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Biomedical subjects

A B Fleischer

Publications and source records attributed to A B Fleischer.

At least 55 records · Page 3Linked to original sources
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

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↗
PubMed2000

Allergists and dermatologists have far more expertise in caring for patients with urticaria than other specialists.

BACKGROUND: Urticaria is a common disease for which numerous treatments have been described, yet there is little information about what agents are commonly used to treat urticaria. There may be differences in the way in which urticaria is treated by different medical specialties. OBJECTIVE: The purpose of this study was to characterize the visits and treatments of urticaria in office-based practices. METHODS: National Ambulatory Medical Care Survey data from 1990 to 1997 were analyzed to determine patient populations, medications used, and physician specialties for visits of urticaria. RESULTS: Women accounted for 69% of all patient visits, but an equal gender distribution was observed in patients 18 years of age and younger. There was a bimodal age distribution with peak visits in patients aged birth to 9 years and 30 to 40 years. H(1) antihistamines and systemic corticosteroids were used in 56% and 14% of visits, respectively. Other medications reported as useful in the treatment of urticaria were used in 12% of visits. Allergists and dermatologists had a mean of 47 and 37 visits per physician per year, respectively, compared with all other physicians who averaged fewer than 10 visits per physician per year. Allergists were the least likely to use a corticosteroid agent (6% of visits), whereas internists were the most likely (29% of visits). Dermatology and allergy recorded a relatively large percentage of visits for urticaria that were referred for their condition by other physicians (49% and 25% of visits, respectively). CONCLUSION: We observed a bimodal utilization curve for age and urticaria not previously described. H(1) antihistamines remain the mainstay in treatment of urticaria, whereas the low use of systemic corticosteroids likely reflects physicians' understanding of their secondary function in the treatment of urticaria.

Adolescent↗
PubMed2000

Pyoderma gangrenosum. A comparison of typical and atypical forms with an emphasis on time to remission. Case review of 86 patients from 2 institutions.

Pyoderma gangrenosum (PG) is an idiopathic, inflammatory, ulcerative disease of undetermined cause. The diagnosis is based on clinical and pathologic features and requires exclusion of conditions that produce ulcerations. An atypical bullous variant (atypical pyoderma gangrenosum, APG) exists with clinical features similar to those of Sweet syndrome. Because PG is a rare disease, few large case series have been reported. Pyoderma gangrenosum was first recognized as a unique disease entity in the first half of the 20th century. Cumulative knowledge of PG is based on a handful of case series and multiple individual case reports. To augment that knowledge, we present our experience with a large number of patients over a significant time. We performed a retrospective analysis of the medical records of 86 patients with PG who were evaluated and treated over 12 years at 2 university-based dermatology departments. The mean (+/- standard deviation) age of onset of PG and APG, respectively, was 44.6 +/- 19.7 years and 52.2 +/- 15.3 years. Lower extremity involvement was most common in PG, whereas upper extremity involvement was most common in APG. Associated relevant systemic diseases were seen in 50% of patients. Inflammatory bowel disease was the most common association in patients with PG, whereas hematologic disease or malignancy was most common in those with APG. Although a few patients were managed with local measures or nonimmunosuppressive treatment, the majority required oral corticosteroid therapy, often with systemic immunosuppressive treatment. PG patients required a mean 11.5 +/- 11.1 months of treatment to achieve remission compared with 9.0 +/- 13.7 months for patients with APG. Five patients (5.8%) had disease that was extremely refractory to multiple intensive therapies. The prognosis and disease associations for PG and APG appear to be different. Compared with PG, APG is more often associated with hematologic disease or malignancy, and remits more quickly.

Adolescent↗
PubMed2000

Per-gram cost of medication is by itself a poor indicator for comparing costs of different psoriasis treatments: a retrospective cohort study of the cost of psoriasis treatment with topical corticosteroids versus topical calcipotriene.

BACKGROUND: New treatments are available for psoriasis that complement or replace the use of topical corticosteroids. OBJECTIVE: The purpose of this article is to assess the relative overall cost difference between regimens based on topical steroids and those using the nonsteroidal anti- psoriasis medication, topical calcipotriene. METHODS: Retrospective data on the cost of therapy of psoriasis were attained through analysis of claims from a national pharmaceutical-and-medical-visit claims-database. Episodes of psoriasis treatment were defined and analyzed for patients whose therapy was initiated with either topical calcipotriene or topical corticosteroids of different potency classes. RESULTS: The average medication cost per episode was greater for topical calcipotriene ($111/episode) compared to ultra-high potency ($70/episode), high potency ($57/episode), mid potency ($47/episode), and low-potency, ($75/episode) topical corticosteroids (p <.05). The average total cost of therapy for the topical calcipotriene regimen ($218) fell within the range for the cost of therapy for topical steroid base regimens ($197 to $457); there were no significant differences in the total cost of therapy between topical calcipotriene monotherapy and other treatment groups. CONCLUSION: The per-gram cost of medication is by itself a poor indicator for comparing the cost of different psoriasis treatment regimens. Given the greater safety and efficacy of combination regimens in terms of both short-term improvement and long-term control, initiating psoriasis treatment with a combination regimen of topical calcipotriene combined with an ultrapotent corticosteroid appears to be the most cost-effective approach to psoriasis treatment.

Administration, Topical↗
PubMed2000

Sex-specific differences in the treatment of severe psoriasis.

BACKGROUND: Psoriasis treatment requires consideration of patient-specific concerns in addition to the severity of skin involvement. There may be sex-specific differences in the treatment of severe psoriasis. OBJECTIVE: The purpose of this study was to determine whether there are sex-specific differences in the treatment of severe psoriasis. METHODS: We analyzed the medications prescribed to patients with a primary and only diagnosis of psoriasis recorded in the 1990-1994 National Ambulatory Medical Care Survey. RESULTS: There were 8.5 million visits to physicians for the treatment of psoriasis in the years 1990-1994. These visits were made by approximately 4.3 million women and 4.1 million men. Only 39% of patients receiving systemic treatments were women. Women received less methotrexate (23% women) and etretinate (35% women) than men, but more psoralen photochemotherapy (PUVA) (63% women) and isotretinoin (100% women) than men. In contrast, there was no notable difference by sex in the potency of topical corticosteroid agents prescribed. CONCLUSION: For mild disease treated with topical agents alone, there is no notable difference in the treatment of men and women. Men are more likely than women to receive intensive treatments for severe psoriasis, at least in part because of the teratogenic potential of these treatments. There is a need for development of new treatments for severe psoriasis that are safe for women of childbearing potential.

Abnormalities, Drug-Induced↗
PubMed2000

Managed care.

Explore the source record for details and available documents.

Antifungal Agents↗
PubMed2000

Use of clotrimazole/betamethasone diproprionate by family physicians.

BACKGROUND AND OBJECTIVES: Clotrimazole/betamethasone diproprionate contains a fluorinated, high-potency topical corticosteroid and is the most frequently prescribed topical agent in the United States. Family physicians are more likely than pediatricians and dermatologists to use this product when faced with a common fungal infection. To better understand the settings in which US family physicians recommend the use of clotrimazole/betamethasone diproprionate, we determined the diagnoses and characteristics of patients for whom family physicians prescribe this drug. METHODS: Data from the National Ambulatory Medical Care Survey were used to determine the demographic characteristics of patients who were given a prescription for clotrimazole/betamethasone diproprionate, the diagnoses of patients treated with the drug, and the potency of other topical corticosteroids by family physicians. Wholesale costs of drugs were used to estimate potential drug cost savings obtainable by switching to specific monotherapy agents. RESULTS: Clotrimazole/betamethasone diproprionate was prescribed at 3.1% of visits to family physicians but at only .6% of visits to dermatologists for either inflammatory or fungal/candidal conditions. Family physicians frequently prescribed clotrimazole/betamethasone diproprionate to children under age 5 and for use on genital skin disorders. Dermatologists rarely used clotrimazole/betamethasone diproprionate in these settings. CONCLUSIONS: The frequent use by family physicians of clotrimazole/betamethasone diproprionate in high-risk settings is of concern. Use of alternative agents with anti-inflammatory and antifungal properties without the risks associated with the use of high-potency topical corticosteroids may be the most practical approach to replacing use of clotrimazole/betamethasone diproprionate.

Administration, Topical↗
PubMed2000

Diagnosis of skin disease by nondermatologists.

OBJECTIVE: To determine how often primary care physicians diagnose and treat skin disease and to compare their experience with that of dermatologists. STUDY DESIGN: Retrospective review of National Ambulatory Medical Care Survey data. METHODS: We reviewed data from the 1990-1994 National Ambulatory Medical Care Survey on outpatient visits to physicians for both dermatologic and nondermatologic disorders. RESULTS: Dermatitis is the most common dermatologic problem diagnosed by internists, family physicians, and pediatricians and is the 35th, 17th, and 15th most common diagnosis made by these providers, respectively. Dermatologists had 728 and 352 office visits per year for acne and contact dermatitis, respectively, whereas internists averaged 3 and 9 visits, family physicians averaged 8 and 27 visits, and pediatricians averaged 8 and 37 visits. Overall, dermatologists spent 930 outpatient hours per year with patients with dermatologic conditions, compared with 21, 53, and 56 hours per year for internists, family physicians, and pediatricians. CONCLUSIONS: Although most visits for skin disease are managed by primary care physicians, these physicians treat few cases of individual skin conditions. The different levels of experience between dermatologists and nondermatologists may affect the quality of dermatologic care and may explain in part the greater expertise dermatologists have in diagnosing and treating skin disease. This should be considered in decisions about the delivery of dermatologic healthcare services and in planning educational programs designed to improve dermatologic care.

Ambulatory Care↗
PubMed1999

Atopic dermatitis. Perspectives on a manageable disease.

Although there is no cure for atopic dermatitis, it can be successfully controlled in most patients. Topical corticosteroids are usually effective, but some patients with recalcitrant disease require phototherapy or use of more potent immunosuppressive agents. Improved understanding of the immunologic basis of atopic dermatitis may provide opportunities for the development of new therapies.

Adult↗
PubMed1999

Treatment of atopic dermatitis: role of tacrolimus ointment as a topical noncorticosteroidal therapy.

Atopic dermatitis is a chronic, relapsing form of eczema characterized by scaling, itchy, inflamed skin that can be triggered by an interplay of genetic, immunologic, and environmental factors. Immune dysregulation appears to play an important role in the cause of atopic dermatitis. Topical corticosteroid agents have been the mainstay of therapy for atopic dermatitis because of their broad immunomodulatory effects. However, topical corticosteroid agents are not ideal agents because when used over the long term, they may cause cutaneous atrophy and immunosuppression. Systemic corticosteroidal agents, certain antihistiminic agents, systemic cyclosporin, and phototherapy have proven value in treating patients with atopic dermatitis. In the search for a noncorticosteroidal topical agent, tacrolimus stands out as being uniquely suited for this condition. Tacrolimus affects a broad spectrum of inflammatory mediators and processes known to be relevant to atopic dermatitis pathogenesis. Tacrolimus demonstrates good percutaneous penetration and appears to have no potential to cause cutaneous atrophy. There are multiple double-blind, controlled studies demonstrating the safety and efficacy of this agent in treating atopic dermatitis. The agent may be of particular benefit in children, among whom an alternative to the chronic use of corticosteroid agents, either topically or systemically, is highly desirable.

Administration, Topical↗
PubMed1999

Prescription of high-potency corticosteroid agents and clotrimazole-betamethasone dipropionate by pediatricians.

Family physicians, internists, and pediatricians are more likely to prescribe combination topical antifungal-topical corticosteroid preparations than are dermatologists. One such preparation, clotrimazole-betamethasone dipropionate, can cause atrophy because it has a high-potency corticosteroid component. We analyzed data from the National Ambulatory Medical Care Survey for visits to pediatricians from 1990 to 1994 and isolated visits at which a topical corticosteroid agent or clotrimazole-betamethasone dipropionate was prescribed. Pediatricians rarely prescribed single-agent, high-potency topical corticosteroid agents in managing patients with skin disorders. High-potency corticosteroid agents accounted for 5.0% of topical corticosteroid prescriptions, whereas 56.3% were low-potency and 38.7% were medium-potency agents. Of the 696,285 mentions of clotrimazole-betamethasone dipropionate, 56.4% (389,920) were for children aged newborn to 4 years; diagnoses were erythematodesquamatous dermatoses, diaper rash, tinea, well-baby visit, and candidiasis. In contrast, for dermatologists nationwide, no drug mention existed for this combination agent for children aged newborn to 4 years over the 5-year study period. Our results show that clotrimazole-betamethasone dipropionate is prescribed inappropriately by pediatricians, especially in the treatment of young children. Pediatricians rarely use high-potency topical corticosteroid agents, but most of their use of clotrimazole-betamethasone dipropionate is in the youngest children, in whom such corticosteroid use is least appropriate. This prescription pattern suggests that some pediatricians may be unaware that clotrimazole-betamethasone dipropionate has a high-potency cortico steroid component.

Administration, Topical↗
PubMed1999

Patients can accurately identify when they have a dermatologic condition.

The use of "gatekeepers" may be rational when patients do not know what specialist to see for their condition. Using representative data on outpatient practice in the United States, we tested the hypothesis that when patients believe they have a skin condition, they have a dermatologic disease. At least 95% of visits for skin symptoms are associated with dermatologic diagnoses. Patients who believe they have skin conditions do have dermatologic diseases and are able to choose the appropriate specialist.

Humans↗
PubMed1999

Psoriasis causes as much disability as other major medical diseases.

BACKGROUND: Little is known about how the health-related quality of life (HRQL) associated with psoriasis compares with that of other patient populations. OBJECTIVE: We describe HRQL associated with psoriasis and compare it with HRQL of patients with other major chronic health conditions. A second aim is to identify which specific aspects of psoriasis contribute most to HRQL. METHODS: A total of 317 patients completed a non-disease-specific measure of HRQL. Responses were compared with those of patients with 10 other chronic health conditions. HRQL was regressed on ratings of 18 aspects of psoriasis. RESULTS: Patients with psoriasis reported reduction in physical functioning and mental functioning comparable to that seen in cancer, arthritis, hypertension, heart disease, diabetes, and depression. Six aspects of psoriasis predicted physical functioning, and 5 different disease aspects predicted mental functioning. CONCLUSION: The impact of psoriasis on HRQL is similar to that of other major medical diseases. Different aspects of psoriasis are related to the different dimensions of HRQL supporting the need for multidimensional treatment models.

Adult↗
PubMed1999

Time-efficiency of nondermatologists compared with dermatologists in the care of skin disease.

BACKGROUND: It has been suggested that using an established primary care doctor potentially could be a more efficient use of physician time than a new visit to a dermatologist for patients seeking care for skin diseases. OBJECTIVE: We test the hypothesis that seeing an established primary care doctor for a skin problem is a more efficient use of physician-time resources than a new visit to a dermatologist. METHODS: The duration (in minutes) of outpatient visits for dermatologic conditions was obtained from the National Ambulatory Medical Care Survey from 1990 to 1994. To control for the complexity of visits, the analysis was limited to the 62% of these visits in which a single dermatologic condition was the only condition being treated. RESULTS: For all outpatient dermatologic visits combined, dermatologist visits for patients 18 years old or younger were 1.5 minutes (12%) shorter than nondermatologist visits, and dermatologist visits for patients older than 18 years were 3.1 minutes (20%) shorter than nondermatologist visits. Compared with nondermatologists, dermatologists have a shorter average visit duration for new, first-time patient encounters and for encounters with established patients. A significant difference in outpatient visit duration does not exist when comparing new, first-time visits for dermatologists to established visits for nondermatologists (P = .3). CONCLUSION: A visit to an established primary care provider for treatment of a skin problem is not a more efficient use of physician resources than a new or return visit to a dermatologist.

Adult↗
PubMed1999

The gatekeeper model is inefficient for the delivery of dermatologic services.

BACKGROUND: Gatekeeper-paradigm managed care systems may discourage the use of dermatologists in the management of skin conditions by limiting direct access. This may limit the quality of care patients with skin disorders receive and may be an inefficient use of medical resources. OBJECTIVE: The purpose of this study was to determine the likelihood that patients with dermatologic conditions who see a primary care provider will be referred to a dermatologist. METHODS: Data on the disposition of outpatient visits to primary care physicians for one and only one dermatologic diagnosis were obtained from the 1990-1994 National Ambulatory Medical Care Survey. These data were used in an econometric model to estimate the likelihood of referral to a dermatologist for an episode of care. RESULTS: Of all visits for a single dermatologic diagnosis, 39% were to primary care physicians. The disposition of referral was more common for these dermatology-related visits than for all office visits to primary care physicians (5.8% vs 4.5%, P < .001). The most frequent diagnoses associated with referral were common dermatologic problems, not rare disorders. The number of visits per episode of care was highly dependent on the assumptions of the analysis, resulting in estimate ranges for referral rates per episode between 6.8% and 18.5% for pediatricians, 8.2% and 23% for family and general practitioners, and 16.6% and 46.5% for internists. CONCLUSION: The relative difficulty for primary care providers of managing skin problems is reflected by their frequent need to refer patients with common skin problems and by the greater likelihood of referral for skin disorders than for other medical conditions. The high rates of referral per episode of care supports the cost-effectiveness of direct access to dermatologists.

Costs and Cost Analysis↗
PubMed1999

Destructive procedures are the standard of care for treatment of actinic keratoses.

BACKGROUND: Actinic keratoses are premalignant lesions resulting from exposure to carcinogens. Recently, some Medicare carriers have limited reimbursement for destruction of actinic keratoses to those lesions unresponsive to topical 5-fluorouracil treatment. OBJECTIVE: Our purpose was to determine whether this policy meets the community standard of care for treatment of actinic keratoses. METHODS: Data from the 1993 and 1994 National Ambulatory Medical Care Survey were used to determine the frequencies at which different treatments are used for actinic keratoses. These were compared with the frequencies at which procedures and medical therapies are used to treat control conditions (warts, psoriasis, acne, and dermatitis) to determine whether procedures are done because they are available or out of medical necessity. RESULTS: Procedures were performed during 78% of visits for actinic keratoses. 5-Fluorouracil was used at 3.6% of visits, and at 39% of these visits a procedure was also performed. There were no observations of use of 5-fluorouracil alone at a first visit for actinic keratosis. Procedures were less likely to be performed at visits for warts, psoriasis, acne, or dermatitis, which indicates that reimbursable procedures are performed not simply because they are available. CONCLUSION: Procedures are performed to destroy actinic keratoses out of medical need. Medicare policies mandating initial use of 5-fluorouracil as initial treatment of actinic keratoses do not represent the community standard of care for treatment of these lesions.

Antimetabolites, Antineoplastic↗