Safe Step Act: does it undermine step therapy?

Drug expenditure in the United States has continued to increase unsustainably; the specialty of dermatology has been particularly affected. Resources are limited - someone has to make decisions about what treatments will be covered and how they will be reimbursed. Step therapy is a cost-control method used by insurers to encourage the use of the most cost-effective treatments before more expensive options are attempted. However, a rigid step therapy policy can be problematic when protocols are out of date, or delay necessary treatment leading to unnecessary suffering, increased morbidity, and overall cost. To address some of these concerns, the proposed Safe Step Act (S. 2546 and H.R. 2279) attempts to create a requirement that insurers provide a transparent, expeditious exceptions process for step therapy protocols. Increased flexibility in this process will allow for the unique circumstances of individual patients and improve access to expensive drugs for special cases. However, this bill may be exploited, further weakening insurers' ability to negotiate on cost. We should be cautious about measures that reduce the effectiveness of this tool, particularly if we, as a society, aim to expand access to basic care to all Americans.

Web App- and Text Message-Based Patient Education in Mohs Micrographic Surgery-A Randomized Controlled Trial.

BACKGROUND: Consent and wound care (WC) videos are used for education in Mohs micrographic surgery (MMS). Postoperative text messaging is poorly studied. OBJECTIVE: Develop and evaluate perioperative resources for MMS patients-video modules (DermPatientEd.com) and postoperative text messaging (DermTexts.com). MATERIALS AND METHODS: A study was conducted on 90 MMS patients. Patients were randomized 1:1:1:1 to videos with text messages, videos-only, text messages-only, or control. Primary outcomes included preoperative anxiety and knowledge of MMS and postoperative care. The secondary outcome included helpfulness/preference of interventions. RESULTS: Patients experienced a 19% reduction in anxiety as measured by a visual analog scale after the MMS video (p = .00062). There was no difference in knowledge after the WC video (p = .21498). Patients were more likely to report the WC video "very helpful" when compared with the pamphlet in understanding postoperative WC (p = .0016). Patients in text messaging groups were not more likely to report the service as "very helpful" when compared with the pamphlet (p = .3566), but preferred to receive WC instructions by text message for future visits (p = .0001). CONCLUSION: These resources proved helpful and effective in reducing preoperative anxiety. Patients prefer text message-based WC instructions over pamphlets after experiencing the service, but do not find them more helpful.

Public Perception of Ethical Issues in Dermatology: Evidenced by New York Times Commenters.

BACKGROUND: A 2017 New York Times (NYT) article questioning the appropriateness of skin cancer treatment modality by dermatology providers stimulated discussion among the public pertaining to ethics in the current state of dermatologic practice. OBJECTIVE: The purpose of this study is to characterize issues raised by the comments on the NYT article, discuss strategies to address these concerns, and encourage reflection on ethics in dermatologic care. MATERIALS AND METHODS: A qualitative analysis was performed on the 309 comments on the NYT article. General themes were identified, resulting in the inclusion of 222 comments. These comments were reviewed and characterized by the type of commenter, his or her stance on health care, and what issues they raised. RESULTS: Providers interested in "profit over patient" was the most common theme, followed by mistrust of APPs, health care system interested in "profit over patient," inadequate supervision by advanced practice providers (APPs), finding the "right" provider, support for coordinated APP and physician care, support for APP credentials, and finally inappropriate elderly care. CONCLUSION: The NYT article raises the concern of identifying quality care and choosing the "right provider"-one who successfully balances the various incentives affecting skin cancer management including appropriate usage of APPs.

Electrosurgery: part I. Basics and principles.

The term electrosurgery (also called radiofrequency surgery) refers to the passage of high-frequency alternating electrical current through the tissue in order to achieve a specific surgical effect. Although the mechanism behind electrosurgery is not completely understood, heat production and thermal tissue damage is responsible for at least the majority--if not all--of the tissue effects in electrosurgery. Adjacent to the active electrode, tissue resistance to the passage of current converts electrical energy to heat. The only variable that determines the final tissue effects of a current is the depth and the rate at which heat is produced. Electrocoagulation occurs when tissue is heated below the boiling point and undergoes thermal denaturation. An additional slow increase in temperature leads to vaporization of the water content in the coagulated tissue and tissue drying, a process called desiccation. A sudden increase in tissue temperature above the boiling point causes rapid explosive vaporization of the water content in the tissue adjacent to the electrode, which leads to tissue fragmentation and cutting.

Electrosurgery: part II. Technology, applications, and safety of electrosurgical devices.

Electrosurgical currents can be delivered to tissue in monopolar or bipolar and monoterminal or biterminal modes, with the primary difference between these modes being their safety profiles. A monopolar electrosurgical circuit includes an active electrode and a dispersive (return) electrode, while there are 2 active electrodes in bipolar mode. In monoterminal mode, there is an active electrode, but there is no dispersive electrode connected to the patient's body and instead the earth acts as the return electrode. Biterminal mode uses a dispersive electrode connected to the patient's body, has a higher maximum power, and can be safer than monoterminal mode in certain situations. Electrosurgical units have different technologies for controlling the output power and for providing safety. A thorough understanding of these technologies helps with a better selection of the appropriate surgical generator and modes.

Cosmetic procedures performed in the United States: a 16-year analysis.

BACKGROUND: Cosmetic procedures, particularly those that are minimally invasive, are in demand. The physician specialties performing these procedures are not well-characterized. OBJECTIVE: To examine changes in the frequency of cosmetic dermatologic procedures performed in the United States from 1995 to 2010 and the physician specialties performing them. METHODS: The volume of cosmetic procedures performed by physician specialties and the types of cosmetic procedures performed were determined from data from the National Ambulatory Medical Care Survey (NAMCS) from 1995 to 2010. RESULTS: Cosmetic procedures constituted 8.7% of all skin procedures and have increased since 1995 (p < .001). Botulinum toxin injections were the most frequently performed cosmetic procedure and increased at the greatest rate over time. Plastic surgeons performed the largest proportion of cosmetic procedures (36.1%), followed by dermatologists (33.7%), but other specialties have been performing an increasing proportion of cosmetic procedures. This study was limited to the provision of outpatient procedures, and the nationally representative data of the NAMCS is subject to sample bias. CONCLUSIONS: Plastic surgeons and other physicians performed the majority of outpatient cosmetic procedures. Dermatologists performed one-third of ambulatory cosmetic procedures from 1995 to 2010. This broadening spectrum of physicians and nonphysicians providing cosmetic procedures may have important implications for patient safety.

Noncosmetic skin-related procedures performed in the United States: an analysis of national ambulatory medical care survey data from 1995 to 2010.

BACKGROUND: Demand for dermatologic care is increasing alongside a known shortage of physicians in the dermatology workforce. Changes in the volume of dermatologic procedures over time and the physician specialties involved in skin-related procedural care are not well characterized. OBJECTIVE: To determine the frequency of dermatologic procedures performed in the United States between 1995 and 2010 and to analyze the changes in the procedures and physicians performing procedures over time. METHODS: The annual volume of skin-related procedures performed by physician specialties and the rate of procedures performed per physician was determined from data from the National Ambulatory Medical Care Survey (NAMCS) between 1995 to 2004 and 2007 to 2010. RESULTS: Dermatologists and primary care physicians performed most procedures (54.7% and 19.5%, respectively). CONCLUSIONS: Dermatologists perform a larger volume of procedures than in the past, although the proportion of procedures performed by dermatologists is unchanged, and other physician specialties are performing more skin-related procedures to meet increasing demand.

Use of topical antibiotics as prophylaxis in clean dermatologic procedures.

BACKGROUND: Topical antibiotics are not indicated for routine postoperative care in clean dermatologic procedures, but may be widely used. OBJECTIVE: We sought to describe topical antibiotic use in clean dermatologic surgical procedures in the United States. METHODS: The 1993 to 2007 National Ambulatory Medical Care Survey database was queried for visits in which clean dermatologic surgery was performed. We analyzed provider specialty, use of topical antibiotics, and associated diagnoses. Use of topical antibiotic over time was analyzed by linear regression. RESULTS: An estimated 212 million clean dermatologic procedures were performed between 1993 and 2007; topical antibiotics were reported in approximately 10.6 million (5.0%) procedures. Dermatologists were responsible for 63.3% of dermatologic surgery procedures and reported use of topical antibiotic prophylaxis in 8.0 million (6.0%). Dermatologists were more likely to use topical antibiotic prophylaxis than nondermatologists (6.0% vs 3.5%). Use of topical antibiotic prophylaxis decreased over time. LIMITATIONS: Data were limited to outpatient procedures. The assumption was made that when topical antibiotics were documented at procedure visits they were being used as prophylaxis. CONCLUSIONS: Topical antibiotics continue to be used as prophylaxis in clean dermatologic procedures, despite being ineffective for this purpose and posing a risk to patients. Although topical antibiotic use is decreasing, prophylactic use should be eliminated.

Topical antibiotic trends from 1993 to 2007: use of topical antibiotics for non-evidence-based indications.

BACKGROUND: Systemic antibiotic use has become more conservative with the emergence of drug resistance. Topical antibiotics are employed for a variety of indications, although there are only a few evidence-based indications. OBJECTIVE: To examine topical antibiotics use in the outpatient setting. METHODS: Topical antibiotic use was characterized using data from the 1993 to 2007 National Ambulatory Medical Care Survey. Visits were identified at which a topical antibiotic was used and analyzed according to patient demographics, diagnoses, procedures, concomitant medications, and provider specialty. Topical antibiotic use over time was analyzed using linear regression. RESULTS: The most frequent diagnoses associated with topical antibiotic use were benign or malignant neoplasm of skin, impetigo, insect bite, and cellulitis. Data revealed a significant downward trend in topical antibiotics associated with dermatologic surgery (p<.001) and a nonsignificant downward trend in use in conjunction with skin biopsies (p=.09). Topical antibiotic use by dermatologists was noted to be decreasing over time, whereas among non dermatologists, it was noted to be increasing, although neither of these trends was statistically significant. CONCLUSION: Topical antibiotics continue to be used for non-evidence-based indications, despite data that suggest that such use may be detrimental for patients and represents significant costs to the health care system. The authors have indicated no significant interest with commercial supporters.

Electrosurgery in dermatology.

Electrosurgery applies high frequency alternating electrical currents to generate heat, thereby creating tissue damage required for cutting, hemostasis, or destruction. Electrosurgery can be delivered in a variety of different ways and can be tailored to achieve the desired clinical effect. Having a command of the underlying principles of electrosurgery will help dermatologic surgeons use the appropriate form of electrosurgery to safely achieve the desired results. We reviewed basic principles of electrosurgery, described the various techniques and devices, and delineated associated risks of electrosurgery for specific patient populations and providers. All modalities of electrosurgery present a risk of electromagnetic interference, which can negatively affect patients with implanted devices, such as pacemakers, defibrillators, cochlear implants, and deep brain stimulators. In particular, electrosurgery may create a smoke plume containing a number of volatile organic compounds potentially noxious; however, the risk of such exposure remains unknown.

What specialties perform the most common outpatient cosmetic procedures in the United States?

BACKGROUND: The number of cosmetic procedures performed annually is on the rise and is being performed by more specialties. PURPOSE: We sought to determine the relative outpatient cosmetic procedure experience of dermatology and other specialties. We also examined demographic data of patients who underwent cosmetic procedures. METHODS: Demographics and data from the National Ambulatory Medical Care Survey (NAMCS) were analyzed to estimate the number of visits for office-based cosmetic procedures from 1995 to 2003 by specialty and type of procedure. RESULTS: In order of decreasing frequency, the percentage of all cosmetic procedures performed in the outpatient setting by specialty was as follows: dermatology (48%), plastic surgery (38%), general surgery (>4%), otolaryngology (>3%), ophthalmology (>3%), facial plastic surgery (1%), family practice (<1%), pediatrics (<1%), and internal medicine (<1%). Most cosmetic procedures were performed on white, female patients in the 40- to 59-year-old age group. There was a mean of 55 visits per 1,000 whites and 27 visits per 1,000 nonwhites. Chemical peels and soft tissue fillers were the two most common procedures. CONCLUSIONS: Dermatology as a specialty performs more office-based cosmetic procedures than other specialties. On a per-physician basis, dermatologists and plastic surgeons have far more experience with cosmetic procedures than other physicians.

Pilot study using topical imiquimod 5% cream in the treatment of nodular basal cell carcinoma after initial treatment with curettage.

BACKGROUND: Nodular basal cell carcinoma (nBCC) is the most common cutaneous malignancy and studies assessing the use of topical imiquimod 5% cream as a monotherapy in the treatment of nBCC have resulted in less than optimal clearance rates. OBJECTIVE: This pilot study was designed to evaluate the efficacy of imiquimod 5% cream on nodular basal cell carcinoma lesions after initial treatment with curettage. METHODS: After obtaining informed consent, 17 nBCCs on 15 patients were included in this institutional review board-approved, open-label study with initial treatment using curettage without electrodesiccation followed by once-daily application of imiquimod 5% cream 5 times per week for 6 weeks. The area was excised and examined histologically 6 weeks after cessation of imiquimod cream. RESULTS: All 17 lesions (100%) showed no histologic evidence of residual tumor on the post-treatment excision. Local site reactions necessitating a rest period from medication application were experienced by most patients (67%), but the majority of patients stated that they would choose this treatment modality over excision if they developed a subsequent tumor. CONCLUSION: Imiquimod 5% cream appears to be an effective treatment method for nodular basal cell carcinoma if combined with curettage prior to application.

Treatment of severe cutaneous ulcerative lichen planus with low molecular weight heparin in a patient with hepatitis C.

The ulcerative variant of lichen planus (LP) commonly involves the oral mucosa but is uncommon and difficult to treat when located on other areas. We describe an unusual case of ulcerative LP involving several surfaces, including the palms and scrotum, in a 50-year-old man with hepatitis C. The patient was recalcitrant to treatment with conventional therapy but obtained clearance with a sustained response using low molecular weight heparin (LMWH). This treatment is an option for patients with LP who are not ideal candidates for standard therapy.

The safety of office-based surgery: review of recent literature from several disciplines.

OBJECTIVE: To review recent literature pertaining to adverse outcomes and mortality associated with office-based surgery. STUDY SELECTION: Representative articles from the general and plastic surgery, medical, health regulatory, and dermatology literature. DATA EXTRACTION: Information regarding which surgical treatments should be performed, which specialties should perform them, what level of anesthesia is appropriate, and who should administer it was assessed, with particular attention to issues of patient safety. CONCLUSIONS: Office-based surgery is safe and cost-effective. We caution against attempts to prohibit or severely restrict this important aspect of medical care.

Cutaneous ulcerative lichen planus exhibiting pathergy, response to acitretin.

While ulcerative lichen planus is a common diagnosis when involving the mucosa, it is uncommonly found on the cutaneous surface. Cutaneous ulcerative lichen planus is usually found on the palmar or plantar surfaces and has only rarely been described elsewhere. We describe a case of cutaneous ulcerative lichen planus involving the pretibia and exhibiting pathergy, which to our knowledge has not been previously reported. We also describe successful treatment with oral acitretin in conjunction with topical and intralesional corticosteroids.

Characteristics of office-based physician visits for cutaneous fungal infections. an analysis of 1990 to 1994 National Ambulatory Medical Care Survey Data.

To our knowledge, visits in the ambulatory setting due to cutaneous fungal infections have not been recently characterized. To provide descriptive epidemiology on ambulatory cutaneous fungal infection visits, we analyzed office-based physician visits for cutaneous fungal infections recorded in the National Ambulatory Medical Care Survey (NAMCS) from 1990 to 1994. The International Classification of Diseases (ICD-9) was used to define the cutaneous fungal infections. Sampling weights were applied to achieve the nationally representative estimates. From 1990 to 1994, an estimated 21.6 million physician office visits at an estimated cost of $216 million/y (office visit plus medication costs) were made for cutaneous fungal infection diagnoses. The total cost of office visits (without medication costs) was approximately $116 million/y. The total cost of the top 5 medications was approximately $68 million/y. According to an analysis of visits per physician specialist, dermatologists had the largest proportion of visits for cutaneous fungal infections. The cost associated with the diagnosis and management of cutaneous fungal infections is significant. Of all the physician specialists, dermatologists treated the most cutaneous fungal infections.