A comparison of hourly block appointments with sequential patient scheduling in a dermatology practice.

BACKGROUND: There is significant demand for dermatologic care, and manpower is limited. Increasing patient encounters stress office processes. Analyses of the effects of schedule manipulation in a high-volume dermatology office have not been described. OBJECTIVE: The purpose of this article is to study the effects of block versus sequential scheduling on patient waiting times, length of patient encounters, and physician patient-free time in two busy dermatology clinics. METHODS: A dermatologist attended at two dermatology clinics, one using sequential patient scheduling and the other, block hourly scheduling. Time of patient arrival, scheduled appointment time, waiting time, time of physician entry into the examining room, face-to-face time with the physician, appointment type, number of same-day cancellations and nonattendance by visit type, length of each clinic, time of clinic closure, and patient-free time were recorded for each clinic and patient encounter. RESULTS: There were no significant differences between patient waiting times at the two clinics. Patients were seen by the physician a mean of 2.6 minutes before their scheduled appointment time using block scheduling of appointments and 6 minutes after their scheduled appointment times with sequential scheduling. Similar times were spent by the physician with the patients at both sites. After adjustment for differing nonattendance rates, block scheduling yielded 330 minutes of additional patient-free time during the course of this study when compared with sequential scheduling. With block scheduling, the clinic finished a mean of 35 minutes earlier than clinics using sequential scheduling. CONCLUSION: Within the parameters of this study, block scheduling did not significantly affect patient waiting times. Block scheduling created more patient-free time for the physician and clinical staff than did sequential scheduling. Block scheduling increased the quality of the practice environment from the perspective of the physician and the staff.

Expression of the cyclin-dependent kinase inhibitor p27 in keratoacanthoma.

BACKGROUND: Keratoacanthomas are characterized by initial rapid enlargement followed by clinical regression. A series of cyclin and cyclin-dependent kinase complexes regulate cell cycle progression. p27(kip) inhibits a variety of cyclin-cyclin-dependent kinase complexes in vitro and may act to hold eukaryotic cells in a quiescent state (G0). OBJECTIVE: We examined expanding and regressing keratoacanthomas for expression of p27(kip). METHODS: An immunohistochemical method was used to visualize and count p27(kip)-labeled cells in 5 expanding and 15 regressing keratoacanthomas. RESULTS: In normal epidermis p27(kip) was found overlying the nuclei of suprabasilar keratinocytes. In expanding keratoacanthoma there was little expression of p27(kip) in nuclei of atypical keratinocytes composing the tumor (1.25 +/- 2.1 labeled cells per high-power field); in regressing keratoacanthoma the nuclei of most suprabasilar keratinocytes in atypical tumor aggregates contained p27(kip) (55.1 +/- 28.6 labeled cells per high-power field). The difference was significant at P values of less than.001. CONCLUSION: The identification of p27(kip) in regressing keratoacanthoma but not in expanding keratoacanthoma suggests that p27(kip) may be playing a role in promoting regression of keratoacanthoma and is a potential target for pharmacologic intervention.

The incidence of cancellation and nonattendance at a dermatology clinic.

BACKGROUND: Same-day cancellation of appointments and nonattendance by patients can disrupt management of certain aspects of medical delivery and lead to inefficient allocation of resources and lost revenue. The frequency of cancellation and nonattendance at dermatology clinics has not been well documented. OBJECTIVE: We measured same-day cancellation and nonattendance in a university dermatology clinic. METHODS: We tabulated clinic attendees, same-day cancellations, and nonattendance for a 6-month period. We examined distribution by gender, type of payer, and clinic visit type (initial or follow-up). RESULTS: Total same-day cancellation rate was 8.3%. Female patients canceled more frequently than male patients (9.2% vs 7.3%, P = .02). Cancellation rates were similar for initial and follow-up visits. The nonattendance rate was 17% with the highest rates found in state-supported categories (26%) and the lowest in commercial insurance programs (13%). Nonattendance rates did not vary significantly by gender or visit type. CONCLUSION: Same-day cancellation and clinic nonattendance is a significant factor in the efficient fiscally sound management of a busy dermatology clinic. The risk of nonattendance is assumed by physicians and seems to be correlated with payer type.

Profitability of a university-based clinic using benchmark time lengths for clinical encounters.

Reductions in reimbursement are applied to all physicians in a region equally. However, physicians do not practice in equivalent situations. For example, there are few fiscal allowances for academic functions associated with teaching and administration. Furthermore, university-based physicians may practice in clinical venues that cannot be as efficient as nonuniversity sites. Unavoidable inefficiencies may include (1) the costs of maintaining one historical record for a large noncontiguous practice; (2) university-required holiday schedules and sick leave, making university personnel less productive; (3) noncompetitive overhead rates assigned to clinic components by university financial offices; (4) university-based accounting systems that are not designed for effective cost control and the timely generation of useful management information; and (5) poorly managed billing services. Until now, declining reimbursements have generally led to sufficient efficiencies in delivery so that revenues and expenses can be in equilibrium.

Log-in/log-out time: a quality factor for a reference laboratory--prolonged times for skin pathology processing in managed care-authorized laboratories.

Managed care organizations may divert skin biopsy specimens to commercial laboratories selected on a cost basis. Diversion to these laboratories could result in service of decreased quality for the patient and referring physician. Log-in/log-out dates were collected for all specimens submitted to managed care-authorized laboratories either from a university-based clinic or from a private practitioner's office for a period of 18 months and compared with data obtained from a local dermatopathology laboratory. A subgroup of specimens containing inflammatory diagnoses or nondiagnostic changes was also examined. Mean log-in/log-out times were 1.338 days in the dermatopathology laboratory, 6.123 days in managed care-authorized laboratories from the university site, and 7.798 days in managed care-authorized laboratories from a practitioner's office. The differences between the dermatopathology laboratory log-in/log-out times and those of the managed care-authorized laboratories were statistically significant (p < 0.0001). The conclusion from this study is that a quality indicator defined as time from log in to log out revealed a significant increase in interpretation time at managed care-designated laboratories. Although managed care plans can decrease their financial risk by contracting with national laboratories to provide all services for a set fee, a decreased quality of service can be demonstrated.

Focal adhesion kinase is expressed in acantholytic keratinocytes associated with pemphigus vulgaris and pemphigus foliaceus.

Focal adhesion kinase is a protein-tyrosine kinase that is found in cellular contact sites and is phosphorylated in response to cell attachment. It is possible that the immunohistochemical detection of this enzyme might be increased in keratinocytes involved in an acantholytic process. Normal skin, pemphigus vulgaris and foliaceus, Darier's disease, Hailey--Hailey disease, warty dyskeratoma, Grover's disease and spongiotic dermatitis were assayed for the immunohistochemical expression of focal adhesion kinase. Focal adhesion kinase was not observed in normal epidermis. This antigen was observed in keratinocytes adjacent to acantholytic spaces and in acantholytic cells in pemphigus vulgaris and foliaceus. Focal adhesion kinase was not detected in keratinocytes involved in focal acantholytic dyskeratoses such as Darier's disease, Grover's disease and warty dyskeratoma but was weakly detected in Hailey--Hailey disease. One consequence of immunologically mediated acantholysis is the upregulation of focal adhesion kinase possibly as a component of biochemical pathways that reconstruct the process of adhesion or respond to the process of acantholysis.

Quality assessment of skin biopsy specimens referred to anonymous consultants.

BACKGROUND AND DESIGN: Managed care organizations may direct dermatopathologic specimens to anonymous consultants. I hypothesized that the quality of the consultation decreases when there is no incentive for an anonymous consultant to actively pursue the dermatologist/consumer. Therefore, I examined 364 consecutive specimens that had been directed to anonymous consultants. The specimens were obtained from patients who consulted a university-based dermatology clinic or the office of a collaborating practitioner. The quality of consultation was evaluated in 5 areas: factual correctness, arguable differences in degree, evidence that the history had been read by the consultant, knowledge of dermatologic disease evident in the interpretative aspects of the report, and appropriate direct interaction with the referring physician when indicated. RESULTS: There was concordance between the interpretation by anonymous consultants and the findings of my review in 66.8% of cases that involved common dermatopathologic diagnoses. There were errors in fact in 26 cases (7.1%). There were examples of failure to correlate histologic findings with clinical history, apparent lack of understanding of dermatologic disease, and failure to resolve conflicts between the histologic pattern and the clinical information. CONCLUSIONS: I found a decrease in the quality of biopsy specimen interpretation received from anonymous consultants. Dermatologists need to maintain and/or upgrade their skills in dermatopathology to supervise the quality of interpretation obtained from anonymous consultants.

Cutaneous eruption of lymphocyte recovery mimicking mycosis fungoides in a patient with acute myelocytic leukemia.

Eruption of lymphocyte recovery (ELR) develops in the setting of leukocyte reconstitution after iatrogenic marrow aplasia and displays a superficial perivascular lymphocytic infiltrate composed of CD3+/CD4+ cells. Epidermal changes are usually minimal to absent. We report a case of an ELR mimicking mycosis fungoides with the formation of CD4+ Pautrier-like microabscesses.

Analysis of the polymerase chain reaction in the detection of herpesvirus DNA from fixed and stained tissue sections.

BACKGROUND AND DESIGN: The polymerase chain reaction (PCR) is a molecular diagnostic technique that has been applied to many infectious processes. Stained and unstained Tzanck smears, vesicle fluid swabs, and crusts have all been used as the source for template DNA for the PCR to document evidence of herpes simplex virus and varicella-zoster virus infection. Thirty-five cases with histologic evidence of acute herpesvirus infection were retrieved from archival tissue blocks that were up to 5 years old. Paraffin and hematoxylin-eosin-stained tissue sections obtained from routinely prepared glass slides from these cases were then examined for herpesvirus DNA using the PCR. RESULTS: The PCR-detected herpesvirus DNA from 34 (97.1%) of 35 paraffin tissue samples. Herpes simplex virus and varicella-zoster virus DNA were detected in eight and 26 of these cases, respectively. For hematoxylin-eosin-stained tissue samples, PCR detected herpesvirus DNA sequences in 16 (45.7%) of 35 cases. Herpesvirus DNA was isolated from paraffin tissue sections and recently prepared hematoxylin-eosin-stained tissue samples obtained from archival tissue blocks that were up to 5 and 2 years old, respectively. CONCLUSIONS: The PCR can detect herpesvirus DNA in extremely high yield from unstained paraffin-embedded tissue samples with histologic evidence of acute herpesvirus infection that are up to 5 years old. Herpesvirus DNA can also be identified in approximately 50% of these cases from hematoxylin-eosin-stained tissue sections obtained from routinely prepared glass slides.

Cutaneous histopathology of Conradi-Hunermann syndrome.

The histopathology of the skin in the ichthyosiform erythroderma associated with classical Conradi-Hunermann syndrome has been rarely described. Skin biopsies from 2 infants with the classical features of Conradi-Hunermann syndrome including ichthyosiform erythroderma contained hyperkeratosis, dilated ostia of pilosebaceous structures, and calcium salts in the stratum corneum detectable with special stains. An unusual feature of one case was dilatation of acrosyringeal structures. We hypothesize that dilatation of acrosyringeal structures is analogous to the plugging noted in pilosebaceous units. Taken together, the ichthyosiform erythroderma of Conradi-Hunermann has a distinctive histologic appearance.

Merkel cells in neurofibromas and neurilemomas.

Merkel cells are an integral component of the cutaneous nervous system. They are commonly associated with dermal nerves under normal physiological conditions. We postulated that Merkel cells may be present in increased numbers within the epidermis overlying benign peripheral nerve sheath tumours such as neurilemomas and neurofibromas. Paraffin-embedded skin biopsy specimens from 21 patients with neurilemomas and 26 with neurofibromas, were analysed for the presence of Merkel cells using a standard immunohistochemical assay (avidin-biotin-peroxidase complex system) with an antibody to cytokeratin 8 (CAM 5.2). Ten cases of leiomyomas were examined as controls. Merkel cells were identified in the interfollicular area of the basal cell layer overlying 14 of 21 (67%) neurilemomas and nine of 26 (35%) neurofibromas. Merkel cells were more frequently observed in increased numbers in a linear array within the basal cell layer in neurilemomas than in neurofibromas, where they were found as individual cells. No Merkel cells were found in the epidermis overlying leiomyomas. The results of this study suggest that Merkel cells are quantitatively increased in the basal cell layer of the epidermis overlying benign peripheral nerve sheath tumours, particularly neurilemomas.

Determining the processing cost of a skin biopsy specimen.

An integral part of directing a pathology laboratory is to understand the nature and behavior of relevant costs. Until recently, pathologists did not need to accurately know the specific costs assigned to various steps in the processing of tissue specimens. With the advent of a more competitive approach to the delivery of health care, laboratory directors must accurately cost their product in order to use competitive pricing strategies. In this article, I review the principles that are used to analyze costs that are identified in a typical dermatopathology laboratory.