Implementation and evaluation of a store-and-forward teledermatology workflow in a United States safety-net hospital urgent care emergency center: A retrospective cohort study.

Background: Teledermatology (TD) is an important method for increasing access to care in outpatient settings. However, less is known regarding its use in emergency/urgent care centers. Objective: To evaluate the effect of TD on urgent care emergency center (UCEC) dwell time and postencounter utilization. Study type and methods: This retrospective cohort study evaluated patients in a safety-net hospital (Parkland Health, Dallas, Texas, USA) UCEC, who (1) received a TD consult in 2018, (2) were referred to dermatology clinic in 2017, or (3) were referred to dermatology clinic in 2018 without a TD consult. Results: We evaluated 2024 patients from 2017 to 2018. Of the 973 referred to dermatology clinic in 2018, 332 (34%) received TD consultations. Mean dwell time for patients receiving TD was longer versus the 2017 cohort (303 vs 204 minutes, respectively). Patients receiving TD consultation with inflammatory skin conditions had lower odds of dermatology clinic visits compared with those that did not (odds ratio, 0.5; 95% CI, 0.3-0.8). Teledermatology was not associated with differences in repeat UCEC utilization. Limitations: Single institution study and inability to account for differences in patient complexity. Conclusion: TD increases dwell time in a safety-net hospital's UCEC but can reduce dermatology clinic utilization for patients with inflammatory skin conditions.

Needs and Attitudes Related to the Adoption of Evidence-Based Practices Among Latinx Mental Health Professionals.

Empirically supported interventions are warranted to achieve desired clinical outcomes and improve service delivery. Thus, efforts to identify, adopt, and implement Evidence-Based Practices (EBPs) are underway across various Latinx communities, including Puerto Ricans, where there is a growing recognition and prevalence of mental health and substance use disorders. This study investigated the needs and attitudes toward EBPs among an interdisciplinary sample of mental health professionals in Puerto Rico. An anonymous survey was distributed to social workers, psychologists, and professional counselors (N = 237). Using structural equation modeling, four dimensions of attitudes towards EBPs (openness, divergence, appeal, and requirement) were regressed on various individual and organizational factors. Some socio-demographic characteristics, educational opportunities, and organizational factors significantly contributed to specific attitudes related to the adoption of EBPs. Female participants and those working in rural settings scored higher in the openness to innovation dimension. Greater organizational support and graduating from a private institution were associated with more divergence from research, while married individuals and those trained on EBPs scored lower on this dimension. The lack of exposure to EBPs in college and younger age predicted greater interest in the appeal of adopting an EBP intervention (i.e., would adopt an EBP if it made sense). No differences in attitudes toward EBPs were found by professional discipline or work setting (i.e., clinical, community, and schools). Recommendations to increase openness and interest in the appeal of EBPs among Spanish-speaking professional communities in Latin America are highlighted.

Margin Size for Unique Skin Tumors Treated With Mohs Micrographic Surgery: A Survey of Practice Patterns.

Mohs micrographic surgery (MMS) has shown lower recurrence rates for unique skin tumors compared with wide local excision, but there is a lack of standardization on margin size. We aimed to assess MMS practice patterns of margin sizes for unique skin tumors. A survey was distributed to members of the American College of Mohs Surgery (ACMS). Demographic information on participants was collected in addition to initial/subsequent MMS margin size for unique skin tumors, including dermatofibrosarcoma protuberans (DFSP), atypical fibroxanthoma (AFX), melanoma, sebaceous carcinoma, microcystic adnexal carcinoma (MAC), poorly differentiated squamous cell carcinoma (SCC), and Merkel cell carcinoma. Eighty-seven respondents completed the survey (response rate <10%). Given that no guidelines exist on MMS margins for less commonly treated skin tumors, this study helps give Mohs surgeons perspective on current practice patterns for margin sizes. Mohs surgeons are more likely to take larger initial margins for these common skin tumors compared with BCCs or SCCs.

Racial and Ethnic Disparities in Survival Among Patients With Hepatocellular Carcinoma in the United States: A Systematic Review and Meta-Analysis.

BACKGROUND AND AIMS: Hepatocellular carcinoma (HCC) is the fastest rising cause of cancer-related death in the United States; however, HCC incidence and mortality are not equally distributed among racial and ethnic groups. Our aim was to characterize the direction and magnitude of racial and ethnic disparities in overall survival and early tumor detection among patients with HCC. METHODS: We searched MEDLINE, EMBASE and Cochrane databases from inception through August 2020 for studies reporting HCC outcomes (early stage presentation and overall survival) by race and ethnicity. We calculated pooled hazard ratios (HRs) and odds ratios (ORs) for each racial and ethnic group (White, Black, Hispanic, Asian) using the DerSimonian and Laird method for a random-effects model. RESULTS: We identified 35 articles comprising 563,097 patients (53.0% White, 17.3% Black, 18.4% Hispanic, 5.0% Asian). Compared with White patients, Black patients had worse survival (pooled HR 1.08; 95% CI, 1.05 - 1.12), whereas Hispanic (pooled HR 0.92; 95% CI, 0.87 - 0.97) and Asian (pooled HR 0.81; 95% CI, 0.73 - 0.88) patients had better survival. Among articles reporting tumor stage (n = 20), Black patients had lower odds of early stage HCC compared with White patients (OR, 0.66; 95% CI, 0.54 - 0.78). Conversely, there was no difference in odds of early HCC detection for Asian (OR, 1.01; 95% CI, 0.97 - 1.05) or Hispanic patients (OR, 0.87; 95% CI, 0.74 - 1.01) compared with White patients. The most common limitation of studies was risk of residual confounding from socioeconomic status and liver dysfunction. CONCLUSIONS: There are significant racial and ethnic disparities in HCC prognosis in the United States, with Black patients having worse overall survival and Hispanic and Asian patients having better overall survival compared with White patients. Interventions are needed to reduce disparities in early HCC detection to improve HCC prognosis.

Evaluation of a Case Series of Patients With Generalized Pustular Psoriasis in the United States.

IMPORTANCE: Generalized pustular psoriasis (GPP) is a chronic, orphan disease with limited epidemiological data. OBJECTIVE: To describe the clinical characteristics, treatments, longitudinal disease course, and disease-specific health care utilization among patients with GPP across the United States. DESIGN, SETTING, AND PARTICIPANTS: A retrospective longitudinal case series involving 95 adults who met the European Rare and Severe Psoriasis Expert Network consensus definition for GPP and were treated at 20 US academic dermatology practices between January 1, 2007, and December 31, 2018. MAIN OUTCOMES AND MEASURES: The primary outcome is to describe the patient characteristics, associated medical comorbidities, treatment patterns complications, and GPP-specific health care utilization. RESULTS: Sixty-seven of 95 patients (70.5%) were women (mean age, 50.3 years [SD, 16.1 years]). In the initial encounter, 35 patients (36.8%) were hospitalized and 64 (67.4%) were treated with systemic therapies. In total, more than 20 different systemic therapies were tried. During the follow-up period, 19 patients (35.8%) reported hospitalizations at a median rate of 0.5 hospitalizations per year (IQR, 0.4-1.6). Women had a decreased risk of an emergency department or hospital encounter (odds ratio, 0.19; 95% CI, 0.04-0.83). CONCLUSIONS AND RELEVANCE: Generalized pustular psoriasis is a rare, chronic disease without standard treatment and is associated with continued health care utilization over time.

Evaluation of a Case Series of Patients With Palmoplantar Pustulosis in the United States.

IMPORTANCE: Palmoplantar pustulosis (PPP) is a is a chronic, orphan disease with limited epidemiological data. OBJECTIVE: To describe the clinical characteristics, treatments, longitudinal disease course, and health care utilization in adults with PPP across the US. DESIGN, SETTING, AND PARTICIPANTS: This retrospective, longitudinal case series from 20 academic dermatology practices in the US included a consecutive sample of 197 adults who met the European Rare and Severe Psoriasis Expert Network consensus definition for PPP between January 1, 2007, and December 31, 2018. Data analysis was performed June 2020 to December 2020. MAIN OUTCOMES AND MEASURES: The primary outcome was to describe the patient characteristics, associated medical comorbidities, treatment patterns, complications, and PPP-specific health care utilization. RESULTS: Of 197 patients, 145 (73.6%) were female, and the mean (SD) age at presentation was 53.0 (12.6) years, with a mean (SD) follow-up time of 22.1 (28.0) months. On initial presentation, 95 (48.2%) patients reported skin pain, and 39 (19.8%) reported difficulty using hands and/or feet. Seventy patients (35.5%) were treated with systemic treatments, and use of more than 20 different systemic therapies was reported. In patients with at least 6 months of follow-up (n = 128), a median (IQR) of 3.7 (4-10) dermatology visits per year were reported; 24 (18.8%) patients had 5 or more visits during the study period. CONCLUSIONS AND RELEVANCE: In this case series, PPP was associated with persistent symptoms, continued health care utilization, and a lack of consensus regarding effective treatments, emphasizing the unmet medical need in this population. Additional research is necessary to understand treatment response in these patients.

The effect of antibiotic prophylaxis on infection rates in mohs micrographic surgery: a single-institution retrospective study.

As data and recommendations regarding antibiotic prophylaxis in dermatologic surgery vary, we tried to describe the effect of antibiotic prophylaxis (AP) in Mohs micrographic surgery (MMS) on infective endocarditis, prosthetic joint infection, and surgical site infection using a single-institution retrospective cohort study of antibiotic use (pre-/intra-operative, post-operative or none) among 2,364 patient encouters treated with MMS. Bivariate logistic regression was evaluated for associations between patient and operative characteristics, antibiotic use, and infectious complications. 85.8% of patients received no AP, 10.0% received post-operative AP, and 4.1% received pre-/intra-operative AP. The overall surgical site infection (SSI) rate was 1.3%. SSI did not differ between patients who received pre-/intra-operative prophylaxis, post-operative prophylaxis or no antibiotics. One patient receiving pre-/intra-operative prophylaxis developed SSI. Repairs involving porcine xenografts and interpolation/pedicle flaps were associated with increased SSI. In addition, there were no patients who post-operatively experienced an infected joint or infective endocarditis. Limitations include selection bias, use of observational retrospective data, low infection rates, single institution analysis, and possible omission of explanatory variables or confounders. There was no difference in rates of SSI when comparing MMS patients who received pre-/intra-operative, post-operative or no AP. There were no cases of infective endocarditis or infected prosthetic joint.

Healthcare Utilization Patterns Among Children With a History of Child Protective Services Investigations.

PURPOSE: Examine whether children with a prior child protective services (CPS) investigation had different healthcare utilization compared to children without a history of CPS investigations. METHODS: The Children's Health Assessment and Planning Survey assessed 6,492 primary caregivers of children ages 0-17 years residing in North Texas in 2015. Caregivers reported prior CPS investigations and child healthcare utilization (emergency department [ED] use, unmet medication needs, and unmet medical care needs). PRINCIPLE FINDINGS: A total of 408 (5%) caregivers reported their child had a CPS investigation. Children with CPS investigations had greater odds of visiting the ED (OR = 1.9; 95% CI: 1.4, 2.5) and not receiving necessary medical care (OR = 1.9; 95% CI: 1.4, 2.8) compared to children without a CPS investigation. CONCLUSIONS: Prior CPS investigation was associated with disparities in receipt of necessary medical care and ED utilization for children.

The impact of intimate partner violence on breast and cervical cancer survivors in an integrated, safety-net setting.

PURPOSE: Characterize prevalence of intimate partner violence (IPV) among breast and cervical survivors receiving care in an urban safety-net healthcare system; Examine the relationship between IPV and clinical characteristics, receipt of cancer treatment, and guideline-recommended survivorship care. METHODS: From 2010 to 2017, breast and cervical cancer survivors were identified and recruited from a large, integrated, safety-net hospital system. Electronic health records (EHR; to measure survivorship care), cancer registry (to measure clinical characteristics), and patient telephone surveys (to measure IPV) were triangulated among 312 survivors. Bivariate and multivariable models assessed the relationship between victimization and clinical characteristics, cancer treatment, and guideline-recommended survivorship care. RESULTS: Among the 312 participants, 54% identified as IPV+. Among breast cancer, IPV+ cancer participants were twice more likely to develop estrogen receptor negative ER- and/or progesterone receptor negative PR- tumor receptors compared with IPV- cancer participants (AOR = 2.31; 95% CI, 1.20, 4.44). IPV+ breast cancer participants were less likely to have surgery and less likely to have hormone therapy as a first course of treatment compared with IPV- participants. There was no relationship between IPV and adherence to guideline-recommended cancer survivorship care. CONCLUSIONS: This study expands our current knowledge on how victimization, and specifically IPV, impact health among specialty care. Future research should determine the feasibility of implementing Trauma-Informed Care in oncology practices to better optimize care. IMPLICATIONS FOR CANCER SURVIVORS: At integrated hospital systems, IPV+ cancer participants should utilize social workers, within their oncology clinics, to connect to victim services.