Encuesta sobre las características y honorarios de la práctica dermatológica privada española en 2023. Actualización y cambios con respecto a 2018 / Survey on Private Dermatology Practice Characteristics and Fees in Spain in 2023. Update and Changes From 2018

El presente trabajo incluye el análisis de los datos obtenidos mediante una encuesta realizada en enero de 2023 a 235 dermatólogos que ejercen actividad asistencial privada en España. Se añade un fotograma posterior al estudio con metodología similar realizado en 2018, al mismo tiempo que se analizan los cambios y adaptaciones que tiene la práctica con los nuevos tiempos y retos emergentes. Comparado con 2018, en 2023 destacan: incrementos en la dedicación a la actividad privada, las teleconsultas, el cobro anticipado de técnicas, la aceptación de pagos con tarjeta bancaria y banca electrónica; cambios en la periodicidad de ajuste de precios; el hecho de que un 60% de los encuestados declare que ha ajustado al alza los precios en el año; un incremento de los precios que se ajusta aproximadamente al del IPC y la observación de que los dermatólogos varones declaran con más frecuencia precios extremos más altos (AU)

The present work includes the analysis of the data obtained through a survey conducted in January 2023 to 235 dermatologists practicing private healthcare activity in Spain. A subsequent frame is added to the study with similar methodology carried out in 2018, while analyzing the changes and adaptations that the practice has with the new times and emerging challenges. Compared to 2018, in 2023 the following findings stand out: increases in dedication to private activity, teleconsultations, advance payment for techniques, acceptance of payments by bank card and electronic banking; changes in the periodicity of price adjustment; the fact that 60% of respondents state that they have adjusted prices upwards in the year; a rise in prices that is approximately in line with that of the CPI, and the observation that male dermatologists more frequently state higher extreme prices (AU)

[Translated article] Private Dermatology Practice Characteristics and Fees in Spain in 2023: A Survey and Comparison With Findings for 2018 / Encuesta sobre las características y honorarios de la práctica dermatológica privada española en 2023. Actualización y cambios con respecto a 2018

This report analyzes findings from a January 2023 survey of 235 dermatologists in private practice in Spain. The data for 2023 are compared to findings from a similar survey of conditions in 2018, to provide a snapshot of each year and identify changes in clinical practice and adaptations to emerging situations and challenges. Noteworthy changes in 2023 vs. 2018 included increased dedication to private practice and teleconsultations, more use of prepayment for procedures, more acceptance of payment by credit card or other electronic means, and variation in the timing of price changes. Sixty percent of the respondents reported planning to raise prices in 2023. The planned pricing adjustments will approximate the rise in the consumer price index. We also found that male dermatologists more often reported fees at the highest end of the range (AU)

El presente trabajo incluye el análisis de los datos obtenidos mediante una encuesta realizada en enero de 2023 a 235 dermatólogos que ejercen actividad asistencial privada en España. Se añade un fotograma posterior al estudio con metodología similar realizado en 2018, al mismo tiempo que se analizan los cambios y adaptaciones que tiene la práctica con los nuevos tiempos y retos emergentes. Comparado con 2018, en 2023 destacan: incrementos en la dedicación a la actividad privada, las teleconsultas, el cobro anticipado de técnicas, la aceptación de pagos con tarjeta bancaria y banca electrónica; cambios en la periodicidad de ajuste de precios; el hecho de que un 60% de los encuestados declare que ha ajustado al alza los precios en el año; un alza de los precios que se ajusta aproximadamente a la del IPC, y la observación de que los dermatólogos varones declaran con más frecuencia precios extremos más altos (AU)

AI outperformed every dermatologist in dermoscopic melanoma diagnosis, using an optimized deep-CNN architecture with custom mini-batch logic and loss function.

Melanoma, one of the most dangerous types of skin cancer, results in a very high mortality rate. Early detection and resection are two key points for a successful cure. Recent researches have used artificial intelligence to classify melanoma and nevus and to compare the assessment of these algorithms to that of dermatologists. However, training neural networks on an imbalanced dataset leads to imbalanced performance, the specificity is very high but the sensitivity is very low. This study proposes a method for improving melanoma prediction on an imbalanced dataset by reconstructed appropriate CNN architecture and optimized algorithms. The contributions involve three key features as custom loss function, custom mini-batch logic, and reformed fully connected layers. In the experiment, the training dataset is kept up to date including 17,302 images of melanoma and nevus which is the largest dataset by far. The model performance is compared to that of 157 dermatologists from 12 university hospitals in Germany based on the same dataset. The experimental results prove that our proposed approach outperforms all 157 dermatologists and achieves higher performance than the state-of-the-art approach with area under the curve of 94.4%, sensitivity of 85.0%, and specificity of 95.0%. Moreover, using the best threshold shows the most balanced measure compare to other researches, and is promisingly application to medical diagnosis, with sensitivity of 90.0% and specificity of 93.8%. To foster further research and allow for replicability, we made the source code and data splits of all our experiments publicly available.

Characterization of Biopsies by Dermatologists and Nonphysician Providers in the Medicare Population: A Rapidly Changing Landscape.

BACKGROUND: Previous studies show that nonphysician providers may require a higher number of biopsies to identify skin malignancies than dermatologists. Therefore, understanding the trends behind the types of providers performing biopsies may help analyze their impact on this vulnerable population. OBJECTIVE: This retrospective study analyzes changes in nationwide, regional, and state-level data on the number and proportion of biopsies performed by dermatologists compared with nonphysician providers. MATERIALS AND METHODS: Biopsy cases were isolated in the Medicare database from 2012 to 2018 using the HCPCS codes 11,100 and 11,101. Cases were limited to biopsies performed by a dermatologist, nurse practitioner (NP), or physician assistant (PA). RESULTS: From 2012 to 2018, national biopsy rates per 100,000 Medicare beneficiaries for dermatologists decreased by 6%, whereas those for NPs and PAs increased by 97% and 82%, respectively. Each state showed variation in both the proportion of biopsies by provider type and the net change in biopsies rates over time. All states saw increases in the number of biopsies per 100,000 Medicare beneficiaries by nonphysician providers. CONCLUSION: As the number of Medicare beneficiaries continues to grow, nonphysician providers are performing an increasing proportion of biopsies, with specific states and regions being affected more than others.

Social media use in residency recruitment during the COVID-19 pandemic.

To investigate the extent to which dermatology programs use social media to connect with applicants, we conducted a search of all 140 residency programs on Instagram, Facebook, Twitter, and YouTube. Our search revealed 74 (53%) Instagram, 21 (15%) Facebook, 20 (14%) Twitter, and four (3%) YouTube accounts for dermatology programs, with the number of Instagram accounts increasing five-fold from the end of 2019 to present. Our results demonstrate that conditions created during the coronavirus disease 2019 (COVID-19) pandemic accelerated dermatology residency programs' acceptance of social media, particularly Instagram, as a means to communicate and share information with applicants.

Expert Consensus on Nail Procedures and Selection of CPT Codes.

BACKGROUND: Dermatologists specialize in treating conditions of the skin, hair, and nails; however, it is our experience that the field of nail diseases is the least discussed facet of dermatology. Even less acknowledged is the complexity of nail procedures and how best to accurately code for these procedures. OBJECTIVE: To convene a panel of experts in nail disease to reach consensus on the most accurate and appropriate Current Procedural Terminology (CPT) codes associated with the most commonly performed nail procedures. METHODS: A questionnaire including 9 of the most commonly performed nail procedures and potential CPT codes was sent to experts in the treatment of nail disease, defined as those clinicians running a nail subspecialty clinic and performing nail procedures with regularity. A conference call was convened to discuss survey results. RESULTS: Unanimous consensus was reached on the appropriate CPT codes associated with all discussed procedures. LIMITATIONS: Although this article details the most commonly performed nail procedures, many were excluded and billing for these procedures continues to be largely subjective. This article is meant to serve as a guide for clinicians but should not be impervious to interpretation in specific clinical situations. CONCLUSION: Billing of nail procedures remains a practice gap within our field. The authors hope that the expert consensus on the most appropriate CPT codes associated with commonly performed nail procedures will aid clinicians as they diagnose and treat disorders of the nail unit and encourage accurate and complete billing practices.

Cutaneous Manifestations of Diabetes.

Diabetes mellitus is a significant worldwide health concern and cutaneous manifestations are common. This review describes characteristic skin findings of diabetes, general skin findings related to diabetes, and findings related to diabetes treatment with a focus on clinical presentation, diagnosis, pathophysiology, epidemiology, and treatment. As the prevalence of diabetes continues to rise, cutaneous manifestations of diabetes mellitus likely will be encountered more frequently by physicians in all disciplines including dermatologists and primary care physicians. Accordingly, knowledge regarding the prevention, diagnosis, and management of cutaneous manifestations is an important aspect in the care of patients with diabetes.

Increasing a Dermatologist's Footprint on Instagram: An Analysis of Top Influencers Performing Nonsurgical Cosmetic Procedures.

BACKGROUND: Patients use social media to find information about cosmetic procedures, yet dermatologists historically lack a social media presence. Misleading information from nonexperts is potentially harmful. OBJECTIVE: To identify the top influencers posting about nonsurgical cosmetic procedures on Instagram, verify their credentials, and analyze their content to empower dermatologists to effectively join the online conversation, combat harmful misinformation, and preserve the expertise and influence of board-certified dermatologists. METHODS AND MATERIALS: Using the Klear marketing platform, Instagram influencers with more than 50,000 followers were identified. Influence rating, top posts, and other metrics were extracted using proprietary algorithms. RESULTS: Ninety nine influencers were identified. Of the top 10, 70% were board-certified plastic surgeons. Physicians not board-certified in a core cosmetic specialty had the highest influencer rating and number of followers. The most popular posts were of before and after photographs and personal posts. CONCLUSION: Dermatologists may be able to increase their Instagram footprint by posting frequently, especially of before and after and personal photographs, using hashtags, Instagram live and Instagram television, and Instagram stories. It is important for the dermatology community to find a way to ethically navigate social media to have a seat at the table and meet patients where they are.

Assessing comfort level with pediatric skin specimens among dermatopathologists and pediatric pathologists: A national cross-sectional survey.

BACKGROUND: Cutaneous histopathologic diagnoses in children often differ from those in adults. Depending on practice setting, these specimens may be evaluated by dermatopathologists or pediatric pathologists. We sought to determine whether comfort level with pediatric dermatopathology is associated with prior training, pediatric dermatopathology exposure during fellowship, career duration, or specimen subtype. METHODS: We surveyed dermatopathologists and pediatric pathologists practicing in the United States. Training and practice variables were evaluated by multivariable regression for association with comfort level. RESULTS: Of the 156 respondents, 72% were dermatopathologists (response rate 11.6%) and 28% were pediatric pathologists (response rate 9.3%). Dermatopathologists reported higher comfort overall (P < .001); this was also true for inflammatory dermatoses and melanocytic neoplasms (P < .001). Thirty-four percent and 75% of dermatopathologists and pediatric pathologists, respectively, reported lower comfort with pediatric skin specimens than their usual cases. Pediatric pathologists were 28% more likely to refer these cases to colleagues. Among dermatopathologists, dermatology-trained were more comfortable than pathology-trained colleagues interpreting inflammatory dermatoses (P < .001). CONCLUSIONS: Pathologists' comfort with pediatric dermatopathology varied significantly based upon prior training, career duration, and specimen subtype. These results suggest opportunities for improving education in this domain.

An international 3-center training and reading study to assess basal cell carcinoma surgical margins with ex vivo fluorescence confocal microscopy.

BACKGROUND: Novel solutions are needed for expediting margin assessment to guide basal cell carcinoma (BCC) surgeries. Ex vivo fluorescence confocal microscopy (FCM) is starting to be used in freshly excised surgical specimens to examine BCC margins in real time. Training and educational process are needed for this novel technology to be implemented into clinic. OBJECTIVE: To test a training and reading process, and measure diagnostic accuracy of clinicians with varying expertise level in reading ex vivo FCM images. METHODS: An international three-center study was designed for training and reading to assess BCC surgical margins and residual subtypes. Each center included a lead dermatologic/Mohs surgeon (clinical developer of FCM) and three additional readers (dermatologist, dermatopathologist, dermatologic/Mohs surgeon), who use confocal in clinical practice. Testing was conducted on 30 samples. RESULTS: Overall, the readers achieved 90% average sensitivity, 78% average specificity in detecting residual BCC margins, showing high and consistent diagnostic reading accuracy. Those with expertise in dermatologic surgery and dermatopathology showed the strongest potential for learning to assess FCM images. LIMITATIONS: Small dataset, variability in mosaic quality between centers. CONCLUSION: Suggested process is feasible and effective. This process is proposed for wider implementation to facilitate wider adoption of FCM to potentially expedite BCC margin assessment to guide surgery in real time.

Postoperative Pain After Mohs Surgery: Physician Perceptions and How Those Perceptions Influence Opioid Prescribing Practices.

BACKGROUND: Little is known about dermatologists' perceptions of postoperative pain and how those perceptions correlate with patient-reported pain and opioid prescribing. OBJECTIVE: To determine dermatologists' accuracy in predicting postoperative pain compared with patient-reported pain and how physicians' perceptions affect opioid prescribing practices. METHODS AND MATERIALS: A prospective observational study in which patients undergoing Mohs surgery rated pain on the Numerical Rating Scale (0-10). Using the same scale, the physician predicted how much pain the patient would experience postoperatively on the evening of surgery. All analgesic medications taken in postoperative period were recorded. RESULTS: A total of 316 patients completed the study (70% completion rate). Physician predictions were correlated with patient-reported pain (p < .001; r = 0.29) and were within 2 points of patient-reported pain in 70% of cases. When physicians overestimated patient-reported by ≥3 points, they were not more likely to prescribe opioids (p = .8094). Physicians predicted higher pain for patients who were prescribed opioids (p = .0002). CONCLUSION: Dermatologists were fairly accurate at predicting postoperative pain. Dermatologists were not more likely to prescribe opioids when pain was overpredicted.

Dermatologists' Perspectives on Defining Moderate Psoriasis: The Canadian Moderate Psoriasis Survey.

BACKGROUND: Psoriasis is commonly classified as either mild or moderate to severe, without specific parameters to differentiate moderate versus severe disease. This may lead to patients with moderate psoriasis being underrecognized and undertreated. OBJECTIVE: An online survey was conducted to assess Canadian dermatologists’ perspectives on the definition and treatment of psoriasis. METHOD: Dermatologists included in the survey were regional and national leaders with expertise in psoriasis. Questions were developed based on feedback from a steering committee of Canadian dermatologists. RESULTS: Of 88 dermatologists contacted, 69 responded; 42.0% were in practice for >20 years. Most dermatologists reported using the percentage of psoriasis-affected body surface area (BSA) to describe disease severity (90.8% for moderate and 87.5% for severe psoriasis). The lower and upper median cutoffs for moderate psoriasis were reported as 5.0% and 10.0% for BSA and 7.0 and 11.5 for the Dermatology Life Quality Index. Most dermatologists also consider psoriasis location (eg, palms, scalp, genital area, face) as an important indicator of disease severity. The majority of Canadian dermatologists (87.5%) identified access to treatment as one of the biggest challenges for patients with moderate psoriasis. Most dermatologists estimated that ≤40% of their patients with moderate plaque psoriasis were being treated with traditional oral systemics, targeted oral systemics, or biologics. CONCLUSIONS: This is the first survey of Canadian dermatologists on moderate psoriasis. Efforts are needed to implement a clinically useful definition of moderate plaque psoriasis to improve patient care and to raise awareness of the definition among regulatory agencies and reimbursement authorities. J Drugs Dermatol. 2021;20(2):126-132. doi:10.36849/JDD.5531.

CME suggestions for pediatricians, allergists, and dermatologists, directed by an online survey on urticaria knowledge.

BACKGROUND: The Mexican Guidelines for the diagnosis and treatment of urticaria have been published. Just before their launch, physicians' knowledge was explored relating to key issues of the guidelines. OBJECTIVE: The aim of this study was to investigate the opinion of medical specialists concerning urticaria management. METHODS: A SurveyMonkey® survey was sent out to board-certified physicians of three medical specialties treating urticaria. Replies were analyzed per specialty against the evidence-based recommendations. RESULTS: Sixty-five allergists (ALLERG), 24 dermatologists (DERM), and 120 pediatricians (PED) sent their replies. As for diagnosis: ALERG 42% and PED 76% believe cutaneous mastocytosis, urticarial vasculitis, and hereditary angioedema are forms of urticaria, versus DERM 29% (P < 0.005). Most of the specialties find that the clinical history and physical examination are enough to diagnose acute urticaria, except DERM 45% (P < 0.01). DERM 45% believe laboratory-tests are necessary, as opposed to <15% ALLERG-PED (P < 0.005). However, PED 69% did not know that the most frequent cause of acute urticaria in children is infections, versus ALLERG-DERM 30% (P < 0.005). Many erroneously do laboratory testing in physical urticaria and ALLERG 51%, DERM 59%, and PED 37% do extensive laboratory testing in chronic spontaneous urticaria (CSU); many more PED 59% take Immunoglobulin G (IgG) against foods (P < 0.005). More than half of non-allergists do not know about autologous serum testing nor autoimmunity (P < 0.05). As for treatment, there were a few major gaps: when CSU was controlled, >75% prescribed antihistamines pro re nata, and >85% gave first-generation antiH1 for insomnia. Finally, >40% of DERM did not know that cyclosporine A, omalizumab, or other immunosuppressants could be used in recalcitrant cases. CONCLUSION: Specialty-specific continuous medical education might enhance urticaria management.

Insurance Acceptance, Appointment Wait Time, and Dermatologist Access Across Practice Types in the US.

Importance: In the 15 years since dermatology access was last investigated on a national scale, the practice landscape has changed with the rise of private equity (PE) investment and increased use of nonphysician clinicians (NPCs). Objective: To determine appointment success and wait times for patients with various insurance types at clinics with and without PE ownership. Design, Setting, and Participants: In this study, PE-owned US clinics were randomly selected and matched with 2 geographically proximate clinics without PE ownership. Researchers called each clinic 3 times over a 5-day period to assess appointment/clinician availability for a fictitious patient with a new and changing mole. The 3 calls differed by insurance type specified, which were Blue Cross Blue Shield (BCBS) preferred provider organization, Medicare, or Medicaid. Main Outcomes and Measures: Appointment success and wait times among insurance types and between PE-owned clinics and control clinics. Secondary outcomes were the provision of accurate referrals to other clinics when appointments were denied and clinician and next-day appointment availability. Results: A total of 1833 calls were made to 204 PE-owned and 407 control clinics without PE ownership across 28 states. Overall appointment success rates for BCBS, Medicare, and Medicaid were 96%, 94%, and 17%, respectively. Acceptance of BCBS (98.5%; 95% CI, 96%-99%; P = .03) and Medicare (97.5%; 95% CI, 94%-99%; P = .02) were slightly higher at PE-owned clinics (compared with 94.6% [95% CI, 92%-96%] and 92.8% [95% CI, 90%-95%], respectively, at control clinics). Wait times (median days, interquartile range [IQR]) were similar for patients with BCBS (7 days; IQR, 2-22 days) and Medicare (7 days; IQR, 2-25 days; P > .99), whereas Medicaid patients waited significantly longer (13 days; IQR, 4-33 days; P = .002). Clinic ownership did not significantly affect wait times. Private equity-owned clinics were more likely than controls to offer a new patient appointment with an NPC (80% vs 63%; P = .001) and to not have an opening with a dermatologist (16% vs 6%; P < .001). Next-day appointment availability was greater at PE-owned clinics than controls (30% vs 21%; P = .001). Conclusions and Relevance: Patients with Medicaid had significantly lower success in obtaining appointments and significantly longer wait times regardless of clinic ownership. Although the use of dermatologists and NPCs was similar regardless of clinic ownership, PE-owned clinics were more likely than controls to offer new patient appointments with NPCs.

Rates of Vascular Occlusion Associated With Using Needles vs Cannulas for Filler Injection.

Importance: Soft-tissue augmentation with skin fillers can be delivered with needles or microcannulas, but unwanted vascular occlusions are possible. Objective: To determine whether filler-associated vascular occlusion events of the face occur more often with injections performed with needles than with microcannulas. Design, Setting, and Participants: This retrospective cohort study included a random sample of board-certified dermatologists deemed eligible based on membership in relevant professional societies and attendance at relevant national professional meetings. Participants completed detailed forms in which they could enter deidentified data and volume statistics pertaining to patients undergoing filler procedures in their practices. Data were collected from August 2018 to August 2019. Exposures: Injectable fillers approved by the US Food and Drug Administration delivered via needles or microcannulas. Main Outcomes and Measures: The primary outcome measure was intravascular occlusion. Occlusion events were graded by severity (no sequelae, scar, and ocular injury or blindness). Results: A total of 370 dermatologists (mean [SD] years in practice, 22.3 [11.1] years) participated and reported 1.7 million syringes injected. The risk of occlusion with any particular filler type using needle or cannula never exceeded 1 per 5000 syringes injected. Overall, 1 occlusion per 6410 per 1-mL syringe injections was observed with needles and 1 per 40 882 with cannulas (P < .001). Of the 370 participants, 106 (28.6%) reported at least 1 occlusion. Multivariate analysis found that injections with cannula had 77.1% lower odds of occlusion compared with needle injections. Participants injecting fillers for more than 5 years had 70.7% lower odds of occlusion than those who were less experienced. For each additional injection per week, the odds of occlusion decreased by 1%, and 85% of occlusions had no long-term sequelae. Nasolabial folds and lips were most likely to be occluded, with mean severity level of occlusions highest at the glabella. Conclusions and Relevance: In this cohort study, filler injections with either needles or cannulas were associated with a very low risk of intravascular occlusion events. Moreover, the vast majority of such events were minor and resolved without scar or other injury. Injections with microcannulas were less often associated with occlusion events than injections with needles. Occlusion risk per syringe appeared decreased after the first few years of clinical practice and was also lower among those who more frequently inject fillers. Whether a needle or cannula is most appropriate for injection may depend on patient factors, anatomic site, and the type of defect being treated.