RESUMEN
BACKGROUND: The prevalence and demographics of atopic dermatitis (AD) in the United States have changed. Little is known about trends and determinants of outpatient health care utilization. OBJECTIVE: Determine the trends and determinants of outpatient health care utilization for AD in US adults and children. METHODS: Data from the 1993-2015 National Ambulatory Medical Care Survey were analyzed, including data on 110,095 pediatric and 642,140 adult outpatient visits. RESULTS: AD visits were made predominantly to primary care physicians (PCPs) (768,882 mean visits annually), dermatologists (466,529 mean visits annually), and allergists (18,445 mean visits annually). The frequency of AD visits increased overall from 1996-1999 to 2012-2015 (from 867,649 to 1,950,546 annually [Rao-Scott chi-square P = .02]), particularly among PCPs (from 339,889 to 1,025,739 [P = .02]). The frequency of AD visits to dermatologists decreased (from 446,669 to 371,003 [P = .01]). AD visits to PCPs were most common among children aged 0 to 4 years (32.0%). Adults with comorbid allergic rhinitis or food allergies had greater odds of seeing an allergist. AD visits to PCPs were more likely to be visits due to an acute condition (51.5%), whereas AD visits to dermatologists were more likely to be visits due to a chronic condition (41.2%). LIMITATIONS: AD severity was unavailable. CONCLUSIONS: Outpatient visits for AD in the United States over time increased overall, but those to dermatologists decreased. Dermatologists are most commonly seeing patients whose visit is due to chronic AD, and they should tailor treatment appropriately.
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Dermatitis Atópica , Eccema , Adulto , Niño , Humanos , Estados Unidos/epidemiología , Dermatitis Atópica/diagnóstico , Dermatitis Atópica/epidemiología , Dermatitis Atópica/terapia , Pacientes Ambulatorios , Eccema/epidemiología , Atención a la Salud , ComorbilidadRESUMEN
Although targeted immunomodulatory medications are increasingly utilized for inflammatory skin conditions like plaque psoriasis, little is known of the trends in the adoption of newly Federal Drug Administration (FDA)-approved immunomodulators by dermatologists. We performed a retrospective, cross-sectional analysis of Medicare Part D Prescriber datasets to identify dermatologists filing Medicare prescription claims for immunomodulatory drugs FDA-approved for plaque psoriasis between 2013 and 2018. Differences in dermatologist characteristics were determined between dermatologists prescribing a psoriasis treatment within two years of its FDA approval, "early adopters" and non-prescriber dermatologists over the same time period. Biologics approved for psoriasis from 2013 to 2018 included certolizumab pegol, secukinumab, brodalumab, ixekizumab, guselkumab, and apremilast. Early adopter dermatologists (n = 783) accounted for 5% of all Medicare Part D prescribing dermatologists. Early adopters were more likely to be male, in practice longer, and had a greater number of average annual beneficiaries than dermatologists who did not. Only six (< 1%) early adopters practiced in a small town or rural areas. We believe these data show that the adoption of novel biologic treatments for psoriasis by dermatologists to Medicare beneficiaries may be associated with clinician experience and practice volume. Additionally, we identified low absolute numbers of dermatologists prescribing biologics overall in non-metropolitan areas, which may represent delayed access to novel psoriasis treatments for many Medicare beneficiaries.
Asunto(s)
Productos Biológicos , Medicare Part D , Psoriasis , Anciano , Humanos , Masculino , Estados Unidos , Femenino , Dermatólogos , Estudios Transversales , Estudios Retrospectivos , Factores Biológicos , Psoriasis/tratamiento farmacológico , Productos Biológicos/uso terapéutico , InmunomodulaciónRESUMEN
BACKGROUND: Use of Mohs micrographic surgery (MMS) is highly prevalent, but little data are available on how surgeon experience affects surgical practice patterns. OBJECTIVE: To determine differences in use of MMS among surgeons of varying experience. MATERIALS AND METHODS: This cross-sectional study sampled from clinicians billing ≥200 mean annual Mohs surgery claims from the 2012 to 2018 Medicare Public Use File. The primary outcome was mean annual Mohs surgery claims for clinicians of varying experience. Secondary outcomes included use of flaps/grafts and prescribing of oral antibiotics, benzodiazepines, and opioids. RESULTS: Among 1,759 unique surgeons, those with 16 to 20 years of experience performed the most mean annual (95% confidence interval) Mohs surgical cases (578.7 [556.7-600.6]). Surgeons with 21 to 25 years of experience prescribed the most antibiotics (240.2 [216.5-263.8] mean annual claims), whereas those with >35 years of experience prescribed the longest courses (15.3 [14.2-16.4] days). CONCLUSION: Midcareer surgeons performed the most mean annual Mohs surgery cases, whereas later career surgeons prescribed more frequent and longer courses of antibiotics suggesting changing practice patterns with additional years of experience.
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Neoplasias Cutáneas , Cirujanos , Anciano , Analgésicos Opioides , Antibacterianos , Benzodiazepinas , Estudios Transversales , Humanos , Medicare , Cirugía de Mohs , Pautas de la Práctica en Medicina , Neoplasias Cutáneas/cirugía , Estados UnidosRESUMEN
We present the first case of a patient with indolent polyarteritis nodosa who suffered severe exacerbations following significant emotional stressors. This report highlights the close relationship between emotions and autoimmune diseases mediated by the deleterious effects of stressors presumptively by skewing immunity from Type 1 to Type 2.
RESUMEN
BACKGROUND: Although patch testing has historically been done by dermatologists, allergists are also patch testing. Little is known about the current utilization of patch testing by medical specialists. OBJECTIVE: The aim was to determine trends in utilization of patch testing in Medicare beneficiaries by various clinicians and demographics. METHODS: Data from the 2012-2017 Medicare Public Use File were analyzed, including 82,241 total unique clinicians of whom 312 filed a patch testing claim. RESULTS: Dermatologists had a steady share of patch tests (annual clinicians; annual patches) from 2012 (158; 258,735) to 2017 (199; 351,994), an increase of 25.9% and 36.0%, respectively. Allergists, however, had a marked increase in utilization of patch tests from 2012 (84; 62,498) to 2017 (187; 182,480), an increase of 122.6% and 192.0%, respectively. In multivariable logistic regression models, male dermatologists and allergists had increased odds of patch testing (P < 0.001 for both), as did clinicians in the Northeast and Southern United States (P ≤ 0.003 for both). LIMITATIONS: Data are only available for Medicare Part B patients; changes in utilization may be different for individuals, private insurance, or Medicare Advantage Plans. CONCLUSIONS: Relative to dermatologists, patch testing is increasing among allergists. Addressing barriers to patch testing may increase rates of patch testing by dermatologists.
Asunto(s)
Dermatitis Alérgica por Contacto/diagnóstico , Personal de Salud/tendencias , Medicare/estadística & datos numéricos , Pruebas del Parche/tendencias , Pautas de la Práctica en Medicina/tendencias , Anciano , Femenino , Humanos , Masculino , Estados UnidosAsunto(s)
Medicare , Neoplasias Cutáneas , Biopsia , Humanos , Piel , Neoplasias Cutáneas/epidemiología , Estados Unidos/epidemiologíaRESUMEN
Little is known about health resource utilization and treatment patterns for herpes zoster (HZV) after the introduction of HZV virus vaccination. The objective of this study is to characterize trends in HZV utilization, racial disparities, and treatment patterns in the United States. Data from the 1993-2015 National Ambulatory Medical Care Survey were analyzed, including 15,400,000 weighted primary acute HZV visits in adults. Overall, the weighted frequency (95% confidence interval) of HZV visits increased from 1993-1998 to 2007-2015 (1,269,815 [565,455-1,974,175]-8,017,911 [6,424,491-9,611,331], P = 0.0001). HZV visits were associated with African-American (38.8% [35.8-41.7%] vs. 8.2% [7.4-9.0%]) and Hispanic race/ethnicity (12.6% [6.6-18.5%] vs. 8.0% [7.3-8.5%]), public insurance (42.7% [36.6-49.2%] vs. 33.7% [32.2-35.2%]) in comparison with all other visits. Oral antiviral agents were prescribed in 64.3% (58.1-70.1%) of HZV visits. HZV visits were associated with higher rates of opioid prescriptions compared to all other visits (18.4% [14.0-23.9%] vs. 6.1% [5.6-6.6%], P < 0.0001). The limitation is no data on HZV severity. HZV visits increased over time, even after introduction of HZV vaccines. There were significant racial/ethnic and healthcare disparities of, and high rates of opiate and corticosteroid prescriptions at HZV visits. Future efforts are needed to address these practice gaps, and encourage vaccination and evidence-based prescribing in HZV.
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Atención Ambulatoria/estadística & datos numéricos , Prescripciones de Medicamentos/estadística & datos numéricos , Herpes Zóster/tratamiento farmacológico , Neuralgia Posherpética/tratamiento farmacológico , Aceptación de la Atención de Salud/estadística & datos numéricos , Pautas de la Práctica en Medicina/estadística & datos numéricos , Administración Oral , Adulto , Negro o Afroamericano/estadística & datos numéricos , Anciano , Atención Ambulatoria/organización & administración , Atención Ambulatoria/tendencias , Analgésicos Opioides/uso terapéutico , Antivirales/uso terapéutico , Estudios Transversales , Quimioterapia Combinada/métodos , Quimioterapia Combinada/estadística & datos numéricos , Femenino , Glucocorticoides/uso terapéutico , Disparidades en Atención de Salud/estadística & datos numéricos , Herpes Zóster/complicaciones , Herpes Zóster/inmunología , Hispánicos o Latinos/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Neuralgia Posherpética/inmunología , Neuralgia Posherpética/virología , Pautas de la Práctica en Medicina/organización & administración , Pautas de la Práctica en Medicina/tendencias , Brechas de la Práctica Profesional/estadística & datos numéricos , Distribución por Sexo , Estados Unidos , Población Blanca/estadística & datos numéricosRESUMEN
Psoriasis, hidradenitis, and atopic dermatitis (AD) are associated with increased cardiometabolic comorbidities. Yet, little is known about screening rates for cardiometabolic comorbidities in patients with these disorders. The objective of this study is to determine rates and predictors of cardiovascular screening among patients with psoriasis, AD, and hidradenitis in the United States. Data from the 2006-2015 National Ambulatory Medical Care Survey were analyzed, including 67,581 pediatric and 322,957 adult outpatient visits. Overall, blood pressure screening was performed less commonly in psoriasis (36.4% [31.0-42.2%]) and AD (41.9% [39.3-44.7%] of visits) compared to other visits (62.5% [61.5-63.6%]) (P < 0.0001). Cholesterol screening was performed more often (adjusted odds ratio [95% confidence interval]) in psoriasis (1.82 [1.20-2.76], P = 0.005) but less often in hidradenitis (0.03 [0.00-0.23], P = 0.001) and AD (0.72 [0.55-0.94], P = 0.02). Obesity screening increased from 2006-2007 to 2014-2015 in AD (31.1% [25.8-36.4%]-44.5% [37.0-81.5%], P = 0.01), psoriasis (19.0% [9.4-28.6%] to 42.8% [30.5-73.3%], P = 0.01), and hidradenitis (28.6% [1.7-55.6%] to 74.2% [55.3-100.0%], P = 0.001), but screening for blood pressure, cholesterol, or diabetes did not. Screening rates for cardiometabolic comorbidities are suboptimal. Future interventions are needed to improve screening rates for cardiometabolic comorbidities.
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Enfermedades Cardiovasculares/diagnóstico , Dermatitis Atópica/epidemiología , Hidradenitis/epidemiología , Tamizaje Masivo/estadística & datos numéricos , Psoriasis/epidemiología , Adulto , Atención Ambulatoria/estadística & datos numéricos , Glucemia/análisis , Factores de Riesgo Cardiometabólico , Enfermedades Cardiovasculares/sangre , Enfermedades Cardiovasculares/epidemiología , Colesterol/sangre , Comorbilidad , Estudios Transversales , Dermatología/estadística & datos numéricos , Femenino , Hemoglobina Glucada/análisis , Encuestas de Atención de la Salud/estadística & datos numéricos , Humanos , Masculino , Visita a Consultorio Médico/estadística & datos numéricos , Estados Unidos/epidemiologíaAsunto(s)
Atención Ambulatoria/economía , Dermatitis Atópica/economía , Dermatitis Atópica/terapia , Servicio de Urgencia en Hospital/economía , Adulto , Niño , Dermatitis Atópica/diagnóstico , Femenino , Humanos , Masculino , Servicio Ambulatorio en Hospital/economía , Pacientes Ambulatorios/estadística & datos numéricos , Admisión del Paciente/economía , Estados UnidosAsunto(s)
Dermatitis Atópica/tratamiento farmacológico , Erupciones por Medicamentos/etiología , Psoriasis/tratamiento farmacológico , Azatioprina/efectos adversos , Azatioprina/uso terapéutico , Estudios Transversales , Ciclosporina/efectos adversos , Ciclosporina/uso terapéutico , Monitoreo de Drogas , Humanos , Metotrexato/efectos adversos , Metotrexato/uso terapéutico , Ácido Micofenólico/efectos adversos , Ácido Micofenólico/uso terapéutico , Estados UnidosAsunto(s)
Artritis Psoriásica/terapia , Productos Biológicos/uso terapéutico , Fármacos Dermatológicos/administración & dosificación , Fototerapia/tendencias , Psoriasis/terapia , Acitretina/administración & dosificación , Adalimumab/uso terapéutico , Administración Oral , Adulto , Utilización de Medicamentos/estadística & datos numéricos , Utilización de Medicamentos/tendencias , Femenino , Glucocorticoides/administración & dosificación , Humanos , Inmunosupresores/administración & dosificación , Masculino , Fototerapia/estadística & datos numéricos , Ustekinumab/uso terapéuticoRESUMEN
MINI: It is unclear whether the ACS NSQIP Surgical Risk Calculator can predict 30-day complications after lumbar and cervical spinal fusions. This study shows that the Risk Calculator is only of marginal benefit in predicting outcomes in cervical fusion and unlikely to be of benefit in lumbar fusions. STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The aim of this study was to assess the American College of Surgeons National Surgery Quality Improvement Program (ACS NSQIP) Risk Calculator's ability to predict 30-day complications after spine surgery. SUMMARY OF BACKGROUND DATA: Surgical risk calculators may identify patients at increased risk for complications, improve outcomes, enhance the informed consent process, and help modify risk factors. The ACS NSQIP Risk Calculator was developed from a cohort of >1.4 million patients, using 2805 unique CPT codes. It uses 21 patient predictors and the planned procedure to predict the risk of 12 different outcomes within 30 days following surgery. METHODS: A retrospective chart review was performed on patients who underwent primary lumbar and cervical fusions with at least 30-day postoperative follow-up between 2009 and 2015 at a single-institution. Descriptive statistics were calculated for the overall sample, anterior versus posterior fusion (cervical only), and single versus multilevel fusion. Logistic regression models were fit with actual complication occurrence as the dependent variable in each model and ACS estimated risk as the independent variable. The c-statistic was used as the measure of concordance for each model. Receiver-operating charateristic curves depicted the predictive ability of the estimated risks. Acceptable concordance was set at c >0.80. RESULTS: A total of 237 lumbar and 404 cervical patients were included in the study. The Risk Calculator risk estimates significantly predicted (Pâ<â0.001) "any complication" and "discharge to skilled nursing facility" among the cervical cohort and demonstrated no significant outcome prediction the lumbar cohort. CONCLUSION: The ACS Risk-Calculator accurately predicted complications in the categories of "any complication" and "discharge to skilled nursing facility" for our cervical cohort and failed to demonstrate benefit for our lumbar cohort. Although the ACS Risk-Calculator may be useful in general surgery, our findings demonstrate that it does not necessarily provide accurate information for patients undergoing spinal surgery. LEVEL OF EVIDENCE: 3.
Retrospective cohort study. The aim of this study was to assess the American College of Surgeons National Surgery Quality Improvement Program (ACS NSQIP) Risk Calculator's ability to predict 30-day complications after spine surgery. Surgical risk calculators may identify patients at increased risk for complications, improve outcomes, enhance the informed consent process, and help modify risk factors. The ACS NSQIP Risk Calculator was developed from a cohort of >1.4 million patients, using 2805 unique CPT codes. It uses 21 patient predictors and the planned procedure to predict the risk of 12 different outcomes within 30 days following surgery. A retrospective chart review was performed on patients who underwent primary lumbar and cervical fusions with at least 30-day postoperative follow-up between 2009 and 2015 at a single-institution. Descriptive statistics were calculated for the overall sample, anterior versus posterior fusion (cervical only), and single versus multilevel fusion. Logistic regression models were fit with actual complication occurrence as the dependent variable in each model and ACS estimated risk as the independent variable. The c-statistic was used as the measure of concordance for each model. Receiver-operating charateristic curves depicted the predictive ability of the estimated risks. Acceptable concordance was set at c >0.80. A total of 237 lumbar and 404 cervical patients were included in the study. The Risk Calculator risk estimates significantly predicted (Pâ<â0.001) "any complication" and "discharge to skilled nursing facility" among the cervical cohort and demonstrated no significant outcome prediction the lumbar cohort. The ACS Risk-Calculator accurately predicted complications in the categories of "any complication" and "discharge to skilled nursing facility" for our cervical cohort and failed to demonstrate benefit for our lumbar cohort. Although the ACS Risk-Calculator may be useful in general surgery, our findings demonstrate that it does not necessarily provide accurate information for patients undergoing spinal surgery. Level of Evidence: 3.