Procedures for skin diseases performed by physicians in 1993 and 1994: analysis of data from the National Ambulatory Medical Care Survey

Years of dermatology experience and geographic region are associated with outlier performance of excision or destruction for nonmelanoma skin cancer

INTRODUCTION

Treatments for nonmelanoma skin cancer (NMSC) include excision (surgical removal) and destruction (cryotherapy or curettage with or without electrodesiccation) in addition to other methods. Although cure rates are similar between excision and destruction for low-risk NMSCs, excision is substantially more expensive. Performing destruction when appropriate can reduce costs while providing comparable cure rate and cosmesis.

OBJECTIVE

To identify characteristics associated with exclusive (outlier) performance of excision or destruction for NMSC.

METHODS

The study consisted of malignant excision and destruction procedures submitted by dermatologists to Medicare in 2019. Proportions of services for each method were analyzed with respect to geographic region, years of dermatology experience, median income of the practice zip code, and rural-urban commuting area code.

RESULTS

Fewer years of experience predicted a higher proportion of excisions (R²=.7, p<.001) and higher odds of outlier excision performance. Outlier performance of excision was associated with practicing in the South, Midwest, and West, whereas outlier performance of destruction was associated with practicing in the Northeast and Midwest.

CONCLUSIONS

Dermatologists with less experience or in certain geographic regions performed more malignant excision relative to destruction. As the older population of dermatologists retires, the cost of care for NMSC may increase.

Antimicrobial, anti-inflammatory and wound healing activity of polyherbal formulation

According to Ayurveda, individual herbs are insufficient to achieve a desired therapeutic effect. When it is optimized as multiple herbs composition in a particular ratio it will give a therapeutic effect in a better way with reduced toxicity. In order to develop such an intervention, the present study was intended to develop a polyherbal drug from methanolic extracts of Plumbago zeylanica Linn, Datura stramonium Linn and Argemone mexicana Linn. The study also aimed to evaluate the impact of polyherbalism on antimicrobial and antioxidant effect, thereafter the ratio of individual plant extracts was optimized accordingly to treat the wound. The poyherbal drug was put on preclinical trial to access the anti-inflammatory and wound healing activity as 2% and 5% polyherbal carbopol-940 gels. The antimicrobial activity was assessed by agar well diffusion and broth dilution method while wound healing activity was evaluated by excision and incision wound models. Topical anti-inflammatory activity was assessed by carrageenan induced paw oedema. The findings of the study revealed the synergistic antimicrobial potential of Polyherbal drug against gram-positive and negative strains. Polyherbal carbopol- 940 gels (2% and 5%w/w) promoted the wound healing and anti-inflammatory effect. The high rate of wound contraction (<0.0001), early epithelialization period (<0.0001) and increased wound breaking strength (<0.0001) were observed in 2% and 5% polyherbal gel treated group when compared to the normal control and negative control group. The antimicrobial and anti-inflammatory effect of Polyherbal drug provoked and promoted the wound healing process through accelerated remodelling of damaged tissue.

Petrolatum: Barrier repair and antimicrobial responses underlying this "inert" moisturizer

BACKGROUND

Petrolatum is a common moisturizer often used in the prevention of skin infections after ambulatory surgeries and as a maintenance therapy of atopic dermatitis (AD). However, the molecular responses induced by petrolatum in the skin have never been assessed.

OBJECTIVE

We sought to define the cutaneous molecular and structural effects induced by petrolatum.

METHODS

Thirty-six healthy subjects and 13 patients with moderate AD (mean SCORAD score, 39) were studied by using RT-PCR, gene arrays, immunohistochemistry, and immunofluorescence performed on control skin, petrolatum-occluded skin, and skin occluded with a Finn chamber only.

RESULTS

Significant upregulations of antimicrobial peptides (S100A8/fold change [FCH], 13.04; S100A9/FCH, 11.28; CCL20/FCH, 8.36; PI3 [elafin]/FCH, 15.40; lipocalin 2/FCH, 6.94, human β-defensin 2 [DEFB4A]/FCH, 4.96; P < .001 for all) and innate immune genes (IL6, IL8, and IL1B; P < .01) were observed in petrolatum-occluded skin compared with expression in both control and occluded-only skin. Application of petrolatum also induced expression of key barrier differentiation markers (filaggrin and loricrin), increased stratum corneum thickness, and significantly reduced T-cell infiltrates in the setting of "normal-appearing" or nonlesional AD skin, which is known to harbor barrier and immune defects.

CONCLUSIONS

Petrolatum robustly modulates antimicrobials and epidermal differentiation barrier measures. These data shed light on the beneficial molecular responses of petrolatum in barrier-defective states, such as AD and postoperative wound care.

Antibacterial, antioxidant, and topical anti-inflammatory activities of Bergia ammannioides: A wound-healing plant

CONTEXT

Despite the traditional use of Bergia ammannioides Henye ex Roth. (Elatinaceae) for the treatment of wounds in India, there is a scarcity of scientific data supporting this use.

OBJECTIVE

The objective of this study is to assess wound-healing potentiality of the plant, to study pharmacological activities that may contribute in eliminating wound complications, and to investigate the biologically active fractions.

MATERIAL AND METHODS

The ethanolic extract (EtOH) of the aerial parts was fractionated to obtain n-hexane (HxFr), chloroform (ClFr), ethyl acetate (EtFr), and n-butanol (BuOH) fractions. EtOH and its fractions were formulated in strength of 5 and 10% w/w ointment and tested for wound-healing activity using the excision model. The topical anti-inflammatory, in vitro antioxidant, and antibacterial activities were evaluated. HxFr and EtFr were chemically investigated to isolate their constituents.

RESULTS

Application of EtOH, HxFr, and EtFr (10% w/w ointments) leads to 71.77, 85.62, and 81.29% healing of the wounds with an increase in the collagen content. HxFr had the strongest anti-inflammatory (64.5% potency relative to Voltaren®) and antibacterial activity (MIC = 104 μg/ml against Staphylococcus aureus), while EtFr showed the strongest antioxidant activity against DPPH, ABTS(•+), and super oxide radical with an IC50 value of 10.25 ± 0.01, 66.09 ± 0.76, and 167.33 ± 0.91 µg/ml, respectively. β-Sitosterol, lupeol, cyclolaudenol, and cycloartenol were isolated from HxFr. Quercetin, ellagic acid, kaempferol-3-O-α-l-rhamnoside, and quercetin-3-O-α-l-rhamnoside were isolated from EtFr.

DISCUSSION AND CONCLUSION

Our study presents scientific evidence for the efficacy of B. ammannioides in enhancing wound healing, and the first isolation of cyclolaudenol and cycloartenol from Bergia.

Skin Conditions in Community-Living Older Adults

Background:

There are considerable gaps in the knowledge of the global epidemiology of skin conditions in the geriatric population.

Objective:

This study attempted to (1) determine the frequency of skin conditions, (2) evaluate the agreement between two different data sources of information (self-report versus administrative), and (3) document medical care service use for skin conditions in a representative sample of community-dwelling older adults.

Methods:

A secondary analysis using data from a longitudinal population-based health survey conducted in Quebec (2005–2008) within a sample of 2,811 community-dwelling older adults.

Results:

Our results highlighted a high prevalence rate of self-reported (13%) and diagnosed skin conditions (21%). Agreement between data sources was low (kappa < 0.20). Most dermatologic-related medical visits were made to dermatologists (almost 60%).

Conclusion:

The epidemiology of skin conditions in the geriatric population is an underresearched field, despite its important prevalence and relevance as a source of information for assessing the health care needs of older adults.

Complementary and alternative medicine use in dermatology in the United States

BACKGROUND

Complementary and alternative medicine (CAM) has an increasing presence in dermatology. Complementary therapies have been studied in many skin diseases, including atopic dermatitis and psoriasis.

OBJECTIVES

This study sought to assess oral CAM use in dermatology relative to medicine as a whole in the United States, using the National Ambulatory Medical Care Survey.

DESIGN

Variables studied include patient demographic characteristics, diagnoses, and CAM documented at the visits. A brief literature review of the top 5 CAM treatments unique to dermatology visits was performed.

RESULTS

Most CAM users in both dermatology and medicine as a whole were female and white and were insured with private insurance or Medicare. Fish oil, glucosamine, glucosamine chondroitin, and omega-3 were the most common complementary supplements used in both samples.

CONCLUSIONS

CAM use in dermatology appears to be part of a larger trend in medicine. Knowledge of common complementary therapies can help dermatologists navigate this expanding field.

Cosmetic procedures performed in the United States: a 16-year analysis

BACKGROUND

Cosmetic procedures, particularly those that are minimally invasive, are in demand. The physician specialties performing these procedures are not well-characterized.

OBJECTIVE

To examine changes in the frequency of cosmetic dermatologic procedures performed in the United States from 1995 to 2010 and the physician specialties performing them.

METHODS

The volume of cosmetic procedures performed by physician specialties and the types of cosmetic procedures performed were determined from data from the National Ambulatory Medical Care Survey (NAMCS) from 1995 to 2010.

RESULTS

Cosmetic procedures constituted 8.7% of all skin procedures and have increased since 1995 (p < .001). Botulinum toxin injections were the most frequently performed cosmetic procedure and increased at the greatest rate over time. Plastic surgeons performed the largest proportion of cosmetic procedures (36.1%), followed by dermatologists (33.7%), but other specialties have been performing an increasing proportion of cosmetic procedures. This study was limited to the provision of outpatient procedures, and the nationally representative data of the NAMCS is subject to sample bias.

CONCLUSIONS

Plastic surgeons and other physicians performed the majority of outpatient cosmetic procedures. Dermatologists performed one-third of ambulatory cosmetic procedures from 1995 to 2010. This broadening spectrum of physicians and nonphysicians providing cosmetic procedures may have important implications for patient safety.

Skin Manifestations of Outpatient Adverse Drug Events in the United States: A National Analysis

Background:

Cutaneous reactions to drugs are among the most common clinical manifestations of adverse drug events (ADEs); however, data on outpatient cutaneous adverse drug events (CADEs) are limited.

Purpose:

To provide national estimates of outpatient CADEs and determine their most frequent causes.

Methods:

Outpatient CADEs recorded in the National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS) between 1995 and 2005 were analyzed. The national incidence of outpatient CADEs in those seeking medical attention in the United States was estimated, and the common medication classes implicated with CADEs were identified.

Results:

There were a mean annual total of 635,982 CADE-related visits, resulting in an annual incidence of 2.26 CADEs per 1,000 persons. Patients took an average of 2.2 medications in addition to the one causing the CADE. The incidence of CADEs increased with age, with a peak in the age group from 70 to 79 years. The medications most frequently causing a CADE were antimicrobial agents. Dermatitis and urticaria were the two main types of skin reactions reported.

Conclusions:

CADEs occur less frequently in outpatients than in inpatients and result in few hospital admissions. Physicians must be particularly cognizant of the occurrence of CADEs when prescribing antimicrobial agents.

Update on topical antibiotics in dermatology

Topical antibiotics are used for various purposes in dermatology. Some of the most common uses include treatment of acne, treatment and prevention of wound infection(s), impetigo or impetiginized dermatitis, and staphylococcal nasal carrier state. It is important for the dermatologist to be familiar with the spectrum of activity, the mechanism of action, and the variables that may interfere with the antibiotic of choice. The following discussion will review an update on topical antibiotic use in acne, wound care, impetigo, and in staphylococcal nasal carriers.

Use of topical antibiotics as prophylaxis in clean dermatologic procedures

BACKGROUND

Topical antibiotics are not indicated for routine postoperative care in clean dermatologic procedures, but may be widely used.

OBJECTIVE

We sought to describe topical antibiotic use in clean dermatologic surgical procedures in the United States.

METHODS

The 1993 to 2007 National Ambulatory Medical Care Survey database was queried for visits in which clean dermatologic surgery was performed. We analyzed provider specialty, use of topical antibiotics, and associated diagnoses. Use of topical antibiotic over time was analyzed by linear regression.

RESULTS

An estimated 212 million clean dermatologic procedures were performed between 1993 and 2007; topical antibiotics were reported in approximately 10.6 million (5.0%) procedures. Dermatologists were responsible for 63.3% of dermatologic surgery procedures and reported use of topical antibiotic prophylaxis in 8.0 million (6.0%). Dermatologists were more likely to use topical antibiotic prophylaxis than nondermatologists (6.0% vs 3.5%). Use of topical antibiotic prophylaxis decreased over time.

LIMITATIONS

Data were limited to outpatient procedures. The assumption was made that when topical antibiotics were documented at procedure visits they were being used as prophylaxis.

CONCLUSIONS

Topical antibiotics continue to be used as prophylaxis in clean dermatologic procedures, despite being ineffective for this purpose and posing a risk to patients. Although topical antibiotic use is decreasing, prophylactic use should be eliminated.

Treatment Patterns and Cost of Nonmelanoma Skin Cancer Management

INTRODUCTION

Nonmelanoma skin cancer (NMSC) is the most common form of cancer in the United States, more common than all other cancers combined. The factors that affect the cost of skin cancer management are not well defined.

OBJECTIVE

The objective was to estimate cost of episodes of NMSC care and the factors that impact those costs.

DESIGN

Medicare Current Beneficiary Survey (MCBS) data from 1999 to 2000 were used to assess costs of episodes of NMSC care. MCBS estimates of the number of episodes occurring in three service settings (physician's office, outpatient/ambulatory surgical center, or hospital) and demographics were obtained.

RESULTS

There were 497 episodes of care in 372 patients. Half the episodes were treated by dermatologists, and two-thirds were managed in physicians' offices. The mean episode cost for management in the office setting was 500 dollars (SD, +/- 487 dollars), and costs were higher when the episodes were treated in either the ambulatory surgical center or the hospital settings, 935 dollars (SD, +/- 456 dollars) and 4,345 dollars (SD, +/- 4939 dollars), respectively.

CONCLUSION

With the rising incidence and cost of NMSC to Medicare, it is increasingly important to preserve the low-cost management of this disease. Maintaining care of NMSC in the office-based setting is more cost-efficient than utilizing ambulatory surgical centers or hospital operating rooms.

The cutaneous surgery experience of multiple specialties in the Medicare population

BACKGROUND

There has been tremendous growth in the performance of ambulatory surgical procedures. Traditional forms of peer review, commonplace for hospital-based procedures, are not typically performed in the office-based setting. Hospital credentialing of physicians has been suggested to be a means of assuring patient safety. Credentialing committees may be unaware of the level of experience of typical office-based physicians who perform cutaneous surgery.

PURPOSE

To compare the levels of cutaneous surgery experience of dermatologists and other surgical specialists.

METHODS

Medicare claims data on number of cutaneous surgery procedures performed by various medical disciplines, including dermatologists, plastic surgeons, general surgeons, and others, were obtained from the 1998-1999 Medicare Current Beneficiary Survey (MCBS) and analyzed. The number of physicians in each specialty was used to normalize the data to a per physician basis.

RESULTS

Dermatologists performed half (50%) of the complex repairs and most of the excisions (58%) and intermediate repairs (62%). Dermatologists performed more flaps (40% of all flaps) than any other specialty, while plastic surgeons performed more total grafts (38%) than any other specialty. Dermatologists and plastic surgeons performed similar numbers of full-thickness skin grafts, while plastic surgeons performed more split-thickness skin grafts.

CONCLUSION

As dermatologists seek hospital credentials for performing cutaneous surgery procedures, these data should help surgical colleagues understand the typical level of experience of their dermatologist colleagues.

The dermatology workforce shortage

BACKGROUND

While many dermatology workforce projections over the past two decades forecasted an impending oversupply, more recent reports have begun to suggest a shortage of dermatologic services.

METHODS

Anonymous surveys administered to practicing dermatologists and to recent training graduates were examined for surrogate indicators of the supply and demand for dermatologic services.

RESULTS

The mean wait time for new patient appointments with dermatologists was 36 calendar days, but ranged widely based on location (means ranged from 9-120 days by state). About half (49%) of practicing dermatologists feel that they need more dermatologists in their communities, while only 20% describe the local supply as too high. The reported need for medical and general dermatologists is far more acute than for dermatologic subspecialists. Many practices (33%) are looking for new associates, and not surprisingly, most new graduates entering the workforce over the past 4 years (86-93%) do not describe any difficulty finding desirable positions. Fewer than 10% of recent graduates are dissatisfied with their current jobs.

CONCLUSION

Based on survey data examining wait times, physician perception, use of physician extenders, searches for new employees, and experience of recent graduates entering the workforce, it appears there is an inadequate supply of dermatologists to meet the demand for services.

Nonmelanoma skin cancer: an episode of care management approach

BACKGROUND

The incidence of nonmelanoma skin cancers (NMSCs) was estimated at 1.3-million cases for the year 2000 and is on the rise. It is the most common form of cancer in the United States, more common than all other cancers combined. To determine the contributors to the cost of NMSC care, an episode of care of NMSC needed to be defined.

OBJECTIVE

To define and validate an episode of NMSC care.

DESIGN

Using survey and Medicare part A and part B claims data of the Medicare Current Beneficiary Survey (MCBS), 1992 to 1995, an algorithm was created to define an episode of care for the diagnosis and treatment of an NMSC. MCBS estimates of the number of episodes occurring in three service settings (physician's office, outpatient/ambulatory surgical center, or hospital) and demographics were compared to data from independent datasets, including the National Ambulatory Medical Care Survey (NAMCS, 1995), the National Survey of Ambulatory Surgery (NSAS, 1994 to 1996), and the National Hospital Discharge Survey (NHDS, 1992 to 1997).

RESULTS

Pathology claims for NMSC diagnosis served as the indicator of NMSC episodes. The procedures, office visits, and tests that resulted in and from the pathology specimen were identified. The sum of the associated charges to Medicare or Medicare payments for all identified claims equaled the total cost of the episode of NMSC care. For example, these preliminary results demonstrated significant differences between medical and surgical subspecialties.

CONCLUSION

This study defined and validated a model of an episode of NMSC care. This model's initial results serve as preliminary data for the design of further studies addressing the differences between specialties and settings. The use of this model will allow identification of factors that determine the cost of NMSC treatment and that are associated with higher cost of care.

Cost of nonmelanoma skin cancer treatment in the United States

BACKGROUND

Despite being the most prevalent form of cancer, the economic impact of nonmelanoma skin cancer (NMSC) in the United States has not been assessed.

OBJECTIVE

To determine the overall cost and to estimate the cost per episode of NMSC care in the United States in physicians' offices, outpatient surgery centers, and inpatient settings.

METHODS

Data from the Medicare Current Beneficiary Study 1992-1995 were analyzed to obtain the total cost of NMSC and the cost in different settings. To normalize these data on a per episode basis, the cost in each setting was divided by the number of procedures performed in each setting obtained from the National Hospital Discharge Survey (NHDS, 1992-1997), the National Survey of Ambulatory Surgery (NSAS, 1994-1996), and the National Ambulatory Medical Care Survey (NAMCS, 1995).

RESULTS

The total cost of NMSC care in the United States in the Medicare population is $426 million/year. Physician office-based procedures for NMSC accounted for the greatest percentage of money spent to treat NMSC and the greatest percentage of procedures. The average cost per episode of NMSC when performed in a physician's office setting was found to be $492. The cost per episode of care in inpatient and outpatient settings were $5537 and $1043, respectively.

CONCLUSION

Compared to other cancers, the relative magnitude of NMSC treatment costs is currently small because NMSC is managed efficiently and effectively, primarily in office-based settings. Legislative or regulatory measures that discourage office treatment of NMSC will lead to increased cost.

The period prevalence and costs of treating nonmelanoma skin cancers in patients over 65 years of age covered by medicare

BACKGROUND

Nonmelanoma skin cancer (NMSC) prevalence and treatment costs are rapidly increasing at an unknown rate.

OBJECTIVE

To determine actual prevalence and treatment costs for NMSC in patients over 65 years of age covered by Medicare.

METHODS

We used a 5% random sample of Medicare claims available for 1994 and 1995. Demographic characteristics, period prevalence, treatment types and frequencies, treating physician specialty, and allowable treatment charges associated with the diagnosis of NMSC were analyzed and described.

RESULTS

More than 789,000 patients over age 65 covered by Medicare had a diagnosis and treatment for NMSC in 1995. Fifty-eight percent were men and 98% were Caucasian. The majority were from the South and West regions of the United States. Dermatologists treated more than 60% of these NMSCs. Treatment costs were approximately $285 million. The largest percentage of treatment expenditures (34%) was for excisions.

CONCLUSION

The number of patients with NMSC is far greater than previous estimates. Dermatologists treat the majority of NMSCs. The mean treatment cost per patient is $329. Total expenditures for NMSC eradication represent 0.7% of the Medicare budget. NMSC is a major public health concern because of its increasing prevalence, costs, and the aging U.S. population.

The specialty of the treating physician affects the likelihood of tumor-free resection margins for basal cell carcinoma: results from a multi-institutional retrospective study

BACKGROUND

Basal cell carcinoma (BCC) is the most common cutaneous malignancy. Surgical experience and physician specialty may affect the outcome quality of surgical excision of BCC.

METHODS

We performed a multicenter retrospective study of BCC excisions submitted to the respective Departments of Pathology at 4 major university medical centers. Our outcome measure was presence of histologic evidence of tumor present in surgical margins of excision specimens (incomplete excision). Clinician experience was defined as the number of excisions that a clinician performed during the study interval. The analytic sample pool included 1459 tumors that met all inclusion and exclusion criteria. Analyses included univariate and multivariate techniques involving the entire sample and separate subsample analyses that excluded 2 outlying dermatologists.

RESULTS

Tumor was present at the surgical margins in 243 (16.6%) of 1459 specimens. A patient's sex, age, and tumor size were not significantly related to the presence of tumor in the surgical margin. Physician experience did not demonstrate a significant difference either in the entire sample (P <.09) or in the subsample analysis (P >.30). Tumors of the head and neck were more likely to be incompletely excised than truncal tumors in all the analyses (P <.03). Compared with dermatologists, otolaryngologists (P <.02) and plastic surgeons (P <.008) were more likely to incompletely excise tumors; however, subsample analysis for plastic surgeons found only a trend toward significance (P <.10). Dermatologists and general surgeons did not differ in the likelihood of performing an incomplete excision (P >.4).

CONCLUSION

The physician specialty may affect the quality of care in the surgical management of BCC.

The gatekeeper model is inefficient for the delivery of dermatologic services

BACKGROUND

Gatekeeper-paradigm managed care systems may discourage the use of dermatologists in the management of skin conditions by limiting direct access. This may limit the quality of care patients with skin disorders receive and may be an inefficient use of medical resources.

OBJECTIVE

The purpose of this study was to determine the likelihood that patients with dermatologic conditions who see a primary care provider will be referred to a dermatologist.

METHODS

Data on the disposition of outpatient visits to primary care physicians for one and only one dermatologic diagnosis were obtained from the 1990-1994 National Ambulatory Medical Care Survey. These data were used in an econometric model to estimate the likelihood of referral to a dermatologist for an episode of care.

RESULTS

Of all visits for a single dermatologic diagnosis, 39% were to primary care physicians. The disposition of referral was more common for these dermatology-related visits than for all office visits to primary care physicians (5.8% vs 4.5%, P < .001). The most frequent diagnoses associated with referral were common dermatologic problems, not rare disorders. The number of visits per episode of care was highly dependent on the assumptions of the analysis, resulting in estimate ranges for referral rates per episode between 6.8% and 18.5% for pediatricians, 8.2% and 23% for family and general practitioners, and 16.6% and 46.5% for internists.

CONCLUSION

The relative difficulty for primary care providers of managing skin problems is reflected by their frequent need to refer patients with common skin problems and by the greater likelihood of referral for skin disorders than for other medical conditions. The high rates of referral per episode of care supports the cost-effectiveness of direct access to dermatologists.

Destructive procedures are the standard of care for treatment of actinic keratoses

BACKGROUND

Actinic keratoses are premalignant lesions resulting from exposure to carcinogens. Recently, some Medicare carriers have limited reimbursement for destruction of actinic keratoses to those lesions unresponsive to topical 5-fluorouracil treatment.

OBJECTIVE

Our purpose was to determine whether this policy meets the community standard of care for treatment of actinic keratoses.

METHODS

Data from the 1993 and 1994 National Ambulatory Medical Care Survey were used to determine the frequencies at which different treatments are used for actinic keratoses. These were compared with the frequencies at which procedures and medical therapies are used to treat control conditions (warts, psoriasis, acne, and dermatitis) to determine whether procedures are done because they are available or out of medical necessity.

RESULTS

Procedures were performed during 78% of visits for actinic keratoses. 5-Fluorouracil was used at 3.6% of visits, and at 39% of these visits a procedure was also performed. There were no observations of use of 5-fluorouracil alone at a first visit for actinic keratosis. Procedures were less likely to be performed at visits for warts, psoriasis, acne, or dermatitis, which indicates that reimbursable procedures are performed not simply because they are available.

CONCLUSION

Procedures are performed to destroy actinic keratoses out of medical need. Medicare policies mandating initial use of 5-fluorouracil as initial treatment of actinic keratoses do not represent the community standard of care for treatment of these lesions.

Dermatologists meet the primary care standard for first contact management of skin disease

BACKGROUND

It has been suggested that first contact for skin disease should be the domain of primary care providers because they provide comprehensive services beyond those offered by dermatologists.

OBJECTIVE

The purpose of this study was to test the hypothesis that dermatologists do not meet the standards for providing primary care to which generalists are held.

METHODS

National Ambulatory Medical Care Survey data from the year 1995 were used to determine the frequency at which counseling and preventive examinations were performed at visits to primary care providers and dermatologists.

RESULTS

Counseling and preventive examinations were performed at a minority of visits for skin disease. No counseling was reported at 91% of the visits to primary care providers and at 94% of visits to dermatologists. Preventive examinations other than blood pressure were done at 4.7% of the visits to primary care providers and at 1.5% of visits to dermatologists.

CONCLUSION

The standard of primary care for skin disease, as set by the generalist, is attention to the skin disease and not comprehensive medical care. Dermatologists are best able to meet this standard.

Nondermatologists are more likely than dermatologists to prescribe antifungal/corticosteroid products: an analysis of office visits for cutaneous fungal infections, 1990-1994

BACKGROUND

Dermatologists have greater accuracy than nondermatologists for diagnosis of skin disease. However, it is not clear whether this affects medical outcome.

OBJECTIVE

We tested the hypothesis that nondermatologists would be more likely than dermatologists to prescribe combination products for the treatment of common fungal skin infections.

METHODS

We analyzed office-based physician visits for fungal skin infections recorded in the 1990-1994 National Ambulatory Medical Care Survey.

RESULTS

There were 4.1 million visits for cutaneous fungal disease of which 82% were to nondermatologists. Nondermatologists were more likely to prescribe combination agents (34.1%) than dermatologists (4.8%, p=0.001). If the percentage of combination agents used by nondermatologists was reduced to that of dermatologists, an estimated $24.9 million or $10.3 million would be saved if clotrimazole or ketoconazole, respectively, were the substituted drug for the combination agent clotrimazole/betamethasone dipropionate.

CONCLUSION

Nondermatologists are more likely to use a more expensive, less effective regimen than are dermatologists, suggesting that dermatologists are more cost-effective than nondermatologists in the treatment of common fungal skin disorders.