Role of phototherapy in the era of biologics.

Phototherapy is a safe and effective treatment for many dermatologic conditions. With the advent of novel biologics and small molecule inhibitors, it is important to critically evaluate the role of phototherapy in dermatology. Surveys have shown that many dermatology residency programs do not dedicate time to teaching residents how to prescribe or administer phototherapy. Limitations of phototherapy include access to a center, time required for treatments, and insurance approval. Home phototherapy, a viable option, is also underused. However, it should be emphasized that modern phototherapy has been in use for over 40 years, has an excellent safety profile, and does not require laboratory monitoring. It can be safely combined with many other treatment modalities, including biologics and small molecule inhibitors. In addition, phototherapy costs significantly less than these novel agents. Dermatologists are the only group of physicians who have the expertise and proper training to deliver this treatment modality to our patients. Therefore, to continue to deliver high-quality, cost-effective care, it is imperative that phototherapy be maintained as an integral part of the dermatology treatment armamentarium.

Phototherapy trends in dermatology.

BACKGROUND: Use of phototherapy in the United States declined during the 1990s, largely due to unfavorable economic incentives. The trends in phototherapy since then are not well characterized. METHODS: We analyzed the National Ambulatory Medical Care Survey (NAMCS) data on quantity of phototherapy visits and associated diagnoses and payment sources. Trends were assessed by linear regression. RESULTS: There were an estimated 230 000 outpatient phototherapy visits per year, with an increasing trend over time (p = 0.03). Dermatologists managed 87% of the visits. Leading diagnoses associated with phototherapy included psoriasis (25%), dermatitis NOS (6%), vitiligo (6%), other dyschromia (6%), and actinic keratosis (5%). CONCLUSIONS: Use of phototherapy for psoriasis has remained relatively low up to 2010. However, phototherapy may be becoming more frequent for conditions other than psoriasis.

[Quantitative analysis of drug expenditures variability in dermatology units]. / Análisis cuantitativo de la variabilidad del gasto farmacéutico en unidades de Dermatología.

BACKGROUND: Variability in adjusted drug expenditures among clinical departments raises the possibility of difficult access to certain therapies at the time that avoidable expenditures may also exist. Nevertheless, drug expenditures are not usually applied to clinical practice variability analysis. AIMS: To identify and quantify variability in drug expenditures in comparable dermatology department of the Servicio Andaluz de Salud. METHODS: Comparative economic analysis regarding the drug expenditures adjusted to population and health care production in 18 dermatology departments of the Servicio Andaluz de Salud. The 2012 cost and production data (homogeneous production units -HPU-)were provided by Inforcoan, the cost accounting information system of the Servicio Andaluz de Salud. RESULTS: The observed drug expenditure ratio ranged from 0.97?/inh to 8.90?/inh and from 208.45?/HPU to 1,471.95?/ HPU. The Pearson correlation between drug expenditure and population was 0.25 and 0.35 for the correlation between expenditure and homogeneous production (p=0.32 and p=0,15, respectively), both Pearson coefficients confirming the lack of correlation and arelevant degree of variability in drug expenditures. CONCLUSION: The quantitative analysis of variability performed through Pearson correlation has confirmed the existence of drug expenditure variability among comparable dermatology departments.

Introducción: La existencia de variabilidad en el gasto farmacéutico ajustado entre unidades asistenciales plantea la posibilidad de dificultades en el acceso a determinadas opciones terapéuticas, así como un posible gasto farmacéutico evitable. Sin embargo, los análisis de variabilidad de la práctica clínica no incorporan en general el gasto farmacéutico como medida de resultado. Objetivo: Identificar y cuantificar la variabilidad en cuanto al gasto farmacéutico de unidades de Dermatología comparables del Servicio Andaluz de Salud. Métodos: Análisis comparativo del gasto farmacéutico de 18 unidades de Dermatología del Servicio Andaluz de Salud, ajustado a población y producción asistencial. Los datos sobre resultados de contabilidad y producción asistencial (unidades de producción homogénea -UPH-) fueron proporcionadas por Inforcoan, sistema de información de contabilidad analítica del Servicio Andaluz de Salud. Resultados: La ratio de gasto farmacéutico observada fue de 0,97 ?/hab-8,90 ?/hab y de 208,45 ?/UPH-1.471,95 ?/UPH. El coeficiente de correlación de Pearson entre el gasto farmacéutico y la población fue de 0,25 y de 0,35 para el gasto farmacéutico y la producción homogénea (p=0,32 y p=0,15) respectivamente, ambos indicando la ausencia de correlación y existencia de variabilidad. Conclusión: El análisis cuantitativo de variabilidad realizado mediante correlación de Pearson ha permitido confirmar y cuantificar la variabilidad existente en cuanto al gasto farmacéutico en unidades de Dermatología comparables.

[Dermatology day-care: between official rules and reality]. / Hôpital de jour de dermatologie : entre circulaire frontière et réalité

BACKGROUND: Official rules published in 2006 and 2010 concerning ambulatory care rates in France led to artificial redistribution of this activity from day-care hospitalization to consultations. In our dermatological day-care establishment, we compared the financial costs engendered for patients admitted for day-care hospitalization and those seen at consultations. PATIENTS AND METHODS: From 2011/01/10 to 2011/02/04, for each patient, we prospectively analyzed the following data: day-care hospitalization or consultation, age, sex, diagnosis, laboratory and radiological examination, non-dermatological consultations, time spent with the patient by doctors (interns, senior doctors) and nurses, with timing by a stop-watch. The hospital cost was the total for medical examinations (official nomenclature), non-dermatological consultations, physicians' and nurses' salaries and establishment overheads (216 €). The hospital revenue regarding the consultation group consisted of the sum of reimbursement for medical examination, dermatological and non-dermatological consultations, and regarding the day-care hospitalization group, the dermatology rate (670 €) or chemotherapy sessions (380 €). Results were compared using a Chi(2) test and a Student's t-test (P ≤ 0.05). RESULTS: One hundred and twenty-seven patients were included: 67 in the day-care hospitalization group and 60 in the consultation group. Patients in the day-care hospitalization group were older and had significantly more radiological examinations and non-dermatological consultations, but the number of laboratory examinations and skin biopsies did not differ between the two groups. The mean time spent by doctors was similar in both groups but the time spent by senior doctors without the help of interns was significantly greater and longer than the time for a standard consultation. Nurses spent a mean 72 minutes with each hospitalized patient and 35 minutes with consultation patients (P = 0.007). Hospital costs were identical in both groups at around 415 €. The hospital showed a profit for day-care hospitalization patients (252 €) and a loss (244 €) for consultation patients. DISCUSSION: Half of the patients studied were in day-care hospitalization and half were seen in consultations. The high number of bed-ridden patients with bullous pemphigoid accounts for the fact that day-care patients were older. The reasons for the significantly longer time spent by nurses with day-care hospitalized patients were administration and supervision of chemotherapy, skin care and nursing of bed-ridden patients. However, nurses spent 35 min with each consultation patient, justifying the need to maintain the posts of these staff in such day-care units. The availability of physicians for patients with severe dermatoses and the organization of medical examinations in the same place in the same day underscore the need for medical structures like day-care hospitalization. At present, time spent on intellectual work involving reflection is regrettably not taken into account, which is detrimental to this specialty. The hospital was in profit for day hospitalizations while consultations resulted in losses, in particular because of the absence of social security reimbursement of the establishment's overheads. CONCLUSION: Rules are in need of modification in order to allow the treatment of patients with more complicated conditions.

[Referrals to dermatology: proportion of banal disorders]. / Demanda derivada a Dermatología: peso de la patología banal.

BACKGROUND AND OBJECTIVE: Skin diseases account for a large number of consultations in primary care. The objective of this study was to determine the characteristics and cost of referrals from primary care to a dermatology clinic. MATERIAL AND METHODS: Descriptive cross-sectional study of referrals from a primary care health center to a dermatology clinic. The dermatology clinic was situated in the same health center and was attended by a dermatologist from Complejo Hospitalario Universitario in Albacete, Spain. The study was performed on 10 days selected at random between April 21, 2009, and June 26, 2009. The data gathered included age, sex, use of cryotherapy, and diagnostic group. Patients were divided into 4 diagnostic groups: A) benign degenerative disease or trivial disorders whose treatment may not merit involvement of the national health service, B) diseases resolved with a single dermatology consultation at the health center, C) diseases requiring evaluation in hospital-based dermatology outpatients, and D) diseases referred for surgical treatment. RESULTS: Data were gathered on 257 patients with a mean age was 41.18 years and there was a slight female predominance. The majority of patients were in diagnostic group B (53.7%), followed by groups A (19.1%), C (19.1%), and D (8.2%). The total estimated cost of these 257 visits was €29 750.32, of which €5672.24 was for trivial disorders. CONCLUSIONS: The current high prevalence of trivial disorders in the caseload of dermatology clinics by trivial disorders makes it necessary to control referrals from primary care more strictly.

Selling skin care products in your medspa.

This article explains the legalities of selling retail products in the medical practice and how to sell effectively and profitably. It additionally explains how this will help retain clients and provides advice on how to encourage those clients to refer their friends with confidence.

Medical spa marketing.

Medical spas are different. We are not just selling medical and dermatology services; we are offering clients viable new solutions to their skin care, body care, and hair care challenges. Traditional medical marketing becomes blurred today, as the expansion and acceptance of medical spas helps you to effectively compete with traditional skin care clinics, salons, and spas, while offering more therapeutic treatments from professionally licensed doctors, nurses, aestheticians, massage therapists, spa professionals, and medical practitioners. We recommend that you make the choice to successfully and competitively become a market-driven medical spa with an annual strategic plan, rather than an operationally driven business.

No show: incidence of nonattendance at a dermatology practice in a single universal payer model.

BACKGROUND: Nonattendance at scheduled appointments is a major problem. Previous studies have shown rates between 17 and 31%. Most US studies found the type of payer to be the greatest determinant of attendance rates. OBJECTIVES: This study examines the no-show rate in a private dermatology practice under a single universal payer model, including the effects of old versus new patient, gender, day of the week, month, and weather. RESULTS: The overall rate of nonattendance was lower than in all previous studies (7.79%), with the only statistically significant variable being established versus new patients. LIMITATIONS: Certain demographic data investigated in previous studies (eg, age, socioeconomic status) were not assessable. Data are from a single office. CONCLUSION: The no-show rate in a single universal payer, private practice model is low, especially for established patients.

Case mix measures and diagnosis-related groups: opportunities and threats for inpatient dermatology.

OBJECTIVE: The changing healthcare environment world-wide is leading to extensive use of per case payment systems based on diagnosis-related groups (DRG). The aim of this study was to examine the impact of application of different DRG systems used in the German healthcare system. METHODS: We retrospectively analysed 2334 clinical data sets of inpatients discharged from an academic dermatological inpatient unit in 2003. Data were regarded as providing high coding quality in compliance with the diagnosis and procedure classifications as well as coding standards. The application of the Australian AR-DRG version 4.1, the German G-DRG version 1.0, and the German G-DRG version 2004 was considered in detail. To evaluate more specific aspects, data were broken down into 11 groups based on the principle diagnosis. MAIN OUTCOME MEASURE: DRG cost weights and case mix index were used to compare coverage of inpatient dermatological services. Economic impacts were illustrated by case mix volumes and calculation of DRG payments. RESULTS: Case mix index results and the pending prospective revenues vary tremendously from the application of one or another of the DRG systems. The G-DRG version 2004 provides increased levels of case mix index that encourages, in particular, medical dermatology. CONCLUSIONS: The AR-DRG version 4.1 and the first German DRG version 1.0 appear to be less suitable to adequately cover inpatient dermatology. The G-DRG version 2004 has been greatly improved, probably due to proceeding calculation standards and DRG adjustments. The future of inpatient dermatology is subject to appropriate depiction of well-established treatment standards.

Implementing a teledermatology programme.

Although teledermatology has been beneficial and cost-effective in some settings, many programmes have failed, not because of the technology but because teledermatology was implemented in isolation. A thorough understanding of an organization's business process and business model is crucial before teledermatology is begun. Unless teledermatology is integrated into the current business process and model, the likelihood of success is greatly reduced. Important steps therefore include: (1) understanding how the organization delivers care; (2) analysing the alternatives, including cost-benefit analysis; (3) obtaining organizational support; (4) formulating an execution plan; (5) training staff and monitoring the process. If implemented correctly in the appropriate setting, teledermatology can significantly improve access and quality of care, while reducing or containing costs.

Integrating biologic therapies into a dermatology practice: practical and economic considerations.

This article discusses the issues involved in the integration of biologic therapies for psoriasis into a dermatology practice. The requirements for staff, space, and other office adaptations are reviewed for infliximab, efalizumab, etanercept, and alefacept in their current injectable forms. Dermatologists will likely elect to offer some or all of these therapies depending on the adjustments necessary within their current practice, patient satisfaction, and the economic possibilities. This article provides information needed to guide dermatology practices in practical decisions regarding the use of biologic therapies.

A cost-minimization analysis of a realtime teledermatology service in northern Norway.

Realtime teledermatology has been a routine service provided by the University Hospital of Tromsø to a primary-care centre in Kirkenes since 1989. The cost of the teledermatology service was compared with the costs of three alternative methods of treatment for the patients. The first was a combination of a visiting service and patient travel to hospital. The second was patient travel to the nearest secondary-care centre. The third was a locally employed dermatologist. At the actual 1998 workload of 375 patients, the total cost of teledermatology was NKr470,780, while the three alternatives cost NKr880,530, NKr1,635,075 and NKr958,660, respectively. Analysis of the unit costs showed that the realtime teledermatology service, including local phototherapy, was less costly than the three alternatives for annual workloads above 195 patients per year. A sensitivity analysis showed that the results were robust to changes in the assumptions about the cost structure.

Cost reduction of skin biopsy and surgical instrumentation.

Saving the physicians time is very desirable in rendering first-rate dermatological service at lower cost. The aim is to reduce surgical instrumentation during skin biopsy procedures and follow-up visits. A combined instrument is used to obtain skin biopsies from 100 patients, and gelatin sponge plugs are used in hemostasis and to assist healing of the biopsy wound site. Skin biopsy samples are obtained simply and with ease, and, as the tissue sample is handled minimally, it appears to be more intact and less distorted in comparison to the usual procedure. Skin biopsy samples can be obtained with the combined instrument in a more cost-effective manner with savings of the physician's time and less instrumentation.