Modeling the Effect of Shared Care to Optimize Acne Referrals From Primary Care Clinicians to Dermatologists

Abstract

IMPORTANCE Access to dermatologists remains a nationwide challenge. Optimizing referrals to a dermatologist may reduce patient wait times.OBJECTIVE To model the effect of algorithm-based acne treatment by primary care clinicians on referral patterns and costs. DESIGN, SETTING, AND PARTICIPANTS Overall, 253 referrals from primary care clinicians to dermatologists for acne from January 2014 through March 2015 were reviewed at Brigham and Women's Hospital. No-show rate, diagnostic concordance between primary care clinicians and dermatologists, treatment at the time of referral, and treatment by a dermatologist were ascertained, and we modeled 2 treatment algorithms-initiation of topical treatments by primary care clinicians (algorithm A) and initiation of topical treatments and oral antibiotics by primary care clinicians (algorithm B)-to identify the most effective referral patterns and costs. MAIN OUTCOMES AND MEASURESThe primary outcome was the elimination of unnecessary appointments with a dermatologist. Secondary outcomes included reduction in delay to treatment, health care cost savings, and decrease in no-show rate.RESULTS Overall, 150 of 253 referred patients were seen and treated by a dermatologist; 127 patients (50.2%) were not on prescription acne treatment at the time of dermatology referral. Model A reduced initial referrals in 72 of 150 cases (48.0%), eliminated referrals in 60 of 150 cases (40%), and reduced average delay-to-treatment by 28.6 days. This resulted in cost savings of $20.28 per patient, reduction of wait time by 5 days per patient, and decreased the no-show rate by 13%. Model B reduced initial referrals in 130 of 150 cases (86.7%), eliminated referrals in 108 of 150 cases (72%), and reduced average delay-to-treatment by 27.9 days. This resulted in cost savings of $35.68 per patient, shortened wait-time by 9 days per patient, and decreased the no-show rate by 24%. CONCLUSIONS AND RELEVANCEAlgorithm-based treatment of acne by primary care clinicians may eliminate unnecessary appointments, reduce wait time for treatment, lower costs, and reduce patient no-shows.

Evaluation of Point-of-Care Decision Support for Adult Acne Treatment by Primary Care Clinicians

“…Despite these challenges, these findings support and expand on existing data regarding the role of primary care clinicians in shared care for evaluation and treatment of acne. 6,7 Importantly, we demonstrated the decision support notification to correlate with the selection of guideline-based acne treatments by referring clinicians, which were not significantly different from treatments by dermatologists (Table 3). Although 4 (7.8%) patients treated by referring clinicians received subsequent referral to a dermatologist, most of these patients were prescribed acne medications on a trial basis for fewer than 2 weeks prior to dermatology assessment.…”

“…Of the 5 patients with appointments who were not seen at the time of analysis, 2 were later evaluated by a dermatologist and prescribed an oral acne treatment (doxycycline and spironolactone); the remaining 3 patients were lost to follow-up, further underscoring the potential consequences associated with immediate referral to a dermatologist for acne. 7 Although this point-of-care notification reduced rates of immediate referral to a dermatologist and improved the likelihood of treatment initiation, a comprehensive approach embedded into the training and practice of primary care clinicians may be needed to improve the efficacy of this intervention. For instance, educational initiatives for primary care clinicians to highlight the opportunities and challenges associated with shared care for relevant disease models (eg, acne) may partially overcome the cognitive overload and alert desensitization associated with electronic health record systems, while priming physicians to be more receptive to best practice notifications.…”

“…5,6 Although referrals to dermatologists for acne are not discouraged, there are consequences of immediate referral by primary care clinicians who do not provide treatment, including delayed treatment and loss to follow-up. 7 Previous studies have demonstrated the potential of education and treatment algorithms to reduce unnecessary referrals to specialty care in nondermatological disease areas. [8][9][10][11][12] Importantly, these studies support the use of real-time decision-support tools to modify physician behavior and reduce unnecessary referrals, specifically for patients with pediatric scoliosis or constipation being referred to specialists by primary care clinicians.…”

Differences in acne therapy prescribing patterns between dermatologists and pediatricians: A population‐based study

“…Specifically, primary care physicians could follow an established evidence-based algorithm that may lead to successful treatment of acne and decrease referrals to dermatologists. 15 EMRembedded guidelines may also be helpful interventions. For example, an EMR ordering tool that provides customized care plans for patients based on acne severity may increase care consistent with national guidelines.…”

Reply to: “Is treatment of acne as simple as encouraging primary care physicians to prescribe more retinoids?”

“…Learning to prescribe a minimally irritating, low-dose topical retinoid routinely for patients with acne would be a safe and effective place to start. 4 The Food and Drug Administration recently approved topical adapalene 0.1% gel for over-thecounter use, and patients will be able to try topical retinoid treatment for acne before seeing any physician. As over-the-counter adapalene use grows in popularity, primary care physicians may have more patient encounters for retinoid side effects and medication counseling, leading to an increased understanding of, and comfort level with, topical retinoids.…”