The United States dermatology inpatient workforce between 2013 and 2019: a Medicare analysis reveals contraction of the workforce and vast access deserts-a cross-sectional analysis.

While time spent practicing inpatient dermatology has decreased since the 1990s, less is known about the current state of inpatient dermatology. We describe the distribution and frequency of inpatient dermatology encounters servicing the United States Medicare population between 2013 and 2019. Cross-sectional analysis of publicly available inpatient Medicare Part B claims data from 2013 to 2019 was conducted. Main outcomes and measures were characteristics and trends of dermatologists performing inpatient encounters. Categorical variables were compared using χ2 analysis. Trends were analyzed for linearity using Pearson correlation coefficient. 782 physicians met inclusion criteria for inclusion. Dermatologists were more often male (56.5%), possessing allopathic Medical Doctorate (MD) (86.3%), and in metropolitan settings (98.2%). However, proportion of female inpatient dermatologists increased significantly (37.9% to 46.2%). Across rural and metropolitan practices, number of inpatient physicians (2013: 356; 2019: 281) and number of medical centers in which dermatology encounters occurred (2013: 239; 2019: 157) decreased, more significantly in non-residency-associated institutions. Spatial analysis revealed wide regions lacking dermatologists meeting defined criteria. Limitations included the need for ten Medicare inpatient encounters for inclusion, counties without reported data. In conclusion, the number of dermatologists performing > 10 inpatient encounters per year is decreasing, and large variations exist in the number of U.S. inpatient dermatology visits.

Eligibility Criteria for Active Ulcerative Pyoderma Gangrenosum in Clinical Trials: A Delphi Consensus on Behalf of the UPGRADE (Understanding Pyoderma Gangrenosum: Review and Assessment of Disease Effects) Group.

At present, there are no standardized guidelines for determining patient eligibility for pyoderma gangrenosum (PG) clinical trials. Thus, we aim to determine which clinical features, histopathological features, or laboratory features should be included in active ulcerative PG clinical trial eligibility criteria for treatment-naïve patients and patients already treated with immunomodulating medications (treatment-exposed patients). This study employed 4 rounds of the Delphi technique. Electronic surveys were administered to 21 international board-certified dermatologists and plastic surgeon PG experts (June 2022-December 2022). Our results demonstrated that for a patient to be eligible for a PG trial, they must meet the following criteria: (i) presence of ulcer(s) with erythematous/violaceous undermining wound borders, (ii) presence of a painful or tender ulcer, (iii) history/presence of rapidly progressing disease, (iv) exclusion of infection and other causes of cutaneous ulceration, (v) biopsy for H&E staining, and (vi) a presence/history of pathergy. These criteria vary in importance for treatment-naïve versus treatment-exposed patients. Given the international cohort, we were unable to facilitate live discussions between rounds. This Delphi consensus study provides a set of specific, standardized eligibility criteria for PG clinical trials, thus addressing one of the main issues hampering progress toward Food and Drug Administration approval of medications for PG.

Smaller hospital discharge volume and urban area are associated with higher proportional cellulitis discharges.

Cellulitis is commonly misdiagnosed, resulting in increased healthcare costs and complications. There is little published work regarding the relationship between hospital characteristics and cellulitis discharge rates. Here, we performed a cross-sectional analysis of cellulitis inpatient discharges using publicly available national data to examine hospital characteristics associated with higher proportional cellulitis discharge rates. The results of our study showed a strong association of increased proportion of cellulitis discharges in association with hospitals that discharged fewer total patients and a direct association with urban location. The factors that influence hospital cellulitis discharge diagnoses are numerous, and while its overdiagnosis remains a source of medical overspending and complications, our study may provide direction for more focused efforts to increase dermatology care in lower volume hospitals and urban areas.

Risk factors for loss of follow-up after asynchronous dermatology eConsult concerning for skin cancer.

Asynchronous electronic consultations (e-consults) can be a useful tool for the screening of cutaneous lesions, but may offer a malpractice risk. We characterized factors affecting initial eConsult office follow-up in a cohort of patients with documented neoplasm of uncertain behavior. Patients with an ICD 10 code of neoplasm with uncertain behavior (D48.5) at The Ohio State University that received an E-consult order from May 2017 to May 2021 were queried. Information collected included patient demographics, status of follow-up in-office appointment, referral status, and health care utilization. In-office follow-up appointments were defined as completed, cancelled/no-show or no-contact. 667 patients with a diagnosis of D48.5 were identified as having completed an eConsult. 427 (64%) patients had a documented phone/electronic message notifying the patient of the results of the eConsult. Year of encounter (0.88 [0.79-0.97]) and number of previously completed ambulatory visits (0.86 [0.77-0.96]) were significantly associated with documentation of phone/electronic message in the univariate and multivariate model. 429 (84%) patients had a dermatology office follow-up encounter while 82 (16%) had no appointment scheduled. Language spoken, referral status and race were significant in the univariate model, though race was the only significant variable in the multivariate model (P < 0.003). Asynchronous electronic consults to assess possible cutaneous neoplasms is an important tool for population screening of skin cancer. Dermatologists and health systems implementing an eConsult model for screening purposes should be aware of risk factors for loss of follow-up. Additional systems need to be implemented to ensure minorities and non-native English speakers are obtaining adequate dermatologic care.

Predictors of 30-day readmission in Stevens-Johnson syndrome and toxic epidermal necrolysis: A cross-sectional database study.

BACKGROUND: The predictors of readmission in Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) have not been characterized. OBJECTIVE: To determine the variables predictive of 30-day readmission after SJS/TEN hospitalization. METHODS: We performed a cross-sectional study of the 2010-2014 Nationwide Readmissions Database. Bivariate and multivariable logistic regression was used to evaluate associations of patient demographics, comorbidities, and hospital characteristics with readmission. Aggregate and per-readmission costs were calculated. RESULTS: There were 8837 index admissions with SJS/TEN reported; of these, 910 (10.3%) were readmitted, with diagnoses including systemic infection (22.0%), SJS/TEN (20.6%), and cutaneous infection (9.1%). Associated characteristics included age 45 to 64 years (odds ratio [OR], 1.88; 95% confidence interval [CI], 1.43-2.49), Medicaid insurance (OR, 1.83; 95% CI, 1.48-2.27), and nonmetropolitan hospital admission (OR, 1.67; 95% CI, 1.31-2.13). Associated comorbidities included HIV/AIDS (OR, 2.48; 95% CI, 1.63-3.75), collagen vascular disease (OR, 2.38; 95% CI, 1.88-3.00), and metastatic cancer (OR, 2.16; 95% CI, 1.35-3.46). The median per-readmission cost was $10,019 (interquartile range, $4,788-$16,485). LIMITATIONS: The Nationwide Readmissions Database lacks the ability to track the same patient across calendar years. The diagnostic code lacks specificity for hospitalizations <3 days. CONCLUSIONS: Thirty-day readmissions after SJS/TEN hospitalizations are common. Dedicated efforts to identify at-risk patients may improve peridischarge continuity.

Improved patient access and outcomes with the integration of an eConsult program (teledermatology) within a large academic medical center.

BACKGROUND: Insurance, racial, and socioeconomic health disparities continue to pose significant challenges for access to dermatologic care. Studies applying teledermatology to increase access to underinsured individuals and ethnic minorities are limited. OBJECTIVE: To determine how the implementation of a teledermatology program affects access to health care and patient outcomes. METHODS: A cross-sectional evaluation was performed of all ambulatory dermatology referrals and electronic dermatology consultations (eConsults) at Ohio State University within a 25-month period. RESULTS: Compared with ambulatory referrals, eConsults served more nonwhite patients (612 of 1698 [36.0%] vs 4040 of 16,073 [25.1%]; P < .001) and more Medicaid enrollees (459 of 1698 patients [27.0%] vs 3266 of 16,073 [20.3%]; P < .001). In addition, ambulatory referral patients were significantly less likely to attend their scheduled appointment compared with eConsult patients, as either "no-shows" (246 of 2526 [9.7%] vs 3 of 62 [4.8%]) or cancellations (742 of 2526 [29.4%] vs 8 of 62 [12.9%]; P = .003). There were fewer median days to extirpation for eConsult patients compared with ambulatory referral patients (interquartile range; 80.7 ± 79.8 vs 116.9 ± 86.6 days; P = .004). CONCLUSION: Integrating dermatologic care through a telemedicine system can result in improved access for underserved patients through improved efficiency outcomes.

Dermatology-specific and all-cause 30-day and calendar-year readmissions and costs for dermatologic diseases from 2010 to 2014.

BACKGROUND: Readmissions for skin disease, particularly for the same diagnosis and over time, have not been well studied. OBJECTIVE: To characterize hospital readmissions for skin disease. METHODS: A cross-sectional observational study examined the Nationwide Readmissions Database from 2010 to 2014, a national sample of hospital discharges in the United States. RESULTS: Of the patients in 3,602,599 dermatologic hospitalizations from 2010 to 2014, 9.8% were readmitted for any cause, 3.3% were admitted for the same diagnosis within 30 days, and 7.8% were readmitted for the same diagnosis within the calendar year (CY). The cost of all CY same-cause readmissions was $508 million per year. Mycosis fungoides had the highest 30-day all-cause readmission rate (32%), vascular hamartomas and dermatomyositis had the highest 30-day same-cause readmission rates (21% and 18%, respectively), and dermatomyositis and systemic lupus erythematosus had the highest CY same-cause readmission rates (31% and 24%, respectively). Readmission rates stayed stable from 2010 to 2014. Readmission for the same diagnosis was strongly associated with Medicaid and morbid obesity. LIMITATIONS: This study is a broad description of hospitalizations for skin disease. Conclusions for individual diseases are not intended. CONCLUSION: The rates and costs of readmissions for skin diseases remained high from 2010 to 2014. This study identifies diseases associated with high risk of hospital readmission, but disease-specific studies are needed. The diseases and risk factors presented should guide additional studies focused on strategies to reduce readmissions in specific skin diseases.

Office-based dermatologic diagnostic procedure utilization in the United States Medicare population from 2000-2016.

BACKGROUND: Potassium hydroxide preparations (KOH) and tissue examinations for ova and parasites (O&P) are cost-effective office-based tests. No studies have quantified their utilization and economic impact. METHODS: The objective is to determine the billing patterns and costs of office-based diagnostic procedures in the Medicare population. We conducted a cross sectional study using the Part B National Summary Data File (2000-2016) and the Physician and Other Supplier Public Use File (2012-2015) released by the Centers for Medicare & Medicaid Services. RESULTS: In 2016, the total number of claims among all providers was 28,432 (KOH) and 52,182 (O&P), representing a decrease since 2000 (KOH, -41.8%; O&P, -43.4%). The total claims for in-office procedures by dermatologists per 10,000 beneficiaries decreased between 2012 and 2015 (KOH, -18.8%; O&P, -26.6%). Fewer dermatologists submitted claims for the tests (KOH, -11.3%; O&P, -16.6%). The total single (SB) and multiple (MB) biopsy claims by dermatologists per 10,000 beneficiaries decreased between 2012 and 2015 (SB, -1.8%; MB, -2.7%). The 2016 aggregate payments (% change since 2000) for KOH and O&P were $163,127.75 (-60.4%) and $299,074.18 (-61.6%), respectively; for SB and MB, they were $240,047,487.98 (+142.3%) and $38,214,117.22 (+79.2%), respectively. CONCLUSION: Fewer dermatologists submit claims for KOH and O&P each year. Future studies should evaluate whether this is due to a loss of cost-efficacy, and secondly, if it is related to decreased reimbursement, burdensome in-office laboratory regulations, or changing provider preferences.

Trends and Scope of Dermatology Procedures Billed by Advanced Practice Professionals From 2012 Through 2015.

Importance: Advanced practice professionals (APPs) such as nurse practitioners and physician assistants independently perform a large number and variety of dermatologic procedures, but little is known about how the number and scope of these procedures have changed over time. Objective: To examine the trends in scope and volume of dermatology procedures billed by APPs over time. Design, Setting, and Participants: A longitudinal study was conducted using the Medicare Provider Utilization and Payment Data: Physician and Other Supplier Public Use File from 2012 through 2015. The data encompass nearly all outpatient procedures paid by Medicare Part B in the United States and include the type of clinician under which procedures were billed. Main Outcomes and Measures: For each type of dermatology procedure, the total number performed by APPs and the total number performed by dermatologists each year. Results: The total number (and percentage) of all dermatologic procedures performed by APPs increased from 2.69 million of 30.7 million (8.8%) in 2012 to 4.54 million of 33.9 million (13.4%) in 2015. The most common procedures performed by APPs in 2015 were destructions of benign neoplasms (3.6 million), biopsies (788 834), and destructions of malignant neoplasms (48 982). The numbers of patch tests, removals of benign and malignant neoplasms, intermediate and complex repairs, flaps, and surgical pathologic specimen examinations by APPs also increased each year from 2012 through 2015. Conclusions and Relevance: The number and scope of dermatologic procedures performed by APPs appear to be increasing over time. These procedures can be difficult and invasive. This study suggests that further studies are needed to determine what association these procedures have with patient outcomes and the potential need for more formal training.

Prescription patterns and costs of acne/rosacea medications in Medicare patients vary by prescriber specialty.

BACKGROUND: Prescription patterns for acne/rosacea medications have not been described in the Medicare population, and comparisons across specialties are lacking. OBJECTIVE: To describe the medications used for treating acne/rosacea in the Medicare population and evaluate differences in costs between specialties. METHODS: A cross-sectional study was performed of the 2008 and 2010 Centers for Medicare and Medicaid Services Prescription Drug Profiles, which contains 100% of Medicare part D claims. RESULTS: Topical antibiotics accounted for 63% of all prescriptions. Patients ≥65 years utilized more oral tetracycline-class antibiotics and less topical retinoids. Specialists prescribed brand name drugs for the most common topical retinoids and most common topical antibiotics more frequently than family medicine/internal medicine (FM/IM) physicians by 6%-7%. Topical retinoids prescribed by specialists were, on average, $18-$20 more in total cost and $2-$3 more in patient cost than the same types of prescriptions from FM/IM physicians per 30-day supply. Specialists (60%) and IM physicians (56%) prescribed over twice the rate of branded doxycycline than FM doctors did (27%). The total and patient costs for tetracycline-class antibiotics were higher from specialists ($18 and $4 more, respectively) and IM physicians ($3 and $1 more, respectively) than they were from FM physicians. LIMITATIONS: The data might contain rare prescriptions used for conditions other than acne/rosacea, and suppression algorithms might underestimate the number of specialist brand name prescriptions. CONCLUSION: Costs of prescriptions for acne/rosacea from specialists are higher than those from primary care physicians and could be reduced by choosing generic and less expensive options.

The cost of topical immunomodulator therapy in Medicare patients varies by prescriber specialty.

BACKGROUND: Topical immunomodulators (TI)-including corticosteroids, calcineurin inhibitors, and vitamin D analogues-are commonly prescribed in multiple specialties, but cost comparisons are lacking. OBJECTIVE: To evaluate differences in costs of TI across specialties and determine associated variables. METHODS: A cross-sectional study was performed using the Centers for Medicare & Medicaid Services 2008 and 2010 Prescription Drug Public Use Profiles, which contain 100% of drug claims made by Medicare beneficiaries. RESULTS: Branded drugs cost an average of $174.02 more than generics per 30-day supply (P < .001). Differences in health insurance benefit phase, drug choice, brand name, and coverage type were the greatest determinants of patient cost (P < .001). Prescriptions for low-, medium-, and high-potency TI from specialists (mostly dermatologists) cost more than those from family medicine, internal medicine, and psychiatry/neurology physicians; total costs of a 30-day supply from a specialist differed from family and internal medicine physicians by $7.36-$14.57, and patient costs were higher for specialists by $1.69-$3.16 (P < .01). Brand names were prescribed 8% of the time by specialists and 1.4%-3.1% by nonspecialists. LIMITATIONS: We were unable to adjust for some confounders of cost, such as medication weight or treated body area, and the data does not reflect previous treatment failures or use by non-Medicare patients. CONCLUSION: The costs of TIs prescribed by specialists (primarily dermatologists) are higher than those prescribed by primary care physicians and could be reduced by choosing more generics within the respective potency classes.