- Email: [email protected]
Counterpoint: Analysis of patient claims data to determine the prevalence of hidradenitis suppurativa in the United States
J AM ACAD DERMATOL
818 Letters
NOVEMBER 2013
complaints. A thorough approach to the informed consent procedure is of the utmost importance. As claimed in our initial article, the patient seeking a cosmetic intervention should be aware the riskbenefit profile of these procedures, including those of a psychosocial type. The patient should also have reasonable expectations about the potential results. Again, probing to find the patient’s motivations, goals, and expectations for the cosmetic procedure is paramount. However, we do disagree with Dr Serna’s claim that cosmetic procedures, as part of dermatologic practice, are medical acts like any other. Cosmetic procedures are generally considered medical enhancement in the field of bioethics, as they are nontherapeutic interventions that improve the appearance of the aging face and skin. In that regard, cosmetic procedures are critically different in our view from traditional, therapeutic medical acts. This disagreement seems to hinge on our respective definitions of medicine. We rely on Callahan’s1 definition of medicine, which centers on the treatment and prevention of disease. For Dr Serna, medical practice seems defined by a particular approach: a detailed history, a physical, informed consent, guidance, and counseling. This is as opposed to a set of predetermined procedures with the aim of healing or preventing illness. This is an interesting debate that will hopefully continue within both the fields of bioethics and dermatology. Again, despite these differences between our views and Dr Serna’s, we are very much in agreement with her central point, and we thank her for her insightful comments. Sotonye Imadojemu, MD, MBE,a and Autumn Fiester, PhDb Departments of Dermatologya and Medical Ethics and Health Policy,b Perelman School of Medicine at the University of Pennsylvania, Philadelphia Funding sources: None. Conflicts of interest: None declared. Correspondence to: Autumn M. Fiester, PhD, Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, 3401 Market St, Suite 320, Philadelphia, PA 19104-3319 E-mail: [email protected] REFERENCE 1. Callahan D. The goals of medicine: setting new priorities. Hastings Cent Rep 1996;26:S1-27. http://dx.doi.org/10.1016/j.jaad.2013.06.036
Counterpoint: Analysis of patient claims data to determine the prevalence of hidradenitis suppurativa in the United States To the Editor: In their article entitled, ‘‘Analysis of patient claims data to determine the prevalence of hidradenitis suppurativa in the United States,’’ Cosmatos et al1 sought to determine the prevalence estimates for hidradenitis suppurativa (HS) using large health care claims databases. Although previous estimates of HS have estimated prevalence rates of 0.00033% to 4%,2 Cosmatos et al1 found a low rate of clinically detected HS, approximately 0.053% in the year of 2007. After obtaining Partners’ institutional review board approval and using retrospective analysis, we sought to determine the prevalence of patients with HS seen at Massachusetts General Hospital (MGH) in the years 2007 and 2011 to determine if the prevalence rates at our institution are similar to those noted by Cosmatos et al,1 and if these rates are changing over time. Included patient populations were as previously described. Of the 429,329 patients seen at MGH in 2007, 494 carried at least 1 of the Current Procedural Terminology codes or diagnosis definitions for inclusion in this study. The total number of patients seen at MGH in 2011 increased to 563,931, 1147 of whom carried a diagnosis code of HS. Prevalence of HS at MGH was calculated to be 0.11% (confidence interval [CI] 0.1-0.13) in 2007, and increased to 0.2% (CI 0.19-0.22) in 2011, a nearly 2-fold increase. In addition, we sought to examine the managing medical practice of the patients with HS identified, and the prevalence of patients with HS seen within each practice. In 2007, the majority of patients with HS were treated in dermatology (n ¼ 98, 20%), general medicine (n ¼ 108, 22%), and the emergency department (n ¼ 168, 34%), with prevalence rates of 0.28% (CI 0.27-0.3), 0.42% (CI 0.4-0.44), and 0.04% (CI 0.04-0.05) within each practice, respectively. The primary treatment clinics of dermatology (n ¼ 176, 15%), general medicine (n ¼ 168, 15%), and the emergency department (n ¼ 287, 25%) for patients with HS remained unchanged in 2011; however, prevalence rates within these clinics increased to 0.37% (CI 0.36-0.39), 0.56% (CI 0.54-0.58), and 0.06% (CI 0.06-0.07), respectively. Prevalence reporting of HS has varied markedly from as low as 1 in 3000 to as high as 4%.2,3 Although our data also demonstrate a relatively low prevalence, it is noteworthy that the prevalence of HS appears to be increasing, as much as 2-fold over the last 4 years. This could be a result of an increase in incidence of HS, which has been reported to be steadily increasing
J AM ACAD DERMATOL
Letters 819
VOLUME 69, NUMBER 5
over the past 4 decades.3 It could also be because of improved coding of the diagnosis, although we did note increases across dermatologists, emergency medicine physicians, and general practitioners. Regardless of cause, the data presented here and in prior studies clearly draw into relief the need for a multidisciplined and collaborative approach to the disease, given the many kinds of practitioners involved. These needs will likely become increasingly apparent as we learn more about HS and its comorbidities and the degree of disease associations inherent to this increasingly prevalent disorder. Sarah Sung, MD, and Alexa B. Kimball, MD, MPH Massachusetts General Hospital, Boston Funding sources: None. Disclosure: Dr Sung is currently a research fellow with partial fellowship funding from the National Psoriasis Foundation and by Janssen. Dr Kimball serves as a consultant and investigator for Abbevie, Janssen, and Amgen. Correspondence to: Alexa B. Kimball, MD, MPH, Clinical Unit for Research Trials and Outcomes in Skin, 50 Staniford St, Suite 240, Boston, MA 02141 E-mail: [email protected] REFERENCES 1. Cosmatos I, Matcho A, Weinstein R, Montgomery MO, Stang P. Analysis of patient claims data to determine the prevalence of hidradenitis suppurativa in the United States. J Am Acad Dermatol 2013;68:412-9. 2. Vazquez BG, Alikhan A, Weaver AL, Wetter DA, Davis MD. Incidence of hidradenitis suppurativa and associated factors: a population-based study of Olmsted County, Minnesota. J Invest Dermatol 2013;133:97-103. 3. Alikhan A, Lynch PJ, Eisen DB. Hidradenitis suppurativa: a comprehensive review. J Am Acad Dermatol 2009;60:539-61. http://dx.doi.org/10.1016/j.jaad.2013.06.043
regardless of where care was provided. The difference in prevalence reported by Sung and Kimball could be a result of differences in coding, methods, and the underlying population reflected in their data. Because we are unsure of the definitions used to identify patients with hidradenitis suppurativa in the Massachusetts General Hospital data, we are not in a position to comment on the impact that different definitions may have had on the differences in prevalence rates. It is also possible that any differences in our studies are a result of regional differences, referral patterns, or other factors, some of which were outlined in their report. For example, Sung and Kimball reported 34% of patients with hidradenitis suppurativa in 2007 were treated in the emergency department, while we reported that only 5% of patients were given a diagnosis there. We were happy to see that Sung and Kimball cited incidence data from Olmsted County,2 which was published after our article. Clearly, the Olmsted County analysis offers some evidence that the number of new cases coming to medical attention appears to be increasing, which would help support their finding of an increase in prevalence. The more databases we interrogate, the more we will learn about the disorder and the people affected by it. We thank Sung and Kimball for reporting their analysis and providing further insights into this population. Irene Cosmatos, MS,a Amy Matcho, BA,a Rachel Weinstein, PhD,a Michael O. Montgomery, MD, CPI,b and Paul Stang, PhDa Janssen Research and Development LLC, Titusville, New Jersey,a and Janssen Services LLC, Horsham, Pennsylvaniab Supported by Janssen Services LLC, Horsham, Pennsylvania. Conflicts of interest: None declared.
Analysis of patient claims data to determine the prevalence of hidradenitis suppurativa in the United States
Correspondence to: Rachel Weinstein, PhD, Janssen Research and Development LLC, 1125 TrentonHarbourton Rd, PO Box 200, Titusville, NJ 08560
To the Editor: We appreciate the comments and the analysis submitted by Sung and Kimball in response to our article, ‘‘Analysis of patient claims data to determine the prevalence of hidradenitis suppurativa in the United States.’’1 Our hidradenitis suppurativa study population was drawn from insurance claims data and reflects the health experience of a commercially insured working population and their families who had continuous coverage throughout 2007. These data likely represent all care provided to a given patient that would have been reimbursed,
E-mail: [email protected] REFERENCES 1. Cosmatos I, Matcho A, Weinstein R, Montgomery MO, Stang P. Analysis of patient claims data to determine the prevalence of hidradenitis suppurativa in the United States. J Am Acad Dermatol 2013;68:412-9. 2. Vazquez BG, Alikhan A, Weaver AL, Wetter DA, Davis MD. Incidence of hidradenitis suppurativa and associated factors: a population-based study of Olmsted County, Minnesota. J Invest Dermatol 2013;133:97-103. http://dx.doi.org/10.1016/j.jaad.2013.06.042
818 Letters
NOVEMBER 2013
complaints. A thorough approach to the informed consent procedure is of the utmost importance. As claimed in our initial article, the patient seeking a cosmetic intervention should be aware the riskbenefit profile of these procedures, including those of a psychosocial type. The patient should also have reasonable expectations about the potential results. Again, probing to find the patient’s motivations, goals, and expectations for the cosmetic procedure is paramount. However, we do disagree with Dr Serna’s claim that cosmetic procedures, as part of dermatologic practice, are medical acts like any other. Cosmetic procedures are generally considered medical enhancement in the field of bioethics, as they are nontherapeutic interventions that improve the appearance of the aging face and skin. In that regard, cosmetic procedures are critically different in our view from traditional, therapeutic medical acts. This disagreement seems to hinge on our respective definitions of medicine. We rely on Callahan’s1 definition of medicine, which centers on the treatment and prevention of disease. For Dr Serna, medical practice seems defined by a particular approach: a detailed history, a physical, informed consent, guidance, and counseling. This is as opposed to a set of predetermined procedures with the aim of healing or preventing illness. This is an interesting debate that will hopefully continue within both the fields of bioethics and dermatology. Again, despite these differences between our views and Dr Serna’s, we are very much in agreement with her central point, and we thank her for her insightful comments. Sotonye Imadojemu, MD, MBE,a and Autumn Fiester, PhDb Departments of Dermatologya and Medical Ethics and Health Policy,b Perelman School of Medicine at the University of Pennsylvania, Philadelphia Funding sources: None. Conflicts of interest: None declared. Correspondence to: Autumn M. Fiester, PhD, Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, 3401 Market St, Suite 320, Philadelphia, PA 19104-3319 E-mail: [email protected] REFERENCE 1. Callahan D. The goals of medicine: setting new priorities. Hastings Cent Rep 1996;26:S1-27. http://dx.doi.org/10.1016/j.jaad.2013.06.036
Counterpoint: Analysis of patient claims data to determine the prevalence of hidradenitis suppurativa in the United States To the Editor: In their article entitled, ‘‘Analysis of patient claims data to determine the prevalence of hidradenitis suppurativa in the United States,’’ Cosmatos et al1 sought to determine the prevalence estimates for hidradenitis suppurativa (HS) using large health care claims databases. Although previous estimates of HS have estimated prevalence rates of 0.00033% to 4%,2 Cosmatos et al1 found a low rate of clinically detected HS, approximately 0.053% in the year of 2007. After obtaining Partners’ institutional review board approval and using retrospective analysis, we sought to determine the prevalence of patients with HS seen at Massachusetts General Hospital (MGH) in the years 2007 and 2011 to determine if the prevalence rates at our institution are similar to those noted by Cosmatos et al,1 and if these rates are changing over time. Included patient populations were as previously described. Of the 429,329 patients seen at MGH in 2007, 494 carried at least 1 of the Current Procedural Terminology codes or diagnosis definitions for inclusion in this study. The total number of patients seen at MGH in 2011 increased to 563,931, 1147 of whom carried a diagnosis code of HS. Prevalence of HS at MGH was calculated to be 0.11% (confidence interval [CI] 0.1-0.13) in 2007, and increased to 0.2% (CI 0.19-0.22) in 2011, a nearly 2-fold increase. In addition, we sought to examine the managing medical practice of the patients with HS identified, and the prevalence of patients with HS seen within each practice. In 2007, the majority of patients with HS were treated in dermatology (n ¼ 98, 20%), general medicine (n ¼ 108, 22%), and the emergency department (n ¼ 168, 34%), with prevalence rates of 0.28% (CI 0.27-0.3), 0.42% (CI 0.4-0.44), and 0.04% (CI 0.04-0.05) within each practice, respectively. The primary treatment clinics of dermatology (n ¼ 176, 15%), general medicine (n ¼ 168, 15%), and the emergency department (n ¼ 287, 25%) for patients with HS remained unchanged in 2011; however, prevalence rates within these clinics increased to 0.37% (CI 0.36-0.39), 0.56% (CI 0.54-0.58), and 0.06% (CI 0.06-0.07), respectively. Prevalence reporting of HS has varied markedly from as low as 1 in 3000 to as high as 4%.2,3 Although our data also demonstrate a relatively low prevalence, it is noteworthy that the prevalence of HS appears to be increasing, as much as 2-fold over the last 4 years. This could be a result of an increase in incidence of HS, which has been reported to be steadily increasing
J AM ACAD DERMATOL
Letters 819
VOLUME 69, NUMBER 5
over the past 4 decades.3 It could also be because of improved coding of the diagnosis, although we did note increases across dermatologists, emergency medicine physicians, and general practitioners. Regardless of cause, the data presented here and in prior studies clearly draw into relief the need for a multidisciplined and collaborative approach to the disease, given the many kinds of practitioners involved. These needs will likely become increasingly apparent as we learn more about HS and its comorbidities and the degree of disease associations inherent to this increasingly prevalent disorder. Sarah Sung, MD, and Alexa B. Kimball, MD, MPH Massachusetts General Hospital, Boston Funding sources: None. Disclosure: Dr Sung is currently a research fellow with partial fellowship funding from the National Psoriasis Foundation and by Janssen. Dr Kimball serves as a consultant and investigator for Abbevie, Janssen, and Amgen. Correspondence to: Alexa B. Kimball, MD, MPH, Clinical Unit for Research Trials and Outcomes in Skin, 50 Staniford St, Suite 240, Boston, MA 02141 E-mail: [email protected] REFERENCES 1. Cosmatos I, Matcho A, Weinstein R, Montgomery MO, Stang P. Analysis of patient claims data to determine the prevalence of hidradenitis suppurativa in the United States. J Am Acad Dermatol 2013;68:412-9. 2. Vazquez BG, Alikhan A, Weaver AL, Wetter DA, Davis MD. Incidence of hidradenitis suppurativa and associated factors: a population-based study of Olmsted County, Minnesota. J Invest Dermatol 2013;133:97-103. 3. Alikhan A, Lynch PJ, Eisen DB. Hidradenitis suppurativa: a comprehensive review. J Am Acad Dermatol 2009;60:539-61. http://dx.doi.org/10.1016/j.jaad.2013.06.043
regardless of where care was provided. The difference in prevalence reported by Sung and Kimball could be a result of differences in coding, methods, and the underlying population reflected in their data. Because we are unsure of the definitions used to identify patients with hidradenitis suppurativa in the Massachusetts General Hospital data, we are not in a position to comment on the impact that different definitions may have had on the differences in prevalence rates. It is also possible that any differences in our studies are a result of regional differences, referral patterns, or other factors, some of which were outlined in their report. For example, Sung and Kimball reported 34% of patients with hidradenitis suppurativa in 2007 were treated in the emergency department, while we reported that only 5% of patients were given a diagnosis there. We were happy to see that Sung and Kimball cited incidence data from Olmsted County,2 which was published after our article. Clearly, the Olmsted County analysis offers some evidence that the number of new cases coming to medical attention appears to be increasing, which would help support their finding of an increase in prevalence. The more databases we interrogate, the more we will learn about the disorder and the people affected by it. We thank Sung and Kimball for reporting their analysis and providing further insights into this population. Irene Cosmatos, MS,a Amy Matcho, BA,a Rachel Weinstein, PhD,a Michael O. Montgomery, MD, CPI,b and Paul Stang, PhDa Janssen Research and Development LLC, Titusville, New Jersey,a and Janssen Services LLC, Horsham, Pennsylvaniab Supported by Janssen Services LLC, Horsham, Pennsylvania. Conflicts of interest: None declared.
Analysis of patient claims data to determine the prevalence of hidradenitis suppurativa in the United States
Correspondence to: Rachel Weinstein, PhD, Janssen Research and Development LLC, 1125 TrentonHarbourton Rd, PO Box 200, Titusville, NJ 08560
To the Editor: We appreciate the comments and the analysis submitted by Sung and Kimball in response to our article, ‘‘Analysis of patient claims data to determine the prevalence of hidradenitis suppurativa in the United States.’’1 Our hidradenitis suppurativa study population was drawn from insurance claims data and reflects the health experience of a commercially insured working population and their families who had continuous coverage throughout 2007. These data likely represent all care provided to a given patient that would have been reimbursed,
E-mail: [email protected] REFERENCES 1. Cosmatos I, Matcho A, Weinstein R, Montgomery MO, Stang P. Analysis of patient claims data to determine the prevalence of hidradenitis suppurativa in the United States. J Am Acad Dermatol 2013;68:412-9. 2. Vazquez BG, Alikhan A, Weaver AL, Wetter DA, Davis MD. Incidence of hidradenitis suppurativa and associated factors: a population-based study of Olmsted County, Minnesota. J Invest Dermatol 2013;133:97-103. http://dx.doi.org/10.1016/j.jaad.2013.06.042