The geographic distribution of the US pediatric dermatologist workforce: A national cross-sectional study

From flare to care: Dermatologists' impact on pediatric atopic dermatitis hospital admissions

BACKGROUND/OBJECTIVES

Atopic dermatitis (AD) is a common chronic skin disease in the pediatric population; however, rates of admissions for flares in patients established with dermatology compared to those that are not established have not been fully assessed in prior studies.

METHODS

We reviewed electronic medical records of patients hospitalized (billing codes 99221-99223, 99217) with diagnoses encompassing AD, eczema, and dermatitis (ICD-10 codes L20.8-L20.9, L30.8-L30.9) between January 1, 2011, and December 31, 2021, at University Hospitals (UH) in Cleveland, Ohio. Patients were considered established with dermatology if they had been seen by a dermatology provider within 6 months prior to admission. Statistical analysis was performed using chi-square goodness of fit.

RESULTS

A total of 95 patient encounters met criteria for inclusion. Fifteen (15.8%) patients were established with dermatology at the time of admission and 80 (84.2%) were not. The chi-square value (x2 = 44.74) was greater than the critical value of 10.828 at one degree of freedom (p < .001). There were 8 patients who had more than one admission for atopic dermatitis flares; 2 of these patients were established with dermatology prior to their first admission, and 4 were established at the time of the second admission.

CONCLUSION

The majority of patients admitted with AD flare were not established with dermatology. Many of these patients lived in a low socioeconomic area and missed follow-up appointments. Increasing access to dermatologic care for patients with atopic dermatitis, especially in lower-income areas, could aid in decreasing atopic dermatitis-related hospitalizations.

The Role of Dermoscopy in Provider-to-Provider Store-and-Forward Dermatology eConsults: A Scoping Review of the Recent Literature

Purpose of Review

This scoping review maps recent literature on dermatology provider-to-provider asynchronous store-and-forward (SAF) electronic consult (eConsult) platforms with dermoscopy. It offers a descriptive overview, highlighting benefits and challenges.

Recent Findings

Incorporating dermoscopy into SAF eConsults improves diagnostic accuracy for benign and malignant skin neoplasms. Diagnostic and treatment concordance with traditional face-to-face (FTF) visits is high. SAF eConsults with dermoscopy enhance access to dermatological care by improving triage and reducing wait times for FTF visits. Pediatric patients benefit with improved evaluation of melanocytic and vascular growths. eConsult platforms with dermoscopy serve as a telementoring opportunity for clinicians interested in improving their dermoscopy skills.

Summary

Adding dermoscopy to SAF eConsults is valuable and results in improved diagnostic accuracy and reduced need for FTF visits. Implementation barriers can be overcome through collaboration between primary care and dermatology. Dermoscopy in SAF eConsults has significant potential for managing skin conditions and reducing the burden caused by unnecessary FTF visit and biopsies.

The distribution of industry payments among pediatric dermatologists from 2015 to 2021

BACKGROUND/OBJECTIVES

To understand the landscape of industry payments to pediatric dermatologists to foster transparency and identify potential disparities in funding.

METHODS

Using the Centers for Medicare and Medicaid Services (CMS) Open Payments database, a national cross-sectional study was performed examining payments to pediatric dermatologists from 2015 to 2021.

RESULTS

Of the 147 pediatric dermatologists who received industry funding, 35 were male and 112 were female. $9 million in payments was amassed, with 10% of pediatric dermatologists accounting for 94% of total industry payments. Consulting was the most common service, with Pfizer Inc., Amgen Inc., and Regeneron Healthcare Solutions Inc. representing the top three companies. Mean payment was $143,836 for males and $35,943 for females (p < .001). Eight female and seven male pediatric dermatologists received payments in the top 10th percentile, with different average payment in this subgroup (females $447,588 vs. males $698,746, p = .03). 11 states did not have a pediatric dermatologist receiving industry payments, while California (19) and Texas (12) had the most.

CONCLUSIONS

There are approximately 400 board-certified pediatric dermatologists in the United States and fewer than 40% are receiving monetary compensation from private industry. A fraction of physicians accounted for a majority of total industry payments and industry payments to male pediatric dermatologists were higher despite nearly triple the number of female pediatric dermatologists. With the rise of valuable partnerships between healthcare and industry in modern medicine, the implications of geographic, gender, and financial disparity of industry payments in pediatric dermatology are worthy of further study.

Patterns and determinants of pediatric dermatologic care in the United States: An evaluation of the National Ambulatory Medical Care Survey from 2009 to 2015

BACKGROUND

Dermatologists and other providers play essential roles in managing the dermatologic care of pediatric patients. This study aims to identify patterns and elucidate factors associated with receiving dermatologic care in the United States.

METHODS

The National Ambulatory Medical Care Survey (NAMCS) was used to identify pediatric patients with dermatologic diagnoses from 2009 to 2015. Clinical and demographic information were evaluated, and visit diagnoses were stratified based on provider type (dermatologists vs. non-dermatologists). Multivariate logistic regression analysis was used to identify key predictors of outpatient dermatology care for pediatric patients. National estimates of diagnoses were procured using weights provided within the NAMCS database to project disease incidence.

RESULTS

A total of 85,217,557 pediatric patients (survey-weighted) were observed during the study period. Of the sampled patients, 29.3% were evaluated by dermatologists, while 70.7% were seen by non-dermatology providers. Atopic dermatitis was the most common diagnosis encountered by dermatologists in ages 0-3 years, while unspecified contact dermatitis was the most common diagnosis reported by non-dermatologists in all age groups. On multivariable logistic regression, ≥1 year of age, Caucasian race, private insurance versus Medicaid, residence in a metropolitan area, referral from another provider, and longer appointment wait time were associated with an increased likelihood of being evaluated by a dermatologist compared to a non-dermatologist.

CONCLUSIONS

Non-dermatologists are responsible for the majority of pediatric dermatologic care. For pediatric patients, health disparities by race, insurance status, and rurality present significant challenges to being evaluated by a dermatologist.

The effect of nursing home closure on local employment in the United States

OBJECTIVE

To estimate the effect of nursing home closure on local employment, overall, and by rurality.

DATA SOURCES AND STUDY SETTING

We obtained 2008-2018 county-level data from the Quarterly Workforce Indicators, Medicare Provider of Services, Area Health Resource, and Urban Influence Codes files. From 2008 to 2018, 878 counties experienced at least one nursing home closure, and 2055 counties did not experience a closure.

STUDY DESIGN

Using a difference-in-difference study design, we compare the changes of total employment, health sector employment and non-health sector employment over time between counties with and without a nursing home closure. We utilize the variation in the year and quarter of nursing home closures to estimate subsequent employment changes as well as employment trends before closure. We also account for contemporaneous events including nursing home entries and hospital entries and closures, and evaluate heterogeneity by rurality.

DATA EXTRACTION

We include data on nursing home closure from the Medicare Provider of Service file. Quarterly county-level employee counts were obtained from the Quarterly Workforce Indicators provided by the Census Bureau. County-level demographic data were obtained from the Area Health Resource Files. We use Urban Influence Codes from the Economic Research Service, Department of Agriculture, to classify metropolitan, micropolitan, and rural (noncore) counties.

PRINCIPAL FINDINGS

Health sector employment decreased by about 3.2%-4.1% (p < 0.01) in counties with a nursing home closure. The reduction was largest in rural counties (approximately 7.2%-9.4%, p < 0.01). The reduction in health sector employment persisted over time, particularly in rural counties. Overall, there was no discernable effect on non-health sector employment.

CONCLUSIONS

Nursing home closure is associated with a persistent decline in health sector employment, particularly in rural counties, suggesting a reduction in the health care workforce and in the ability to sustain health care services supply, particularly in rural areas.

Evaluation of a pediatric dermatology electronic consult program in a rural state with subanalysis of infantile hemangioma cases

An electronic consultation (e-Consult) store-and-forward teledermatology program was implemented to improve access to dermatologic care in Maine. While initially designed to triage potential skin cancers, we found this program to be heavily used for pediatric patients, especially infants. Our findings suggest e-Consult expedites care for pediatric dermatology patients, particularly those with infantile hemangiomas. The addition of dermoscopy to e-Consult platforms has the potential to expand e-Consult effectiveness.

Access to pediatric dermatology

PURPOSE OF REVIEW

To identify factors that impact accessibility to pediatric dermatology and review healthcare delivery models that improve access and address these barriers.

RECENT FINDINGS

Up to one-third of pediatric primary care visits include a skin-related problem, yet pediatric dermatology subspecialist services are highly inaccessible. Workforce shortages and geographic, sociocultural, and economic barriers perpetuate inaccessibility. Teledermatology expands care, particularly to underserved or geographically remote communities, and reduces healthcare-related costs. Federal legislation to support telehealth services with adequate reimbursement for providers with parity between live, video, and phone visits will dictate the continued feasibility of virtual visits. Innovative care delivery models, such as language-based clinics, multidisciplinary teleconferencing, or embedded dermatology services within primary care are other promising alternatives.

SUMMARY

Despite efforts to expand access, dermatology still ranks among the most underserved pediatric subspecialties. Improving access requires a multipronged approach. Efforts to expand exposure and mentorship within pediatric dermatology, diversify the workforce and clinical curriculum, recruit and retain clinicians in geographically underserved areas, and collaborate with policymakers to ensure adequate reimbursement for teledermatology services are necessary.

Dermatology Workforce in the United States - Part 1: Overview, Transformations, and Implications

The dermatology workforce continues to evolve to meet the growing and diversified demands of the United States population. Part 1 of this continuing medical education (CME) series is designed to provide an overview of the dermatology workforce as well as delineate the motivators and socio-economic implications of significant workforce transformations which are impacting dermatologic health care. Part 2 of the series will consider the impact of workforce challenges on patient outcomes and discuss potential actions that may help to optimize workforce organization and care delivery.

Efficacy of pediatric dermatology Extension for Community Healthcare Outcomes (ECHO) sessions on augmenting primary care providers' confidence and abilities

Due to the shortage of pediatric dermatologists and the abundance of skin disorders presenting in childhood, general pediatricians shoulder the management of many pediatric dermatologic disorders and would benefit from additional dermatology-specific training. To address this educational gap, general pediatricians were enrolled in a pediatric dermatology-specific Project Extension for Community Healthcare Outcomes (ECHO) program and surveyed to assess the efficacy of the program in increasing providers' ability and confidence in managing pediatric dermatologic conditions. Providers unanimously reported increased confidence and abilities in assessment and management of pediatric dermatologic conditions. Pediatric dermatology Project ECHO demonstrated high efficacy in improving general practitioners' comfort and knowledge on dermatology-specific topics and may be used as an education model for enhancing primary care providers' knowledge and management of common disorders.

Access as equity: Addressing the distribution of the pediatric dermatology workforce

While overall shortages in the pediatric dermatologist workforce have been well-documented, recent evidence indicates a geographic maldistribution of providers, which can further exacerbate health disparities for children. Wide geographic gaps in access to pediatric care constitute a critical public health issue and impede upon a child's right to access care. In this review, we examine the issue of geographic maldistribution of pediatric dermatologists through the lens of health equity: describing the problem, exploring the enablers of and barriers to change, and offering potential solutions.

Geographic distribution and characteristics of the pediatric dermatology workforce in the United States

BACKGROUND/OBJECTIVES

Up to 30% of pediatric primary care visits include a cutaneous complaint, yet the pediatric dermatology workforce has historically been too small to provide adequate specialized care. This study assesses the geographic distribution of pediatric dermatologists to determine physician-to-patient ratios, analyzes urban-rural disparities, and determines post-fellowship migration patterns.

METHODS

Board-certified pediatric dermatologists were identified using the Society for Pediatric Dermatology's public database, and their demographics and credentials were subsequently verified by an online search. Analysis included physician density per 100 000 children for each state and region, along with geographic distribution for rural and urban areas, based on the United States Census Bureau's definitions. The distances between practice locations and the American Board of Dermatology-approved Pediatric Dermatology fellowship training sites were reviewed.

RESULTS

An estimated 336 board-certified pediatric dermatologists currently work in the United States with 76.8% being women and 71.1% practicing within 50 miles of the nearest fellowship program. 96.4% are located in urban areas and 3.6% in rural areas with an average ratio of 0.54 and 0.09 per 100 000 children, respectively. The average ratio of pediatric dermatologists in the United States was 0.46 per 100 000 children. On average (standard deviation), there are 6.6 (8.8) pediatric dermatologists per state but with 7 states having zero.

CONCLUSIONS

The demand for pediatric dermatologists continues to outpace the current physician availability with a disparity between urban and rural areas. Further awareness and emphasis on training and recruitment of additional pediatric dermatologists are essential to addressing this important issue.

Achieving equity and inclusion in pediatric dermatology research: Priorities and considerations

As we increase our focus and energy on equity, diversity, and inclusion (EDI)-relevant research, we must consider the "what, why, and how" of our work. The goals of this paper are to highlight unique issues pediatric dermatologists face in providing equitable care, pose considerations when reporting data on race and ethnicity, and advocate for standardized classification of race and ethnicity in research.

Management of Pediatric Atopic Dermatitis by Primary Care Providers: A Systematic Review

BACKGROUND

Primary care providers (PCPs), including pediatricians and general practitioners, are often the first to see children with eczema/atopic dermatitis (AD). Little is known about management of pediatric AD by PCPs and adherence to national guidelines.

OBJECTIVE

To review existing literature examining management components of pediatric AD (topical corticosteroids [TCS], topical calcineurin inhibitors [TCIs], antihistamines, bathing, emollients, and diet) by PCPs.

DATA SOURCES

PubMed/Medline and Embase.

STUDY ELIGIBILITY CRITERIA

English-language articles dated 2015 to 2020 reporting outcomes addressing management of pediatric AD by PCPs.

STUDY APPRAISAL AND SYNTHESIS METHODS

Two authors independently screened titles/abstracts, reviewed full-text articles, extracted relevant data, and evaluated study quality. Disagreements were resolved by a third author.

RESULTS

Twenty articles were included. Surveys and national database analyses were the most common methodologies (n = 7 each). PCPs commonly prescribed TCS but had a preference for low-potency agents, overprescribed nonsedating antihistamines, and avoided TCIs. PCPs commonly recommended emollients, although this was not universal. Data characterizing nonmedication management were limited.

LIMITATIONS

Most studies did not examine individual patient encounters, but rather relied on providers reporting their general behaviors. Provider behavior may vary based on country of practice.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Knowledge and management gaps exist among PCPs in treating pediatric AD in key areas including knowledge of TCS safety profiles and prescribing of TCIs. The current literature is largely limited to small studies that evaluate prescribing behaviors with limited data characterizing nonmedication management, highlighting the need for future research in this area.

Barriers to healthcare access in pediatric dermatology: A systematic review

Barriers to healthcare access are healthcare inequities that have been widely studied across different medical specialties. No studies have previously evaluated the state of barriers to healthcare access research in pediatric dermatology. A systematic review was conducted to examine the types of barriers identified within pediatric dermatology literature. Relevant information was extracted and categorized into the themes of systemic, sociocultural, or individual barriers. The systemic barriers we found include finances, wait times, and geography. The sociocultural barriers included culture beliefs and communication. Patient beliefs and health knowledge were found as individual barriers. The small number and limited scope of studies we identified suggest that barriers to healthcare access in pediatric dermatology remain an understudied topic. Additional research is needed to further characterize these barriers to dermatologic care, as well as the impact of any interventions designed to overcome them.