Race and ethnicity are inadequate predictors of ambulatory visit length and utilization of preventive services.

Health disparities can be experienced by any disadvantaged group who has limited access to healthcare or decreased quality of care. Quality of care can be measured by physician-patient communication measures such as length of visit, health outcomes, patient satisfaction, or by the services one receives such as screening or health education. This study aims to determine the relationship between length of physician-patient encounter, number of preventive services, ethnicity, and race. This study utilizes data from the National Ambulatory Medical Care Survey (NAMCS) from 2007 to 2016. Visits with a single diagnosis were selected. Visits with the five most frequent diagnoses were selected by International Classification of Diseases, Ninth or Tenth Revision (ICD-9/ICD-10) classification. The primary outcome is time spent with a physician in minutes and the number of preventive services provided represented by the Preventive Service Index (PSI). Of 255,916 visits, non-white individuals made up 16.2% (95% Confidence Interval 15.9-16.4) while Latinos represented 13.4% (95%CI 13.2-13.6) of individuals. Multivariate analysis revealed minimal differences in visit length in race and ethnic groups regardless of diagnosis. Greater PSI was associated with individuals less than 43 years old (Odds Ratio (OR) 2.0, 95% CI 1.8-2.3, p =< 0.0001), those who reside in metropolitan statistical areas (MSAs) (OR 1.2, 95% CI 1.1-1.4, p = 0.006), non-white individuals (OR 1.2, 95% CI 1.1-1.3, p = 0.004), and those with private insurance (OR 1.3, 95% CI 1.1-1.4, p =< 0.0001). Race and ethnicity do not predict length of time with a physician regardless of diagnosis. Age, race, location within a metropolitan area, and insurance are significant but minimal predictors of receiving preventive services in the rank-order leading five most frequent diagnoses. This large, population-based study highlights improvements in the distribution of healthcare services from previous studies.

Recommendations for Cost-Conscious Treatment of Basal Cell Carcinoma.

BACKGROUND: Basal cell carcinoma (BCC) affects 3.3 million Americans annually. Treatment modalities for BCC include many surgical and nonsurgical options. The cost of BCC treatment can pose a substantial burden to patients and the healthcare system. Cost can be an important consideration in BCC treatment planning. OBJECTIVE: We present an approach to the management of BCC when cost reduction is a priority. METHODS: A PubMed literature search identified studies on effectiveness of current BCC therapies. Treatment prices were obtained from the Medicare National Fee Schedule, GoodRx, and pharmaceutical companies. The American Academy of Dermatology's (AAD) guidelines for treating BCC were used to develop recommendations for cost-reductive treatment. RESULTS: The cost of treating a primary superficial BCC < 0.5 cm arising on Area M (cheeks, forehead, scalp, neck, jawline, pretibial surface) was $143 with curettage and electrodesiccation (C&E), $143 with cryosurgery, $210 with standard excision and simple reconstruction (SE), $1221 with Mohs Micrographic Surgery (MMS) and simple reconstruction, $472 with imiquimod, $186 with 5-fluorouracil (5-FU), and $354-$371 for photodynamic therapy (PDT). The cost of treating a primary nodular BCC 1.1-2 cm arising on Area L (trunk and extremities, excluding pretibial surface, hands, feet, nail units and ankles) was $183 with C&E, $183 with cryosurgery, $251 with SE and simple reconstruction, $1163-1351 with MMS and simple reconstruction, $472 with imiquimod, $186 with 5-FU, and $354-$371 for photodynamic therapy (PDT). The cost of treating a giant BCC (BCC > 10 cm with aggressive behavior) was $465-3311 with radiation, $139,560 with vismodegib, $144,452 with sonidegib, ~ $44.5 with cisplatin (medication cost only), and at least $184,836 with cemiplimab-rwlc. CONCLUSIONS: For a primary superficial BCC < 0.5 cm arising on Area M, the cost-conscious algorithm prioritizes C&E or cryosurgery. For a primary nodular BCC 1.1-2 cm arising on Area L, the cost-conscious algorithm prioritizes C&E, cryosurgery, or 5-FU. For a giant BCC, the cost-conscious algorithm identifies superficial radiation therapy as first line.

An effective patient-supporting intervention for topical treatment of psoriasis is also cost-effective.

BACKGROUND: A randomized controlled trial (RCT) of topical treatment combined with regular patient support provided by dermatological nurses in structured consultations of 20-min duration every fourth week improved psoriasis severity, quality of life and treatment adherence compared with topical treatment combined with standard patient support, which is seeing a dermatologist every third month. OBJECTIVES: To examine the economic impact of the patient support from a healthcare-sector perspective in the RCT. METHODS: Costs for primary care, secondary healthcare services and costs of prescription medication were compared for the intervention and nonintervention groups over 48 weeks. Health benefits were expressed in terms of quality-adjusted life-years (QALYs) measured by the EuroQoL five-dimension three-level questionnaire. Regression analyses were used to estimate incremental cost and QALYs. RESULTS: The incremental cost was estimated at £462, with an average increase of 0.08 QALYs per patients for participants receiving the intervention compared with those receiving standard care. The incremental cost-effectiveness ratio for patients was £5999/QALY. The intervention had an almost 100% probability of being cost-effective at a willingness-to-pay threshold of £30 000 per QALY. CONCLUSIONS: Addressing adherence issues is critical to improving outcomes for patients with psoriasis who use topical treatment. The personal support intervention was effective with an acceptable increase in costs.

Patient Preferences for Acne Vulgaris Treatment and Barriers to Care: A Survey Study.

The associated direct and indirect costs of acquiring acne vulgaris (acne) treatment from a clinician may prohibit some patients from doing so. Barriers to care may also influence patient preferences for treatment, and while both over-the-counter (OTC) and prescription acne treatments are efficacious, preferences for OTC or prescription acne medications are not well established. We recruited 529 adult subjects from the United States through Amazon Mechanical Turk (MTurk), and subjects were surveyed about acne, their acne treatment preferences, and any barriers to care. A total of 450 subjects passed the attention check and were included in the analysis. Of respondents who had tried both OTC and prescription treatments (n=223), more respondents reported that they preferred prescription treatments (130/223, 58.3%), compared with OTC treatments (64/223, 28.7%); or no preference (29/223, 13.0%; P=0.00001). Almost half of all respondents also stated that they experienced barriers to accessing medical care for acne treatment (192/450 42.7%); cost and transportation were the top 2 factors. Considering how common barriers are, and their everchanging nature, some patients may benefit from a discussion of alternative non-prescription acne treatments, serving as a bridge to therapy or while patients are unable to reach a medical provider. J Drugs Dermatol. 2022;21(11):1191-1195. doi:10.36849/JDD.6940.

Reducing costs in atopic dermatitis.

Atopic dermatitis (AD) is a common relapsing inflammatory skin condition associated with a high economic burden due to its chronicity and multitude of direct and indirect treatment costs. AD disproportionately impacts children and minority populations, and treatment choices are cost-prohibitive for many patients. Our objective was to describe the treatment and management of AD from a cost-conscious perspective. A review of the literature was conducted with PubMed using the following keywords: AD, cost, medications, treatment, management, efficacy, adherence, education, and prophylactic. The use of moisturizers prophylactically in high-risk infants who have yet to develop AD may reduce incidence of disease and associated costs. Increasing patient medication adherence and moisturizing between flares also reduces costs in AD. The use of corticosteroids as the first-line treatment is efficacious and cost-effective for mild cases of AD, however, in severe cases of AD corticosteroids alone are not sufficient. Systemic biologics are necessary in some patients with severe cases of AD; however, they are associated with high costs. Phototherapy, through portable home units, tanning beds, and natural sunlight are cost-effective alternatives. Effective management of AD improves with education programs for both the patient and their family, reducing long-term costs in the management of this disease. Reducing AD treatment costs requires consideration of prophylactic therapies, patient education, and should differ based on the severity of disease. A multifaceted approach to AD treatment reduces costs and health-care barriers.

Patient assessment of 5-fluorouracil and imiquimod for the treatment of actinic keratoses: a retrospective study of real-world effectiveness.

BACKGROUND: Despite the superior efficacy of topical therapies for the treatment of actinic keratoses in clinical trials, cryosurgery remains a frequent treatment modality in clinical practice. Little is known about patients' experience of real-world use of topical therapy. OBJECTIVE: To determine the real-world effectiveness and tolerability of 5-fluorouracil and imiquimod in the treatment of actinic keratoses. METHODS: A phone survey and chart review was conducted among 51 patients prescribed 5-fluorouracil (N = 27) or imiquimod (N = 24) for actinic keratoses. RESULTS: Six patients (22%) in the 5-fluorouracil group and five patients (21%) in the imiquimod group reported severe local skin reactions, and three patients in both groups (11% and 13%, respectively) were unwilling to use the respective topical therapies again. Patients in the 5-fluorouracil group had, on average, 3.3 fewer cryosurgery spot treatments following topical treatment. Patients in the imiquimod group averaged 2.0 fewer spot treatments. LIMITATIONS: While this study provides information on real-world experiences, patients' responses were limited by the ability to recall treatment and potential adverse effects. CONCLUSION: High rates of skin reactions, prolonged discomfort, and the continued need for procedural treatments may make patients less willing to use topical 5-fluorouracil or imiquimod for actinic keratoses.

Adherence to levetiracetam for management of epilepsy: Assessment with electronic monitors.

INTRODUCTION: Anti-seizure medications are used to manage epilepsy and require long-term adherence to maintain therapeutic drug levels. We assessed adherence to levetiracetam and the use of a digital intervention to improve adherence in patients with epilepsy. METHODS: 30 participants with epilepsy were randomized 1:1 either to a digital email adherence intervention or control group. All patients were provided levetiracetam equipped with electronic monitoring caps to assess patient adherence to medication. Patients were followed for 6 months, with return visits at 1 month, 3 months, and 6 months. RESULTS: Subjects randomized to the control arm (n = 15) took 66% of the prescribed doses compared to the intervention group, who took 65% of prescribed doses (n = 15). Nine participants did not complete the study. Of the twenty-one participants that completed the study, the overall rate of adherence was 72% of prescribed doses taken. Two subjects in the control group and three subjects in the intervention group were adherent every month of the study-taking at least 80% of prescribed doses. Those randomized to the control group took the correct number of doses 44% of days in the study, and those in the intervention group took the correct number of doses 37% of days. DISCUSSION: Poor adherence to levetiracetam is common. An internet-based email survey intervention did not improve adherence to levetiracetam in epilepsy patients. Further advances in adherence are needed to help patients receive the maximum benefit of their medical treatments.

Long-term improvement of psoriasis patients' adherence to topical drugs: testing a patient-supporting intervention delivered by healthcare professionals.

BACKGROUND: Psoriasis affects 2-4% of the Western adult population and is a socio-economic burden for patients and society. Topical drugs are recommended as first-line treatment for mild-to-moderate psoriasis, but low adherence is a barrier to treatment success. Psoriasis patients require support, in order to improve their long-term use of topical drugs. The project aims to test whether a patient-supporting intervention delivered by dermatology nurses can reduce the severity of psoriasis, improve the use of topical drugs, and is cost-effective compared to standard procedure. METHODS: The intervention consists of improved support delivered to patients by three experienced dermatology nurses, who will support patients on a regular basis by consultations with a focus on providing reminder systems, accountability, reinforcement, and building trust in the treatment. Each patient will be supported by the same dermatology nurse throughout the entire study period. The effect will be compared with standard procedure. The intervention will be tested in a randomized controlled trial during a 48-week period. A group of patients with moderate-to-severe psoriasis (psoriasis affecting ≥ 4% of the total body surface area) and 18-85 years of age who are prescribed topical treatment will be randomized to a non-intervention (n ≈ 57) or intervention group (n ≈ 57). Participants in both arms will be prescribed topical preparations containing corticosteroid and/or calcipotriol. The primary outcome will be a change in the severity of psoriasis, measured as reduction in the Lattice-System Physician's Global Assessment. Secondary outcomes will include changes in health-related quality of life (measured by disease specific and generic questionnaires), primary adherence (i.e., proportion of filled prescriptions), and secondary adherence by objective measure (rate of topical drug consumption (obtained by weighing medication packages) compared to estimated recommended consumption). A health economic evaluation is planned to run alongside the trial. Participants' total health costs will be estimated on the basis of health costs reported to the national health registries and costs spent on the intervention, after which a cost-utility and cost-effectiveness analysis will be carried out. DISCUSSION: If the intervention can reduce the severity of psoriasis in a significant manner and is economically favorable compared to standard treatment, there is potential for implementing the intervention in dermatology clinics. TRIAL REGISTRATION: Clinicaltrials.gov NCT04220554 . Registered on January 7, 2020. Study results, either positive, negative, or inconclusive, will be published on www.clinicaltrials.gov . Trial registration no. with the Danish Regional Committee on Health Research Ethics, registration no. 72613.

How the National Ambulatory Medical Care Survey has been used to identify health disparities in the care of patients in the United States.

BACKGROUND: Healthcare disparities negatively impact patient health outcomes; addressing disparities could improve quality of life and decrease overall healthcare cost. The National Ambulatory Medical Care Survey (NAMCS) is an objective and reliable source for collecting information on United States (U.S.) ambulatory medical care service visits and may be a useful tool for identifying potential disparities in care. OBJECTIVE: The purpose of this literature review is to describe studies utilizing NAMCS to capture U.S. healthcare disparities. METHODS: PubMed was searched for scientific articles that utilized NAMCS to determine health disparities in the U.S. The keywords queried included "NAMCS" or "National Ambulatory Medical Care Survey" and "disparity" or "disparities" as a pair or additionally paired with one of the following: "race", "ethnicity", "age", "gender", "geography", or "insurance". RESULTS: 66 studies were found that incorporated NAMCS data from 1980-2016 into their methods to measure outcomes relating to health disparities. Disparities were found in the following categories: race/ethnicity, geographic location, age, insurance type, gender, specialist care versus primary care, body habitus, and preexisting conditions affecting patient outcomes. Disparities were identified in pain management, neurology, dermatology, psychiatry, patient communication access, and non-specialty specific or primary care visits related to disease conditions, screening, and treatment plans. LIMITATIONS: Only PubMed was utilized as a search engine and may not encompass all studies on NAMCS and health disparities. NAMCS is a cross-sectional database and does not allow for longitudinal analyses. CONCLUSIONS: NAMCS may be an underused tool given the limited number of articles that identify health disparities using it. Research studies utilizing NAMCS may identify potential disparities ultimately leading to better healthcare outcomes.

Real-world biologic and apremilast treatment patterns and healthcare costs in moderate-to-severe plaque psoriasis.

Plaque psoriasis is a chronic disease requiring long-term therapy. However, long-term real-world treatment patterns and costs are not well characterized. This study examined treatment patterns and healthcare costs among patients newly initiating a biologic or apremilast for moderate-to-severe plaque psoriasis. Included patients had ?1 prescription for secukinumab, ixekizumab, adalimumab, ustekinumab, etanercept, or apremilast between 01/01/2015 and 08/31/2018, no prior use of the index medication, and continuous enrolment 12 months pre-index and 24 months post-index. Treatment adherence, non-persistence, discontinuation, switching, use of combination therapy, and re-initiation were assessed at 12, 18, and 24 -months post-index. In addition, total and psoriasis-related healthcare costs were evaluated at 24 months. A total of 7,773 patients with 24-month follow-up were included. Overall, adherence was low (21.3%-33.5%) and non-persistence was high (58.4%-86.5%) over 24 months. Discontinuation (38.4%-51.3%), switching (29.7%-52.6%), combination therapy (27.6%-42.9%), and re-initiation of the index medication (19.3%-44.5%) were common. Healthcare costs were high and mostly contributed by psoriasis treatment. Therefore, maintaining disease control on long-term therapy is still challenging for many patients.

Comparative cost-effectiveness of tildrakizumab and other commonly used treatments for moderate-to-severe psoriasis.

OBJECTIVES: To compare the cost-effectiveness of tildrakizumab with other commonly used biologics and apremilast as the first-line treatment for moderate-to-severe plaque psoriasis from a US health plan's perspective. METHODS: A 10-year cost-effectiveness model was developed to compare the incremental cost per extra month with a Psoriasis Area and Severity Index (PASI) 75 response. Patients were assumed to receive one of the treatments evaluated as their first-line treatment at the outset of the analysis. Nonresponders (PASI <75) discontinued their current treatment; 25% went on to receive a mix of topical therapies, phototherapies, and other systemic therapies, while 75% received a second-line therapy before receiving a mix of topical therapies, phototherapies, and other systemic therapies. Direct medical costs were calculated based on drug acquisition, administration, and monitoring costs. RESULTS: The incremental cost per extra month a patient had a PASI 75 response was lowest for brodalumab ($3,685), infliximab ($4,102), apremilast ($4,770), and tildrakizumab ($5,150), followed by risankizumab ($5,319), secukinumab ($5,675), guselkumab ($5,784), ixekizumab ($5,900), adalimumab ($5,943), ustekinumab ($6,131), etanercept ($6,618), and certolizumab pegol ($13,476). CONCLUSION: Tildrakizumab was among the most cost-effective first-line treatments for moderate-to-severe psoriasis and was more cost-effective than risankizumab, secukinumab, guselkumab, ixekizumab, adalimumab, ustekinumab, etanercept, and certolizumab pegol.

Real-world treatment patterns and healthcare costs of biologics and apremilast among patients with moderate-to-severe plaque psoriasis by metabolic condition status.

OBJECTIVES: To compare treatment patterns and costs among psoriasis patients with and without metabolic conditions newly initiating a biologic or apremilast. METHODS: Adult patients included had ≥1 prescription for secukinumab, adalimumab, ustekinumab, etanercept, or apremilast between 01/01/2015 and 08/31/2018 (date of first prescription was index date) and no index drug use in the 12-months pre-index, and continuous enrollment in the 12-month pre-index and 24-month post-index periods. Patients were divided into mutually exclusive treatment cohorts and stratified by their pre-index metabolic condition status. Treatment patterns (adherence, non-persistence, switching, discontinuation, use of combination therapy, and re-initiation) and healthcare costs were compared. RESULTS: Overall, 7773 patients were included; 47.5-56.7% had a metabolic condition. Except for the apremilast group, patients with metabolic conditions had higher discontinuation (secukinumab: 50.6% vs. 43.7%; adalimumab*: 53.9% vs. 48.7%; ustekinumab*: 41.9% vs. 35.1%; etanercept: 42.8% vs. 41.2%; apremilast: 43.1% vs. 46.1%) and switching (secukinumab: 48.1% vs. 41.2%; adalimumab*: 47.8% vs. 41.9%; ustekinumab*: 34.5% vs. 25.3%; etanercept*: 53.6% vs. 51.5%; apremilast: 45.8% vs. 44.6%) than patients without (*p < .05). Patients with metabolic conditions incurred significantly higher costs. CONCLUSION: Many psoriasis patients initiating biologics or apremilast had metabolic conditions. These patients had higher discontinuation and switching, and significantly higher healthcare costs.

Clinical recommendations made in dermatology publications are frequently not supported by adequate evidence.

OBJECTIVES: Absolute risk and cost-benefit analyses are necessary to guide clinical decision making. The purpose of this study was to evaluate whether clinical recommendations in dermatology publications were supported by adequate evidence. We also assessed whether dermatology residents report sufficient evidence when they author publications. METHODS: We analyzed the clinical cohort, case-control, and case series studies published in JAMA Dermatology and the Journal of American Academy of Dermatology from January 2018 to December 2018 for statistical significance, absolute associations, diagnostic and therapeutic clinical recommendations, and risk-benefit analysis. We also identified articles with a U.S. dermatology resident as first or second author. RESULTS: We found that the majority of articles reported statistical significance, but only 3% included absolute risk analyses and none had risk-benefit analysis. Furthermore, 42% of studies with a dermatology resident as a primary author reported statistical significance, but none provided absolute risk or risk-benefit analyses. CONCLUSIONS: Reviewers need to be more aware of the evidentiary needs required for clinical recommendations, and dermatology residents may benefit from additional statistics training.

An mHealth App to Support Patients With Psoriasis in Relation to Follow-up Consultations: Qualitative Study.

BACKGROUND: Teledermatology has the potential to help deliver health care by transforming the relationship between patients and health care professionals (HCPs), shifting the power of consultation so that patients can become more informed, assertive, and involved in their care. Mobile health (mHealth) is a promising and reliable tool for the long-term management of patients with psoriasis on systemic treatment. In an attempt to facilitate a more patient-centered approach in clinical practice, we designed and developed an mHealth solution to support patients with self-management and empowerment. OBJECTIVE: The aim of this study is to explore the experiences and perceptions of patients and health care professionals of using an mHealth solution that was developed using a participatory design approach. METHODS: This was an exploratory qualitative study. Data were collected through semistructured interviews with patients and focus group interviews with HCPs. RESULTS: All participants found it easy to use the mHealth solution, and the patients found it convenient. Patients' reflexivity was improved because they could prepare ahead of consultations. Video consultations provided patients with a degree of freedom in their everyday lives, with not having to attend in-person visits. Among the HCPs, there were concerns regarding their medical responsibilities, as they could not assess the patients' skin as they used to. The mHealth solution required new workflows and procedures that were not part of the existing consultation routines. CONCLUSIONS: The mHealth solution can strengthen the relationship between HCPs and patients and facilitate patients to become more active in their care. Alignment and structure in relation to the selection of eligible patient candidates for being offered the mHealth solution could reduce social health inequalities. In addition, video consultations changed HCPs' work practice, necessitating new types of skills to communicate with patients.

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.