Subspecialty Care Clinics May Be Useful in Dermatology

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Although most patients were referred by rheumatologists or dermatologists, 87% received a change in diagnosis or treatment.
Although most patients were referred by rheumatologists or dermatologists, 87% received a change in diagnosis or treatment.

The use of dermatology subspecialty clinics among patients with connective tissue disorders (CTDs) can have an impact on their diagnosis and treatment, according to the results of a single-center, retrospective analysis conducted in a CTD clinic at Brigham and Women's Hospital in Boston, Massachusetts, and published in the Journal of the American Academy of Dermatology.

The records of all new Brigham and Women's Hospital initial patient visits to the CTD clinic between July 2008 and December 2013 were retrospectively reviewed with respect to demographics, diagnosis, change in diagnosis, referring provider, prior treatment(s), switch in therapy, additional biopsies/referrals/studies, and presence of residents/fellows.

A total of 483 new patients were seen in the clinic during this time period, with the majority of them having been referred by rheumatologists or dermatologists. Among these patients, 68% received new diagnoses, including 20 individuals who were diagnosed with dermatomyositis after being referred for systemic lupus erythematosus, discoid lupus erythematosus, juvenile inflammatory arthritis, atopic dermatitis, or undifferentiated CTD.

Overall, 60 patients with unspecified CTDs received specific diagnoses. Moreover, 76 persons who were referred to the clinic for CTDs were subsequently found not to have a CTD. Among those referred to the clinic, 72% received new treatments. In addition, among those who received a new CTD diagnosis, 31.2% were started on a new systemic treatment. Rheumatologists most often referred patients with systemic lupus erythematosus or subacute cutaneous lupus erythematosus, and dermatologists most commonly referred patients with dermatomyositis.

Patients who were referred by rheumatologists were significantly more likely to undergo skin biopsies (odds ratio [OR] 4.08; 95% CI, 1.54-10.8; P <.05). In contrast, patients who were referred by rheumatologists or primary care physicians were significantly less likely to have any additional testing ordered (OR 0.48; 95% CI, 0.28-0.82; P <.05 and OR 0.28; 95% CI, 0.14-0.58; P <.05, respectively).

The investigators concluded that although most patients were referred by rheumatologists or dermatologists, 87% received a change in diagnosis or treatment, which demonstrated the clinical contribution of a CTD clinic to patient care. The percentages of diagnostic and therapeutic changes were consistent across nondermatologic specialties.

Because these data are reflective of findings from a single institution, broader studies and follow-up are warranted to investigate the impact of focused subspecialty care clinics on metrics including cost-effectiveness, clinical response, and patient-reported outcomes, and fully assess their value.

Reference

Tong LX, Nambudiri VE, Vleugels RA. Dermatology subspecialty clinic for patients with connective tissue disease impacts diagnosis and treatment: a single-center, retrospective analysis [published online April 21, 2018]. J Am Acad Dermatol. doi: 10.1016/j.jaad.2018.04.031

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