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Biomedical subjects

Steven R Feldman

Publications and source records attributed to Steven R Feldman.

At least 37 records · Page 2Linked to original sources
PubMed2006

Predictors of treatment choices and associated outcomes in actinic keratoses: results from a national physician survey study.

OBJECTIVES: Actinic keratoses (AKs) are common skin lesions with the potential to progress to squamous cell carcinoma. Many effective treatment alternatives exist, yet the reasons for treatment choice have not been explored. This study examined which AK therapy was preferred among dermatologists and primary care physicians (PCPs), as well as potential determinants of therapeutic selection. METHODS: A random national sample of 534 dermatologists and PCPs selected from the American Medical Association database completed AK questionnaires. The final sample included 1184 AK patients treated by dermatologists and 559 AK patients treated and/or referred by PCPs. All analyses were weighted using the survey sampling weights. RESULTS: Patients who had new and recurring lesions as well as patients who had a mean duration of more than a year since the last AK episode treatment (all p<0.05) were more likely to receive pharmacotherapy. Patients being treated by a dermatologist, receiving pharmacotherapy treatment only, and having both new and recurring lesions (all p<0.05) were less likely to have a complete treatment success. CONCLUSIONS: This study identifies several patient and physician factors associated with treatment preference and related outcomes in patients being treated for AK.

Aged↗
PubMed2006

Trends in on and off-label calcipotriene use.

Following its introduction in 1994, calcipotriene quickly became the single most prescribed medication for psoriasis according to National Ambulatory Medical Care Survey (NAMCS) data. Primarily through regulation of cellular differentiation, calcipotriene may be effective in dermatoses other than psoriasis. We characterize the clinical trends in the utilization of calcipotriene by analyzing a representative sample of visits to US physicians. Demographic characteristics, specialty of the provider, and off-label uses are reported. Calcipotriene was mentioned at 5.8 million of all NAMCS visits during the study period. Nearly 57% of mentions of calcipotriene were not linked to a diagnosis of psoriasis. Adjusted use for gender and race were relatively stable; there was a rise in non-psoriasis uses and use among non-dermatologists in 1997. Our findings support previous reports of the utility of calcipotriene in treating other dermatoses as witnessed by the numerous conditions for which its use was observed. Physicians and policy-makers should be aware of the role that this medication plays in the delivery of dermatologic care.

Calcitriol↗
PubMed2006

Death from psoriasis: representative US data.

OBJECTIVES: Psoriasis can be associated with severe, life-threatening exacerbations. We sought to approximate the mortality associated with hospitalizations for psoriasis. MATERIALS AND METHODS: We analyzed data from two sources to estimate a death rate associated with psoriasis. RESULTS: There were 471 hospital admissions for psoriasis from 1988 to 2001 with a corresponding mortality rate of 1.5%. Documented on nationwide death certificates, there were a total of 29, 33, and 25 deaths attributable to psoriasis in 2001, 2000, and 1999, respectively. CONCLUSIONS: Though effective therapies for severe psoriasis are available, access to them is not guaranteed. It is disturbing to think that the deaths observed here could, at least in part, be prevented with the appropriate use of treatments.

Adult↗
PubMed2006

Critical factors determining the potency of topical corticosteroids.

The vasoconstrictor assay is a highly reliable method used to determine the bioequivalence of topical corticosteroid preparations. By assessing skin blanching, the assay describes the delivery of the active agent through the skin barrier, intrinsic activity at the receptor, and the rate of clearance from the site of application. Vasoconstrictor rankings are generally good predictors of efficacy in clinical trials. Vasoconstrictor assays are not as predictive of outcomes in clinical practice because these assays do not account for a critical factor: how well patients use the medication. Patient compliance plays a vital role in corticosteroid potency.

Administration, Cutaneous↗
PubMed2006

How much of a topical agent should be prescribed for children of different sizes?

BACKGROUND: Compared with guidelines for the quantity of topical corticosteroids to apply in adults, standards for the use of topical corticosteroids in children are not well described. OBJECTIVE: To devise simple-to-use guidelines for topical corticosteroid quantities needed in infants, children, pre-teens, and adults. METHODS: We determined body surface area (BSA) using mean heights and weights in order to calculate the appropriate quantities of medication to be prescribed. RESULTS: As a rough estimate, infants require one-fifth of adult doses, children two-fifths of adult doses, and adolescents two-thirds of adult doses. However, the assessment of BSA may vary considerably between clinicians. Patients may also vary in how thickly they apply topical medication. CONCLUSIONS: A simple guideline for how much topical corticosteroid to prescribe may facilitate the treatment of young children with skin disease.

Administration, Topical↗
PubMed2006

Adverse events from systemic therapies for psoriasis are common in clinical practice.

BACKGROUND: Patients with moderate-to-severe psoriasis frequently require systemic treatment and these medications may be associated with adverse effects. Little is known about the frequency of these events when systemic agents are used in true clinical practice. OBJECTIVE: To determine the frequency of adverse events associated with various systemic psoriasis therapies. METHODS: A retrospective chart review of 753 patients treated in an academic dermatology practice was performed to identify the frequency of adverse events. Poisson regression was used to estimate the odds of significant events for each systemic therapy; UVB-treated patients served as a control population. RESULTS: Methotrexate seemed to be the most prescribed medication. Adverse events were noted with all forms of systemic psoriasis therapy. The highest event rate was seen with oral retinoids, though most of these were considered minor (64%). Cyclosporine had the highest significant adverse event rate (0.9 events/patient). For 'significant' adverse events, oral agents had an adjusted odds ratio>6 compared to standard UVB therapy. The highest risk was for cyclosporine (OR = 20.3); however, the estimate was imprecise (95% confidence interval [4.3, 96.6]). CONCLUSIONS: Traditional psoriasis therapies are associated with significant adverse events in some patients despite toxicity-sparing approaches such as combination therapy. Clinicians need to be aware of screening for adverse events in order to best ensure the safety of their patients and to maximize the efficacy of a given agent. There is still a need for the development of safe and effective treatments for patients with moderate-to-severe psoriasis.

Adult↗
PubMed2006

Medication adherence and health care costs associated with biologics in Medicaid-enrolled patients with psoriasis.

BACKGROUND: Costs and patients' adherence related to biologics are important factors to consider while making informed decisions regarding therapy with biologics in psoriasis management. OBJECTIVE: To examine predictors of adherence related to biologics, total health care costs, and service utilization among psoriasis patients. METHODS: This was a longitudinal cohort study of psoriasis patients (<65 years old) enrolled in North Carolina Medicaid who were prescribed biologics (alefacept, efalizumab, and etanercept). Patients' medication adherence, health care costs, and service utilization patterns in the pre- and post-biologics period were examined. RESULTS: Adherence to biologics was significantly higher compared with the other psoriasis medications (0.66 vs 0.39; p<0.001). Prescription costs were significantly higher in the post-biologics period (3796.77 US dollars vs 11,706.32 US dollars; p<0.001). However, total health care costs in the post-biologics period did not differ significantly from the pre-biologics period (14,662.22 US dollars vs 16,156.10 US dollars; p>0.05). Patients' adherence and health care costs did not differ significantly across the biologics. After controlling for other variables, patients had a significantly lower number of hospitalizations in the post-biologics period (p<0.001). CONCLUSIONS: Although costs associated with prescriptions for biologics were higher, total health care costs did not differ significantly in the post-biologics period. Biologics had a better adherence rate compared with other psoriasis medications.

Adult↗
PubMed2006

Correlates of health-related quality of life in women with severe facial blemishes.

BACKGROUND: Facial appearance plays a large role in self-perception and interaction with others. Visible facial skin lesions are a common condition. Purpose This study assessed factors associated with health-related quality of life (HRQOL) in women with visible facial skin lesions. METHODS: The study included 73 women with one or more of the following conditions: acne, dermatosis papulosis, hypopigmentation, lentigenes, melasma, rosacea, vascular proliferations and other facial scars. The Skindex-16 was used as a measure of HRQOL. Fear of negative evaluation (FNE) was assessed to determine whether self-perception characteristics relate to HRQOL. RESULTS: There were strong correlations in both bivariate and multivariate analyses among increased FNE, heightened perception of QOL without the facial condition and lower overall HRQOL (P< 0.05 and P< 0.01, respectively). There were no differences in HRQOL by type of facial condition, as well as no effects of the area covered by the condition on HRQOL. Interestingly, women not using foundations represented only 10% of the study population and had better HRQOL than women who did use foundations. CONCLUSIONS: Severe facial blemishes of any cause have a significant impact on women's QOL, and the effect of these lesions is mediated in part by psychological characteristics related to self-perception and self-presentation.

Adolescent↗
PubMed2006

Psoriasis treatment in the United States at the end of the 20th century.

BACKGROUND: Psoriasis presents many management complexities. A cornerstone of therapy has been topical corticosteroids, although over the past 10 years there have been many additions to the medication armamentarium. Furthermore, various combination regimens and approaches have been advocated. OBJECTIVE: We sought to characterize various patterns of psoriasis health care delivery and the changes associated with these patterns from 1990 to 2001. METHODS: Visits for psoriasis were identified using National Ambulatory Medical Care survey data, a representative survey of visits to physician offices in the United States. We determined basic demographic characteristics, specialty of the physician provider and medications listed at these visits over the 1990-2001 interval. RESULTS: There were more than 13.5 million visits for psoriasis during the 12-year study period. Dermatologists were responsible for the majority of the visits over the study interval (82%) although there was an overall decline in the proportion of psoriasis visits to dermatologists. As a category, the most common medications used for psoriasis were topical steroids. Topical calcipotriene was the single-most listed medication. There was no observed use of non-corticosteroid topical agents at visits to non-dermatologists. Non-dermatologists were as likely as dermatologists to list a systemic medication at a visit as well as use a systemic as monotherapy. DISCUSSION: In conclusion, the primary topical therapies for psoriasis remain clobetasol and calcipotriene. The decreasing role of dermatologists in the treatment of psoriasis is probably a complex issue, but may relate in part to the difficulty of obtaining access to dermatology care.

Administration, Topical↗
PubMed2006

Frequency and cost of actinic keratosis treatment.

BACKGROUND: Actinic keratosis (AK) is a common lesion with its highest incidence in the aged population. Although treatment strategies for AK have continued to develop, the cost of such treatments has not been recently investigated. PURPOSE: The purpose of this article is to determine the frequency of visits for AK, the methods used to treat AK, and the cost of the treatments used annually. METHODS: Data from the Medicare Current Beneficiary Survey and National Ambulatory Medical Care Survey were used to determine the frequency of office visits for AK and the frequency of destructive procedures and topical treatment of AK. Medicare reimbursement rates were used to estimate the cost of the procedures performed. Costs of medications were based on published wholesale costs. RESULTS: There are an estimated 5.2 million AK visits annually, 60% of which are made by the Medicare population. A total of Dollars 920 million was spent on the treatment of AK annually, 6% being spent on topical therapy, 43% on office visits, and 51% on destructive procedures. CONCLUSIONS: Even though new topical therapies are evolving for the treatment of AK, destructive procedures remain the standard of care when considering frequency of use, efficacy, and cost control.

Aged↗
PubMed2006

Treatment patterns and cost of nonmelanoma skin cancer management.

INTRODUCTION: Nonmelanoma skin cancer (NMSC) is the most common form of cancer in the United States, more common than all other cancers combined. The factors that affect the cost of skin cancer management are not well defined. OBJECTIVE: The objective was to estimate cost of episodes of NMSC care and the factors that impact those costs. DESIGN: Medicare Current Beneficiary Survey (MCBS) data from 1999 to 2000 were used to assess costs of episodes of NMSC care. MCBS estimates of the number of episodes occurring in three service settings (physician's office, outpatient/ambulatory surgical center, or hospital) and demographics were obtained. RESULTS: There were 497 episodes of care in 372 patients. Half the episodes were treated by dermatologists, and two-thirds were managed in physicians' offices. The mean episode cost for management in the office setting was 500 dollars (SD, +/- 487 dollars), and costs were higher when the episodes were treated in either the ambulatory surgical center or the hospital settings, 935 dollars (SD, +/- 456 dollars) and 4,345 dollars (SD, +/- 4939 dollars), respectively. CONCLUSION: With the rising incidence and cost of NMSC to Medicare, it is increasingly important to preserve the low-cost management of this disease. Maintaining care of NMSC in the office-based setting is more cost-efficient than utilizing ambulatory surgical centers or hospital operating rooms.

Aged↗
PubMed2006

Nonmelanoma skin cancer: is the incidence really increasing among patients younger than 40? A reexamination using 25 years of U.S. outpatient data.

OBJECTIVE: An increasing incidence of basal cell carcinomas and squamous cell carcinomas in patients younger than 40 years old diagnosed during years 1973 to 2003 was found in a recent population-based study in Olmsted County, Minnesota. We performed additional analyses using nationally representative patient samples to confirm these trends. STUDY DESIGN: We analyzed a cross-sectional survey data on outpatient diagnoses, the National Ambulatory Medical Care Survey data from 1979 to 2003, for melanoma skin cancer. RESULTS: A total of 4,100 office visits for nonmelanoma skin cancers were recorded, including 230 in patients younger than 40. Multivariate analysis indicated no significant increase in the number of office visits related to nonmelanoma skin cancer in younger patients [odds ratio (OR), 2.77; 95% CI, 0.75-10.26]. The mean age of office visits for nonmelanoma skin cancer did not change significantly. The ages of the office visit patients were 64.7 years and 69.02 years in the years 1979 and 2003, respectively. CONCLUSIONS: Based on a representative sample of outpatient visit diagnoses, visits are not increasing for nonmelanoma skin cancer among patients 40 years and younger in the United States, albeit direct measurement of tumor incidence was not possible with this database.

Adult↗
PubMed2006

The utility of a data-logging device for measuring adherence to home phototherapy.

BACKGROUND: Treatment adherence to home phototherapy is not well characterized. PURPOSE: To develop an accurate measure of home phototherapy unit usage. METHODS: We tested a commercially available data logger containing a photo-sensor on two home phototherapy units. RESULTS: The data logger accurately recorded actual usage and did not record stray light sources over the study period. CONCLUSION: A data logger can accurately capture usage patterns for a home phototherapy unit. These devices could potentially be used in clinical trials to measure adherence to home phototherapy treatment regimens.

Electronic Data Processing↗
PubMed2006

Treating skin disease: self-management behaviors of Latino farmworkers.

Latino migrant and seasonal farmworkers experience high rates of skin disease that result from their working and living conditions. Knowledge of the ways farmworkers treat skin disease symptoms will provide a foundation for developing culturally appropriate health education, improving the delivery of health services, and improving occupational health policy for agricultural workers. The purpose of this paper is to describe skin disease self-management practices among Latino migrant and seasonal farmworkers in North Carolina. This analysis uses a qualitative design based on in-depth interviews with 30 Latino farmworkers (six females, 24 males). Computer assisted, systematic procedures are used to analyze the verbatim transcripts of these interviews. Participants shared a consistent set of health self-management actions in treating skin disease. These actions were within the domains of self-care and medical care. A model of skin disease self-management among Latino farmworkers includes the self-care actions of hygiene, use of home remedies and use of over-the-counter remedies, with farmworkers often combining different domains of self-care. While farmworkers acknowledge the benefits of medical care, they are also mindful of barriers to its use, including cost, transportation and language. The large percentage of farmworkers who experience skin problems indicates that health outreach workers who serve this population need to provide education on preventing and treating skin problems, and they need to recommend to farmworkers appropriate over-the-counter medicines for the treatment of these skin problems. Appropriate medical care for treating skin problems that are dangerous and reduce farmworkers' quality-of-life needs to be made available to this population.

Adolescent↗
PubMed2006

What is the best approach to reducing birth defects associated with isotretinoin?

BACKGROUND TO THE DEBATE: Isotretinoin is an effective treatment for severe acne, a condition which can be physically, emotionally, and socially disabling. Because the drug is teratogenic, causing severe birth defects, women taking the drug are directed to avoid pregnancy. In the United States, a series of risk reduction programs have been implemented that aim to prevent pregnant women from taking the drug and to prevent women taking it from getting pregnant. The most recent, and most stringent, is an Internet-based, performance-linked system called iPLEDGE, which tries to ensure that the drug is dispensed only when there is documentary proof that the patient is not pregnant and is using two forms of birth control. Is iPLEDGE the best way to reduce isotretinoin birth defects, or is it an unproven and overly burdensome system?

Abnormalities, Drug-Induced↗
PubMed2006

Cost-effectiveness of moderate-to-severe psoriasis treatment.

Psoriasis is a common, chronic inflammatory disease that can cause as much disability as cancer, diabetes or other major medical illnesses. Traditional therapies for treating moderate-to-severe psoriasis include phototherapy, methotrexate, oral retinoids and ciclosporin. New biological treatments provide further therapeutic options, but add to the already considerable cost of managing psoriasis. Expert panels have published guidelines for the use of biological agents in managing moderate-to-severe psoriasis; however, few if any of these guidelines appropriately consider the cost-effectiveness of treatment options. When considering cost-effectiveness in addition to safety and efficacy, ultraviolet Type B phototherapy seems to be the best first-line agent for the control of moderate-to-severe psoriasis, despite a small potential for cumulative toxicity. The biologics should be considered as second-line agents alongside the traditional systemic treatments when phototherapy proves to be ineffective or is otherwise contraindicated, such as in patients with psoriatic arthritis.

Cost-Benefit Analysis↗
PubMed2006

The Acne Quality of Life Index (Acne-QOLI): development and validation of a brief instrument.

BACKGROUND: Acne affects many people and can be detrimental to affected patients' quality of life. Assessing the impact of acne on quality of life requires well-validated and reliable measures of acne-specific quality of life that are brief and easy to administer and interpret. OBJECTIVES: This paper reports on the development and validation of the Acne Quality of Life Index (Acne-QOLI) for use in clinical care, research, and product development. METHODS: Focus groups consisting of people from demographically different populations were conducted to identify the most relevant domains of functioning affected by acne; on the basis of these findings, candidate items were developed. An initial item pool of 58 items was included in a survey of 480 persons with mild to severe acne ranging in age from 12 to 62 years. Factor analysis and qualitative analysis were used to reduce the item pool to 21 items. The construct validity, concurrent validity, internal consistency, and test-retest reliability of the items were evaluated. RESULTS: The 21-item Acne-QOLI showed excellent face validity, content validity, concurrent validity, and construct validity. High internal consistency and test-retest reliability were also found. CONCLUSIONS: Quality of life is now recognized as an important outcome in medical care. The Acne-QOLI is a brief and easily administered and interpreted measure of acne-related quality of life that can be used in clinical care, research, and product development.

Acne Vulgaris↗