Waiting times to see a dermatologist are perceived as too long by dermatologists: implications for the dermatology workforce

The Past, the Present and the Future of Teledermatology: A Narrative Review

Teledermatology may be defined as the application of telemedicine to dermatology. According to published data, teledermatology is more widespread in Europe and North America, probably where resources for health care are greater than in other areas of the world. Indeed, teledermatology requires advanced technology to be efficient, as high image quality is necessary to allow the dermatologist to make correct diagnoses. Thanks to the recent advances in this field, teledermatology is become routinary in daily clinical practice. However, its use has been improved over time, overcoming several challenges. The aim of this narrative review is to retrace the almost 30-year history of teledermatology, to address the new challenges posed by advancing technologies such as artificial intelligence and the implications it may have on healthcare.

Social Media and Dermatology During the COVID-19 Pandemic: Analyzing User-Submitted Posts Seeking Dermatologic Advice on Reddit

INTRODUCTION

Reddit, a popular social media website, has numerous forums where users may discuss healthcare-related topics and request diagnostic and treatment advice for dermatologic conditions. We sought to analyze and grade user-submitted requests for dermatologic advice and their top responses on Reddit.

METHODS

User-submitted posts requesting diagnostic advice and their respective responses on two popular Reddit forums, SkinCareAddiction (ScA) and DermatologyQuestions (DQ), were reviewed by three board-certified dermatologists using a grading rubric designed for this study.

RESULTS

300 posts and comments were reviewed. Diagnoses among all graders matched in 52.3% of posts with a mean grader confidence score of 4/5 (95% CI 3.89-4.11). 31% of responder's comments recommended a diagnosis not included by any reviewer. Mean scores for the top comment's accuracy, appropriateness, and potential to be misleading/dangerous were 3.28/5 (95% CI 3.12-3.45), 3.3/5 (95% CI 3.14-3.45), and 2.33/5 (95% CI 2.18-2.48), respectively.

CONCLUSION

Reddit may be informative to patients requesting dermatologic advice. However, responses should be taken with caution as the information provided may be inaccurate or insufficient for treatment recommendations. Dermatologists should be aware of these resources used by patients.

Comparison of teledermatological examinations with conventional office visits in management of acne vulgaris: A review of current literature

Acne vulgaris is the most common skin disease in the world, particularly affecting adolescents and young adults. Telemedicine has grown rapidly in the past few years and represents a new simplification in modern medicine. The aim of this literature review is to provide an overview of acne vulgaris in teledermatology and to identify the differences between teledermatological examinations and face-to-face consultations. For this purpose, a systematic literature search of the PubMed database was performed, up to the end of 2019. The content of 109 studies matching the keywords acne, acne vulgaris, teledermatology, telehealth, or telemedicine was screened, and 13 studies were systematically reviewed and compared. The analysis of the studies shows that patients living in remote areas benefit greatly from online visits since it is less time consuming and financially favorable, which is also associated with higher patient satisfaction. In addition, the satisfaction of doctors, the main safety concerns of patients, and a brief insight into telemedicine in other specialties are discussed. Taking the results of the different studies into account, the conclusion is that telemedicine is well accepted and often even desired by most patients and will likely become a very important part of modern medicine in the future.

Perceptions of dermatology and dermatologists by residency program directors of other medical specialties

More data are needed to characterize the perceptions of dermatology by nondermatologist physicians in order to address how current perceptions may be improved. Residency program directors of 21 medical specialties were contacted by e-mail and directed to a survey created with Research Electronic Data Capture software. Data from survey responses were collated and analyzed. A total of 80 residency program directors completed the survey. Physicians who worked more frequently with dermatologists were more likely to describe dermatologists positively. Most physicians believed dermatologists manage skin conditions, but fewer knew that they also manage hair, nail, or mucosal conditions. Cross-specialty collaboration between nondermatologists and dermatologists is associated with positive perceptions of dermatology. Further collaboration could provide the opportunity to educate physicians regarding the conditions treated by dermatologists and how their expertise may benefit patient care.

Deep Neural Frameworks Improve the Accuracy of General Practitioners in the Classification of Pigmented Skin Lesions

This study evaluated whether deep learning frameworks trained in large datasets can help non-dermatologist physicians improve their accuracy in categorizing the seven most common pigmented skin lesions. Open-source skin images were downloaded from the International Skin Imaging Collaboration (ISIC) archive. Different deep neural networks (DNNs) (n = 8) were trained based on a random dataset constituted of 8015 images. A test set of 2003 images was used to assess the classifiers' performance at low (300 × 224 RGB) and high (600 × 450 RGB) image resolution and aggregated data (age, sex and lesion localization). We also organized two different contests to compare the DNN performance to that of general practitioners by means of unassisted image observation. Both at low and high image resolution, the DNN framework differentiated dermatological images with appreciable performance. In all cases, the accuracy was improved when adding clinical data to the framework. Finally, the least accurate DNN outperformed general practitioners. The physician's accuracy was statistically improved when allowed to use the output of this algorithmic framework as guidance. DNNs are proven to be high performers as skin lesion classifiers and can improve general practitioner diagnosis accuracy in a routine clinical scenario.

Increasing Access to Specialized Dermatology Care: A Retrospective Study Investigating Clinical Operation and Impact of a University-Affiliated Free Clinic

Introduction

Our objective was to study the impact and clinical operation of an integrated model for free specialized dermatology care via collaboration between an academic institution and a nonprofit outpatient clinic through an analysis of patient demographics and care provided.

Methods

Hope@UMHS is a partnership between the University of Michigan Health System (UMHS) and Hope Clinic (HC) which provides free specialty consultations to uninsured residents of Southeast Michigan. A retrospective chart review was completed for patients referred to the UMHS Dermatology clinic as part of the HOPE@UMHS collaboration from April 2012 through February 2020.

Results

Of the 294 referred patients, 264 were managed in 30 clinic sessions over 8 years, staffed by 92 unique volunteers. Patients most commonly presented with atopic dermatitis (10.5%), seborrheic dermatitis (7.9%), and actinic keratosis (7.4%). The majority of patients (68.2%) were prescribed at least one new medication. Nine skin cancers, including one melanoma, were diagnosed and treated. There were 102 procedures performed. Eighty-seven percent of patients received conclusive evaluation and treatment at the time of their consultation.

Conclusion

Our experience illustrates that providing free, comprehensive dermatology care in a university hospital by partnering with a nonprofit clinic is both feasible and beneficial to the greater community.

Teledermatology: current indications and considerations for future use

Telemedicine is one of the most consequential technologies in modern healthcare. In certain situations, it allows for the delivery of care with high quality and minimal difficulty. This is particularly true in dermatology, in which many dermatological conditions can be treated remotely. The burden on dermatology patients has been greatly reduced for certain pathologies due to telemedicine. Health care providers also achieve improved job satisfaction following the convenience of meeting their patients. This paper details select dermatological conditions, and subsequently divides them into those treatable by telemedicine appointments, and those requiring face to face appointments.

Definitions, survey methods, and findings of patient satisfaction studies in teledermatology: a systematic review

Remote consultations likely will grow in importance if the COVID-19 pandemic continues. This review analyzes which methods of teledermatology patients prefer by categorizing how recent studies have defined satisfaction, conducted surveys and concluded patients respond to the different modalities of teledermatology. Using PubMed and Cochrane databases, we reviewed studies from April 5th, 2010 to April 5th, 2020 that included the search terms patient satisfaction and teledermatology. All studies that included patient satisfaction as an outcome were included, but studies not published in English were excluded. We examined domains of satisfaction, survey method, study characteristics (including patient population, country, age, study design and evidence score), findings and statistical comparisons. We thoroughly reviewed 23 studies. Definitions of satisfaction varied, but all concluded patients were satisfied with the live-interactive and store-and-forward modalities. The studies reveal that store-and-forward is appropriate for clinicians with established patients who require regular follow-up. Verified areas of care include treatment of chronic conditions, topical skin cancer therapy, wound monitoring, and post-procedural follow-up. Only four studies conducted statistical analyses. One of those studies compared patient preference for each modality of teledermatology with face-to-face dermatology. While this study reported high satisfaction with each mode of teledermatology, patients still preferred face-to-face. Favorable responses to remote diagnostic capabilities suggest that these offerings improve preference for teledermatology. With only one study evaluating preference between each modality and face-to-face dermatology, more studies should address the discrepancy. Surveys that cover all domains of satisfaction may improve assessments and identify where gaps in preference exist.

Mechano-vibrational spectroscopy of skin: Are changes in collagen and vascular tissue components early signs of basal cell carcinoma formation?

BACKGROUND

The modulus and resonant frequency of cancer cells and extracellular matrix are increased in both basal cell and squamous cell carcinomas, and in addition, the collagen stiffness is increased. The organization of the extracellular matrix surrounding cancer cells is clearly different than the extracellular matrix that is seen in normal skin.

MATERIALS AND METHODS

We have used vibrational optical coherence tomography (VOCT) to measure the resonant frequency and stiffness of collagen, vascular, and reorganized fibrous extracellular matrix components. Measurements of vessels and fibrotic collagen content made on basal cell carcinomas (BCCs) are compared to similar measurements made on normal skin from different anatomical locations.

RESULTS

Lesions with basal cell carcinomas exhibit characteristic resonant frequencies and moduli of reorganized extracellular matrix characteristic of fibrotic tissue. Cancerous lesions are characterized by dermal collagen (100 Hz), vascular (150 Hz), and fibrotic peaks (200-230 Hz). The fibrotic peak is not found in areas of normal skin.

CONCLUSIONS

Based on this pilot study, it is hypothesized inflammation may promote precancerous lesion formation in the surrounding extracellular matrix. Measurement of the increases in vaculature and fibrotic content may be useful in early detection of BCCs.

The Impact of Suspension of Dermatology On-Call Services

BACKGROUND

Dermatological conditions are commonly seen in the emergency department and inpatient wards. The ability to access dermatology on-call services improves the accuracy of diagnosis and management of common and sometimes life-threatening conditions. Limitations of dermatologist availability led to the suspension of the dermatology on-call service for 3 months in Ottawa, Canada.

OBJECTIVES

Our objective was to assess the impact of this call suspension on patient care and the need for a dermatology on-call service at our hospital, as perceived by nondermatologist physicians at our center.

METHODS

A survey was sent to all departments at The Ottawa Hospital, addressed to staff physicians and residents. Participation was entirely voluntary. Descriptive statistics were used to analyze survey responses.

RESULTS

A total of 105 physicians completed the survey including staff physicians (85%) and resident trainees (15%). The most represented specialties were emergency medicine (N = 21), general internal medicine (N = 19), nephrology (N = 17), neurology (N = 13), and plastic surgery (N = 13). Over half of the respondents felt that the lack of dermatology on-call service impacted the care of their patients by a moderate or great extent. Over half reported performing dermatology-related clinical work during the call suspension and two-thirds of these individuals reported feeling uncomfortable or very uncomfortable doing so. Most (94%) participants felt that an on-call dermatology service was useful and 57% deemed it essential.

CONCLUSION

Our survey results demonstrate a significant impact of the suspension of a dermatology on-call service, as perceived by nondermatologist physicians. Hospitals need to recognize the importance of on-call dermatology consultations and provide support for divisions to enable this service to continue.

Comparison of Dermatologist Density Between Urban and Rural Counties in the United States

Importance

As the US population continues to increase and age, there is an unmet need for dermatologic care; therefore, it is important to identify and understand the characteristics and patterns of the dermatologist workforce.

Objective

To analyze the longitudinal dermatologist density and urban-rural disparities using a standardized classification scheme.

Design, Setting, and Participants

This study analyzed county-level data for 1995 to 2013 from the Area Health Resources File to evaluate the longitudinal trends and demographic and environmental factors associated with the geographic distribution of dermatologists.

Main Outcomes and Measures

Active US dermatologist and physician density.

Results

In this study of nationwide data on dermatologists, dermatologist density increased by 21% from 3.02 per 100 000 people to 3.65 per 100 000 people from 1995 to 2013; the gap between the density of dermatologists in urban and other areas increased from 2.63 to 3.06 in nonmetropolitan areas and from 3.41 to 4.03 in rural areas. The ratio of dermatologists older than 55 years to younger than 55 years increased 75% in nonmetropolitan and rural areas (from 0.32 to 0.56) and 170% in metropolitan areas (from 0.34 to 0.93). Dermatologists tended to be located in well-resourced, urban communities.

Conclusions and Relevance

Our findings suggest that substantial disparities in the geographic distribution of dermatologists exist and have been increasing with time. Correcting the workforce disparity is important for patient care.

Nonphysician Practice of Cosmetic Dermatology: A Patient and Physician Perspective of Outcomes and Adverse Events

BACKGROUND

Nonphysicians are expanding practice into specialty medicine. There are limited studies on patient and physician perspectives as well as safety outcomes regarding the nonphysician practice of cosmetic procedures.

OBJECTIVE

To identify the patient (consumer) and physician perspective on preferences, adverse events, and outcomes following cosmetic dermatology procedures performed by physicians and nonphysicians.

MATERIALS AND METHODS

Internet-based surveys were administered to consumers of cosmetic procedures and physician members of the American Society for Dermatologic Surgery. Descriptive statistics and graphical methods were used to assess responses. Comparisons between groups were based on contingency chi-square analyses and Fisher exact tests.

RESULTS

Two thousand one hundred sixteen commenced the patient survey with 401 having had a cosmetic procedure performed. Fifty adverse events were reported. A higher number of burns and discoloration occurred in the nonphysician-treated group and took place more often in a spa setting. Individuals seeing nonphysicians cited motivating factors such as level of licensure (type) of nonphysician, a referral from a friend, price, and the location of the practitioner. Improper technique by the nonphysician was cited most as a reason for the adverse event. Both groups agree that more regulation should be placed on who can perform cosmetic procedures. Recall bias associated with survey data.

CONCLUSION

Patients treated by nonphysicians experienced more burns and discoloration compared with physicians, and they are encountering these nonphysicians outside a traditional medical office, which are important from a patient safety and regulatory standpoint. Motivating factors for patients seeking cosmetic procedures may also factor into the choice of provider.

KEY POINTS

Both patients and physicians think more regulation should be in place on who can perform cosmetic procedures. More adverse events such as burns and discolorations occurred with patients seeing nonphysicians compared with those seeing physicians. In addition, for those seeing nonphysicians, a majority of these encounters took place in spa settings. Patient safety is of utmost concern when it comes to elective cosmetic medical procedures. More adverse events and encounters occurring outside traditional medical settings when nonphysicians performed these procedures call into question the required training and oversight needed for such procedures.

Skin cancer screening after solid organ transplantation: Survey of practices in Canada

Guidelines recommend annual dermatology screening after solid organ transplantation to facilitate early detection of keratinocyte carcinoma (nonmelanoma skin cancer), the most common posttransplant malignancy. There are limited data on adherence levels and barriers to screening. We conducted a cross-sectional survey of 477 physicians and nurses providing posttransplant care in Canada. The questionnaire asked about skin cancer screening and education practices, including the perceived importance and barriers. Whereas care providers viewed skin cancer screening as important for adult patients (median rating of 10/10, interquartile range 8-10), only 53% ensured annual screening for white adult transplant recipients. Having a screening policy in place (adjusted odds ratio 6.78, 95% confidence interval 3.12-14.74) and a dermatologist present at the transplant center (adjusted odds ratio 2.19, 95% confidence interval 1.03-4.67) were independently associated with higher adherence. Long wait times, lack of specialized transplant dermatologists, long travel distances, and insufficient priority were cited as the most common barriers for access to dermatologic care. Skin cancer education was provided to patients by over three quarters of care providers. Given the self-reported lack of adherence to annual skin cancer screening, there is need to develop, evaluate, and implement interventions that improve screening rates and skin cancer outcomes.

Dermatologic Training and Practice in Canada: A Historical Overview

The specialty of dermatology is constantly changing to meet the medical needs of our society. The discipline is in flux because of a variety of factors such as growing population needs, technological advancements, fiscal restraint, and demographic changes. As part of an in-depth review of the specialty, the Dermatology Working Group (DWG) for the Royal College of Physicians and Surgeons of Canada sought to determine whether the current training configuration is suitably preparing graduates to meet the societal health needs of dermatology patients. In this first of a 2-part series, the authors conducted comprehensive literature and historical reviews and a jurisdictional analysis to understand the current state of dermatology practice in Canada. Herein, they explore trends in the dermatology workforce, population needs, accessibility, and wait times, as well as issues in undergraduate and postgraduate medical education. In a subsequent publication, the DWG will utilize information gained from this historical analysis and jurisdictional review, stakeholder perspectives, and a national survey to shape the future of dermatology training in Canada.

A Cross-Sectional Survey of Population-Wide Wait Times for Patients Seeking Medical vs. Cosmetic Dermatologic Care

Background

Though previous work has examined some aspects of the dermatology workforce shortage and access to dermatologic care, little research has addressed the effect of rising interest in cosmetic procedures on access to medical dermatologic care. Our objective was to determine the wait times for Urgent and Non-Urgent medical dermatologic care and Cosmetic dermatology services at a population level and to examine whether wait times for medical care are affected by offering cosmetic services.

Methods

A population-wide survey of dermatology practices using simulated calls asking for the earliest appointment for a Non-Urgent, Urgent and Cosmetic service.

Results

Response rates were greater than 89% for all types of care. Wait times across all types of care were significantly different from each other (all P < 0.05). Cosmetic care was associated with the shortest wait times (3.0 weeks; Interquartile Range (IQR) = 0.4–3.4), followed by Urgent care (9.0 weeks; IQR = 2.1–12.9), then Non-Urgent Care (12.7 weeks; IQR = 4.4–16.4). Wait times for practices offering only Urgent care were not different from practices offering both Urgent and Cosmetic care (10.3 vs. 7.0 weeks).

Interpretation

Longer wait times and greater variation for Urgent and Non-Urgent dermatologic care and shorter wait times and less variation for Cosmetic care. Wait times were significantly longer in regions with lower dermatologist density. Provision of Cosmetic services did not increase wait times for Urgent care. These findings suggest an overall dermatology workforce shortage and a need for a more streamlined referral system for dermatologic care.

Total body photography for skin cancer screening

BACKGROUND

Total body photography may aid in melanoma screening but is not widely applied due to time and cost. We hypothesized that a near-simultaneous automated skin photo-acquisition system would be acceptable to patients and could rapidly obtain total body images that enable visualization of pigmented skin lesions.

METHODS

From February to May 2009, a study of 20 volunteers was performed at the University of Virginia to test a prototype 16-camera imaging booth built by the research team and to guide development of special purpose software. For each participant, images were obtained before and after marking 10 lesions (five "easy" and five "difficult"), and images were evaluated to estimate visualization rates. Imaging logistical challenges were scored by the operator, and participant opinion was assessed by questionnaire.

RESULTS

Average time for image capture was three minutes (range 2-5). All 55 "easy" lesions were visualized (sensitivity 100%, 90% CI 95-100%), and 54/55 "difficult" lesions were visualized (sensitivity 98%, 90% CI 92-100%). Operators and patients graded the imaging process favorably, with challenges identified regarding lighting and positioning.

CONCLUSIONS

Rapid-acquisition automated skin photography is feasible with a low-cost system, with excellent lesion visualization and participant acceptance. These data provide a basis for employing this method in clinical melanoma screening.

Time needed to schedule dermatological consultations in Brazil

BACKGROUND

It is not clear what the population's demand for dermatologists is, nor how many professionals are needed in order to provide adequate care in this area of expertise. Knowledge of the flow of patients at dermatological clinics throughout the country allows for the formation of expansion and distribution policies regarding professionals, and provides backing for the decision to increase medical residency places.

OBJECTIVES

To evaluate the time it takes to schedule a private dermatological consultation in Brazil, and other factors concerning consultations.

METHODS

Survey with a random sample of 14% of Brazilian dermatologists, simulating the scheduling of emergency clinical and cosmetic consultations, and botulinum toxin procedures. Also, details relating to cost and professionals, were studied. Data were adjusted for each region of the country.

RESULTS

A total of 873 dermatologists were evaluated. Full SBD members represented 85%, and 66% were women. The median time to schedule a consultation ranged from 6 (out-of-pocket payment) to 7 (medical insurance) consecutive working days. Times varied depending on the region. A multivariate analysis showed that out-of-pocket consultations and procedures were scheduled sooner than with medical insurance, regardless of whether they were clinical or cosmetic.

CONCLUSION

The characteristics of dermatologists are varied throughout regions of the country. Private consultations and procedures are scheduled sooner than with insurance companies.

Mobile teledermatology: a promising future in clinical practice

BACKGROUND

As a product of electronic health, teledermatology is a cost-effective means of improving access to care, facilitating specialist consultations, and supporting patient self-management. Even so, use of traditional teledermatology services is limited by infrastructure and costs in the form of digital cameras, computers, and Internet access.

METHODS

Considering the significant improvement in smartphone camera resolution and the rapidly increasing number of physicians using smartphones, we explored the use of smartphones as reliable, effective clinical tools in store-and-forward teledermatology. We describe the technical specifications of modern smartphone cameras, the widespread use of smartphones by physicians, and the advantages of smartphones over traditional camera and Internet teledermatology, and we propose recommendations as to how mobile teledermatology may be more effectively used in modern dermatologic practice.

Noncosmetic skin-related procedures performed in the United States: an analysis of national ambulatory medical care survey data from 1995 to 2010

BACKGROUND

Demand for dermatologic care is increasing alongside a known shortage of physicians in the dermatology workforce. Changes in the volume of dermatologic procedures over time and the physician specialties involved in skin-related procedural care are not well characterized.

OBJECTIVE

To determine the frequency of dermatologic procedures performed in the United States between 1995 and 2010 and to analyze the changes in the procedures and physicians performing procedures over time.

METHODS

The annual volume of skin-related procedures performed by physician specialties and the rate of procedures performed per physician was determined from data from the National Ambulatory Medical Care Survey (NAMCS) between 1995 to 2004 and 2007 to 2010.

RESULTS

Dermatologists and primary care physicians performed most procedures (54.7% and 19.5%, respectively).

CONCLUSIONS

Dermatologists perform a larger volume of procedures than in the past, although the proportion of procedures performed by dermatologists is unchanged, and other physician specialties are performing more skin-related procedures to meet increasing demand.

Melanoma prevention: are we doing enough? A Canadian perspective

Melanoma is the most dangerous form of skin cancer, and its incidence is increasing significantly among Canadians. In parallel with the rising incidence and morbidity, the financial burden caused by this disease will continue to increase dramatically for the government and for individuals alike. More concerted effort to raise awareness of melanoma in Canada is therefore needed.Risk factors-such as family history, childhood sunburn exposure, and age-play a significant role in an individual's likelihood to develop melanoma. Ultraviolet radiation exposure is the most modifiable variable in melanoma causation. It is therefore important for the general public, in particular the country's youth, to understand the consequences of lifestyle choices-especially tanning bed use and "sun worshipping." Many of these issues are not being addressed fully at either the national or the provincial level, with Canadian efforts trailing those of other nations facing similar challenges. Canada also has workforce issues, with an inadequate distribution and number of physicians who can detect and treat melanoma at an early curative stage. With proper education and public awareness, melanoma prevention can be an achievable goal in Canada.

Patient-centered online management of psoriasis: a randomized controlled equivalency trial

BACKGROUND

Previous research suggests that technology-enabled health care delivery may improve access to dermatologic specialty care. Outcomes research using validated outcomes measures is necessary for evaluation of novel health care delivery models.

OBJECTIVE

We sought to compare the clinical equivalence of a novel patient-centered online health care delivery model with standard in-office care for follow-up treatment of patients with psoriasis.

METHODS

A total of 64 participants with psoriasis were randomized to receive follow-up care either in-office or online over a 24-week period. Patients randomized to the online group underwent standardized training on capturing high-quality digital images of their psoriatic skin and transmitting these images and clinical history to a dermatologist securely. The dermatologist then performed asynchronous, online evaluation and provided recommendations directly to patients. We used clinically validated disease severity and quality-of-life measures to assess effectiveness between the models.

RESULTS

Both online and in-office groups showed improvement in psoriasis disease severity as measured by mean improvement in Psoriasis Area and Severity Index (online group: mean = -3.4, in-office: mean = -3.4). Patient-centered online care resulted in similar improvement in psoriasis severity compared with in-person follow-up care (mean difference in Psoriasis Area and Severity Index change 0.1, 95% confidence interval -2.2 to 2.3, a priori equivalence margin of 2.5). Investigator Global Assessment and Dermatology Life Quality Index scores also improved during the study period; no significant differences existed between the two groups.

LIMITATIONS

The follow-up period was limited to 24 weeks.

CONCLUSION

A patient-centered online model may be an effective alternative to in-office care for follow-up management of psoriasis.

A psoriasis-specific model to support decision making in practice - UK experience

OBJECTIVES

The balance of service provision for people with psoriasis across community and hospital sectors is inappropriate in many localities. Disease-specific models are being used by policy makers to inform public health decision making and guide their long-term budgets. The aim of the present study was to develop an interactive psoriasis model to compare the 2-year outcomes of topical treatment strategies in patients with moderately severe psoriasis in real-world settings.

RESEARCH DESIGN AND METHODS

A previously published 1-year economic analysis of the two-compound formulation (TCF) calcipotriol plus betamethasone dipropionate and other commonly used topical agents in plaque psoriasis was adapted. Literature review and an interview programme identified additional relevant data to inform model assumptions. The model estimated local psoriasis costs and resources in accord with decision makers' priorities. A key element of the model was the facility for all default input data to be adapted to reflect local circumstance. Model validation was not undertaken. The UK experience is described.

RESULTS

Topical treatment with high-efficacy first-line therapies is a cost-effective treatment strategy in moderate plaque psoriasis. The model predicts potential savings in psoriasis care for a UK population of £126 million over 2 years if all psoriasis patients received the TCF in a community setting. A frequently used feature of the model was to identify ways of reducing inappropriate referrals to hospital, and so enabling secondary care resources to be focussed on the most resilient psoriasis cases.

CONCLUSIONS

The present study psoriasis disease model could facilitate collaboration between healthcare professionals to optimise healthcare in the UK. Psoriasis management strategies in primary care can be compared in a variety of realistic clinical settings, allowing the identification of optimal treatment regimens. This model is adaptable to tailor inputs to reflect local situations, providing an attractive tool to GP commissioners. Country-specific adaptations are being researched in other European countries.

The two-compound formulation of calcipotriol and betamethasone dipropionate for treatment of moderately severe body and scalp psoriasis - an introduction

Psoriasis is a common chronic inflammatory skin disease and many patients require lifelong treatment. Characteristic scaly, itchy, unsightly psoriatic lesions affect many body areas and most patients commonly experience scalp involvement. The cosmetic embarrassment of visible body lesions, inaccessibility of scalp skin to application of therapies and proximity of sensitive facial skin add to the challenges of most patients managing their psoriasis long term. Psoriasis can severely impact patients' quality of life. This can impact significantly on the patient. In economic terms patients may incur increased out-of-pocket expenditure or extended time away from work as a direct consequence of psoriasis, particularly in severe cases; In many countries, specialist review of patients provides pressures on hard-pressed services and the costs of psoriasis care are substantial, particularly in patients with severe recalcitrant psoriasis which may require lengthy inpatient admission. Around 80% of patients with psoriasis have mild to moderately severe disease and the majority are treated with topical medicines by their physician in primary care. Despite the availability of a wide range of treatment options, regimens have been unsatisfactory, associated with patient dissatisfaction, poor compliance and often safety concerns with long-term use. Evidence-based clinical guidelines aim to improve healthcare of patients and while there are such guidelines for psoriasis, to date the challenges of (and recommendations for) managing scalp psoriasis are often limited or missing from these treatment guidelines. In the following in-journal supplement, a connected suite of five papers focus on the use of topical therapies for the treatment of the person afflicted with psoriasis. This work harnesses robust evidence from randomised clinical trials (RCTs) of topical therapies commonly used in psoriasis patients and translates this into recommendations for the most appropriate treatment of patients with body or scalp psoriasis, from an efficacy, safety and cost-effectiveness perspective. Based upon systematic review and harnessing 'state of the art' evidence assessment methodologies, the modelling work suggests that the use of a two-compound formulation (TCF) product of calcipotriol and betamethasone dipropionate is the most appropriate treatment option for both body and scalp psoriasis. This Editorial acknowledges the results of any modelling exercise have limitations; indeed such limitations are acknowledged in each modelling contribution in this issue. With these caveats in mind, this introductory paper considers the implications of this research and distillation of the evidence. This work should guide cost-effective treatment choices for body and scalp psoriasis, assist in recommendations for management of scalp psoriasis in future iterations of psoriasis clinical guidelines and help primary care physicians striving to attain best outcomes in the care of the person with psoriasis.

Teledermatology consultations provide specialty care for farmworkers in rural clinics

CONTEXT

Rural patients have limited access to dermatologic care. Farmworkers have high rates of skin disease and limited access to care.

PURPOSE

This exploratory study assessed whether teledermatology consultations could help meet the needs of health care providers for farmworkers in rural clinics.

METHODS

Dermatologists provided 79 consultations, using store-and-forward teledermatology, to farmworkers who presented with a skin disease to rural North Carolina clinics. Clinic providers rated the value of the consultation.

FINDINGS

Most requests for consultations (94%) came from family nurse practitioners or physician assistants. Twelve percent of consultations were rated somewhat helpful, and the remainder helpful or very helpful. After receiving the consultation, providers changed the diagnosis in 13% of cases. The consultation led providers to contact or attempt to contact 21% of patients to change treatment recommendations.

CONCLUSIONS

Access to expert dermatologic services is needed by rural health care providers. Teledermatology consultations may be a helpful tool to meet this need.

The dermatology work force: a focus on urban versus rural wait times

BACKGROUND

Recent studies suggest a shortage of dermatologists with an average wait time of 36 days in the United States and 40 days in Ohio for a routine dermatology visit. To date, no previous studies have examined supply and demand of dermatology services in rural versus urban populations.

OBJECTIVE

We sought to determine the average wait time for a dermatology appointment for new and established patients in both urban and rural areas.

METHODS

The offices of 250 dermatologists in Ohio were contacted by telephone to determine the wait time for the next available appointment for new and established patients with a changing mole.

RESULTS

The average wait time for new (4.5 weeks) and established (3.1 weeks) patients was similar to times reported in previous studies. A greater density of all dermatologists and medical (general) dermatologists practice in cities, but wait times were not statistically different in rural versus urban settings.

LIMITATIONS

Neither insurance status or use of physician extenders were considered. The findings may not be applicable to areas outside Ohio.

CONCLUSION

There is a shortage of medical dermatologists throughout Ohio. Training more medical dermatologists or adding physician extenders to dermatology practices would be expected to decrease the waiting time for dermatology appointments. Providing incentives for dermatologists to practice in underserved rural areas may not be necessary judging by the similarities in wait times between rural and urban settings.

Canaries in the mineshaft: the dermatology workforce shortage in Eastern Ontario

BACKGROUND

The number of dermatology residency positions in Canada has not reflected the growing workforce shortage. Until 2005, all dermatology residents at the University of Ottawa were committed to return to their funding area at the completion of their training. This has left Eastern Ontario with a critical shortage of dermatologists.

OBJECTIVE

To survey dermatologists practicing in Eastern Ontario to understand the basis of the workforce shortage and outlook for the future.

METHODS

Mailed surveys sent in 1999, 2003, and 2006 to all dermatologists in Eastern Ontario requesting demographic information, workload data, and future career plans.

RESULTS

There was a 100% response rate in each survey year. Between 1999 and 2006, the total number of practicing dermatologists decreased from 26 to 23, whereas the average age increased from 51.4 to 57.4 years. The waiting time to see new and returning patients increased, from 5.8 to 18.5 weeks and 4.9 to 11.8 weeks, respectively. Ten of the 23 dermatologists practicing in 2006 plan to retire within the next 5 years.

CONCLUSIONS

The inadequate supply of dermatologists in Eastern Ontario will increasingly threaten patient care. This emphasizes the need for additional funding for dermatology training positions, continued mentorship, and improved dermatology training for nondermatologists.

Short wait times for patients seeking cosmetic botulinum toxin appointments with dermatologists

BACKGROUND

Wait times for both routine and urgent dermatology appointments typically exceed 3 to 4 weeks. Many factors affecting physician workforce adequacy and patient access have been explored, but little is known about the impact of increasing numbers of doctors offering cosmetic services.

OBJECTIVE

We sought to evaluate access to dermatologists for patients requesting cosmetic services.

METHODS

Scripted patient telephone calls were made to 898 dermatologists in 12 metropolitan areas to assess wait times for an appointment to receive cosmetic botulinum toxin injections. The areas chosen were surveyed completely, and respondents represented about one tenth of practicing dermatologists in the United States. The methodology was identical to that used in a previous study of wait times for evaluation of a changing mole (a possible indicator of malignancy).

RESULTS

Half of dermatologist respondents (455, 50.7%) offered appointments for botulinum toxin injections, and the median wait time was 8 days. Acceptance rates and wait times varied greatly by geographic area (range of median wait times 6.0-32.5 days), with dermatologists in Miami, Fla, and Orange County, California, most likely to provide a botulinum toxin appointment with a short wait time. Many dermatologists (241, 27%) employed physician extenders, and 39% of these extenders also offered appointments for botulinum toxin injections (median wait time 6 days). In comparison with a previous study showing median wait times of 26 days for evaluation of a changing mole in these communities, wait times for cosmetic injections were significantly shorter (P < .001).

LIMITATIONS

The metropolitan areas surveyed contain no highly rural areas and do not represent a random sample of all US dermatology practice sites. The cosmetic and medical studies were not conducted concurrently, but were carried out in the same metropolitan areas.

CONCLUSIONS

Patients seeking a cosmetic botulinum toxin injection have more rapid access to dermatologists than has been previously reported for patients seeking urgent consultation for a changing mole. This study cannot differentiate between many possible explanations for the observed differences in wait times. Because physicians in many other specialties with physician shortages are also offering cosmetic services, further studies are needed to assess the broader policy implications of these findings.

Intervention program to reduce waiting time of a dermatological visit: managed overbooking and service centralization as effective management tools

BACKGROUND

Long waiting times are an impediment of dermatological patient care world-wide, resulting in significant disruption of clinical care and frustration among carers and patients.

OBJECTIVE

To reduce waiting times for dermatological appointments.

METHODS

A focus group including dermatologists and management personnel reviewed the scheduling process, mapped potential problems and proposed a comprehensive intervention program. The two major approaches taken in the intervention program were revision of the scheduling process by managed overbooking of patient appointments and centralization of the dermatological service into a centralized dermatological clinic.

RESULTS

Following the intervention program, the average waiting time for dermatological appointments decreased from 29.3 to 6.8 days. The number of scheduled appointments per 6 months rose from 17,007 to 20,433. Non-attendance proportion (no-show) decreased from 33% to 28%. Dermatologist work-hours were without significant change.

CONCLUSIONS

Waiting lists for dermatological consultations were substantially shortened by managed overbooking of patient appointments and centralization of the service.

The Hershey access clinic: a model for improving patient access

BACKGROUND

When waiting times for new and return patient visits at Hershey Medical Center's Department of Dermatology approached 4 and 2 months, respectively, the Hershey access clinic was implemented to increase access for patients with acute problems.

OBJECTIVE

The purpose of this study was to assess the impact of the Hershey access clinic on patient care.

RESULTS

The great majority of patients were satisfied with the access clinic. However, there has been no effect on the no-show rates or patient waiting times for routine appointments. Fifty-seven percent of patients had eruptions, most commonly acne/rosacea, and 43% had neoplasms, most commonly warts.

LIMITATIONS

This study was limited by the fact that it was a survey filled out by the patients after their encounter.

CONCLUSION

The Hershey access clinic successfully provides acute problem-focused care, and patient satisfaction is high.

Delayed access to health care and mortality

OBJECTIVE

To measure the relationship between time spent waiting for health care services and patients' mortality.

DATA SOURCE

Data on the number of days until the next available appointment at 89 Veterans Affairs (VA) medical centers in 2001 were extracted from a VA administrative database. These facility-level data were merged with individual-level data for a sample of veterans who visited a VA geriatric outpatient clinic in 2001. The merged dataset includes facility-level data on waiting times and individual-level data on demographics, health status (e.g., diagnoses), and mortality.

STUDY DESIGN

This was a retrospective observational study using secondary data from administrative sources. The dependent variable was mortality within a 6-month follow-up period. The main explanatory variable of interest was VA facility-level wait times for outpatient visits measured in number of days. Random effects logistic regression models were risk adjusted for prior individual health status and facility-level differences in case mix.

PRINCIPAL FINDINGS

Veterans who visited a VA medical center with facility-level wait times of 31 days or more had significantly higher odds of mortality (odds ratio=1.21, p=0.027) compared with veterans who visited a VA medical center with facility-level wait times of <31 days.

CONCLUSIONS

Our findings support the largely assumed association between long wait times for outpatient health care and negative health outcomes, such as mortality. Future research should focus on the causes of long waits for health care (e.g., physician reimbursement levels), the consequences of long waits in other populations, and effective policies to decrease long waits for health care services.

Derm Access: A New Triage System to Rapidly Identify Suspicious Skin Lesions

BACKGROUND

Many screening programs have been implemented for the general population; however, dermatology appointment wait times continue to be long. Changes in scheduling would allow patients with suspicious skin lesions access to more immediate care.

OBJECTIVES

The objective was to introduce a method for decreasing dermatology appointment wait times to allow patients with a high-risk skin lesion to be seen in a more efficient manner.

METHODS

A telephone screening method was developed to allow for the most suspicious lesions to be seen within 72 hours if the patient wished to do so; appointment time slots were left open in physician schedules to accommodate these patients; and wait time, procedure, and treatment data were collected and compared against national wait time data.

RESULTS

A total of 233 patients were seen during this study. A total of 146 of these patients were diagnosed with a cancerous or precancerous lesion. This was 63% of the total study population. The mean wait time in actual working days was 7.44 for this same period.

CONCLUSION

This program substantially decreased patient anxiety, increased patient satisfaction, increased public relations for the practice, and increased public awareness of skin cancer. The Derm Access strategy can be implemented in any practice to reduce wait times for suspicious skin lesions.