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S R Feldman

Publications and source records attributed to S R Feldman.

At least 19 recordsLinked to original sources
PubMed2001

The primary care provider and the care of skin disease: the patient's perspective.

OBJECTIVE: To ascertain the patient's perspective on dermatologic care provided by primary care providers (PCPs) or dermatologists. DESIGN: Cross-sectional survey of patients drawn from primary care and dermatology clinics. SETTING: Academic Veterans Affairs medical center. PATIENTS: Convenience sample of patients in either a primary care or a dermatology clinic. INTERVENTION: Survey questionnaire. MAIN OUTCOME MEASURES: Patients' confidence in having their skin problems cared for by PCPs and dermatologists and satisfaction with previous care rendered. RESULTS: A total of 137 patients in the primary care clinic (group 1) and 100 patients in the dermatology clinic (group 2) participated. Patients (N = 237) expressed confidence in their PCP's ability to treat rashes (62%), diagnose skin cancer (65%), perform skin biopsies (60%), "freeze" lesions with liquid nitrogen (50%), and perform cutaneous surgery (46%). Group 2 patients were significantly less likely to have confidence in their PCP than group 1 patients for all measures other than the use of liquid nitrogen. High levels of confidence were expressed in a dermatologist's ability for all 5 measures: 92%, 91%, 92%, 83%, and 85%, respectively. Patients were more confident in dermatologists' abilities to perform these procedures compared with PCPs (P<.001 for all comparisons). Of patients previously treated for skin disorders, there was a high rate of satisfaction with the treatment rendered by PCPs (81% for group 1 and 75% for group 2) and by dermatologists (92% for group 1 and 90% for group 2). However, patient satisfaction was higher for dermatology vs primary care for the treatment of skin disease (P<.001). Direct access to dermatologists was preferred. CONCLUSIONS: Although patients have confidence in their PCP to care for their skin disease, they have greater confidence in the care provided by dermatologists. Among patients previously treated for skin disease, satisfaction was higher with care rendered by dermatologists vs PCPs. Most patients prefer direct access to dermatologists should they develop a skin problem.

Aged↗
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

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

Clinical management of psoriasis: principles and practice.

A chronic condition that compromises many patients' quality of life, psoriasis is treatable with a range of agents, either alone or in combination. Clinical management strategies using these therapies can be organized as a stepped-care approach. For mild disease, corticosteroids and other topical therapies (step 1) are often appropriate. When lesions are more pronounced or extensive, phototherapy (step 2) is often the treatment of choice, and topical treatments or the step 3 agent acitretin can be added to enhance or accelerate therapeutic responses. Step 3 agents, which also include cyclosporine and methotrexate, may be contemplated when psoriasis is moderate or severe. Acitretin may cause acute adverse effects, including mucocutaneous effects, which can be avoided by reducing dosage. Methotrexate treatment can lead to bone marrow suppression and hepatotoxicity, and cyclosporine can cause nephrotoxicity. The clinical uses of these agents are illustrated in part through case presentations drawn from the authors' practices, and the supportive role of the National Psoriasis Foundation is reviewed.

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↗
PubMed2000

Treatment of psoriasis: an algorithm-based approach for primary care physicians.

Psoriasis is characterized by red, thickened plaques with a silvery scale. The lesions vary in size and degree of inflammation. Psoriasis is categorized as localized or generalized, based on the severity of the disease and its overall impact on the patient's quality of life and well-being. Patient education about the disease and the treatment options is important. Medical treatment for localized psoriasis begins with a combination of topical corticosteroids and coal tar or calcipotriene. For lesions that are difficult to control with initial therapy, anthralin or tazarotene may be tried. The primary goal of therapy is to maintain control of the lesions. Cure is seldom achieved. If control becomes difficult or if psoriasis is generalized, the patient may benefit from phototherapy, systemic therapy and referral to a physician who specializes in the treatment of psoriasis.

Adrenal Cortex Hormones↗
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

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

Economic aspect of health care systems. Advantage and disadvantage incentives in different systems.

European health care delivery systems illustrate the effect of economic incentives on health care delivery. Each country faces the issue of trying to balance the desire for economic efficiency with comprehensive, quality medical care. Without careful use of economic incentives achievable with central control, one gets to pick only two of the three desired goods--high quality, low cost, and comprehensive coverage. In the United States, payment approaches for health care have been undergoing tremendous changes since the early 1980s. These changes have escalated during the 1990s. The basic approach for reimbursing hospital care has been completely restructured by many payers for care, and payment approaches for physicians and long-term care providers also are being restructured. Financing approaches vary from provider to provider and payer to payer, and financing approaches will continue to evolve over time. In the traditional fee-for-service reimbursement system, the incentive to physicians is to do more because more services lead to more revenue. The use of incentives to influence health care practitioners' behavior is common. Incentives are generally financial in nature and expose health care providers to some risk or reward for certain patterns of behavior. Some common incentives used in managed care include capitation payment, in which a physician is paid a fixed fee, regardless of the number of services administered; bonus distribution; and withhold accounts, through which a practitioner stands to gain or lose some amount of money for overuse or underuse of medical resources against budget. In many countries, a strengthening of the position of primary care providers can be observed: Finland, Germany, Greece, Italy, the Netherlands, Norway, Sweden, the United Kingdom, and now the United States. General practitioners are assumed to function as a gatekeeper to second-line care, such as specialist care, prescription drugs, and hospital care. A further step is to give the primary care providers financial responsibility for the costs of the follow-up care provided by others to their patients. By examining the health care systems of other countries, the potential negative impact of such an approach on the use of specialists can be seen. The negative impact of these approaches on patient care is clear when dermatologists and general practitioners are compared in the delivery of dermatologic health care.

Delivery of Health 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↗
PubMed2000

Growing impediments to the delivery of dermatologic care.

Government regulations have a broad and deep impact on the delivery of dermatologic health services. It is incumbent on dermatologists to be involved in the development and discussions of these issues and to educate government officials about the effects of existing and proposed regulations on the delivery of dermatologic health care.

Delivery of Health Care↗
PubMed2000

New topical treatments change the pattern of treatment of psoriasis: dermatologists remain the primary providers of this care.

BACKGROUND: Psoriasis is a common chronic skin disorder that can be debilitating both physically and psychologically. The treatment of psoriasis is complicated by the many manifestations of the disease, different patients' subjective impression of the disease, and the availability of numerous topical agents, systemic agents, and phototherapy options for the disease. Purpose The purpose of this study was to characterize how topical psoriasis treatment is changing in the USA. Methods Data from the National Ambulatory Medical Care Survey (1990-1996) were used to characterize the use of medication at physician office visits for psoriasis vulgaris. Corticosteroid agents in the years 1990-1994 were classified by relative potency. Results There were 1.0 million yearly visits for psoriasis. Dermatologists were responsible for 95% of these office visits. Topical corticosteroids were the only medication listed at 50% of psoriasis visits, and were used in combination with another medication in an additional 26% of visits. High and superpotent corticosteroid agents accounted for 55% of all topical corticosteroid agents listed. Topical calcipotriene was the most commonly used noncorticosteroid treatment, and its use in combination with corticosteroids increased from 17% to 84% between 1994 and 1996. CONCLUSION: s 80% or more of people with psoriasis do not see a physician for the disease in any given year. A combination of different topical medications is commonly used to treat psoriasis. Patients should be aware of the availability of new therapeutic options and the special expertise of dermatologists in managing complex treatment regimens for psoriasis.

Administration, Topical↗
PubMed2000

Clearance is not a realistic expectation of psoriasis treatment.

BACKGROUND: Psoriasis is a disease with many manifestations for which numerous treatments are available. OBJECTIVE: The purpose of this article is to assess whether complete clearance is a realistic expectation given the currently available treatments for psoriasis. METHODS: Clinical trials of the treatment of psoriasis were identified from the medical literature, and the reported rates of clearance were compared. RESULTS: The percentage of patients who experienced complete clearing of their psoriasis varied with the different monotherapy treatments from 2% with tazarotene gel to a maximum of 86% with narrow-band UVB. Combinations of systemic retinoids (etretinate, acitretin) and photochemotherapy (PUVA) attained the maximum reported clearance rate as combination therapy. CONCLUSION: The new treatments available for psoriasis give physicians new opportunity to control the severity of psoriasis. Despite the availability of novel treatments for psoriasis, complete clearing of psoriasis is obviously not a realistic expectation of topical treatment. Phototherapy and systemic therapy provide greater improvement, but studies rarely report complete clearing of the disease as an endpoint. At this time, optimal therapy consists of using combinations of different treatments to obtain short-term improvement and long-term control of the disease.

Humans↗
PubMed2000

Skin examinations and skin cancer prevention counseling by US physicians: a long way to go.

BACKGROUND: Nonmelanoma skin cancer and actinic keratoses may be partially preventable by physician counseling. OBJECTIVE: The purpose of this study was to assess the frequency of counseling for skin cancer prevention. METHODS: Data on skin cancer counseling and skin examinations were obtained from representative visits to outpatient physicians in the United States from the 1997 National Ambulatory Medical Care Survey. A limitation of the skin examination data is that the extent of the skin examination was not reported. RESULTS: Skin examinations occurred in 60 million (8.6%) of 703 million office visits, and skin cancer prevention counseling or education occurred in 12 million visits (1.5%). For patients younger than 20 years, such prevention counseling occurred in only 1.0% of 169 million visits. For those patients with a current or previous history of nonmelanoma or melanoma skin cancer or actinic keratosis (high-risk patients) identified by the treating physician, 2.8 million (35%) of 7.9 million patients received such counseling. In high-risk patients, dermatologists provided such counseling at 41% of visits, compared with 24% for general and family practice, 9.3% for otolaryngology, 13% for general surgery, and 7.7% for internal medicine. In such high-risk patients, skin examinations were performed at 78% of dermatology visits, 69% of otolarynogolgy visits, 36% of general surgery visits, and 27% of family physician visits. Capitation did not lead to greater primary preventive practices; skin cancer prevention counseling occurred in 4% of high-risk capitated patients compared with 38% of noncapitated patients. CONCLUSION: Physicians provide skin cancer prevention counseling or education at fewer than half of visits for high-risk patients. High-risk patients are likely to receive skin cancer prevention messages depending on the specialty of physician that they visit in roughly the following scheme: dermatologists>family physicians>all other specialties. Economic restraints within managed care systems may affect their "health maintenance" function.

Counseling↗