Urgent referrals from primary care to dermatology for lesions suspicious for skin cancer: patterns, outcomes, and need for systems improvement.

Ideally, urgent dermatology referrals for evaluation of a lesion concerning for skin cancer should be triaged and processed with appropriate urgency by primary care and dermatology, respectively. We performed a retrospective single-institution study by conducting chart reviews of all dermatology referrals designated by primary care as urgent for evaluation of a lesion concerning for skin cancer. We identified 320 referrals placed between January 1 and December 31, 2018. Dermatology encounters for these patients occurred on or before 30 days for 50.6% of referrals and on or after 31 days for 38.4% of referrals, with 10.9% never completed. The percentage of all races excluding whites, non-Hispanic in the delayed appointment group (≥ 31 days) was 15.1% higher (95% CI 5.3-24.9) than in the timely appointment group (≤ 30 days). Similarly, the percentage of non-English languages in the delayed group was 7.1% higher (95% CI 0.5-13.7) than in the timely group. Overall, 15.8% of these referrals yielded diagnoses of malignancy, while 76.8% and 7.4% resulted in benign and pre-malignant diagnoses, respectively. The primary care team documented referral status (i.e., completed, incomplete, or pending) during their subsequent visits with the patients in only 37.5% of these referrals. Our findings demonstrate the need to improve the reliability of urgent referrals to ensure they occur in a timely manner with confirmation of "referral loop" closure at the referring clinician's end.

Moving forward with teledermatology: Operational challenges of a hybrid in-person and virtual practice.

Since the COVID-19 outbreak, teledermatology services have become an integral part of our daily practice. In this study, we compared three practice models of an academic department in an urban setting: 1) in-person only, 2) teledermatology only, and 3) hybrid of in-person and teledermatology. Our study demonstrated that older patients prefer in-person visits over teledermatology visits, while non-English-speaking patients prefer teledermatology visits over in-person visits. In addition, teledermatology services can be better utilized for evaluation of acne and psoriasis, as these diagnoses do not require in-person reevaluation, unlike the evaluation of concerning lesions. Considering these findings, our study highlights the need to continuously examine our practice models to understand patient preferences, overcome practice-driven barriers, and ensure the sound allocation of limited health care resources.

A single-institution retrospective evaluation of Mohs incision angles and histopathologic specimen quality.

BACKGROUND: Traditionally, Mohs layers are excised using a beveled incision to facilitate tissue flattening for tangential sectioning. Some surgeons perform non-beveled incisions; however, these specimens may be harder for the histotechnician to process. Limited data exist comparing slide quality between these techniques. METHODS: Retrospective review of cases performed by two Mohs surgeons (surgeon 1 = non-beveled incision; surgeon 2 =  beveled incision) using different incision angles between June 2014 and December 2016. Daily histopathologic slide quality assessment scores (maximum score = 5, minimum score = 1) of the day's first case were compared. RESULTS: About 536 slides (surgeon 1 = 277, surgeon 2 = 259) were evaluated from 2,825 cases. Mean quality assessment scores were similar between surgeons (4.89 and 4.86; P = 0.31) with missing or folded epidermis being the most commonly reported issue for both surgeons. CONCLUSION: Similar slide quality can be achieved via both beveled and non-beveled Mohs cutting angles. While more relaxing incisions may be necessary to optimize tissue flattening with non-beveled incisions, there is no associated increased loss of epidermal margins. The potential benefits of non-beveled incisions, such as minimizing tangentially cut adnexal structures and creating vertical wound edges optimized for repair, may offer an alternative technique with positive clinical implications.

Examining the prior authorization process, patient outcomes, and the impact of a pharmacy intervention: A single-center review.

BACKGROUND: Dermatology experiences a disproportionately high burden of prior authorizations (PAs). OBJECTIVE: To examine the effect of a centralized pharmacy intervention on the PA process and the impact of PAs on patient outcomes. METHODS: A retrospective review of PAs submitted for medications before and after implementation of pharmacy intervention was conducted. RESULTS: PA was required for 8.1% of all prescriptions. PAs were most frequently submitted for topical steroids, topical antibiotics and antifungals, and topical retinoids. Most common indications included acne, psoriasis, and dermatitis. Biologic agents (55.2%) and brand-name only medications (42.8%) required PA at higher rates. Pharmacy intervention resulted in shorter time to PA submission (4 days vs 1 day, P < .001) and decision (6 days vs 1 day, P < .001) and higher approval rates (63.9% vs 80.6%, P < .001) but did not decrease the total number of PAs. Patients with approved PAs had higher likelihood of disease improvement vs those with denied PAs (71.1% vs 58.0%, P = .013). LIMITATIONS: Data were collected from a single academic institution. Patient medication compliance was not assessed. CONCLUSIONS: The current PA process may result in delays in care and a negative impact on patients. A centralized pharmacy intervention is an effective measure but does not eliminate the overall burden of PAs.

Consensus for Nonmelanoma Skin Cancer Treatment, Part II: Squamous Cell Carcinoma, Including a Cost Analysis of Treatment Methods.

BACKGROUND: Cutaneous squamous cell carcinoma (cSCC) is the second most common cancer in the United States. Cutaneous squamous cell carcinoma has an estimated incidence of more than 700,000 new cases per year and a 5% risk of metastasis. OBJECTIVE: To provide clinicians with guidelines for the management of cSCC based on evidence from a comprehensive literature review and consensus among the authors. MATERIALS AND METHODS: The authors conducted an extensive review of the medical literature on treatment methods for cSCC, taking into consideration cure rates, recurrence and metastatic rates, aesthetic and functional outcomes, and cost effectiveness of the procedures. RESULTS: Surgical treatments provide the best outcomes for cSCC. Mohs micrographic surgery is a cost-effective procedure that affords the highest cure rate, maximal tissue preservation, and superior cosmetic outcomes. Nonsurgical methods may be used as a primary treatment for low-risk squamous cell carcinomas, but the cure rates are lower. CONCLUSION: The cure rate remains the most important consideration in choosing the treatment method, but additional factors, such as the patient's general medical condition, psychosocial circumstances, the location of the tumor and cost effectiveness of the therapy should be considered. Mohs micrographic surgery remains the preferred treatment for high-risk tumors and tumors located in cosmetically sensitive areas.

A multistep approach to improving biopsy site identification in dermatology: physician, staff, and patient roles based on a Delphi consensus.

IMPORTANCE: Excisional skin cancer surgery is a common procedure, with no formal consensus for mitigating the risk of wrong-site cutaneous surgery. OBJECTIVE: To systematically consider the usefulness and feasibility of proposed methods for correct biopsy site identification in dermatology. EVIDENCE REVIEW: Survey study with a formal consensus process. Item development was via a literature review and expert interviews, followed by 2 stages of a Delphi process to develop consensus recommendations. FINDINGS: In total, 2323 articles were reviewed in the literature search, with data extraction from 14. Twenty-five experts underwent 30-minute structured interviews, which were transcribed and coded. The resulting survey was composed of 42 proposed interventions by multiple stakeholders (biopsying physicians, operating physicians, nurses, ancillary staff, patients, caregivers, and family members) at 3 time points (day of biopsy, delay and consultation period, and day of definitive surgery). Two rounds of a Delphi process with 59 experts (25 academic and 34 private practice) scored the survey. Strong consensus was obtained on 14 behaviors, and moderate consensus was obtained on 21 other behaviors. In addition, a 2-state simultaneous algorithm was developed to model surgeon behavior on the day of definitive surgery based on surgeon and patient perceptions. CONCLUSIONS AND RELEVANCE: When definitive surgery is performed after the initial biopsy and by a different surgeon, procedures can be implemented at several time points to increase the likelihood of correct site identification. The specific circumstances of a case suggest which methods may be most appropriate and feasible, and some may be implemented. The risk of wrong-site cutaneous surgery can be reduced but not eliminated.

Cutaneous squamous cell carcinoma.

Cutaneous SCC is the second most common skin cancer among whites. Most cases of primary cutaneous SCC are induced by UV radiation. Chronic sun exposure is the major risk factor, and favored locations include the head and neck and other sun-exposed areas. Moreover, it is important for the clinician to recognize other risk factors associated with this malignancy, including HPV infection, occupational exposures, various genodermatoses, scarring dermatoses, chronic wounds, and burn scars. The allogenic transplant population is at most risk for developing cutaneous SCC. For these patients, aggressive patient education, control of immunosuppression, and clinical surveillance should be the standard of care. Most patients who have primary SCC have an excellent prognosis, and treatment is usually straightforward. A substantial minority of these neoplasms, however, may recur or metastasize. Obtaining a complete history and performing a total-body skin examination can help to identify tumors at high risk for recurrence or metastasis in addition to those that may be more easily treated. For those individuals with metastatic disease, however, the long-term prognosis is guarded. Based on recent reports, in the future, there may be a role in SLNB for cutaneous SCC to diagnose subclinical metastasis accurately. Larger studies and better guidelines need to be developed before SLNB can be routinely used in the management of metastatic disease. Physicians should emphasize to their patients the benefits of sun avoidance and protection from sunlight, beginning in childhood, to minimize the risk for developing this potentially life-threatening neoplasm.