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Biomedical subjects

A B Fleischer

Publications and source records attributed to A B Fleischer.

At least 37 records · Page 2Linked to original sources
PubMed2001

Demographics of aging and skin disease.

What are the dermatologic needs of aging and skin disease in the elderly in the new millennium? This question may be impossible to answer, but predictions may be derived from current sources of data. Data from the US Census Bureau and the National Ambulatory Medical Care Survey are used to characterize current use of dermatologic care in the aging population of the United States and to estimate possible future trends in dermatologic care as the elderly population continues to grow. Dermatologic accompaniments of aging are briefly reviewed, as are issues in health care financing.

Aged↗
PubMed2001

Cost of nonmelanoma skin cancer treatment in the United States.

BACKGROUND: Despite being the most prevalent form of cancer, the economic impact of nonmelanoma skin cancer (NMSC) in the United States has not been assessed. OBJECTIVE: To determine the overall cost and to estimate the cost per episode of NMSC care in the United States in physicians' offices, outpatient surgery centers, and inpatient settings. METHODS: Data from the Medicare Current Beneficiary Study 1992-1995 were analyzed to obtain the total cost of NMSC and the cost in different settings. To normalize these data on a per episode basis, the cost in each setting was divided by the number of procedures performed in each setting obtained from the National Hospital Discharge Survey (NHDS, 1992-1997), the National Survey of Ambulatory Surgery (NSAS, 1994-1996), and the National Ambulatory Medical Care Survey (NAMCS, 1995). RESULTS: The total cost of NMSC care in the United States in the Medicare population is $426 million/year. Physician office-based procedures for NMSC accounted for the greatest percentage of money spent to treat NMSC and the greatest percentage of procedures. The average cost per episode of NMSC when performed in a physician's office setting was found to be $492. The cost per episode of care in inpatient and outpatient settings were $5537 and $1043, respectively. CONCLUSION: Compared to other cancers, the relative magnitude of NMSC treatment costs is currently small because NMSC is managed efficiently and effectively, primarily in office-based settings. Legislative or regulatory measures that discourage office treatment of NMSC will lead to increased cost.

Ambulatory Surgical Procedures↗
PubMed2001

Tacrolimus ointment for the treatment of atopic dermatitis in adult patients: part II, safety.

In two randomized, double-blind, multicenter studies, a total of 631 adult patients with moderate to severe atopic dermatitis applied tacrolimus ointment (0.03% or 0.1%) or vehicle twice daily for up to 12 weeks. The mean percent body surface area (%BSA) affected at baseline was 45%, and 56% of patients had severe atopic dermatitis. As previously reported, these studies showed that tacrolimus ointment was superior to vehicle for all efficacy parameters measured. This report focuses on the safety of tacrolimus ointment in these studies. The most common adverse events were the sensation of skin burning, pruritus, flu-like symptoms, skin erythema, and headache. Skin burning and pruritus were more common among patients with severe or extensive disease; these events were usually brief and were resolved during the first few days of treatment. Common adverse events with a significantly higher incidence in one or both of the tacrolimus ointment groups than in the vehicle group included skin burning, flu-like symptoms, and headache. More patients in the vehicle group discontinued the study because of an adverse event than in either of the tacrolimus ointment groups. There were no notable or consistent changes in any laboratory variables. Tacrolimus was not detected in 80% of blood samples collected. Measurable concentrations of tacrolimus were transitory and were not associated with adverse events. Tacrolimus ointment is a safe therapy for the treatment of adult patients with atopic dermatitis on the face, neck, or other body regions.

Adolescent↗
PubMed2001

The specialty of the treating physician affects the likelihood of tumor-free resection margins for basal cell carcinoma: results from a multi-institutional retrospective study.

BACKGROUND: Basal cell carcinoma (BCC) is the most common cutaneous malignancy. Surgical experience and physician specialty may affect the outcome quality of surgical excision of BCC. METHODS: We performed a multicenter retrospective study of BCC excisions submitted to the respective Departments of Pathology at 4 major university medical centers. Our outcome measure was presence of histologic evidence of tumor present in surgical margins of excision specimens (incomplete excision). Clinician experience was defined as the number of excisions that a clinician performed during the study interval. The analytic sample pool included 1459 tumors that met all inclusion and exclusion criteria. Analyses included univariate and multivariate techniques involving the entire sample and separate subsample analyses that excluded 2 outlying dermatologists. RESULTS: Tumor was present at the surgical margins in 243 (16.6%) of 1459 specimens. A patient's sex, age, and tumor size were not significantly related to the presence of tumor in the surgical margin. Physician experience did not demonstrate a significant difference either in the entire sample (P <.09) or in the subsample analysis (P >.30). Tumors of the head and neck were more likely to be incompletely excised than truncal tumors in all the analyses (P <.03). Compared with dermatologists, otolaryngologists (P <.02) and plastic surgeons (P <.008) were more likely to incompletely excise tumors; however, subsample analysis for plastic surgeons found only a trend toward significance (P <.10). Dermatologists and general surgeons did not differ in the likelihood of performing an incomplete excision (P >.4). CONCLUSION: The physician specialty may affect the quality of care in the surgical management of BCC.

Aged↗
PubMed2001

Patients seen in a dermatology clinic have unmet preventive health care needs.

Dermatologists provide special expertise in the care of patients with skin disease, whereas primary care providers have special expertise in preventive care. Patients bypassing their primary care provider to use dermatologists directly may miss an opportunity for identification of preventive health needs. We conducted a pilot study to determine whether patients seeing a dermatologist have unmet general preventive health care needs. A 1-page assessment was developed in accordance with the US Preventive Services Task Force guidelines and was distributed to a convenience sample of 161 patients in a dermatology clinic. Unmet needs were identified in the areas of screening tests, counseling, immunizations, vitamins, and replacement hormones. Of subjects aged 25 to 64 years, 94% without a primary care provider had unmet needs compared with 28% of subjects with a primary care provider. We found that patients seeing a dermatologist often had unmet preventive health needs. Dermatologists and primary care providers must work together to provide optimal skin care and preventive health care needs for the patient.

Adolescent↗
PubMed2001

Implications of a utility model for ultraviolet exposure behavior.

Over the past several decades, the incidence of skin cancer has reached epidemic proportions. Despite numerous efforts to increase public awareness of the risks associated with solar radiation, people continue to sunbathe, use indoor tanning facilities, avoid photoprotective clothing, and fail to use sunscreen. We propose using an economic model, the utility model, to better understand how to reduce tanning behaviors. This model has been widely applied in financial decision-making as well as in analysis of risk-taking behaviors such as smoking. The model takes into account both the current perceived benefits of tanning and the future long-term risks. People tend to discount the future; they tend to weigh current benefits more heavily than future risks. As predicted by the model, past prevention efforts that have focused on long-term benefits gained by sun-protective behavior have been largely ineffective. In the current social environment, we cannot expect tanning reduction measures based solely on health education to be very effective. Only by changing public perceptions of a tan will efforts to decrease ultraviolet exposure behavior likely be successful.

Decision Making↗
PubMed2001

Condylomata acuminata (genital warts): patient demographics and treating physicians.

BACKGROUND: Condylomata acuminata (genital warts), caused by the human papillomavirus, are common and sexually transmitted. However, the use of healthcare services for condylomata has never been characterized from a national probability sample study. GOAL: To understand better the demographics of patients seen by physicians for this disorder. STUDY DESIGN: Data from office visits for warts, both condylomata and noncondylomatous types, were obtained from the 1994 to 1998 National Ambulatory Medical Care Survey. RESULTS: The age distribution of those treated for condylomata peaked in 20- to 39-year-olds, with more than 70% of patients in this age category. A younger and wider age distribution was seen in patients with noncondylomatous warts. Women accounted for 67% of the population seen for condylomata, whereas a more equal number of women and men were seen for noncondylomatous warts. Per capita healthcare use for condylomata was equal between blacks and whites, and whites had almost five times more per capita healthcare use than blacks for noncondylomatous warts. Obstetrician/gynecologists were the most commonly consulted physicians for condylomata. Per capita condylomata visits per physician were highest for obstetrician/gynecologists, dermatologists, and urologists, and lower for all other physicians. CONCLUSIONS: The difference in age distribution between condylomata and noncondylomatous visits likely results from differing modes of transmission and age at first sexual contact. Females are more likely than males to use health care for condylomata, which may be attributable to increased prevalence, differences in treatment efficacy, differences in the gender frequency of genital health screenings, or psychosocial causes. Healthcare use for condylomata appears equal between blacks and whites. Patients with condylomata acuminata were most often seen by obstetrician/gynecologists, whereas patients with noncondylomatous warts most often consulted dermatologists. The fact that per capita condylomata visits per physician were highest for obstetrician/gynecologists, dermatologists, and urologists may imply that specialists in these fields have expertise in treating these patients.

Adolescent↗
PubMed2001

Physicians' and patients' perspectives on office-based dispensing: the central role of the physician-patient relationship.

OBJECTIVE: To describe physicians' and patients' reasons for participating in office-based sales of dermatologic products. DESIGN: Survey data on the attitudes, opinions, and beliefs of dermatologists and their patients were analyzed. SETTING: A market research study of office-based selling. PARTICIPANTS: Thirty dermatologists involved in direct selling from the office, 20 dermatologists not involved in direct selling, 22 patients who purchase products from their dermatologists' offices, and 25 office managers. MAIN OUTCOME MEASURE: The hypotheses of this study were formulated after the market research study had been done. The main outcome measure was the physicians' and patients' reported reasons for patients purchasing skin care products from dermatologists rather than from retail stores. RESULTS: "Trust" was the most frequent reason cited by physicians for patient purchases, while "physician knowledge" was the most frequent reason cited by the purchasing patients. The most common location to display the products was the waiting room (20 [67%] of the physicians). The most common types of products sold included glycolic acid products (15 [50%]), moisturizers (13 [43%]), sunscreens (12 [40%]), and alpha-hydroxy acid products other than glycolic acid (9 [30%]). CONCLUSION: The interaction between physicians who sell products in their offices and their patients is highlighted by 2 key elements of the physician-patient relationship: trust and physician knowledge.

Adult↗
PubMed2001

Are patients' chief complaints generally specific to one organ system?

BACKGROUND: The coordinator of care function is one of the most important roles played by primary care physicians. This role is essential for efficient delivery of healthcare to patients with unfocused medical problems. OBJECTIVES: To identify which chief complaints are unfocused and to determine how often visits to office-based physicians are for unfocused chief complaints. STUDY DESIGN: Retrospective review of National Ambulatory Medical Care Survey data. METHODS: We defined an unfocused chief complaint as one for which fewer than 95% of the office visits for the top 10 diagnoses associated with that chief complaint were related to a single organ system or specialty area. We analyzed data from the 1990-1994 National Ambulatory Medical Care Survey to determine the frequency of new patient visits to physicians for different chief complaints and to determine the frequency with which common chief complaints yield diagnoses in a single organ system. RESULTS: The 3 most common chief complaints in each of 12 symptom categories accounted for 80 million (32%) of the 250 million new patient office visits made during the survey period. Unfocused conditions accounted for 26% of visits for these chief complaints. The unfocused chief complaints included musculoskeletal conditions (back pain, knee pain, low back pain), mental/nervous system conditions (anxiety/nervousness, smoking problems, headaches, vertigo/dizziness), abnormal pulsations, swollen glands, and abdominal pain. CONCLUSIONS: Patients' chief complaints and the resulting diagnoses are often within the same organ system. We found that a coordinator of care role for primary care physicians is appropriate for common neurologic, rheumatologic, and general complaints. A coordinator of care is not needed for specific specialty areas, including ophthalmology, dermatology, obstetrics/gynecology, urology, and otolaryngology, because patients typically can accurately self-refer to these specialists. Our study did not address reasons to use primary care physicians as coordinators of care, such as preventive care, patient preference, or cost effectiveness of care.

Data Collection↗
PubMed2001

Women commonly seek care for rosacea: dermatologists frequently provide the care.

Rosacea is a common dermatosis affecting the central portion of the face. The purpose of this study is to describe the demographics of patients and the treatments prescribed. Data on rosacea visits from 1990 to 1997 were obtained from the National Ambulatory Medical Care Survey There were 1.1 million outpatient visits for rosacea annually in the United States. Most rosacea patients were Caucasian (96%). Most visits were by women (69%), and the mean age (SD) of patients was 50 +/- 17 years. Visits to dermatologists accounted for 78% of visits. Common comorbid diagnoses included actinic keratoses, acne and cysts, and seborrheic and contact dermatitis. Topical metronidazole was the most commonly prescribed treatment; tetracycline was the most commonly prescribed systemic therapy. Combination treatment with an oral and a topical agent was commonly used. Because rosacea appears most often in fair-skinned women, these patients may benefit from the textural features and safety profiles of certain topical metronidazole preparations newly available and from oral antibiotics (eg, tetracycline). People with rosacea should be aware of the experience that dermatologists have in treating this disorder.

Administration, Oral↗
PubMed2001

Scabies and lice: review of the clinical features and management principles.

Health care providers frequently encounter human infestations of scabies and lice. When a person is identified as having either of these infestations, he/she should be treated. More importantly, their close contacts should be examined and treated if needed. It is vital for dermatology nurses to understand the epidemiology, transmission, symptoms, distribution, diagnosis, complications, and treatment for scabies and lice infestations.

Aged↗
PubMed2000

Thalidomide: current and potential clinical applications.

More than three decades after its withdrawal from the world marketplace, thalidomide is attracting growing interest because of its reported immunomodulatory and anti-inflammatory properties. Current evidence indicates that thalidomide reduces the activity of the inflammatory cytokine tumor necrosis factor (TNF)-alpha by accelerating the degradation of its messenger RNA. Thalidomide also inhibits angiogenesis. Recently, the drug was approved for sale in the United States for the treatment of erythema nodosum leprosum, an inflammatory complication of Hansen's disease. However, it has long been used successfully in several other dermatologic disorders, including aphthous stomatitis, Behçet's syndrome, chronic cutaneous systemic lupus erythematosus, and graft-versus-host disease, the apparent shared characteristic of which is immune dysregulation. Many recent studies have evaluated thalidomide in patients with human immunodeficiency virus (HIV) infection; the drug is efficacious against oral aphthous ulcers, HIV-associated wasting syndrome, HIV-related diarrhea, and Kaposi's sarcoma. To prevent teratogenicity, a comprehensive program has been established to control access to the drug, including registration of prescribing physicians, dispensing pharmacies, and patients; mandatory informed consent and education procedures; and limitation of the quantity of drug dispensed. Clinical and, in some patients, electrophysiologic monitoring for peripheral neuropathy is indicated with thalidomide therapy. Other adverse effects include sedation and constipation. With appropriate safeguards, thalidomide may benefit patients with a broad variety of disorders for which existing treatments are inadequate.

Angiogenesis Inhibitors↗
PubMed2000

Characterization of diaper dermatitis in the United States.

BACKGROUND: Diaper dermatitis is the most common dermatologic disorder of infancy. This study evaluates the frequency of outpatient visits resulting in this diagnosis, specialties of physicians providing services, demographics of patients, and leading agents used in treatment. DESIGN: Records of 272,841 encounters from the National Ambulatory Medical Care Survey (1990-1997) were examined for visits in which diaper dermatitis was diagnosed in children. The likelihood of diagnosis in the general pediatric population was calculated and the leading treatment agents were ranked. RESULTS: There were approximately 8.2 million visits in which diaper dermatitis was diagnosed. For the pediatric population in the at-risk age range, there was a 1 in 4 likelihood of being diagnosed with the skin disorder. Pediatricians provided 75% of services for the treatment of diaper dermatitis; the demographics of patients were similar to those of comparably aged individuals in the general population. Nystatin was the leading treatment agent prescribed (27% of visits), followed by clotrimazole (16%), a combination product of nystatin and triamcinolone (16%), hydrocortisone (8%), and a combination product of clotrimazole and betamethasone dipropionate (6%). CONCLUSIONS: Visits for diaper dermatitis are frequent, and pediatricians are the physicians most often called on to provide treatment. No portion of the pediatric population is disproportionately diagnosed. The frequent use of potent corticosteroids contained in combination agents is a potential target for improving the management of diaper dermatitis.

Administration, Topical↗
PubMed2000

The combination of 2% 4-hydroxyanisole (Mequinol) and 0.01% tretinoin is effective in improving the appearance of solar lentigines and related hyperpigmented lesions in two double-blind multicenter clinical studies.

BACKGROUND: Solar lentigines are a chronic condition of the aging population resulting from years of cumulative sun exposure. A topical treatment that is both safe and effective would be welcome and useful. Combinations of therapeutic agents are often used and allow synergy of mechanisms with tolerability. A tyrosinase inhibitor in use in Europe, 4-hydroxyanisole (Mequinol), and the retinoid tretinoin have been used singly as depigmenting agents. OBJECTIVE: The efficacy and safety of the combination product of 2% 4-hydroxyanisole (4HA [mequinol]) /0.01% tretinoin solution (tradename Solagé) were evaluated in two phase III, randomized, controlled, double-blind trials. METHODS: Subjects were randomized to treatment with 4HA/tretinoin solution, one of the active components (4HA or tretinoin), or vehicle. Subjects applied the test solution with a wand applicator twice daily to all solar lentigines and related hyperpigmented lesions on the face, forearms, and backs of hands for up to 24 weeks. Trial 1 had a 24-week no-treatment regression phase and trial 2 had a 4-week no-treatment regression phase. Information collected included clinical assessments of Target Lesion Pigmentation, Physician's Global Assessment of Improvement/Worsening, an Assessment of Overall Cosmetic Effect, and a Subject's Self-Assessment Questionnaire. RESULTS: The 4HA/tretinoin combination was clinically superior to each of its active components and to the vehicle in the treatment of solar lentigines. At the end of treatment, in trial 1 and trial 2, 4HA/tretinoin was statistically superior to each of its active components and vehicle on the forearms and face (P </=.03), except versus tretinoin on the face in trial 2 (P =.2). In trial 2, a trend toward greater efficacy of 4HA/tretinoin over tretinoin on the face was demonstrated at the end of treatment (P =.2), which was also increasingly evident at the end of the 4-week follow-up (P =.06). Most skin-related adverse events were mild and were similar for both the 4HA/tretinoin and tretinoin treatment groups. CONCLUSION: For the treatment of solar lentigines and related hyperpigmented lesions, the topical combination product containing 2% 4HA/0.01% tretinoin solution is well tolerated and superior to either active component.

Administration, Cutaneous↗
PubMed2000

Introduction. The magnitude of skin disease in the United States.

Skin disease is common in the United States and accounts for a considerable fraction of all outpatient visits. Dermatologists care for more skin disease visits than any other single specialty, while still accounting for a minority of visits overall. The data presented in this introduction, from 1997, do not show a drastic drop in the number of visits to dermatologists as might be feared to occur with the growth in managed care. These visits for skin disease represent a considerable disease burden in the United States. Skin disease is not simply a cosmetic problem. As the data on psoriasis show, skin disease has a tremendous impact on HRQL. The magnitude of this impact on the individual patient is comparable to the impact of other medical disorders.

Ambulatory Care↗
PubMed2000

Role of the dermatologist in the delivery of dermatologic care.

Dermatology faces an uncertain future because of changes in the mechanisms of health care delivery. The Westwood-Squibb Center for Dermatology Research was created to foster the care of patients through research and education that supports the delivery of optimal dermatologic health care. The center performs health care research to effect policy decisions that impact dermatologic health care delivery. Results from a broad range of these studies clearly demonstrate the value of dermatologists as primary care providers for patients with skin disease. Future studies at the Westwood-Squibb Center for Dermatology Research expand on these findings, demonstrate the cost-effectiveness of care by a dermatologist, and address the expertise of dermatologists at management of surgical problems of the skin.

Delivery of Health Care↗
PubMed2000

The emerging role of physician assistants in the delivery of dermatologic health care.

The NAMCS provides a wealth of information on use of PAs in all practices, including dermatology. Two important points regarding the NAMCS and SDPA data are addressed here: the number of visits to PAs for dermatologic symptoms and the expected growth of PA use in dermatologists' offices. Dermatologic symptoms were evaluated frequently by PAs, accounting for 14% of PA visits. These statistics do not address the number of referrals those PAs made to dermatologists. Perhaps PAs as a group should be targeted for increased dermatologic education, particularly stressing the need for appropriate referral to a dermatologist. PAs could increase the number of dermatology referrals from primary care offices with improved understanding of the importance of the dermatologist in the management of patients' overall skin health. At projected growth rates, the number of PAs employed by dermatologists should exceed 500 by the end of 2000. Most of this growth has been in private practices and rarely in HMOs or in large multispecialty clinics. There are a number of reasons for this growth, as follows: A PA may help reduce the patient load on the dermatologist, especially with sameday appointments and drop-ins. Some dermatologists are moving away from clinical dermatology into cosmetics, which not only leaves a vacuum in clinical dermatology, but also creates job opportunities for PAs in cosmetic dermatology. Regarding managed care growth, PAs can have a positive impact on the problem of having to see more patients for less money. PAs are cost-effective. In the 1998 SDPA survey, the ratio of billings generated (production) to gross income for the average dermatology PA ranged from 3:1 to 6:1. Even with inexperienced PAs new to dermatology, this ratio was usually at least 2:1 at the end of the first year. PAs can cover satellite offices, allowing for practice expansion. Effective with the new Medicare laws of January 1, 1998, PAs can now see new Medicare patients or Medicare patients with new conditions without the physician being on site, opening up the possibility for satellite offices in remote areas. Just as dermatologists may move toward specialization in surgery, cosmetics, or medical dermatology, PAs may do the same, filling a niche in a particular practice. As in other specialties, patient acceptance of seeing dermatology PAs has not been a significant problem. Continued access to the dermatologist remains unfettered, but, over time, many patients become willing to see either. Are PAs likely to become future competitors of dermatologists? Genuinely concerned dermatologists worry that a dermatology-trained PA will become part of a gatekeeper system that impedes patient access to dermatologists. This is not happening and is not at all likely to become a trend, for a number of reasons. First, primary care cannot compete with dermatology practices in remuneration for PAs. Just as financial benefits in high-production specialty practices entice physicians, the same benefits entice PAs as well. Second, according to member surveys of the SDPA, virtually 100% of fellow members work with dermatologists. Although PAs can work in any type of practice and evaluate dermatologic symptoms just as a general practitioner would, PAs who specialize in dermatology primarily practice with dermatologists, a collegial association most PAs seek out. PAs have steadfastly maintained their dependent, noncompetitive relationship with physicians and would not have it any other way. Although PAs see a good number of patients (2.8 million) with dermatologic symptoms, the NAMCS data indicate that most (72%) of these patients are also seen by a physician. Third, physicians are ultimately responsible for the actions of their PA employee. A general practitioner not trained to perform excisions or manage certain dermatologic conditions should not allow a PA to perform such duties. Similar to much of medicine, the PA profession continues to evolve, with many members moving awa

Delivery of Health Care↗