Equity in the usage of biologics for psoriasis in the working poor

Biologic therapy often produces excellent outcomes for psoriasis; however, their high cost may create a barrier to appropriate usage, especially in the working poor population. This study defines working poor as income below 150% of the federal poverty level and holding or seeking work at least half a year. Our study aims to identify gaps in access to biologic therapy for psoriasis based on working poor status. This retrospective cross-sectional study was conducted utilizing data from the Medical Expenditure Panel Survey (MEPS) from 2007 to 2018. Patients were stratified into working poor (57,091), non-working poor (43,421), and non-poor (693,841) groups for analysis. In univariate analysis, WP (4.0%, ph p = 0.003) and NWP (2.8%, ph p = 0.006) were less likely to use biologics than NP (15.8%) (X² p < 0.001). A binary logistic regression showed that WP vs. NP status (OR 0.27, p = 0.05), female vs. male sex (OR 0.55, p = 0.05), Black vs. White race (OR 0.14, p = 0.02), and Medicare vs. private insurance (OR 0.09, p = 0.03) had lower odds of using biologics. After correcting for age, sex, race, and insurance, WP confers an independent risk factor to lower biologic prescriptions. The high cost of biologics in the setting of financial barriers for some patients should be considered by physicians prescribing biologic therapy for psoriasis.

Treatment Options and Outcomes for Squamous Cell Carcinoma of the Nail Unit: A Systematic Review

BACKGROUND

Nail squamous cell carcinoma (nSCC) is the most common nail unit malignancy. However, no studies to date have evaluated treatment options for nSCC based on recurrence data while controlling for invasion.

OBJECTIVE

To identify temporal trends in nSCC treatment modalities and compare treatment outcomes based on invasion.

METHODS AND MATERIALS

The authors performed a systematic review of articles published on PubMed, MEDLINE, and Scopus from inception to April 2020 reporting treatment of nSCC. The primary outcome was disease recurrence.

RESULTS

Reports of nSCC treatments have increased in the past decade. Mohs micrographic surgery (MMS) is the most common treatment reported overall. The lowest recurrence rates for in situ nSCC were seen with wide surgical excision (WSE) and MMS. For invasive disease, the recurrence rates were lowest with amputation, MMS, and WSE.

CONCLUSION

Complete surgical excision of nSCC with either WSE or MMS is associated with lower recurrence rates than limited excision and nonsurgical therapies, regardless of degree of invasion. The prognostic significance of in situ versus invasive disease remains unclear. Confirmation of complete excision may improve outcomes. Digital amputation is indicated for nSCC with bone invasion. Prospective studies and randomized controlled trials are needed to directly compare surgical modalities for nSCC.

Pain Intensity Assessment Scales for Dermatologic Surgery Patients: A Systematic Review

BACKGROUND

Pain assessment plays an important role in dermatologic surgery. The numeric rating scale (NRS), visual analog scale (VAS), verbal rating scale (VRS), and Faces Pain Scale (FPS) are commonly used scales for pain measurement. Conflicting evidence exists regarding the use of each. Prompt pain recognition and treatment during procedures result in higher patient satisfaction.

OBJECTIVE

Determine the most applicable scale for acute pain measurement in dermatologic surgery.

MATERIALS AND METHODS

This systematic review was performed in accordance with PRISMA-Supplemental Digital Content 4, http://links.lww.com/DSS/A976 (PROSPERO; CRD42018091058). PubMed, Cochrane, EMBASE, Scopus, and Web of Science were searched between April 24, 2018, and May 06, 2018. The search query consisted of pain, pain measurement (NRS, VAS, VRS, and FPS), and assessment/comparison. The inclusion criteria included English language literature with primary/secondary outcome objectives directly comparing ≥2 pain scales in acute pain (age: 13+). Study end points included interscale correlations, patient preferences, provider preferences, study author recommendations, and failure rates.

RESULTS

Eight hundred seven studies were retrieved: A total of 42 studies were included. The visual analog scale (n = 42) was most studied, followed by NRS (n = 29), VRS (n = 27), and FPS (n = 11). 93.1% studies showed a high statistical correlation between VAS and NRS. Patients preferred NRS (n = 8/11), followed by FPS (n = 3/11), VRS (n = 2/11), and VAS (n = 1/11). Study authors recommended NRS/VAS (n = 8/19), VRS (n = 6/19), and FPS (n = 1/19). Providers preferred NRS (n = 2/3) and VRS (n = 1/3). The visual analog scale had the highest failure rate (n = 11/12).

CONCLUSION

The numeric rating scale is most applicable for dermatologic surgery because of reported patient and provider preferences, lowest failure rates, and most frequent study author recommendations.

Consensus-Based Recommendations on the Prevention of Squamous Cell Carcinoma in Solid Organ Transplant Recipients: A Delphi Consensus Statement

IMPORTANCE

There is a paucity of evidence to guide physicians regarding prevention strategies for cutaneous squamous cell carcinoma (CSCC) in solid organ transplant recipients (SOTRs).

OBJECTIVE

To examine the development and results of a Delphi process initiated to identify consensus-based medical management recommendations for prevention of CSCC in SOTRs.

EVIDENCE REVIEW

Dermatologists with more than 5 years' experience treating SOTRs were invited to participate. A novel actinic damage and skin cancer index (AD-SCI), consisting of 6 ordinal stages corresponding to an increasing burden of actinic damage and CSCC, was used to guide survey design. Three sequential web-based surveys were administered from January 1, 2019, to December 31, 2020. Pursuant to Delphi principles, respondents thoroughly reviewed all peer responses between rounds. Supplemental questions were also asked to better understand panelists' rationale for their responses.

FINDINGS

The Delphi panel comprised 48 dermatologists. Respondents represented 13 countries, with 27 (56%) from the US. Twenty-nine respondents (60%) were Mohs surgeons. Consensus was reached with 80% or higher concordance among respondents when presented with a statement, question, or management strategy pertaining to prevention of CSCC in SOTRs. A near-consensus category of 70% to less than 80% concordance was also defined. The AD-SCI stage-based recommendations were established if consensus or near-consensus was achieved. The panel was able to make recommendations for 5 of 6 AD-SCI stages. Key recommendations include the following: cryotherapy for scattered actinic keratosis (AK); field therapy for AK when grouped in 1 anatomical area, unless AKs are thick in which case field therapy and cryotherapy were recommended; combination lesion directed and field therapy with fluorouracil for field cancerized skin; and initiation of acitretin therapy and discussion of immunosuppression reduction or modification for patients who develop multiple skin cancers at a high rate (10 CSCCs per year) or develop high-risk CSCC (defined by a tumor with approximately ≥20% risk of nodal metastasis). No consensus recommendation was achieved for SOTRs with a first low risk CSCC.

CONCLUSIONS AND RELEVANCE

Physicians may consider implementation of panel recommendations for prevention of CSCC in SOTRs while awaiting high-level-of-evidence data. Additional clinical trials are needed in areas where consensus was not reached.

Emergency department utilization for impetigo among the pediatric population: A retrospective study of the national emergency department sample 2013-2015

BACKGROUND

Despite the large burden of impetigo in childhood and high frequency of pediatric emergency department (ED) visits for skin conditions, limited information exists on the use of EDs for impetigo among US children.

OBJECTIVE

Our study aimed to generate national estimates of ED utilization and to identify sociodemographic predictors of impetigo-related ED visits.

METHODS

This was a retrospective, cross-sectional study of children ages 1-17 presenting to EDs with a primary diagnosis of impetigo using years 2013-2015 of the Nationwide Emergency Department Sample.

RESULTS

Impetigo accounted for 163 909 of the 71 488, 511 pediatric ED visits and was the fourth most common presenting skin diagnosis. Controlling for sociodemographic factors, patients presenting to the ED with impetigo were most likely to be 6-11 years old, male, and from lower-income quartiles. Patients were most likely to be uninsured and most likely to present on weekends in the summer.

CONCLUSION

This study provided national-level estimates of ED use for impetigo among US children. Ultimately, the identification of factors associated with increased ED utilization may help in developing targeted interventions to reduce the use of emergency care for impetigo.

Factors associated with matching into research-focused dermatology residency programs

Although dermatology is one of the most competitive specialties to match into, there is limited transparency in the residency match process. In this retrospective cohort study of 2234 allopathic medical graduates, we identify applicant characteristics associated with matching into research oriented dermatology programs. Many of the statistically significant variables in our study, including PhD/MD status, graduating from a Top-25 NIH funded medical school, increasing total number of pre-residency publications (PRPs), and increasing number of high-impact PRPs, correlate with future academic employment. Although literature shows an association between an increasing number of first author PRPs and future academic employment, we did not find number of first or last author PRPs to be predictive of matching into a research oriented residency program. A more comprehensive evaluation of an applicant's research output, considering both the final products of an applicant's research endeavors and an applicant's role in various projects, may better approximate an applicant's commitment to academics.

Validated Outcome Measures and Postsurgical Scar Assessment Instruments in Eyelid Surgery: A Systematic Review

BACKGROUND

Determining which postsurgical scar assessment instruments, if any, cover important eyelid outcome measures can either attest to the strength of one or more instruments or reveal the need for a more comprehensive scale.

OBJECTIVE

To systematically review validated outcome measures after eyelid surgery and postsurgical scar assessment tools to see whether any individual or combination of 2 assessment tools encompass all relevant, validated eyelid outcome measures.

METHODS

Systematic reviews of validated eyelid outcome measures and postsurgical scar assessment tools were conducted using PubMed/MEDLINE and Ovid. Outcome measure papers that met inclusion criteria were sorted into 8 categories: Patient Subjective, Visual Function, Mechanical Function, Daily Activities, Adverse Effects, Aesthetic Quantitative: Clinical Measurements, Aesthetic Qualitative: Global, and Aesthetic Qualitative: Specific. Outcome measure papers were categorized into tiers of evidence support, and assessment tools were evaluated based on which outcome measures each covered.

RESULTS

No one or combination of 2 assessment tools covered all selected eyelid outcome measures. Although measures related to the subjective patient experience were included in several of the assessment scales, none covered measures of visual function or eyelid-specific clinical measurements.

CONCLUSION

There is currently no existing postsurgical scar assessment instrument that covers all important eyelid-specific outcome measures.

Validated Outcome Measures and Postsurgical Scar Assessment Instruments in Auricular Surgery: A Systematic Review

BACKGROUND

The utilization of an assessment instrument that successfully analyzes validated outcome measures for auricular surgery is important for advancing evidence-based medicine.

OBJECTIVE

To systematically review postsurgical scar assessment instruments and outcome measures after auricular surgery to assess if any individual or combination of 2 assessment instruments encompass all relevant, validated auricular outcome measures.

METHODS

Two systematic reviews were conducted using the PubMed/MEDLINE and Ovid databases: one for postauricular surgical outcome measures and another for postsurgical scar assessment instruments. Auricular outcome measure articles were selected for inclusion if they included at least one auricular-specific validated outcome measure, and assessment tool articles were included if they referenced one or more specific tool(s) specifically designed to assess postsurgical scars. Assessment tools were evaluated based on which outcome measures each covered.

RESULTS

There was no single postsurgical scar assessment instrument or combination of 2 instruments that covered all outcome measures within the 5 different categories (psychosocial well-being, functional, objective appearance, subjective appearance, and clinical-related outcomes) after auricular surgery. None of the instruments measured functional outcomes, such as the ability to wear glasses and hearing outcomes.

CONCLUSION

There is currently no existing postsurgical scar assessment instrument that covers all outcome measures after auricular surgery.

Trends of Research Output of Allopathic Medical Students Matching Into Dermatology, 2007-2018

IMPORTANCE

According to the National Residency Matching Program's biennial Charting Outcomes in the Match (NRMP ChOM) reports, the mean number of research items of matched allopathic dermatology applicants has nearly tripled since 2007, rising from 5.7 to 14.7. Research items are self-reported by applicants and serve as an approximation of research output. Because the NRMP research items field is unverified and reported as an aggregate of several different research pursuits, it may not be an accurate representation of applicant research output.

OBJECTIVE

To determine if the rise in NRMP-reported data is associated with a rise in verifiable, indexed publications from matched allopathic dermatology applicants from 2007 to 2018.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional study including a bibliometric analysis on accepted applicant research output among 2234 matched allopathic dermatology applicants, with a total of 6229 publications, in dermatology residency programs for the years 2007, 2009, 2011, 2014, 2016, and 2018.

MAIN OUTCOME AND MEASURES

The primary outcomes were the mean number of peer-reviewed indexed publications and mean number of NRMP ChOM research items. Secondary outcomes assessed the quality of indexed publications by analyzing article type and journal of publication.

RESULTS

From 2007 to 2018, the mean number of indexed publications per matched dermatology applicant increased from 1.6 to 4.7 (203% increase). Indexed publications consistently compose a minority of NRMP ChOM research items (28.8% across the 6 years of the study). Nonindexed research items increased at more than double the rate of indexed publications. Bibliometric analysis showed that all other types of publications are increasing at a rate of 6 to 9 times that of basic science publications, dermatology-related publications increased at 5 times the rate of non-dermatology publications, and publications in lower-impact factor dermatology journals increased at 4 times the rate of publications in higher-impact factor dermatology journals.

CONCLUSIONS AND RELEVANCE

This cross-sectional study provides data on the research output of matched dermatology applicants. Indexed publications compose a minority of NRMP research items. Medical student self-reports of research output may emphasize research quantity over quality.

Opioid Prescribing Recommendations After Mohs Micrographic Surgery and Reconstruction: A Delphi Consensus

BACKGROUND

Prescription opioids play a large role in the opioid epidemic. Even short-term prescriptions provided postoperatively can lead to dependence.

OBJECTIVE

To provide opioid prescription recommendations after Mohs micrographic surgery (MMS) and reconstruction.

METHODS

This was a multi-institutional Delphi consensus study consisting of a panel of members of the American College of Mohs Surgery from various practice settings. Participants were first asked to describe scenarios in which they prescribe opioids at various frequencies. These scenarios then underwent 2 Delphi ratings rounds that aimed to identify situations in which opioid prescriptions should, or should not, be routinely prescribed. Consensus was set at ≥80% agreement. Prescription recommendations were then distributed to the panelists for feedback and approval.

RESULTS

Twenty-three Mohs surgeons participated in the study. There was no scenario in which consensus was met to routinely provide an opioid prescription. However, there were several scenarios in which consensus were met to not routinely prescribe an opioid.

CONCLUSION

Opioids should not be routinely prescribed to every patient undergoing MMS. Prescription recommendations for opioids after MMS and reconstruction may decrease the exposure to these drugs and help combat the opioid epidemic.