Healthcare Grapples With the Value of Dermatology Hospitalists

The role of dermatology is more than just that of an outpatient specialty. In years past, it was common for hospital dermatology departments to have dedicated inpatient programs; however, changes in reimbursement systems have affected the care landscape in hospitals.¹

Dermatological Disarray

According to an editorial published in the Journal of the American Academy of Dermatology, between 1982 and 1997, the number of dermatology patients who were admitted to hospitals in the care of other physician providers increased from 15.5% to 32.4%, with “few dedicated admitting dermatology services remaining in practice today.”¹

“General medical training in the recognition and management of uncommon and severe skin disorders is deficient,” wrote Lindy P. Fox, MD, from the Department of Dermatology at the University of California, San Francisco. “As such, lack of inpatient dermatology consultants might lead to the inappropriate management of patients with cutaneous disease — including patients admitted by dermatologists for escalation of care.”¹

Dr Fox and coauthor Lauren M. Madigan, MD, from the Department of Dermatology at the University of Utah, Salt Lake City, noted the importance of clinical expertise in the dermatology field for hospitalized patients.³ One study, published in the International Journal of Dermatology^,2 found that although 45% of dermatologist consultations were requested from internal medicine teams, only 6.5% were requested within 24 hours of the appearance of cutaneous findings. After dermatology consultation, 81.9% of patients underwent a change in treatment.²

“Dermatology consultations play an important role in patient care in hospital settings with significant positive effects on quality of life,” the authors noted.²

In a 2016 study published in JAMA Dermatology, ³ Daniela Kroshinsky, MD, MPH, from the Department of Dermatology at Massachusetts General Hospital, Boston, and colleagues came to a similar conclusion. In a retrospective, multi-institution, cross-sectional cohort study, Dr Kroshinsky and colleagues examined the effect of consultative dermatologists in a hospital setting over the course of 12 months.³ Results of this analysis found that, as in other studies, consultation by a dermatologist “changed the final diagnosis in 71% of consultation requests.”

“This research demonstrates that dermatology consultation is associated with improved diagnostic accuracy of cutaneous disorders in hospitalized patients and facilitates early appropriate intervention,” the researchers concluded.³

Inpatient dermatology consultation is also of high value in patients with complex cutaneous conditions, defined in one study as dermatologic conditions with “potential systemic implications or related to systemic disease.”² Dermatology consultations in this population resulted in “significantly more” treatment changes (97%) compared with simple cutaneous conditions.² “[D]ermatology consultation not only provides value but might also significantly impact morbidity and mortality,” Dr Fox noted. ¹

Ultimately, inpatient dermatology consultations ensure that dermatologists treat the patients who most need them. “By not participating in hospital consultations, dermatologists are surrendering the care of patients with these challenging conditions to non-dermatologists. This situation stands to affect the care these patients receive and also to de-skill the dermatologist in caring for patients with extensive skin disease,” wrote Mark D. P. Davis, MD, from the Department of Dermatology at the Mayo Clinic, Rochester, Minnesota, and colleagues, in a study published in the International Journal of Dermatology.⁴

The Economic Burden, Examined

Although practical, care-based concerns are at the forefront of the consultative dermatology conversation, the economic burden of inpatient dermatology care should also be considered when arguing the importance of hospital-based dermatologists.

Cellulitis accounts for more than 600,000 hospital admissions yearly.¹ Because of the nature of the disease, a correct diagnosis, complicated by the lack of pathognomonic features and clinical signs mimicked across other diseases, “relies on the presence of an experienced practitioner.”¹

Four studies^5-8 examined the economic burden of cellulitis on the healthcare system. Investigators in one study⁵ found that in cases of suspected cellulitis, dermatology consultation could prevent 50,000 to 130,000 unnecessary hospitalizations and $195 to $515 million in annual, avoidable healthcare spending. Another study⁸ found that dermatologist consultation in suspected cellulitis could prevent up to 256,000 avoidable inpatient days and eliminate from $80 to $210 million in avoidable healthcare spending.

However, these studies are limited only to a single disease state. When reporting on the effect of dermatology consultation on all inflammatory skin conditions,⁶consultation resulted in a 10-fold reduction in the odds of hospital readmission and was linked to a mean 2.64-day reduction in hospitalization length.⁶

Although the cost savings and improvements in patient care are significant, further research is needed to “better quantify the direct impact [of dermatology hospitalists] on morbidity and mortality.”¹

Practical Solutions

In response to these concerns, as well as to the demonstrated, significant need for the expertise of dermatology consultants, the Society for Dermatology Hospitalists was created.⁹ In a 2009 letter to the editor published in the Journal of the American Academy of Dermatology,¹⁰ Dr Fox and colleagues, all founding members of the society, proposed a dermatology hospitalist model shaped by the internal hospitalist movement initiated in the mid-1990s.

The Society for Dermatology Hospitalists aims to “develop the highest standards of clinical care of hospitalized patients with skin disease by promoting clinical expertise, fostering research, and furthering education in the management of hospitalized patients with cutaneous disease.”¹ In its 10 years of existence, the group has grown from 5 to 145 members and is supported by the American Academy of Dermatology. In addition to creating postgraduate fellowships for the training of dermatology hospitalists, members have authored a number of research studies within the field.¹

“Much has been achieved in the 9 years since the formal inception and specialty’s acceptance of inpatient dermatology as a subspecialty of dermatology,” wrote Dr Fox.¹ However, she noted, multiple gaps remain, including the lack of access to dermatology hospitalists outside of academic institutions.

“Although the value inpatient dermatology provides…has been supported by data and the significance of inpatient dermatology has been recognized by many within our specialty, further efforts are necessary to establish dermatology as an essential part of hospital-based care,” Dr Fox concluded.¹

References

1. Madigan LM, Fox LP. Where are we now with inpatient consultative dermatology?: Assessing the value and evolution of this subspecialty over the past decade. J Am Acad Dermatol. 2019; 80(6):1804-1808.

2. Galimberti F, Guren L, Fernandez AP, Sood A. Dermatology consultations significantly contribute quality to care of hospitalized patients: a prospective study of dermatology inpatient consults at a tertiary care center. Int J Dermatol. 2016; 55(10):e547-e551.

3. Kroshinsky D, Cotliar J, Hughey LC, Shinkai K, Fox LP. Association of dermatology consultation with accuracy of cutaneous disorder diagnoses in hospitalized patients: a multicenter analysis. JAMA Dermatol. 2016; 152(4):477-480.

4. Storan ER, McEvoy MT, Wetter DA, et al. Experience of a year of adult hospital dermatology consultations. Int J Dermatol. 2015; 54(10):1550-1556.

5. Weng QY, Raff AB, Cohen JM, et al. Cost and consequences associated with misdiagnosed lower extremity cellulitis. JAMA Dermatol. 2017; 153(2):141-146.

6. Milani-Nejad N, Zhang M, Kaffenberger BH. Association of dermatology consultation with patient care outcomes in hospitalized patients with inflammatory skin diseases. JAMA Dermatol. 2017; 153(6):523-528.

7. Ko LN, Garza-Mayers AC, St John J, et al. Effect of dermatology consultation on outcomes for patients with presumed cellulitis: A randomized clinical trial. JAMA Dermatol. 2018; 154(5):529-536.

8. Li DG, Xia FD, Khosravi H, et al. Outcomes of early dermatology consultation for inpatients diagnosed with cellulitis. JAMA Dermatol. 2018;154(5):537-543.

9. Society for Dermatology Hospitalists. Homepage for the Society of Dermatology Hospitalists. https://societydermatologyhospitalists.com/. Accessed June 25, 2019.

10. Fox LP, Cotliar J, Hughey L, et al. Hospitalist dermatology. J Am Acad Dermatol. 2009;61(1):153-154.