Reorganising dermatology care: predictors of the substitution of secondary care with primary care

Clinical Features Associated with the Demand of In-Person Care by Dermatologists: An Observational Cross-Sectional Study

Background: The factors necessitating the need for referrals for in-person evaluations by a dermatologist are not adequately understood and have not been studied using automated text mining so far. The objective of this study was to compare the prevalence of required in-person dermatologist care in the presence or absence of certain clinical features. Methods: Observational cross-sectional study of 11,661 teledermatology reports made from February 2017 to March 2020. Results: The need for dermoscopy was associated with a 348% increase in the possibility of referral for in-person dermatologist evaluations (prevalence ratio [PR]: 4.48, 95% confidence interval [CI]: 4.17-4.82). Infectious diseases were associated with a 64% lower possibility of referral (PR: 0.36, 95% CI: 0.30-0.43). Discussion: Some lesions and poorly documented cases are challenging to assess remotely. This study presents a different approach to research more detailed data from teledermatology reports, using text mining, and points out the risk magnitude for demanding dermatologic in-person care of which feature analyzed. As limitations, the variables related to lesion location, size, and extension were not analyzed and the dictionaries used were originally in Brazilian Portuguese. Conclusions: Teledermatology seems sufficient for the management of 75% of clinical cases, especially acute in young patients with inflammatory or infectious lesions. Referrals for in-person dermatologist consultations were not only strongly associated with the need for dermoscopy, but also for therapeutic reasons like surgical procedures, phototherapy, and the use of some systemic medications.

Assessment of Primary Care Physicians' Expertise of Common Dermatological Conditions in the Jouf Region, Saudi Arabia: A Mixed Methods Study

Primary care physicians (PCPs) are the first line of defense for the management of common dermatological conditions (DCs). This study aimed to assess how dermatological diseases are identified, managed, and referred to in primary healthcare centers (PHCs). This was a mixed methods study comprising a cross-sectional survey and semi-structured interviews recruited through PHCs across the Jouf region of Saudi Arabia. Sixty-one PCPs completed the data, and eight participants were interviewed. A survey based on a sample of 22 photographs of common DCs in the Kingdom was administered to the participants to answer questions about the correct diagnosis, appropriate management, referral strategy, and encounter rate. In our sampled population, the mean overall knowledge level on a scale of 10 was 7.08 (±1.3). Among participants that had good to acceptable scores, 51 (83.6%) were in the overall knowledge parameter, 46 (75.4%) in the diagnosis parameter, and 49 (80.3%) in the management parameter. PCPs with five years or more of experience were found to have significantly higher overall knowledge and management scores. Most of our PCPs demonstrated sufficient knowledge of common DCs and had good to acceptable scores in all parameters. However, educational and regulatory aspects of PCPs' clinical management were identified. Focused training, provision of workshops, and improving medical school curricula regarding common DCs are recommended.

Healthcare utilization patterns for knee or hip osteoarthritis before and after changes in national health insurance coverage: A data linkage study

INTRODUCTION

Medical guidelines aim to stimulate stepped care for knee and hip osteoarthritis, redirecting treatments from hospitals to primary care. In the Netherlands, this development was supported by changing health insurance coverage for physio/exercise therapy. The aim of this study was to evaluate healthcare utilization patterns before and after health changes in health insurance coverage.

METHOD

We analyzed electronic health records and claims data from patients with osteoarthritis in the knee (N = 32,091) and hip (N = 16,313). Changes between 2013 and 2019 in the proportion of patients treated by the general practitioner, physio/exercise therapist or orthopedic surgeon within 6 months after onset were assessed.

RESULTS

Joint replacement surgeries decreased for knee (OR 0.47 [0.41-0.54]) and hip (OR 0.81 [0.71-0.93]) osteoarthritis between 2013-2019. The use of physio/exercise therapy increased (knee: OR 1.38 [1.24-1.53], hip: OR 1.26 [1.08-1.47]). However, the proportion treated by a physio/exercise therapist decreased for patients that had not depleted their annual deductibles (knee: OR 0.86 [0.79 - 0.94], hip: OR 0.90 [0.79 - 1.02]). This might be affected by the inclusion of physio/exercise therapy in basic health insurance in 2018.

CONCLUSION

We have found a shift from hospitals to primary care in knee and hip osteoarthritis care. However, the use of physio/exercise therapy declined after changes in insurance coverage for patients that had not depleted their deductibles.

Substitution or addition: An observational study of a new primary care initiative in the Netherlands

OBJECTIVE

In 2014, the Primary Care Plus (PC+) model was introduced in the Netherlands to shift low-complex specialised care from the hospital to the primary care setting. While positive effects of PC+ have been documented at individual patient level concerning health-related quality of life, perceived quality of care and care costs, its impacts on service use at the population level remain uncertain.

METHODS

In this observational study, we used retrospective health insurance reimbursement claims data from the largest health insurer in the intervention region to determine service use. We assessed PC+ and secondary care insurance claims (i.e. claims of the regional hospital and claims of other secondary care settings in and outside the region visited by patients from the intervention region) from 2015 to 2018 and compared these to the national level.

RESULTS

The total number of claims related to low-complex specialised care in the intervention region showed an increase over time. The increase in claims was related to PC+. The number of claims related to the regional hospital and other secondary care settings decreased over time. During the same period, a declining trend in claims at the national level was observed.

CONCLUSION

The introduction of the PC+ model in one region in the Netherlands was associated with an increase in the use of low-complex specialised care. This suggests that the ability of the PC+ model to substitute for specialist care at population level may be limited. Going forward, it will be important to continue monitoring and evaluating service use as substitution effects may materialise only over a longer timeframe.

The spectrum of skin-related conditions in primary care during 2015-2019-A Finnish nationwide database study

Background

Skin‐related conditions are the frequent cause of doctors’ consultations in primary care.

Methods

Based on nationwide data bank information of the Finnish Institute for Health and Welfare, we analysed the 20 most frequent main diagnoses for each ICD‐10 category of all general practitioners’ visits in the public health care in Finland over the years 2015–2019.

Results

The total amount of doctor’s visits was 19 204 613 of which 1 489 228 consultations (7.80%) had a skin‐related condition as the main diagnosis. The most frequent skin‐related conditions were eczematous eruptions, bacterial skin infections and benign skin neoplasms accounting for 749 351 consultations (50.32%). The spectrum of skin‐related conditions was diverse, with a large quantity of rarer diagnoses. Some diagnoses showed significant proportional changes.

Conclusions

The results demonstrate that a limited amount of conditions comprises most of the skin‐related consultations in primary care in Finland. Undergraduate education in dermatology should concentrate on the most frequent conditions seen by general practitioners, but also address the wide range of skin problems.

Measuring Atopic Dermatitis Disease Severity: The Potential for Electronic Tools to Benefit Clinical Care

Severity of atopic dermatitis (AD) correlates with impact on health-related quality of life (HRQoL), work productivity, and burden on health systems. Tools to measure severity inform regulatory approval, drug access, and value- or measurement-based care. A core set of instruments for measuring AD has been established. Clinician-reported tools are divided broadly into multi-item global estimates or precise calculators that also weigh affected corporeal surfaces. Increasingly, subjective patient-reported outcomes are valued, with the potential to capture vast amounts of health-related data. Patient-reported outcomes can be disease-agnostic, skin-related, or AD-specific, and evaluate global disease, itch severity, long-term control, or overall HRQoL. Patient-reported outcomes are expansive in number; therefore, item banks and adaptive digital user interfaces will be increasingly needed, along with capacity to store and analyze data. Technologies for AD include tools for communication, severity assessment, or data exchange, as well as electronic health records (EHRs). For clinicians, a limited number of applications exist, with relatively poor interoperability with EHRs to date. For patients, a growing number of mobile health (mHealth) applications exhibit variable compliance with international guidelines for self-management. Data privacy and information security governance are key considerations in the development of information technologies for AD. Integrated and streamlined digital operational processes for disease measurements may build capacity for high value and efficient care of patients with AD across the globe.

Addressing the challenges to skin health of refugees and migrants in the WHO European region

The prevalence of dermatological disease and skin conditions is a significant issue facing refugees and migrants in the WHO European Region. Displaced populations in particular are vulnerable to dermatological diseases, due to the often poor conditions in which they live and transit through at different stages of their journey. Exposure to adverse weather conditions and heightened risk for injuries and violence are also potential causes for skin conditions and abnormalities. Through a review of published literature focusing on refugee and migrant health, this paper outlines the prevalence of skin conditions and dermatological diseases among these populations, and the impact of migration and displacement on susceptibility for them. It then discusses some of the challenges associated with managing skin conditions and highlights key opportunities to strengthen the integration of skin health within health care for migrants and refugees in the WHO European Region.