managed appropriately by the GP using first-line modalities. It is then likely that the advice and assistance of their supervisor may support registrars’ management of AD in the context of them having considerable learning-needs in the area. It was also apparent that referral for AD may be associ- ated with a more complex or problematic AD presentation: longer consultation duration, greater learning-goal gener- ation, more supervisor assistance sought, more pathology ordered, and fewer non-AD problems addressed in the index consultation. Another notable finding of this study was that while the dermatologist is the specialist of choice for AD, a relatively large proportion of patients are referred to allergists/immu- nologists. The roles of each of these specialists as a part of the multidisciplinary team have previously been recognized in the care of moderate-severe AD [25]. Significantly, the choice of specialist has been shown to influence management practices [26, 27]. Allergists and dermatologists diverge in their recommendations for systemic treatments, adjunctive therapies, and preventative measures [25]. Given the natural emphasis of their training, allergists/immunologists are more likely to focus on preventative strategies and potential allergic triggers [27]. Our results suggest registrars are quite frequently pri- oritizing allergy pathways in AD management. The 17% referred to allergists/immunologists may reflect the rise in primary care recognition of the association of eczema with food allergy. A review of studies by Werfel et al. in 2007 found a prevalence of food allergy in 33%-63% of cases [28]. The exact relationship between food allergy and AD remains controversial. Food allergy as an aggravating factor of AD in infants and young children is well accepted [29], but there is a lack of consensus regarding food allergy as an exacerbating factor versus a cause [25, 30]. It has previously been suggested that primary care pro- viders overemphasize the role of food allergy in AD [30]. Our results also suggest a registrar emphasis on a possible allergic component to AD. Overemphasis on allergies versus the overarching etiology of AD can lead to miscommunica- tion, which results in a parent erroneously believing that a food allergy is causing their child’s AD [30]. This can then lead to restrictive diets, risking possible nutritional defi- ciencies, and diversion from the basics of optimizing AD management such as education, skin care, and optimal use of topical corticosteroids [30]. Referral rates for AD in this study are reflective of the existing literature, as is our finding of AD as a persistent learn- ing-need for GP registrars. As yet, there is limited literature to compare our findings of registrar AD referral pathways, and the implications of specialist choice on clinical outcomes. Supplementary Table 1. Included Diagnostic Codes Excluded Diagnostic Codes Dermatitis, atopic Eczema Eczema, infantile Rash; atopic Dermatitis; flexural Dermatitis; allergic Dermatitis 8 Research | Dermatol Pract Concept 2021;11(1):e2021118 strengths and Limitations This study has a number of strengths, in particular, its high response rate (96.1%) and broad data set (595,412 data points) and geographic distribution throughout areas clas- sified as urban, rural, and remote across multiple Australian states. As such, findings are generalizable across Australia and, potentially, internationally. A limitation of the analysis was the limited clinical context provided within the con- sultation data. We did not have contextual information on severity of AD, of AD past history, of medicine regimens, of concurrent conditions and, thus, were unable to ascertain if individual referrals were appropriate for care escalation. Implications for Practice and Future research Our findings suggest that registrars are engaging with diag- nosis and management of AD, but that AD (as with skin disease generally), remains a priority learning-need for regis- trars. Continued reevaluation of postgraduate dermatology curricula would best focus on management components and understanding of appropriate indications for referral. Clarification, such as through referral pathways, for specific specialist involvement would help to guide appropriate spe- cialist referral according to patient presentation. Furthering awareness of and access to multidisciplinary clinics, wherein a variety of specialists are available, may also help to optimize GP registrars’ contribution to AD management. Conclusions Our findings show that GP registrars are engaging with AD, yet it is apparent this is still a learning-need for many registrars. 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