Inpatient consultative dermatology: Where are we now?
Acta Eruditorum
Dr. Schwarzenberger is the former physician editor of DermWorld. She interviews the author of a recent study each month.
By Kathryn Schwarzenberger, MD, May 1, 2019
In this month’s Acta Eruditorum column, Physician Editor Kathryn Schwarzenberger, MD, talks with Lauren Madigan, MD, and Lindy Fox, MD, about their recent JAAD article, “Inpatient consultative dermatology: Where are we now? Assessing the value and evolution of this sub-specialty over the past decade.”
Dr. Schwarzenberger: Thank you for your informative article about the status of inpatient dermatology consultation and for the excellent work all of you are doing. Some of us are old enough to remember inpatient dermatology units. What happened to them, anyway? For those who may not be familiar with the concept, can you explain what a dermatology hospitalist is and what he or she does?
Drs. Madigan and Fox: As you mentioned, inpatient dermatology units were not uncommon prior to 1985 and are now exceedingly rare. While the reasons behind this change are multifactorial, one of the most significant contributors was the adoption of the diagnosis-related group (DRG) system in 1983. This drastically changed health care financing and metrics for hospitalization — including end points. Time constraints, structured outpatient practices, and often cumbersome inpatient electronic medical records also made it increasingly challenging for outpatient clinicians to care for these complex patients. A “dermatology hospitalist” is a committed individual, or group, that addresses this need at an institution. They are providers uniquely adept at delivering high-level care to hospitalized patients through their expertise in the acute management of severe skin disease, increasingly varied therapeutics, and comorbid disorders. They are dedicated to bettering care for this subgroup of patients and promoting education within the larger health care system. Many are also involved in research to improve how care is delivered to this subset of patients.
Dr. Schwarzenberger: How big is the burden of skin disease in the inpatient setting and what conditions would you say you most frequently see? Is there any disease or group of diseases you feel we can particularly impact?
Drs. Madigan and Fox: While there is certainly a need for dedicated providers to manage dermatology patients requiring escalation of care, a greater number of consults come from the general medical population. In a recent publication, it was estimated that one in eight hospitalized adults are diagnosed with skin disease, either as a primary or secondary disorder (J Am Acad Dermatol. 2019;80(2):425-432). Data like this highlight the high burden of cutaneous disease among inpatients, a need which was previously underrecognized. Taken in aggregate, the most common final diagnoses rendered by dermatology hospitalists fall within five general categories: Drug eruptions, cutaneous infections, chronic dermatoses (including psoriasis and eczema), contact dermatitis, and vascular disorders.
Dermatology consultation has a dramatic impact on patient care — as demonstrated by the fact that treatment is changed in 58-82% of consults. This impact is even greater for complex cutaneous conditions where expertise in management is essential. This is not to say, however, that more common conditions cannot benefit from early evaluation. Investigations surrounding cellulitis misdiagnosis and management have estimated that dermatology consultation could prevent hundreds of millions in avoidable health care spending annually.
Dr. Schwarzenberger: How does your involvement impact the care of these inpatients with dermatologic disorders?
Drs. Madigan and Fox: The importance of expertise cannot be understated. The most common reason for consultation is often ill-defined (“skin lesions,” “rash,” “unknown”). Thus, dermatology consultants not only impact management but are also necessary to help formulate an appropriate morphology-based differential diagnosis. As noted, the rate of concordance between primary teams and dermatology consultants is very low, resulting in a significant opportunity for treatment change. Studies have also demonstrated reductions in adjusted length of stay and readmission rates for patients with inflammatory skin disease who were seen by dermatologists during their hospitalization. Finally, data now exist supporting a significant financial cost to patients, payers, and the larger health care system when dermatology evaluation is lacking.
Dr. Schwarzenberger: If a dermatologist doesn’t provide this care, who does?
Drs. Madigan and Fox: When dermatology consultants are not available, the responsibility of care falls to the primary admitting service (i.e., internal medicine, surgery, oncology, etc.). While these providers aim to provide high-level care, general medical training in the recognition and management of uncommon and severe skin disorders is deficient. As a result, there is concern that a lack of dermatologists might lead to the inappropriate management of patients with cutaneous disease.
Dr. Schwarzenberger: If you had a crystal ball, what would you envision for the future of inpatient dermatology?
Drs. Madigan and Fox: The field of inpatient dermatology is still in its infancy. As mentioned above, we are gathering manpower, and data now demonstrate the value of inpatient dermatology to the care of hospitalized patients with skin disease. However, most established inpatient dermatologists are in academic centers. Ideally, the future would include active inpatient dermatology expertise being delivered as routine in community hospitals and areas that have traditionally had much less access to inpatient dermatologic care. Data would continue to emerge regarding the value added of having inpatient dermatologists. Evidence-based guidelines to evaluate and treat the rare, but severe, diseases we see would be developed. We would also continue to develop post-graduate training programs for those interested in pursuing a career in inpatient dermatology. We still have a lot of work to do and can’t wait to see where it all goes.
Lauren Madigan, MD, is an assistant professor of dermatology at the University of Utah. Lindy Fox, MD, is professor of clinical dermatology, director of the Hospital Consultation Service, and director of the Complex Medical Dermatology Fellowship in the Department of Dermatology at the University of California, San Francisco. Their article appeared in JAAD. https://doi.org/10.1016/j.jaad.2019.01.031.
