Transition to Medicare Does Not Contribute to Rise in Outpatient Visits for Nonmelanoma Skin Cancer, Actinic Keratosis, or Actinic Cheilitis in the US Population.

BACKGROUND: Outpatient visits for nonmelanoma skin cancer (NMSC) and actinic keratoses (AK) have risen steadily in the United States, notably among Medicare beneficiaries. Individuals may delay seeking care for minimally symptomatic conditions until they qualify for Medicare coverage, indicating potential delay of nonurgent screening interventions for uninsured or underinsured patients younger than 65 years. OBJECTIVE: This study investigates whether an atypical increase in outpatient visits for NMSC, AK, or actinic cheilitis (AC) occurs at the age of Medicare transition by utilizing the National Ambulatory Care Survey from 1993 to 2019. MATERIALS AND METHODS: The National Ambulatory Care Survey data were analyzed for patients aged within 5 years of 65 years. Diagnoses were identified using International Classification of Diseases codes. Linear regression and outlier detection were used to identify a relationship between Medicare eligibility and outpatient visits for NMSC and AK/AC. RESULTS: Predicted visits for AK/AC and NMSC increased with age. However, there was no evidence of a disproportionate increase in outpatient visits for NMSC and AK/AC at the age of Medicare eligibility. CONCLUSION: Outside evidence indicates health care utilization increases after Medicare transition. This study's data do not support a corresponding rise in outpatient visits for NMSC and AK/AC at the age of Medicare eligibility.

Women of Childbearing Age With Hidradenitis Suppurativa Frequently Prescribed Medications With Pregnancy Risk.

Copy: Hidradenitis suppurativa (HS) disproportionately affects women of childbearing age. As almost half of pregnancies in the United States are unplanned, dermatologists must give special consideration to medication safety when managing patients in this population. METHODS: We conducted a population-based cross-sectional analysis utilizing the National Ambulatory Medical Care Survey from 2007 to 2018 (most recent years available) in order to characterize the treatment modalities most commonly being used for treatment of hidradenitis suppurativa in women of childbearing age. RESULTS: There were 43.8 million estimated total visits for females ages 15 to 44 with HS. Women of childbearing age with HS were most commonly seen by general and family practice (28.6%), general surgery (26.9%), and dermatologists (24.6%). Obstetricians saw 1.84% of all visits. Oral clindamycin was the most commonly prescribed drug, followed by amoxicillin-clavulanate, minocycline, naproxen, and trimethoprim-sulfamethoxazole. Adalimumab was prescribed at an estimated 10.3 thousand visits (0.211%). At visits in which medication from the 30 most common therapies was prescribed, 31% of visits included a medication that was pregnancy category C or above. DISCUSSION: Nearly a third of women of childbearing age with HS are receiving medications considered teratogenic. As many female patients feel that their physicians are not counseling them regarding the impact of HS therapy on childbearing, the results of this study serve as a reminder to dermatologists and non-dermatologists managing skin disease to continue to facilitate conversations about potential pregnancy risk when prescribing medications with pregnancy risk. Peck G, Fleischer AB Jr. Women of childbearing age with hidradenitis suppurativa frequently prescribed medications with pregnancy risk. J Drugs Dermatol. 2023;22(7):706-709. doi:10.36849/JDD.6818.

The Persistence of Nystatin Use for Dermatophyte Infections.

BACKGROUND: Despite the limited use of nystatin for tinea infections, physicians may continue to use it. METHODS: We assessed the National Ambulatory Medical Care Survey for all to determine the extent of topical nystatin use in tinea infections. RESULTS: Topical nystatin was used at 4.3% (2.1%, 6.0%) of all tinea infection visits. It was not used at visits with dermatologists and was most common among family medicine physicians (P=.02). DISCUSSION: Physicians are continuing to use nystatin for the treatment of tinea infections. Dermatologists have discontinued this treatment regimen, whereas other specialties have an opportunity to further improve their knowledge in this regard. J Drugs Dermatol. 2023;22(12):e49-e50.     doi:10.36849/JDD.5606e.

Onychomycosis Treatment Prescribed at Only Twenty Percent of Visits: A Cross-Sectional Analysis of the National Ambulatory Medical Care Survey 2007 to 2016.

BACKGROUND: Onychomycosis represents the highest proportion of nail disorders seen in clinical practice. Onychomycosis management may differ amongst specialties, with impact on patient outcomes and quality of life (QoL). OBJECTIVE: We aimed to characterize onychomycosis treatment across specialties, accounting for patient demographics, to assess for potential onychomycosis practice gaps. MATERIALS/METHODS: We conducted a population based cross-sectional analysis using the National Ambulatory Medical Care Survey (NAMCS) 2007 to 2016 (the most recent years available). RESULTS: Overall, 71.6% of onychomycosis visits were with general practitioners (GPs), 25.8% with dermatologists, and 2.58% with pediatricians. No onychomycosis treatment was prescribed at 82.0% of dermatology visits and 78.9% of GP visits. Dermatologists (Odds Ratio (OR):2.27 [95% Confidence Interval (CI):[2.14-2.41]; P<0.0001) and GPs (OR:2.32 [2.21-2.44]; P<0.0001) were more likely than pediatricians to prescribe treatment vs no treatment. Dermatologists were more likely than GPs to prescribe both no treatment vs treatment and topical vs oral antifungals (OR:1.33 [1.16-1.52]; P<0.0001 and OR:4.20 [3.80-4.65]; P<0.0001), respectively. DISCUSSION: Our study showed that there is a low treatment rate for onychomycosis, with treatment prescribed at only 20% of visits. Untreated onychomycosis might result in secondary infection, pain, and negative QoL impact.1 Although dermatologists are specialists in nail disease management, they saw only about 25% of onychomycosis visits. Future efforts should be directed towards promoting onychomycosis therapy, and educating both patients and referring physicians that dermatologists are primary resources for nail disorder treatment.J Drugs Dermatol. 2023;22(10):1040-1045 doi:10.36849/JDD.6770.

Workforce requirements for keratinous cysts: clinicians expend 1200 full-time effort years annually.

Keratinous cysts are amongst the 10 most common dermatologic ambulatory diagnoses. Thus, we aimed to estimate the time and cost spent annually on management of keratinous cysts. We conducted a cross-sectional study using the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey between 2007 and 2018 (most recent years available). Conservatively, $2.1 billion per year was spent on healthcare for keratinous cysts. On average, the full-time work of 1200 (840-1800) physicians and non-physician providers are required to manage keratinous cysts yearly in the outpatient and emergency departments.We used Medicare reimbursement rates for the cost analysis which provides a conservative estimate of the total cost. Keratinous cysts impose a significant time and cost burden on the healthcare system. Treating inflamed, draining, or painful keratinous cysts or ones that occur in undesirable locations such as the face are likely of high-value due to the quality of life impact. Managing asymptomatic keratinous cysts may be of lower value. Given this burden, clinicians should continue to evaluate the value they are providing to the patient when managing keratinous cysts.

Workforce Requirements for Skin Cancer and Related Skin Tumors Continue to Increase: Clinicians Expend an Average of 1,740 Full-Time Effort Years Annually.

BACKGROUND: With an aging population, estimating workforce requirements for management of common conditions such as skin cancer will be necessary to meet the health care needs of the American people. OBJECTIVE: The authors aimed to estimate the workforce requirements for managing skin cancer and other skin tumors. MATERIALS AND METHODS: The authors conducted a population-based, cross-sectional analysis using data from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey between the years 2007 and 2016, the most recent years available. The significance threshold was set at a p-value <.05. RESULTS: The full-time effort of 1,740 (95% confidence interval: 1,340-2,220) clinicians is required to care for skin cancer and other skin tumors each year. The full-time effort years necessary for management of melanoma (p = .006), keratinocytic carcinoma (p < .0001), actinic keratosis (p < .0001), and all skin cancers and tumors (p < .0001) were significantly increasing from 2007 to 2016. CONCLUSION: Clinicians expend a significant amount of time managing skin cancer and other skin tumors, and the time required for management increased over the study period. These workforce requirement trends can likely be attributed to increased prevalence and incidence rates of cutaneous malignancy secondary to an aging population and increased whole-body skin examinations.

Risk Factors That Are Associated With Outliers in Mohs Micrographic Surgery in the National Medicare Population, 2018.

BACKGROUND: Physician variation exists in the mean number of stages performed per Mohs micrographic surgery (MMS) case. Physicians who are outliers in medical practice may be leading to a higher health care cost burden. OBJECTIVE: To identify factors that influence being a high outlier in the mean stages per MMS case. MATERIALS AND METHODS: The study comprised a retrospective analysis of 2018 data from physicians who billed Medicare Part B for Current Procedural Terminology (CPT) 17311 and 17312 (MMS of the head, neck, hands, feet, or genitalia) and/or CPT 17313 and 17314 (MMS of the trunk, arms, or legs). RESULTS: For CPT 17311 and 17312, the odds ratio for being an outlier for a physician in a solo practice relative to a multiphysician facility is 2.4 (1.6-3.8), for a physician who is not an American College of Mohs Surgery (ACMS) member relative to a ACMS member is 2.0 (1.2-3.2), and for a practice located in the West, Northeast, and South is 7.7 (2.8-21.6), 6.2 (2.1-18.6), and 1.8 (0.6-5.4), respectively, relative to in the Midwest. CONCLUSION: Physicians who are practicing solo, practicing in the West or Northeast, and are not ACMS members are more likely to be a high outlier in the mean stages per MMS case.

United States burden of melanoma and non-melanoma skin cancer from 1990 to 2019.

BACKGROUND: Skin cancer is the most common cancer worldwide. OBJECTIVE: To evaluate the burden of skin cancer in the US from 1990 to 2019. METHODS: Age-standardized incidence, prevalence, disability-adjusted life years (DALY), and mortality rates from skin cancer in the US were evaluated from the Global Burden of Disease 2019. RESULTS: Incidence, prevalence, DALY, and mortality rates for melanoma per 100,000 persons in 2019 were 17.0, 138, 64.8, and 2.2, respectively; for squamous cell carcinoma, rates were 262, 314, 26.6, and 0.8, respectively; and for basal cell carcinoma, rates were 525, 51.2, 0.2, and zero, respectively. Incidence and prevalence rates of melanoma and non-melanoma skin cancer (NMSC) have increased since 1990, while mortality rates have remained fairly stable. Males have had higher incidence, prevalence, DALY, and mortality rates from melanoma and NMSC every year since 1990. Incidence and prevalence of melanoma was relatively higher in the northern half of the US than in the southern half. LIMITATIONS: Global Burden of Disease is derived from estimation and mathematical modeling. CONCLUSIONS: Health care professionals can utilize differences and trends noted in this study to guide allocation of resources to reduce incidence and morbidity from skin cancer.

Global Epidemiology of Urticaria: Increasing Burden among Children, Females and Low-income Regions.

Urticaria has a high socioeconomic burden worldwide. However, the global epidemiology of urticaria and its geographical and temporal trends are not well studied. Using the Global Burden of Disease dataset, the aim of this study was to analyse the age-standardized prevalence, incidence, years lived with disability, and mean duration of urticaria in 195 countries from 1990 to 2017. In addition, the relationship between socioeconomic development and urticaria was evaluat-ed. The global prevalence of urticaria in 2017 was 86 million people. Females and children aged 1-4 years were more commonly affected than males and adults, respectively: these differences were outside the 95% uncertainty intervals. Regression analyses show-ed that a lower gross domestic product per capita was associated with a higher prevalence and incidence of urticaria (p < 0.001). The global prevalence of urticaria, incidence, and years lived with disability have remained stable from 1990 to 2017.

Comparing prescribing patterns for topical corticosteroids based on their FDA indication by age.

BACKGROUND/OBJECTIVES: Atopic dermatitis (AD) affects up to 20% of the pediatric population, with a growing prevalence over the past 30 years. Topical corticosteroids (TCS) are commonly used as a first-line topical therapy for AD and are prescribed in 59% of all AD visits. However, some topical corticosteroids are prescribed outside of their age range indications. This paper aims to explore the frequency with which topical corticosteroids are prescribed for AD outside of their FDA-approved age range. METHODS: Data on prescribing patterns for AD were obtained from the National Ambulatory Medical Care Survey (NAMCS). We assessed the frequency of off-label use of topical corticosteroids with respect to age indications in four specific age-groups, as delineated in the data (0-1, 2-7, 8-18, and 19+ years). RESULTS: All prescribed topical corticosteroids found in the NAMCS database have an indication for AD or other inflammatory dermatoses or pruritic dermatoses. However, some medications were prescribed outside of their FDA-approved age indications. These off-label prescription rates ranged from 52% for desoximetasone to 0% for halobetasol and alclometasone, or rates lower than could be detected by our study. CONCLUSIONS: Much like other medications for AD treatment, TCS are sometimes used off-label. The off-label use of topical corticosteroids to treat pediatric AD highlights a gap between clinical practice and regulating guidelines. Additional pediatric studies would offer a greater body of evidence to maintain or expand label indications for the use of TCS in younger patients.

Sanitation, Obesity, and Low Body Mass Index as Risk Factors for Bacterial Skin Infections.

BACKGROUND: Bacterial skin infections can cause significant disability and can lead to mortality with inadequate treatment. OBJECTIVE: To determine whether sanitation and body mass index (BMI) are statistically significant risk factors for the incidence and prognosis of bacterial skin infections. METHODS: Country-level data regarding the age-standardized rates of incidence, prevalence, and years lived with disability (YLD) from bacterial skin infection per 100 000 persons from the Global Burden of disease dataset, and country-level data on age-standardized prevalence of obesity (BMI ≥30) and low BMI (BMI <18.5) from World Health Organization Global Health Observatory data repository were analyzed. Regression models were created to examine the effects of sanitation, obesity, and low BMI on the burden of bacterial skin infections. RESULTS: The percentage of population using basic sanitation services was positively associated with incidence, prevalence, and YLD from bacterial skin infections (P < .05). After controlling for sanitation, in countries with more than 50% of the population using basic sanitation services, obesity was positively associated with incidence, prevalence, and YLD from bacterial skin infections (P < .05). In countries with less than or equal to 50% of the population using basic sanitation services, low BMI was positively associated with incidence, prevalence, and YLD from bacterial skin infections (P < .05). CONCLUSIONS: Improving sanitation access in all countries, reducing the percentage of obese population in countries with good sanitation/hygiene techniques, and addressing malnutrition in countries with poor sanitation/hygiene techniques may help to reduce the burden of bacterial skin infections.

Time Intervals Until the First Return Office Visit After New Medications.

INTRODUCTION: Poor patient adherence to medications is common in dermatology and can result in negative health outcomes. A short interval until the first return office visit after starting a medication can increase adherence. METHODS: We conducted a retrospective cross-sectional study by using the National Ambulatory Medical Care Survey from 2014 to 2016 to determine the length of time until the scheduled return visit. RESULTS: Our study examined 10.9 (95% confidence interval 9.43, 12.5) million estimated visits in the NAMCS. Patients with acne, atopic dermatitis, and psoriasis prescribed at least one new medication had dispositions to return at two months or greater or to return as needed at 73.5% (38.8, 100), 49.1% (12.6, 92.0), and 55.0 % (14.0, 100) of visits, respectively. CONCLUSIONS AND RELEVANCE: The time for a first return visit is frequently more than two months after a new medication is prescribed. Incorporating an earlier visit when prescribing a medication may be a means to improve adherence. J Drugs Dermatol. 2020;19(12): doi:10.36849/JDD.2020.5542.

Guideline-based medicine grading on the basis of the guidelines of care for ambulatory atopic dermatitis treatment in the United States.

PURPOSE: This study was designed to assess the adherence to evidence-based guidelines of care for atopic dermatitis (AD). METHODS: To characterize AD treatment in the United States, ambulatory visits from the 2006-2015 National Ambulatory Medical Care Survey were analyzed. For each medication prescribed, a grade was assigned on the basis of the American Academy of Dermatology treatment guidelines for topical and systemic medications. Considering all visit prescriptions, I calculated a composite grade, analogous to the US academic grading system (scores A-F). RESULTS: I noted prescribing differences across specialty groups. Systemic corticosteroids were more likely to be prescribed by family and general physicians and less likely by pediatricians. Dermatologists were more likely than other specialties to prescribe nonsedating antihistamines, which lack a guideline base supporting their use. Depending upon modeling of care assumptions, all physician specialty visits earned mean guideline-based grades of B or C in their care of AD patients. LIMITATIONS: The clinical, social, and demographic factors influencing prescribing behavior cannot be completely assessed by using extant data. CONCLUSIONS: This preliminary study demonstrates that physicians might benefit from reviewing guidelines of care; there might be an educational gap in the implementation of these guidelines.

An assessment of the use of antihistamines in the management of atopic dermatitis.

BACKGROUND: Antihistamines are often used to treat pruritus associated with atopic dermatitis (AD) despite lack of evidence for their efficacy. The American Academy of Dermatology does not recommend the general use of antihistamines in the management of AD, although the value of short-term sedating antihistamine use for insomnia secondary to itch is recognized. OBJECTIVE: To assess the use of sedating and nonsedating antihistamines for AD in 2003-2012. METHODS: The National Ambulatory Medical Care Survey provided data on physician visits in 2003-2012. Sedating and nonsedating antihistamine use was identified at visits for AD. RESULTS: There were 990,000 annual visits for AD. Antihistamines were prescribed for AD in a significant proportion of visits across physician specialties (16%-44%). Dermatologists and pediatricians primarily used sedating antihistamines (58%-70%), whereas the majority of family/general practitioners, internists, and other specialists prescribed nonsedating antihistamines for AD (55%-100%) LIMITATIONS: We were limited by the accuracy of AD diagnosis and medication recording. CONCLUSIONS: Antihistamines are widely used for the treatment of AD. There is no high-level evidence to suggest that nonsedating antihistamines reduce itch in patients with AD or that sedating antihistamines provide benefit in controlling AD symptoms (except perhaps sleep and AD comorbidities, such as allergic rhinitis).

Trends in Atopic Dermatitis Management: Comparison of 1990-1997 to 2003-2012.

BACKGROUND: Atopic dermatitis (AD) is primarily treated with topical therapies, systemic immunosuppressants, or adjunctive therapies. OBJECTIVE: As novel treatment approaches for AD emerge, we characterize AD treatment and examine trends in treatment over time. METHODS: Visits for AD were identified in the 2003-2012 National Ambulatory Medical Care Survey (NAMCS). We identified topical corticosteroids (TCS), antibiotics (Abx), antihistamines (AH), topical calcineurin inhibitors (TCI), and systemic immunosuppressants (SI) prescribed at AD visits. RESULTS: There were 990,000 annual visits for AD from 2003-2012 (3.2 visits/1000 people/year). TCS were the most frequently used medication (59% of visits). Topical calcineurin inhibitors (TCI) were the second most prescribed medication for AD among dermatologists (23% of visits), while antihistamines were second among all other physicians (16-44% of visits). Unlike other medications, use of TCIs decreased over time. LIMITATIONS: The NAMCS does not follow individual patients over time. CONCLUSIONS: TCI use has been decreasing. New topical AD treatments may provide an alternative to TCS, better treatment outcomes for moderate-to-severe atopic dermatitis, and an alternative to systemic antihistamines whose efficacy in AD is unproven and whose general use in AD management is discouraged by the American Academy of Dermatology. J Drugs Dermatol. 2018;17(2):135-140.

Higher Risk of Care for Hidradenitis Suppurativa in African American and Non-Hispanic Patients in the United States.

Hidradenitis suppurativa (HS) is a chronic cutaneous inflammatory disease. Few reports have been published on the influence of race, ethnicity, and other patient demographic factors as determinants of care for HS. Data from the 2005 to 2011 National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS) were analyzed for to assess factors that were predictive of outpatient visits for HS. Logistic regression controlling for demographic and other factors showed several disparities. African Americans are more likely to experience clinic visits for HS than Whites (Odds Ratio (OR) 2.00, p = 0.047). Moreover, non-Hispanic, non-Latino patients are more likely to visit the clinic for HS than Hispanic, Latino patients (OR 5.49, p = 0.002). Additionally, with increasing patient age, there is less likelihood of a clinic visit for HS (OR 0.99; p = 0.03). Although obese patients were 3.5 times more likely to have an HS office visit than normal weight individuals, this difference was not significant (p = 0.07). Since weight was not collected in this survey until 2005 and data collection continues, further years of data may refine these estimates. These results suggest there may be either increased risk of HS among specific groups, disparities in health access for care of HS, or both.