This month's news from across the specialty

March 1, 2021

In this monthly column, members of the DermWorld Editorial Advisory Workgroup identify exciting news from across the specialty.  

The American Journal of Public Health published a series of analyses on wasteful spending in United States health care (2020:110(12);1731-57). A synthesis of available literature led to six categories of wasteful spending: clinical inefficiencies, missed prevention opportunities, overuse, administrative waste, excessive prices, and fraud and abuse. Decreasing spending in any of these categories could help the private sector by increasing wages, reducing unemployment, and enhancing international competitiveness. It could also help federal and state governments invest in social and environmental initiatives. The series points out that decreasing prices is much less likely to lead to political resistance than volume reductions and can have a major impact. According to the authors, just reducing “excessive health care prices” could fund “universal childcare ($42 billion), paid family leave ($28 billion), and double the budget of the Supplemental Nutrition Assistance Program ($68 billion).” We should expect to see continually increasing pressure for price transparency, competition, and government interventions all with the goal of reducing prices for medical services.

Clinical information is often conveyed to the dermatopathologist in the form of a differential diagnosis on the pathology requisition form. In a retrospective study, the authors reviewed 348 cases of biopsied inflammatory skin disease and measured the correlation between the clinical differential diagnosis on the pathology requisition and the final diagnosis (Am J Dermatopathol. 2014; 36(4): 298-302). The final diagnosis was obtained from progress notes after biopsy and reflected the compilation of all clinical, laboratory, and patient follow-up data. Clinical diagnoses that matched final diagnoses were considered true positives, and those that did not match final diagnoses were false positives. Skin biopsies were submitted on 3,785 patients during the one-year study period. Of these, 391 were for inflammatory skin diseases. Cases with only general terms, such as “rash,” on the requisition forms were excluded (four cases). Cases in which there was no final diagnosis in the hospital information system were excluded (19 cases). Cases in which no definite diagnosis was reached (four cases), those lost to follow-up (10 cases), and those submitted by non-dermatologists (six cases) were also excluded.

The median number of clinical diagnoses on the pathology form per patient was three (range: 1-6). The entry of “other” did not count as a diagnosis. Only one case listed six diagnoses. Approximately 78% of cases included the correct final diagnosis among the listed diagnoses on the pathology requisition form. The first-listed clinical diagnosis was correct in 55% of cases, whereas subsequent diagnoses in the clinical differential were much less likely. Diagnoses in the 2nd through 4th positions were rarely correct (2%-12%). None of the 5th and 6th diagnoses were correct. This confirms that dermatologists tend to list diagnoses in order of likelihood. The number of clinical diagnoses on pathology requisition forms did not correlate with diagnostic accuracy, indicating that a long differential diagnosis may represent clinical uncertainty. Of the differential diagnoses that had the correct diagnosis, 71% of these correct diagnoses were listed in the 1st position on the differential. This indicates that the initial clinical diagnosis had the highest positive predictive value. Adding numerous other possible diagnoses did not improve diagnostic accuracy. In sum, the likelihood of the final diagnosis being in the clinical differential diagnosis was not affected by the number of diagnoses on the requisition form. That is, listing more diagnoses was not associated with higher diagnostic accuracy. (Acknowledgment to Kiran Motaparthi, MD, for bringing this article to my attention.)

One of the greatest moments in science occurred in December 2020, as we faced the grim reality that COVID-19 was only worsening. Pfizer-BioNTech and Moderna have become household names, with both of their COVID-19 vaccines receiving the Emergency Use Authorization from the FDA for the prevention of COVID-19. Since the first study detailing the successful injection of mRNA into mice with subsequent protein production in 1990, advances in this technology have given us a chance to end this pandemic, given how rapidly the vaccines can be developed and manufactured. To share details from the BNT162b2 mRNA vaccine study, funded by BioNTech and Pfizer, this was a trial with 152 sites worldwide where subjects 16 years of age or older received two doses, 21 days apart, of either placebo or the vaccine candidate. Exclusion criteria included a medical history of COVID-19 or immunosuppressed status. Overall, 21,720 received the vaccine candidate, and 21,728 received placebo. 21% of subjects had at least one coexisting condition (N Engl J Med. 2020;383(27):2603-15). Headline news: The vaccine was 95% effective in preventing COVID-19, regardless of coexisting conditions or other demographic factors measured. Mild-to-moderate pain at the injection site was the most common side effect in about 75% of participants. Systemic side effects did occur and were notable for fatigue, headache, chills, fever, muscle pain, and joint pain. These systemic side effects were thankfully rare, though severe fatigue was seen in about 4% of vaccine recipients. Even after the first dose, vaccine efficacy was calculated to be 52% — there is some early protection, albeit imperfect. This story will continue.

With the ongoing pandemic and the recent surges in COVID cases, our typical or initial usage of telemedicine is soaring to new heights. Patient concerns regarding the safety of coming to offices has changed some of their behaviors and kept them at home. This combined with deployments of support staff in academic centers keeps telemedicine at the top of hot topic lists in dermatology. Some studies have shown that teledermatology pre-COVID had good concordance when compared to in-person visits. Those authors argued that teledermatology was cost effective, increased utilization of dermatology, and allowed better triaging of patients with reduced wait times and improved care (J Am Acad Dermatol. 2020; 83:797-802). Studies done through the COVID period have questioned those findings. A recent research letter in the JAAD found that number of inpatient consults was down during COVID and that of those inpatient consults, who were later seen in person, there was a change of diagnosis in half of the cases (2021; 84: 156-8). Additionally, incidental skin cancers were found when in-person visits were conducted, enhancing the quality of care given to the patient. The authors further report that virtual consultations resulted in “significantly reduced diagnostic certainty.” Only 60% of the virtual consults had a definitive diagnosis compared to 90% when in-person consults were done. The differences in prior studies, and this recent study, highlight the practice gaps and learning curve many of us still have when it comes to teledermatology in the inpatient setting.

Another research letter in JAAD this month, reported that although teledermatology was used to help reduce COVID exposures, differences abound between patient and physician perspectives on the success of teledermatology (2021; 84: 158-61). Patients were very pleased with the time savings and valued the convenience of teledermatology more so than providers. Patients were much more content with the quality of care than their providers. The patients were also more accepting of the video and picture quality than their providers. Teledermatology will undoubtedly continue to be debated and refined as we all have different experiences, comfort levels, and expectations of quality care, quality images, and what diseases can be managed in this platform. When the acute crisis of COVID is finally behind us, this experience will have left us with a new appreciation of teledermatology and hopefully a system that will be refined and utilized to optimize quality patient care and access for patients and providers in the inpatient and outpatient setting.

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