Short supply

Need for inpatient dermatologic care increases


Short supply

Need for inpatient dermatologic care increases


By Jan Bowers, contributing writer

If there were ever a doubt that dermatologists can have a powerful, even life-saving impact on the care of hospitalized patients, the stories related by hospital-based dermatologists, whose viewpoints are bolstered by a growing body of research, demonstrate the critical importance of dermatologic expertise in the inpatient setting. “I look at this role as being an ambassador for dermatology,” said Dr. Micheletti. “Our medical colleagues really value what we bring to the table. When you put yourself out there, you get to see interesting cases, converse with your colleagues, and have tremendous ability to shape patient care. But you have to be there, be in the game.” On column to the right, five dermatology hospitalists share their experience and discuss the issues underlying the shortage of dermatologists willing to do inpatient consults. 

The impact on inpatient care

If there’s a poster child depicting the frequency with which dermatologists correct or head off a misdiagnosis, cellulitis may be it. “Cellulitis is an arena where dermatology expertise can play a tremendous role in better outcomes for patients, hospitals, and the health care system as a whole,” said Daniela Kroshinsky, MD, director of inpatient dermatology and pediatric dermatology at Massachusetts General Hospital. Dr. Kroshinsky co-authored a study (JAMA Dermatol. 2017;153(2):141-146) examining the costs and consequences resulting from misdiagnosed lower extremity cellulitis. The study included 259 patients admitted with presumed cellulitis from the emergency department of a large urban hospital. Among the findings: of the 259 patients, 79 (30.5 percent) were misdiagnosed with cellulitis. Of those misdiagnosed, 52 were admitted primarily for cellulitis treatment; 44 of the 52 did not require hospital admission, and 48 received unnecessary antibiotics. The authors estimate that misdiagnosis of cellulitis results in $195 million to $515 million annually in unnecessary spending in the U.S., “exclusive of the costs of antibiotics and complications resulting from inappropriate treatment.” In another cellulitis study not yet published, Dr. Kroshinsky said she was able to demonstrate that “having a dermatologist intervene and assess these patients within 24 hours of their presentation resulted in reduced length of hospital stay and antibiotic use. In addition, we found that patients felt they were better cared for and had better outcomes if they saw a dermatologist during their stay.”

Another JAMA Dermatology study (2017;153(6):523-528), co-authored by Dr. Kaffenberger, examined the impact of dermatology consultation for patients with inflammatory skin conditions on hospital length of stay and readmission. Multivariable modeling showed that dermatology consultations were associated with a reduction of 2.64 days in hospital length of stay (as measured from the time of the consult to discharge). In addition, “if you had a dermatology consult, your chances of being readmitted were one-tenth of those who did not receive a consult,” Dr. Kaffenberger noted.

In addition to correcting the misdiagnosis of common skin disorders, dermatologists frequently identify rare disorders that the primary care team didn’t suspect. These conditions may be primary disorders, or they may result from immunosuppression or reaction to a drug. “Stevens-Johnson syndrome is kind of the classic dermatologic emergency,” said Dr. Micheletti. “It’s a very severe drug reaction, and a number of medications can cause it. It can result in blistering of the skin, eyes, and mouth, and the average mortality is 20 to 25 percent. The average non-dermatologist maybe could name the disorder, but this is an example of where the dermatologist serves as the quarterback of care for these patients.”

A review of dermatology consults at Penn revealed that about a quarter came from the bone marrow transplant unit, Dr. Micheletti noted. “Half of those are neutropenic, 30 percent are really complex, really immunosuppressed, and in about 60 percent of the cases the final dermatologic diagnosis that we made was not considered in the differential diagnosis of the primary team.”

THE SHORTAGE OF INPATIENT CONSULTS

In academic settings, and in many but not all urban areas, it’s relatively easy for the hospital primary care team to bring in a dermatologist for a consult, said Dr. Musiek. “I think the struggle is in areas underserved by dermatologists in the first place, rural and community hospitals. In medical school, you don’t get much dermatology training, so people on the front lines may not have had any exposure to dermatologic conditions. And in areas where demand for physicians outstrips supply, leaving clinic early or devoting a half day to inpatient consults isn’t necessarily an option for many dermatologists in private practice. Even if it’s just one or two inpatient consults, that still takes significant time away from a provider’s practice.”

And time is just one of the barriers that deter dermatologists from making themselves available for hospital consults. “I get the sense from talking to recent dermatology graduates that the biggest factor is the amount of credentialing and paperwork required by the hospital,” said Dr. Kaffenberger. “The hospital is going to want you to use their EMR, they want you to do so many hours of credentialing education, so many Joint Commission-required courses, all for a small number of consults. Hospitals aren’t making it easy for dermatologists to do this. And the result is, here in Columbus there’s a huge non-academic hospital with 800 beds, and they have no option for dermatology consults.”

Other logistical challenges abound, said Misha A. Rosenbach, MD, assistant professor of dermatology at the Hospital of the University of Pennsylvania. “You have to travel to the hospital, park, figure out where the patient is, look through the chart to see what other teams are doing, then read about what is probably a very complicated patient,” he pointed out. “Then you go in and see the patient, document your visit, and maybe have a discussion with the primary team. If the patient needs a procedure, you have to set it up, consent the patient, take the specimen, bring it where it needs to go, and then follow up on that.”

In the end, “most reasons to decide not to do inpatient consults boil down to financial ones,” said Dr. Micheletti. “I want to be careful to say that it’s not as simple as, some of us are altruistic and others are just in it for the money. I don’t think that’s the case at all. There are true barriers in the community setting — it takes a long time to see patients and it doesn’t pay very well. But at the end of the day, it’s the right thing to do, and we should be excited by the opportunity to see interesting things and make a difference. But it’s challenging; I do understand that.” His colleague, Dr. Rosenbach, remarked that “generally, you make more from a quarter of a day in clinic than in five days of consults. And the question is, why would anyone do that? You’re providing care for patients who really need it, but the more physicians who participate in occasionally being available, the more it helps the field as a whole.” If dermatologists are perceived as unconcerned about hospital inpatients, “this comes back to bite us in reimbursement negotiations and discussions within the house of medicine about things like diagnostic codes,” Dr. Rosenbach insisted. “With the shift toward alternative payment models and accountable care organizations, there is a very real chance physicians will be required to participate in health care plans, to be present and affiliated with hospitals, and dermatologists need to be aware of that.”

A WAY FORWARD

For some dermatology residents, the work they do with inpatients during their residency propels them toward a career as a dermatology hospitalist. “I like the hospital setting; I like to be actively doing things,” said Dr. Musiek. “We certainly see a ton of cases that are very routine, and we try to be as helpful to the team as possible. But there are a lot of opportunities to come in and make the big diagnosis that no one was thinking of, and I think that’s a fun opportunity too.”

Dr. Kroshinsky was one of five founding members of the Society for Dermatology Hospitalists, a group formed 10 years ago that has grown to more than 90 members. She noted that one of the society’s missions is to think of ways to bring dermatology consults to community hospitals and other institutions that can’t support a full-time dermatology hospitalist. “If we think creatively of how to utilize those individuals who are interested in hospital dermatology but can’t do it full-time, or don’t see hospital dermatology as their main focus, we can be integrating them in different ways. One approach is to partner with community hospitals, coming in perhaps once or twice a week or on an as-needed basis, being amenable to triage and assessment via teledermatology and then working with the full-time primary care teams in those hospitals.” There could be an arrangement whereby a dermatologist sees the inpatient “but is not necessarily responsible for the administrative component that would result from that visit.” Regarding issues like credentialing and billing, “there’s going to have to be some flexibility on both sides. It’s not realistic to expect outpatient dermatologists to be credentialed in 10 different community hospitals and facile with five different EMRs.”

By engaging other specialties within the hospital to think through the problem, dermatology hospitalists “may be able to advocate for our outpatient colleagues to be able to participate in a way that does overcome a lot of these barriers. You need dermatologists in the hospital. We just have to be constantly reconsidering how we can deliver that care in response to how the face of medicine is changing.”

Teledermatology is one possible avenue for private practitioners to provide inpatient consults, the hospitalists said, but reimbursement varies, and dermatologists are advised to confirm with their malpractice carriers that their policy includes coverage for it. “Recent research shows that in the hospital setting, diagnosis via teledermatology is very similar to in-person diagnosis,” said Dr. Kaffenberger. “We tried to do it with one of our affiliates, but there’s no insurer that will pay for it in the hospital setting in our area. That being said, we still do it as a service for our affiliate hospital; we just don’t bill for it or get paid for it. I think we’re getting more traction for it over time, though; that’s our goal.”

Dermatologists with an outpatient practice can always turn to full-time dermatology hospitalists as a resource if they’re considering doing inpatient consults, said Dr. Rosenbach. “Engaging with a local hospital can be incredibly valuable, not just in enhancing the perception of our field, but from a private practice standpoint,” he noted. “You develop a great relationship with a whole host of doctors, and suddenly those doctors are willing to treat your patients on short notice because you treat their patients on short notice. It helps everyone.” 

SkinSerious

SkinSerious is the AAD’s effort to let the medical community and policymakers know that dermatologists treat serious conditions, work as partners with the health care team, and are committed to improving access for patients.

Learn how your colleagues are collaborating with other physicians and increasing patient access, and share your story, at www.aad.org/skinserious.