John S. Barbieri, MD, MBA, with Lisette Hilton
Dermatologists may be the only health care providers caring for a substantial proportion of patients with common chronic inflammatory and autoimmune skin diseases. So, what roles do dermatologists play in screening for and managing known comorbidities of chronic skin disease, including cardiovascular disease and mental heath disorders?
“As dermatologists, it is important not just to think about caring for the skin disease that we see on our patients, but also to think more broadly about the other ways these conditions can manifest and can impact our patients’ lives,” said dermatologist John S. Barbieri, MD, MBA, author of the study “Use of primary care services among patients with chronic skin disease seen by dermatologists,” published March 1, 2021 in the Journal of the American Academy of Dermatology International (JAAD International).1
Skin diseases can have diverse mental and physical effects on patients.
“For instance, psoriasis, which is a common inflammatory skin disease, is associated with increased risk of mortality and cardiovascular disease, as well as with depression. … 85% of adolescents will experience acne at some point. It can be associated with profound mental health impacts, including depression and suicidality,” said Dr. Barbieri, a Postdoctoral Research Fellow at University of Pennsylvania, Philadelphia.
Dr. Barbieri and coauthors retrospectively analyzed US claims data among patients seeing dermatologists for psoriasis, hidradenitis suppurativa, acne, and alopecia areata. They focused on those 4 diseases because they are common dermatologic conditions and are associated with important systemic and mental health comorbidities, according to the paper.
In their research, Dr. Barbieri and colleagues asked how many patients seeing dermatologists for chronic inflammatory skin diseases had seen primary-care providers, including pediatricians, internal medicine doctors, and family medicine specialists, in the year after establishing care with their dermatologists.
“We know from other research that about half of commercially insured patients do not have a primary-care doctor that they see regularly,” Dr. Barbieri said. “If they are only seeing their dermatologist, the assumption that their primary-care doctor may take care of some of these other issues might be a false premise. It suggests the need for a dermatologist to play a larger role, either helping to connect patients with associated clinicians who could help manage these comorbidities, or even to take a role themselves, at least initially screening for some of these conditions.”
…Among patients seeing a dermatologist for psoriasis, hidradenitis suppurativa, acne, and alopecia areata, from nearly 17% to more than 31% did not see a primary-care clinician in the year after their initial dermatology visit.
The investigators found that among patients seeing a dermatologist for psoriasis, hidradenitis suppurativa, acne, and alopecia areata, from nearly 17% to more than 31% did not see a primary-care clinician in the year after their initial dermatology visit.
More specifically, of the 71,857 psoriasis patients identified in the study, 21.6% of men and 16.9% of women had no primary-care encounters. Among 5407 hidradenitis suppurativa patients, 28.1% of men and 22% of women had no primary-care visits in the following year; among 238,647 acne patients, 27.1% of men and 26.2% of women; and among 10,904 alopecia areata patients, 31.2% of men and 19.2% of women.
“About 20% to 25% [of dermatology patients] overall did not have a visit with a primary-care doctor in 12 months of their initial dermatology encounter for these conditions. So, it does support that many of our patients who we are seeing may not have a primary-care doctor whom they are seeing regularly or may not have a primary-care doctor at all,” he said.
In terms of subgroups, men, as well as younger patients (particularly those between 20 and 40 years old) were less likely to have visited primary-care providers in the year after their dermatologic appointments.
The investigators did sensitivity analyses revealing that between 15.2% and 21.9% of men and 11.4% to 18.9% of women did not see primary-care providers 6 months prior to the initial dermatology visit, or index date. And 12.3% to 18.7% of men and 8.7% to 14.3% of women did not have any primary-care encounters 2 years after the index date.
“I think those findings largely reflect that the underlying demographics of use of primary-care services in the United States,” Dr. Barbieri said.
Dermatology visits were the only health care encounters, including with other specialists, for 9.4% to 15.8% of men and 4.1% to 5.8% of women who sought treatment for the 4 skin conditions studied.
“We don’t know about other skin diseases, but I suspect that we might find similar results if we looked at other diseases, such as eczema,” he said.
Another study published October 2 in JAMA Network Open reported that COVID-19 fueled the downward trend.2 Primary-care visits decreased by 21.4% during the second quarter of 2020 compared with the average quarterly visit volume of the second quarters of 2018 and 2019.
“Evaluations of blood pressure and cholesterol levels decreased owing to fewer total visits and less frequent assessment during telemedicine encounters,” authors of the study wrote.
Implications for dermatologists
“Dermatologists should address important comorbidities when patients may not be seeking care outside the dermatology practice.”
—John S. Barbieri, MD, MBA
Dermatologists should address important comorbidities when patients may not be seeking care outside the dermatology practice, Dr. Barbieri said.
“From an ethical standpoint … we want to make sure that we are doing the best for our patients. And that may involve expanding some of the scope of practice that we as dermatologists do when it comes to managing these conditions,” he said.
First, dermatologists need to be aware that inflammatory skin diseases and many of the skin conditions that dermatologists manage can have associated comorbidities, such as increased risk for cardiovascular disease and impact on patients’ mental health. The next step is for dermatologists to screen for some of these conditions or to have a plan for patients to see primary-care or other providers.
Dermatologists can use simple patient-reported outcome measures, such as the Patient Health Questionnaire-2 (PHQ-2) or the Patient-Reported Outcomes Measurement Information System (PROMIS) depression measure, both of which have been used successfully in routine dermatology clinical practice, according to Dr. Barbieri. And dermatologists suggesting that patients go to a primary-care doctor or another clinician should help pave the way for those visits, including making referrals and helping to eliminate barriers to care, he said.
“Dermatologists should consider offering services in the office that are simple and require little infrastructure, like vaccinations,” he said.
Offering flu and other recommended vaccines in the dermatology practice makes sense when one considers that many of the medications that dermatologists prescribe to treat inflammatory skin diseases may suppress the immune system and put patients at increased risk for infection.
“Certainly, I don’t think it would make sense for dermatologists to do things they don’t know how to do or don’t feel comfortable doing. We want to make sure that in those scenarios we refer patients to other clinicians who can help…. We want to make sure that we’re building collaborative health care networks with groups of clinicians who can work together to manage the spectrum of impact from skin diseases,” he said.
DISCLOSURES
Dr. Barbieri reports no relevant financial interests.
REFERENCES
1. Barbieri JS, Mostaghimi A, Noe MH, et al. Use of primary care services among patients with chronic skin disease seen by dermatologists. 2021; JAAD International. 2:31-36. https://doi.org/10.1016/j. jdin.2020.10.010
2. Alexander GC, Tajanlangit M, Heyward J, et al. Use and content of primary care office-based vs telemedicine care visits during the COVID-19 pandemic in the US. JAMA Netw Open. 2020;Oct 1;3(10):e2021476. doi: 10.1001/jamanetworkopen.2020.21476.
