Cognitive Bias in the Patient Encounter: Part I. Background and significance.

Cognitive bias may lead to diagnostic error in the patient encounter. There are hundreds of different cognitive biases, but certain biases are more likely to affect patient diagnosis and management. As during morbidity and mortality rounds, retrospective evaluation of a given case, with comparison to an optimal diagnosis, can pinpoint errors in judgment and decision-making. The study of cognitive bias also illuminates how we might improve the diagnostic process. In Part 1 of this series, cognitive bias is defined and placed within the background of dual process theory, emotion, heuristics, and the more neutral term judgment and decision-making bias.

Cognitive Bias in the Patient Encounter: Part II. Debiasing using an adaptive toolbox.

Cognitive bias may lead to medical error, and awareness of cognitive pitfalls is a potential first step to addressing the negative consequences of cognitive bias (see Part 1). For decision-making processes that occur under uncertainty, which encompass most physician decisions, a so-called "adaptive toolbox" is beneficial for good decisions. The adaptive toolbox is inclusive of broad strategies like cultural humility, emotional intelligence, and self-care that help combat implicit bias, negative consequences of affective bias, and optimize cognition. Additionally, the adaptive toolbox includes situational-specific tools such as heuristics, narratives, cognitive forcing functions, and fast and frugal trees. Such tools may mitigate against errors due to cultural, affective, and cognitive bias. Part 2 of this two-part series covers metacognition and cognitive bias in relation to broad and specific strategies aimed at better decision-making.

The association of anxiety with granuloma annulare: a case-control study of the National Institutes of Health 'All of Us' research programme.

Dear Editor, Granuloma annulare (GA) is an inflammatory skin disease that has been associated with diabetes, dyslipidaemia, hypothyroidism and autoimmune disorders.1,2 The annualized incidence and prevalence of GA in the USA are approximately 0.04% and 0.06%, respectively (with a female predominance).3 GA is clinically classified as localized (75% of cases), generalized or subcutaneous.4 There is a body of evidence supporting an association between several inflammatory dermatoses, such as psoriasis, and mental health conditions.5 Improvement of depression and anxiety following treatment of certain inflammatory dermatoses has also been described.5 It has been postulated that this association may, in part, relate to proinflammatory cytokines, which have been proposed to mechanistically connect inflammatory dermatoses and mental health conditions.6 A recent nested case-control study demonstrated a significant association of GA with depression, insomnia, opioid dependence and post-traumatic stress disorder.7 This study aims to investigate whether an association exists between GA and anxiety.

Racial and ethnic differences in barriers to care among US adults with chronic inflammatory skin diseases: A cross-sectional study of the All of Us Research Program.

BACKGROUND: Research on racial and ethnic differences in barriers to care among patients with chronic inflammatory skin diseases (CISDs) is limited. OBJECTIVE: To investigate the prevalence of a broad range of barriers to care among patients with CISDs across different racial and ethnic groups. METHODS: A cross-sectional study was conducted using survey data from participants with CISDs in the All of Us Research Program. Multivariable regression was used to analyze the relationship between race and ethnicity and experiencing barriers to care. RESULTS: Our study included 16,986 patients with CISDs. Compared to White patients, Black and Hispanic patients were significantly more likely to delay care because of cost and a broad range of additional structural barriers, including transportation, work, childcare, adult care, living in a rural area, and the lack of health care workforce diversity. However, associations between race and ethnicity and many barriers to care were substantially attenuated after controlling for insurance, income, and education. LIMITATIONS: The population studied was not a representative sample of US adults, and responses were not specific to dermatologic care. CONCLUSION: Racial and ethnic minority patients with CISDs, especially Black and Hispanic patients, are disproportionately affected by a broad range of barriers to care.

Baseline skin cytokine profiles determined by RNA in situ hybridization correlate with response to dupilumab in patients with eczematous dermatitis.

BACKGROUND: Dupilumab has revolutionized the treatment of atopic dermatitis. However, not all patients respond optimally, and this may relate to underlying molecular heterogeneity. Nevertheless, clinically useful and accessible methods to assess such heterogeneity have not been developed. OBJECTIVE: We assessed whether cytokine staining and/or histologic features correlate with clinical response to dupilumab in patients with eczematous dermatitis. METHODS: We retrospectively analyzed biopsies from 61 patients with eczematous dermatitis treated with dupilumab (90.2% met Hanifin-Rajka criteria for atopic dermatitis). RNA in situ hybridization was used to measure markers of type 2 (interleukin [IL]4, IL13), type 1 (interferon gamma) and type 3 (IL17A, IL17F, IL22) inflammation. Histologic features were also assessed. Patterns were compared among complete (n = 16), partial (n = 37), and nonresponders (n = 8) to dupilumab. RESULTS: We found that increased IL13 expression was associated with optimal response to dupilumab. In contrast, nonresponders tended to express less IL13 and relatively greater levels of type 1 and 3 cytokines. In addition, certain histologic features tended to correlate with improved response to dupilumab. LIMITATIONS: Retrospective approach and small size of the nonresponder group. CONCLUSION: Cytokine RNA in situ hybridization may aid in treatment selection for eczematous disorders. Moreover, personalization of treatment selection for inflammatory skin diseases may be possible.

Acute Epstein-Barr virus infection resembling cutaneous T-cell lymphoma.

Primary, acute Epstein-Barr virus (EBV) infection is associated with a variety of cutaneous eruptions, including the viral exanthem of infectious mononucleosis and erythema multiforme. Latent, chronic EBV infection can rarely result in development of lymphoproliferative disorders with cutaneous manifestations; however, these disorders do not arise from primary infection. In this report, we present a case of primary, acute EBV infection presenting with histopathologic features closely mimicking aggressive cytotoxic cutaneous T-cell lymphoma.

Migraine among adults with atopic dermatitis: a cross-sectional study in the All of Us research programme.

Atopic dermatitis (AD) has been previously associated with migraine headaches in paediatric and adolescent populations, though there is less evidence for this relationship among adults. In this cross-sectional study, we investigated the association between AD and migraine among a cohort of US adults in the All of Us research programme. After controlling for common comorbidities, we found that adults with AD were 89% more likely to have a diagnosis of migraine (OR = 1·89, P < 0·001).

Leveraging behavioral economics to promote treatment adherence: A primer for the practicing dermatologist.

The problem of suboptimal treatment adherence among patients with dermatologic or other diseases has not been adequately addressed in health care. Despite a wide range of efficacious therapies, nonadherence remains a primary driver of suboptimal clinical outcomes. Novel solutions to address this unmet need can be found in behavioral economics. By leveraging our understanding of human decision-making, we may better promote treatment adherence, thereby improving quality of life and decreasing economic burdens. Behavioral economics has been studied extensively in relation to topics such as health policy and health behaviors; however, there is a dearth of research applying this approach to chronic diseases and only a handful within dermatology. We conducted a scoping review in PubMed to identify articles that discuss behavioral economics and its application to treatment adherence in dermatologic patients, with a particular focus on psoriasis, followed by a summary of key ethical considerations. We found that such principles can be employed in cost-effective, scalable interventions that improve patient adherence to a range of medical therapies and lifestyle modifications.

Paradoxical eruptions to targeted therapies in dermatology: A systematic review and analysis.

BACKGROUND: Antibody-based therapies that inhibit proinflammatory cytokine signaling are commonly used in dermatology. Paradoxically, these medications may induce or exacerbate inflammatory disorders. OBJECTIVE: To summarize the spectrum of manifestations, incidence, timing, potential mechanisms of, and general management approaches to paradoxical cutaneous reactions induced by cytokine-targeted antibodies in dermatology. METHODS: We performed a systematic review and analysis of published cases of cutaneous paradoxical reactions (PRs) reported in association with tumor necrosis factor α, interleukin (IL) 12/23 (p40), IL-17A/17R, IL-23 (p19), and IL-4Rα inhibitors. RESULTS: We identified 313 articles reporting 2049 cases of PRs. Tumor necrosis factor α inhibitors resulted in 91.2% (1869/2049) of all cases, followed by IL-17/17R (3.5%), IL-4Rα (2.7%), IL-12/23 (2.4%), and IL-23 (0.01%) inhibitors. Psoriasiform and eczematous eruptions were the most commonly reported, but a wide spectrum of patterns were described. Phenotypically overlapping reaction patterns were common. Time to onset typically ranged from weeks to months but could occur more than a year later. Improvement or resolution upon discontinuation of the inciting drug was common. LIMITATIONS: This was a retrospective analysis. CONCLUSIONS: Familiarity with the clinical features of PRs from cytokine-blocking antibodies may facilitate efficient recognition and management.

Vaccination Recommendations for Psoriasis and Atopic Dermatitis Patients on Biologic Therapy: A Practical Guide.

Novel biologic therapies have revolutionized the treatment of psoriasis and atopic dermatitis. Although they are generally safe, they are immunomodulatory and therefore unique considerations apply in regards to infections and vaccine administration. This review aims to provide a clear and practical guide for dermatologists or other healthcare providers to reference when caring for psoriasis or atopic dermatitis patients being treated with biologic therapies using currently available guidelines and clinical data. Vaccinations for approved biologics including TNFα, IL-12/23, IL-23, IL-17, and IL-4/13 inhibitors will be discussed, with a special note on current COVID-19 vaccination recommendations.

Trends in the Cost and Utilization of Omalizumab in the Medicare Population: 2013-2017.

Background: Omalizumab has been demonstrated to be effective in treating chronic spontaneous urticaria (CSU) and was FDA approved for this indication in 2014. Previous work has shown that access to injectable biologics varies across US counties. In the present study we evaluate geographic and temporal trends in the utilization of omalizumab in the Medicare population by dermatologists, with its use by allergists and pulmonologists as comparators. Methods: We analyzed year-over-year trends in omalizumab utilization across geographic regions using the Medicare Provider Utilization and Payment Data: Part D files. Results: Utilization of omalizumab by dermatologists increased rapidly after its FDA approval, from 0.08 claims/100,000 enrollees totaling $209/100,000 enrollees in 2014 to 1.45 claims/100,000 enrollees totaling $3115/100,000 enrollees in 2017. Nonetheless, prescribing dermatologists were present in only 2.8% (95% Confidence Interval (CI): 2.0%-3.9%) and 0.2% (95% CI: 0.0%-0.5%) of metropolitan and non-metropolitan counties, respectively, in 2017, demonstrating limited availability, especially in non-metropolitan counties. Similarly, prescribers of any specialty were available in 32.9% (95% CI: 30.2%-35.6%) and 3.8% (95% CI: 3.1%-4.8%) of metropolitan and non-metropolitan counties, respectively, in 2017. Conclusions: Our data suggest that despite increasing omalizumab utilization, there remains a lack of access across many counties, particularly in non-metropolitan regions. Efforts to expand omalizumab prescriber accessibility in these counties may improve outcomes for patients with CSU.

Utilization, cost, and provider trends in patch testing among Medicare beneficiaries in the United States from 2012 to 2017.

BACKGROUND: Patch testing is the best diagnostic test for allergic contact dermatitis. However, there is presently a lack of data on the test's geographic availability and the characteristics of the providers offering this test across the United States. OBJECTIVE: To evaluate the geographic variation in the availability of patch testing for the Medicare population and to characterize the temporal trends of patch testing cost, use, and provider specialty from 2012 to 2017. METHODS: Retrospective cohort study of the Medicare Provider Utilization and Payment Data from 2012 to 2017. RESULTS: As of 2017, patch testing was available in 20.3% of metropolitan counties and in 1.1% of nonmetropolitan counties. From 2012 to 2017 in metropolitan regions, the number of beneficiaries tested by dermatologists grew by an average annual growth rate of 1.84%, whereas those tested by allergists grew by an average annual growth rate of 20.31%. Most providers that averaged use of 80 or more patches per beneficiary were dermatologists (76.3%). LIMITATIONS: Analysis was restricted to Medicare Part B claims; data were unavailable on individuals with commercial insurance. CONCLUSIONS: Most of the increase in patch testing utilization from 2012 to 2017 has been in metropolitan regions. Although growth was especially prominent among allergists in metropolitan counties, the majority of providers performing comprehensive patch testing were dermatologists.

Employment and Migration Patterns of Recent Micrographic Surgery and Dermatologic Oncology Fellowship Graduates.

BACKGROUND: There is currently an uneven distribution of the Mohs surgery workforce, with a dearth in nonurban areas. The relationship between training and employment locations of Mohs surgeons has not been studied. OBJECTIVE: To analyze the employment location of recent micrographic surgery and dermatologic oncology (MSDO) graduates in reference to residency and fellowship locations. MATERIALS AND METHODS: Data collection of training and practice locations of 421 MSDO fellowship graduates from 2012 to 2017. RESULTS: Thirty-two percent (n = 136) and 53% (n = 225) of MSDO fellowship graduates' first employment locations were located within 10 and 100 miles of either their residency or fellowship locations. Ninety-six percent of graduates were employed in a metropolitan location. Female graduates worked closer to training sites than male graduates, with 62% (n = 124) versus 46% (n = 102) working within 100 miles of either training site. Analysis by fellowship census region showed that graduates clustered around training sites in all regions, with 45% to 60% of graduates working within 100 miles of either training site. CONCLUSION: The majority of graduates chose to work in a metropolitan area. Training location strongly predicts employment location. More than 45% of graduates in any region worked within 100 miles of their residency or fellowship site, and a sizeable portion worked within 10 miles.

Psoriasis With Eczematous Features: A Retrospective Clinicopathologic Study.

BACKGROUND: Dermatopathologists sometimes encounter patients with features of psoriasis vulgaris and additional changes of eczematous dermatoses. These cases are challenging to diagnose, and the clinical implications are unclear. In the age of targeted therapy, it is important to improve our understanding of these findings so that patients are managed appropriately. OBJECTIVE: To characterize the clinical characteristics, histopathological features, diagnostic workup, successful treatment, and outcomes of patients with overlapping histopathologic features of psoriasis vulgaris and eczema. METHODS: We conducted a retrospective chart review of 20 patients who had received the histopathologic diagnosis of psoriasis vulgaris with eczematous changes noted on skin biopsy. A database that included information about clinical characteristics, comorbidities, histopathological features, diagnostic workup, treatment modalities, and outcomes was created and analyzed. RESULTS: Twenty patients were included in this study, with an average age of 57.3 years. After clinicopathologic correlation, most patients were diagnosed with psoriasis (85%), and the remainder were determined to have an eczematous dermatitis. Thirty-five percent of patients were diagnosed with allergic contact dermatitis, either in combination with psoriasis (6 patients) or alone (1 patient). Topical glucocorticoids were the most common effective therapy used, and systemic therapies were required in nearly half of patients for successful treatment. CONCLUSION: This study offers insights into the clinically and histopathologically challenging diagnosis of psoriasis vulgaris with eczematous changes and offers the diagnostic term "eczematized psoriasis" to describe these patients. The presence of allergic contact dermatitis should be considered in these patients.

Trends in office visits and treatment for urticaria in children in the United States, 1998-2016.

BACKGROUND/OBJECTIVES: Urticaria is a common condition with an estimated prevalence of up to 23% in the pediatric population. Studies characterizing visits and treatments for urticaria in the pediatric population are unavailable. Understanding visit and treatment trends for urticaria in the pediatric population may help inform care for patients with urticaria. METHODS: A total of 108 278 outpatient records from the National Ambulatory Medical Care Survey representing 3.4 billion visits by patients of age 18 and younger were analyzed. This study included the calendar years 1998 through 2016. RESULTS: Pediatricians saw the largest proportion of all visits (52.7%). Male and female patients accounted for approximately equal proportions of all visits for urticaria. There was a slight male predominance in visits to pediatricians (53.7%), whereas dermatologists saw female patients more frequently (63.3%). Most visits for urticaria were by non-Hispanic (78.1%) and White (78.2%) patients. H1 antihistamines were the most commonly prescribed treatment (70.3%), whereas topical corticosteroids were prescribed least frequently (4.9%). Topical corticosteroids were most frequently prescribed by dermatologists (7.7%). Non-H1 antihistamine and non-corticosteroid therapy were prescribed in 9.7% of all visits and in 4.5% of visits to pediatricians. Most visits for urticaria were to physicians in metropolitan areas (88.8%). Pediatricians saw the highest number of non-metropolitan area visits (56.3%). CONCLUSIONS: H1 antihistamines were the most commonly used therapy (70%), consistent with established treatment guidelines. Male and female pediatric patients present equally often for urticaria, but sex differences were seen with visit frequencies to certain specialties.

Cost-effectiveness of skin biopsies performed by non-physician clinicians for Medicare beneficiaries.

An increasing number of non-physician clinicians (NPCs) are providing dermatologic care. We compared the cost-effectiveness of skin biopsies performed by dermatologists and dermatology NPCs using publicly-available Medicare claims data and numbers needed to biopsy (NNBs) published in the literature. We estimated that dermatology NPCs performed slightly greater mean numbers of skin biopsies per beneficiary (0.51 versus 0.47) at a lower payment per biopsy ($44.93 versus $55.10) as compared to dermatologists. However, we estimated a higher mean cost per malignancy diagnosed by dermatology NPCs relative to dermatologists (range based on literature NNB values, $39.08 to $190.23). This translated to a $16.7M-$43.3M aggregate cost of additional, benign biopsies performed by NPCs on Medicare beneficiaries. Although this preliminary analysis has several limitations, including the reliance on NNB values for calculations, it likely highlights the importance of training, education, and supervision to promote diagnostic accuracy. Further investigation is needed so that the potential cost of additional skin biopsies performed by NPCs can be appropriately weighed against the improvement in dermatologic access by including NPCs in the dermatology workforce.

Early Adoption of Dupilumab in the Medicare Population in 2017.

Background: In March of 2017, dupilumab became the first FDA approved injectable biologic for treatment of moderate-to-severe atopic dermatitis (AD). As the first drug in this class for AD, dupilumab has revolutionized the disease's treatment and improved patient outcomes significantly. Previous work has demonstrated that dermatologic injectable biologics are not uniformly accessible to patients in the US, and that patients in more rural regions are less likely to have access to these medications. In this study, we aimed to evaluate the early utilization trends of dupilumab for the Medicare population in the first year of its FDA approval (2017). Methods: Retrospective cohort study of the Medicare Provider Utilization and Payment Data. Counties were categorized by Rural-Urban Continuum Codes (RUCC) based on size, extent of urbanization, and proximity to a metropolitan (metro) area as defined by the National Center for Health Statistics Urban-Rural Classification Scheme for Counties. Results: There were 142 individuals who prescribed dupilumab at least 10 times in 2017, 80% of whom were dermatologists. Of these providers, 130 (91.5%) practiced in metropolitan (metro) counties and 12 practiced in non-metro counties. There were 14 cities with two or more dupilumab prescribers, with highest numbers observed in New York, NY (8 providers); Philadelphia, PA (6 providers); Phoenix, AZ (5 providers); and Norfolk, VA (4 providers). Conclusions: There are differences in access to dupilumab in the Medicare population based on geographic location in the US. Trends of decreased access to novel dermatologic biologics in rural areas of the US may begin at their introduction to the market, identifying a potential target for future interventions to equalize access.