- Email: [email protected]
Hospitalization for severe skin disease improves quality of life in the United Kingdom and the United States: a comparative study
Hospitalization for severe skin disease improves quality of life in the United Kingdom and the United States: A comparative study R. Sowjanya Ayyalaraju, MRCP,a Andrew Y. Finlay, FRCP,a Peter J. Dykes, BSc,a Jennifer T. Trent, MD,b Robert S. Kirsner, MD,b,c and Francisco A. Kerdel, BSc, MBBSb Cardiff, United Kingdom, and Miami, Florida Background: Financial and managerial constraints have resulted in the rationalization of dermatology inpatient services in the United Kingdom and the United States. Therapeutic regimes may vary locally, regionally, and internationally but the clinical outcome of treatment remains the same. Objective: We studied 2 inpatient units: the University of Wales College of Medicine, Cardiff, United Kingdom, and the University of Miami School of Medicine, Miami, Florida, to compare the use and effectiveness of the service provided. Methods: Data were collected prospectively from inpatients during a 12-month period. The Dermatology Life Quality Index was administered on admission and after discharge. Data were recorded about the diagnosis, duration of admission, and referring dermatologist. Results: In all, 295 patients (Cardiff, UK) and 366 patients (Miami, Fla) participated. The average duration of admission in Miami was 6.7 days compared with 14.2 (P ⬍ .0001) in Cardiff. In Miami, the most common reasons necessitating admission were extensive disease (54%), the patient being unwell (18%), photophoresis (14%), outpatient treatment failure (8%), and acute deterioration of disease (4%). In Cardiff, the common reasons were acute deterioration (35%), extensive disease (28%), outpatient treatment failure (22%), and liver biopsy (4%). The most common diagnoses in Cardiff were psoriasis (31%) and eczema (26%). In contrast, the most common diagnoses in Miami, were psoriasis (19%), leg ulcers (17%), and mycosis fungoides (14%). The mean Dermatology Life Quality Index value for all patients decreased after admission in Cardiff (14.9-8.2, P ⬍ .0001) and Miami (12.0-8.5, P ⬍ .0001). Conclusion: Despite the differences in the 2 health care systems, inpatient therapy remains an important and effective therapeutic option in the United States and the United Kingdom. (J Am Acad Dermatol 2003; 49:249-54.)
From the Departments of Dermatology at University of Wales College of Medicine, Cardiff a and University of Miami School of Medicine.b and the Department of Epidemiology and Public Health, University of Miami School of Medicine.c Funding sources: None. Disclosure: Professor Finlay is joint copyright owner of the Dermatology Life Quality Index used in this study. Dr Kirsner was recipient of the Dermatology Foundation Health Care Policy Clinical Career Development Award from 1995 until 1998. The results have been presented at the British Association of Dermatologists Annual Meeting, Edinburgh, United Kingdom, July 1999 (Ayyalaraju RS, Finlay AY, Dykes PJ, Trent JT, Kirsner RS, Kerdel FA. Dermatology inpatient services: a UK/USA comparative study. Br J Dermatol 1999;141[Suppl 55]:79-80), and at the International Dermatoepidemiology Association annual meeting, Chicago, Ill, May 2000, (Ayyalaraju RS, Finlay AY, Dykes PJ, Trent JT, Kirsner RS, Kerdel FA. Dermatology inpatient services: a UK/USA compara-
F
inancial and administrative pressures have resulted in the rationalization of inpatient services in the United States and the United Kingdom. Although dermatology is predominantly an outpatient specialty, there has been a shift away
tive study. J Invest Dermatol 2000;114:886). Some of the data have been presented in the following article: Ayyalaraju RS, Finlay AY. Inpatient dermatology: United Kingdom and United States similarities. Dermatol Clin 2000;18:397-404. Accepted for publication December 2, 2002. Reprint requests: R. Sowjanya Ayyalaraju, MRCP, Department of Dermatology, University Hospital of Wales, Heath Park, Cardiff CF14 4XN, United Kingdom. Copyright © 2003 by the American Academy of Dermatology, Inc. 0190-9622/2003/$30.00 ⫹ 0 doi:10.1067/S0190-9622(03)00897-1
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from inpatient therapy toward outpatient-based treatment, which is viewed to be less expensive. In the United States, the number of academic units with dedicated dermatology beds has decreased, with a corresponding reduction in the number of patients admitted annually.1 In the United States, during the last few decades the payers have placed limitations on financial reimbursement for admissions. Recently in the United Kingdom, an overall reduction in the number of beds for all medical and surgical specialties has resulted in both ward closures and a reduction in bed numbers. This is particularly the case for dermatology. Accompanying these structural and administrative changes in the health services are alterations in the end points of inpatient treatment. Previously, the aim of inpatient care was complete clearance of skin disease. The goal has now changed. The aim is now for patient disease to improve sufficiently to allow outpatient treatment. This reflects changing medical practices and the need to accommodate patients’ personal and employment obligations. Despite this change in emphasis, ultimate treatment outcome aims remain similar. Although the preferred therapeutic regime may vary between differing countries, regions, and even between physicians within the same unit, a subset of patients remains for whom inpatient care remains essential, needing intensive nursing and medical care. For all patients, including this subset, in addition to the improvement in the skin disease, improvement in the patients’ quality of life,2 and levels of stress and anxiety are important outcomes as well.3 The aim of this study was to determine the effect of hospitalization for skin disease on patients’ quality of life at 2 teaching institutions. We assessed 2 teaching hospital inpatient dermatology units: the University Hospital of Wales (UHW), Cardiff, United Kingdom; and the University of Miami School of Medicine (UMSM), Miami, Fla, to determine whether there were any differences in the use and effectiveness of their inpatient service. These 2 hospitals operate in different health care systems in different countries but both have been subject to similar pressures of financial containment.4
METHODS Institutions Cardiff is the capital of Wales, United Kingdom, and has a population of 277,182. The population is predominantly white (93.7%) with minority groups of the Indian subcontinent (2.6%), blacks (1.3%), and Chinese and others (1.8%).5 The inpatient facility at UHW is the only unit for the city of Cardiff, United Kingdom. At the time of the study there were
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16 beds (now reduced to 10), 5 dermatology physicians (consultants), and 4 dermatology trainees (registrars). The city of Miami, Fla, is situated on the east coast of Florida. The city itself has a population of 362,470 and the greater Miami, Fla, area had a population of 3 million. The population is also predominantly white (66.6%) with minority groups of blacks (22.3%), Asians (0.9%), mixed (4.7%), and other (5.4%). Of the total population, 65.8% define themselves as being Latino or Hispanic in origin.6 The inpatient facility at UMSM is the only inpatient dermatology facility in southern Florida. There are 16 beds, 12 attending dermatology (2 full-time inpatient attending) physicians, and 20 dermatology trainees (residents). All patients admitted because of a skin condition to the above centers during a 12-month period were invited to participate in the study. Patients with dermatologic conditions admitted to beds in the same hospital but outside the unit were included in the study but patients without dermatologic conditions occupying beds on the unit were excluded. Patients not originally admitted by the dermatologists were invited to participate on the date of transfer to the dermatology unit. A number of scales have been devised to measure the clinical severity of specific skin diseases objectively but their results may not correlate with the patients’ subjective morbidity.7 Quality of life measures may be used to assess the impact of an illness on patients’ lives, and the response to treatment from the patients’ perspective.8 The Dermatology Life Quality Index (DLQI)9 was used to assess impact of inpatient therapy. The DLQI score ranges from 0 (no impairment) to 30 (maximum impairment). The DLQI has been validated in the United Kingdom,10-13 the United States,14,15 and other countries16,17 in a wide variety of skin diseases. Study design Data were collected prospectively. Patients were administered the DLQI on admission. A second DLQI was mailed to the patient 1 week after discharge with an additional section to obtain patients’ views about their inpatient stay. Questionnaires that were returned up to 4 weeks after discharge were accepted. The duration of admission, the source of referral for admission, the reason for admission, and the diagnosis were recorded for each patient. Data analysis Data were entered into a software spreadsheet (Excel, Microsoft), and means and SD of parameters calculated. Statistical analysis was carried out using software (Unistat for Windows, Version 4.5) in Excel (Microsoft) overlay mode. For independent vari-
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Table I. Most frequent diagnoses on admission in Cardiff, United Kingdom, and Miami, Florida Type of admission
Cardiff, UK
Totals
Psoriasis Atopic eczema Other eczema Leg ulcers Cellulitis Vasculitis Pustular eruption Varicose eczema Urticaria Blistering eruption Others (ⱕ3 per category)
No. of patients
109 60 44 8 8 7 5 5 3 3 43 295
ables the pooled variance t test was used with a level of significance of P ⫽ .05. For paired variables, such as before and after comparisons in the same patients, the paired t test was used at a level of significance of P ⫽ .05.
RESULTS Data were collected for 12 months, from January 1998 (UHW) and from March 1998 (UMSM). In all, 295 (154 men, 141 women) of 341 patients admitted to UHW and 366 (154 men, 212 women) of 508 admitted to UMSM consented to participate in the study. Average age for UHW was 50.6 years (SD ⫽ 20.1) and 58.8 years for UMSM (SD ⫽ 19.3, P ⬍ .0001). There was no significant difference between the mean ages of men and women at UHW and UMSM. The average duration of admission at UMSM was only 6.7 days (SD ⫽ 5.3) compared with 14.2 (SD ⫽ 14.4, P ⬍ .0001) at UHW. If the patients with mycosis fungoides were removed from the calculations, the average duration of admission at UMSM increased to 7.40 (SD ⫽ 5.29, n ⫽ 314). However, the difference between UMSM and UHW was still highly significant (P ⬍ .0001). At UMSM the most common reasons necessitating the admission were extensive disease (199, 54%), the patient being unwell (66, 18%), photophoresis (52, 14%), outpatient treatment failure (29, 8%), and acute deterioration of disease (15, 4%). At UHW, the common reasons were acute deterioration (104, 35%), extensive disease (84, 28%), outpatient treatment failure (65, 22%), and liver biopsy (11, 4%). The most common diagnoses at UHW were psoriasis and eczema, accounting for 72.2% of the total admissions (Table I). In contrast, the most common diagnoses at UMSM were psoriasis, leg ulcers, and mycosis fungoides, accounting for 50% of the total admissions (Table I). The sample numbers for bul-
Miami, Fla
Type of admission
No. of patients
Psoriasis Leg ulcers Mycosis fungoides Immunobullous disorders Cellulitis Atopic eczema Pyoderma gangrenosum Lupus Erythroderma Others (ⱕ6 per category)
71 61 51 18 16 13 13 12 8 103 366
lous disease may be inappropriately low, as these are more likely to be older patients, some of whom may not have been able to give consent to participate in the study. At UHW there is a separate specialist wound-healing unit, accounting for the low incidence of inpatients with leg ulcers compared with UMSM. Though both centers had a long list of less frequent diagnoses, UMSM had a broader range of common diagnoses but with lower individual figures. The admission figures for mycosis fungoides are high in the United States, most patients being admitted for a 2-day overnight admission for photophoresis, which is not in common for this condition in the United Kingdom. The mean DLQI value for all patients decreased after admission at UHW and UMSM (Table II) (P ⬍ .0001). The mean DLQI decreased for the common diseases with the exception of mycosis fungoides. Omitting the patients with mycosis fungoides made little difference to the first and second DLQI mean values (Table II). The mean DLQI scores for all the individual diseases improved after admission with the exception of mycosis fungoides. Psoriasis was the only condition for which disease-specific comparisons could be made between the 2 centers (Fig 1). The majority of patients thought that they benefited from their admission (87% UHW, 92% UMSM), that if they had not been admitted their skin condition would have deteriorated (91% UHW, 86% UMSM), that their admission would help their disease in the future (62% UHW, 80% UMSM), and that they had adequate information about their skin condition and treatment, respectively (68%, 73% UHW; 81%, 89% UMSM).
DISCUSSION Dermatology is predominantly an outpatientbased specialty. In recent years the scope of outpa-
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Table II. Changes in Dermatology Life Quality Index with treatment in Cardiff, United Kingdom, and Miami, Florida
Disease
Cardiff
Miami
All patients Psoriasis Atopic eczema Eczema Leg ulcers Cellulitis All patients All patients less patients with MF Psoriasis Leg ulcers MF Cellulitis Atopic eczema Lupus
Mean first DLQI
SD
Nⴝ
Mean second DLQI
14.9 13.7 18.5 15.9 11.4 13.0 12.0 12.9
7.2 6.8 5.3 5.9 3.8 5.9 6.9 6.5
283 109 60 44 8 8 366 315
14.6 12.8 6.3 13.3 13.9 13.6
6.4 6.8 6.7 6.1 5.0 5.5
71 61 51 16 13 12
SD
Nⴝ
Percentage Change
Pooled varience
8.2 6.2 11.1 8.4 5.3 6.8 8.5 8.9
6.5 5.1 6.9 4.3 3.0 8.2 7.7 7.9
253 99 58 38 7 8 292 241
⫺45.6 ⫺54.6 ⫺40.1 ⫺47.5 ⫺53.5 ⫺48.1 ⫺28.9 ⫺30.7
P ⬍.0001 P ⬍.0001 P ⬍.0001 P ⬍.0001 P ⫽ .0049 P ⫽ .1 P ⬍ .0001 P ⬍ .0001
8.2 8.6 6.2 7.9 5.8 12.2
8.3 7.7 5.8 8.2 4.6 10.6
56 44 51 10 9 12
⫺44.1 ⫺33.3 ⫺1.4 ⫺40.4 ⫺58.5 ⫺10.4
P ⬍ .0001 P ⫽ .003 P ⫽ .94 P ⫽ .07 P ⫽ .001 P ⫽ .69
DLQI, Dermatology Life Quality Index; MF, mycosis fungoides.
Fig 1. Improvement in Dermatology Life Quality Index (DLQI) for psoriasis in Cardiff, UK, and Miami, Fla.
tient care has widened with the advent of cosmetically more acceptable creams, outpatient-based day treatment, phototherapy, and the introduction of systemic immunosuppressive agents. However, inpatient treatment remains an important therapeutic option. Patterns of inpatient care are changing throughout medicine with all specialties trying to minimize the duration of admission. However, subsets of patients exist for whom inpatient care is essential. The reduction of bed numbers is continuing in the United States as in the United Kingdom. Despite the administrative and financial pressures driving these changes, every effort should be made to ensure that the quality of inpatient care is not compromised at the patients’ expense. Even though therapeutic options may vary, paramount importance
must be given to provide the treatment that is most appropriate for the patients. The optimal therapy for a condition is often the subject of debate. Objective assessment of the impact on disease needs to be correlated with the patients’ subjective morbidity. However, the two may not always concur.8 The 2 centers involved in this study operate in different health care systems, with different population bases and treatment practices. Access to the units and reasons for admission varied. Although there were limitations in the disease-specific comparisons as a result of insufficient numbers, there was a significant improvement in quality of life after inpatient care in both units. The majority of patients believed they benefited from their admission, in both the immediate postdischarge period and in the long term. A significant improvement in quality of life after hospitalization has been shown to persist at 3 months postdischarge.18 Inpatient therapy offers a number of advantages. The skin is a very visible organ. Often the symptoms requiring admission are chronic and may result in self-depreciation and low self-esteem.19 Patients who were admitted had higher DLQI scores than their outpatient counterparts, with the highest mean score on the question relating to their symptoms and feelings.3,18,20 The ward environment can provide social support and the opportunity for education from the staff and other patients. Topical therapies may be laborious, time-consuming, messy, and difficult to apply. As a skin condition becomes more extensive, more dedicated
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time and motivation is required with a subsequent decrease in compliance.21 During the period of intensive inpatient therapy, patients are not limited by their usual daily routine or the pressures of work and are assisted by trained staff to effect a rapid clinical improvement. When compared with day treatment, inpatient therapy results in a greater improvement over a shorter period of time.18 However, inpatients had greater disease severity and poorer quality of life at the start of the treatment period.22 We found extent or severity of disease to be the most common reason for admission in both centers. This was also found in a recent audit of admissions in the northwest United Kingdom, with a similar improvement in the quality of life after admission.23 Quality of life after discharge becomes similar to the corresponding outpatient population.18,22 Patients with a good quality of life and psychologic outlook, despite extensive skin disease, may cope better with an outpatient therapeutic regime. Though disease severity is cited as the most common reason for admission, the effect of skin disease on quality of life may be a confounding bias and the true reason for admission. Evidence of a patient’s life being severely affected by his or her skin disease may aid the physician in the decision process over whether to admit a patient. If quality of life measures were used routinely as 1 aspect of recording skin disease status, high scores indicating severe disability would provide an additional alert to a physician over the need for intervention. In the United Kingdom the dermatology units operate in a national health service, which is free for patients and funded by general taxation. In the United States the method of private funding, by traditional fee for service or by health maintenance organizations, may add another factor to the threshold for admission. Once admitted, however, there was no significant difference in the duration of stay, investigation, or treatment between patients on varying financial schemes.24 In recent years, a wealth of new treatment options has been introduced for skin conditions. The majority of these are outpatient-based and have only caused a small expansion in inpatient care.1 The patient profile in this study concurs with most previous publications1,19,21,25,26 but not all,27 reflecting regional variation in the patient population, dermatology practice, and specialty interests. Even though units deal with different patient profiles, the decision-making process on whether to deliver outpatient as opposed to inpatient treatment for an individual is the same. Inpatient therapy remains an important and essential option of dermatologic treatment. In the majority of patients who have been admitted, inpatient care is thought to be the pre-
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ferred therapeutic option even if optimal outpatient facilities were available.23 Since the introduction of patient information services and the ease of access to the Internet, patients can keep up to date with the latest medical advances. In this study the majority of patients had adequate information about their skin condition and treatment, but still believed they wanted more. Though available, information and education may not always lead to greater patient understanding. Physicians no longer dictate therapy but serve as a guide, allowing the patient to make an informed choice of the available therapeutic options. The advancement of dermatology, with continuing research and the advent of newer treatments, will allow the scope of both inpatient and outpatient therapies to broaden further. New treatments are often expensive. Therapies that are most cost-effective are more likely to be adopted, providing that a high standard of quality of care and patient satisfaction is maintained. We thank all the patients who participated in this study in Cardiff, UK, and Miami, Fla. REFERENCES 1. Kirsner RS, Yang DG, Kerdel FA. The changing status of inpatient dermatology at American academic dermatology programs. J Am Acad Dermatol 1999;40:755-7. 2. Kurwa H, Finlay AY. Dermatology inpatient admission greatly improves life quality. Br J Dermatol 1995;133:575-8. 3. Hurwitz D, Kerdel FA, Kirsner RS. Hospitalization for skin disease improves quality of life. Arch Dermatol 1997;133:797-8. 4. Ayyalaraju RS, Finlay AY. Inpatient dermatology: United Kingdom and United States similarities. Dermatol Clin 2000;18:397404. 5. Office of Population and Census Surveys. 1991 census county report: South Glamorgan part 1. London: HMSO Books; 1992. 6. US Census Bureau. Census 2000. Geographic comparison table: race, Hispanic or Latino. Redistricting data, public law 94-171 summary file. Generated by American fact finder. Available from: www.census.gov. Accessed: September 2001. 7. Finlay AY, Khan GK. Dermatology life quality index (DLQI): a simple practical measure for routine clinical use. Clin Exp Dermatol 1994;19:210-6. 8. Jemec GB, Wulf HC. Patient-physician consensus on quality of life in dermatology. Clin Exp Dermatol 1996;21:177-9. 9. Finlay AY. Quality of life measurement in dermatology: a practical guide. Br J Dermatol 1997;136:305-14. 10. Hutchings CV, Shum KW, Gawkrodger DJ. Occupational contact dermatitis has an appreciable impact on quality of life. Contact Dermatitis 2001;45:17-20. 11. Mallon E, Newton JN, Klassen A, Stewart-Brown SL, Ryan TJ, Finlay AY. The quality of life in acne: a comparison with general medical conditions using generic questionnaires. Br J Dermatol 1999;140:672-6. 12. Klassen AF, Newton JN, Mallon E. Measuring quality of life in people referred for specialist care of acne: comparing generic and disease–specific measures. J Am Acad Dermatol 2000;43: 229-33.
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13. Kent G, Al-Abadie M. Factors affecting responses on dermatology life quality index items among vitiligo sufferers. Clin Exp Dermatol 1996;21:330-3. 14. Nichol MB, Margoilies JE, Lippa E, Rowe M, Quell J. The application of multiple quality of life instruments in individuals with mild-to-moderate psoriasis. Pharmacoeconomics 1996;10:64453. 15. Drake L, Prendergast M, Maher R, Korman N, Satoi Y, Beusterien KM, et al. The impact of tacrolimus ointment on health-related quality of life of adult and pediatric patients with atopic dermatitis. J Am Acad Dermatol 2001;44(Suppl):S65-72. 16. Von der Werth JM, Jemec GBE. Morbidity in patients with hidradenitis suppurativa. Br J Dermatol 2001;144:809-13. 17. Lundberg L, Johannesson M, Silverdahl M, Hermansson C, Lindberg M. Health-related quality of life in patients with psoriasis and atopic dermatitis measured with SF-36, DLQI and a subjective measure of disease activity. Acta Derm Venereol 2000;80: 430-4. 18. Vensel E, Hilley T, Trent J, Taylor JR, Kirsner RS, Kerdel FA, et al. Sustained improvement of the quality of life of patients with psoriasis after hospitalization. J Am Acad Dermatol 2000;43:85860. 19. Zachariae R, Zachariae C, Ibsen H, Mortensen JT, Wulf HC. Der-
20.
21. 22. 23. 24.
25.
26.
27.
matology life quality index: data from Danish inpatients and outpatients. Acta Derm Venereol 2000;80:272-6. Zaghloul S, Gonzalez M, Judodihardjo H, Finlay AY. In psoriasis, the greater the disability, the poorer the topical treatment compliance. Br J Dermatol 1999;141:48. Helbing I, Muston HL, Ferguson JE. Audit of admissions to dermatology beds in the northwest. Br J Dermatol 2000;143:42. Haynes M. Examining day-case and inpatient psoriasis care. Professional Nurse 2000;16:893-6. Ginsburg IH. The psychosocial impact of skin disease. Dermatol Clin 1996;14:473-83. Kirsner RS, Hannon W, Agarwal A, Kerdel FA. The effect of health care delivery systems on admissions to and treatment at an inpatient dermatology unit. Dermatol Clin 2000;18:391-5. Ferguson JA, Goldacre MJ, Newton JN, Dawber RP. An epidemiological profile of inpatient workload in dermatology. Clin Exp Dermatol 1992;17:407-12. Munro CS, Lowe JG, Loone P, White MI, Hunter JAA. The value of in-patient dermatology: a survey of in-patients in Scotland and northern England. Br J Dermatol 1999;140:474-9. Garcia-Doval I, Feal C, de la Torre C, Abalde MT, Florez A, Cruces MJ. Inpatient dermatology: characteristics of patients and admissions in a Spanish hospital. J Eur Acad Dermatol Venereol 2002;16:334-8.
CORRECTION Management of Acne: A Report From a Global Alliance to Improve Outcomes in Acne (J Am Acad Dermatol 2003;49:S1-38) In the July supplement to the Journal, an incorrect attribution was made in the footnotes on page S1. The attribution should have read: ⬙Author affiliations are listed on pages 1A and 2A (blind folios) of the supplement.⬙ Production and publication of the supplement was made possible by an educational grant from Galderma. It represents the work and opinions of the guest editors and authors. It was not produced by the American Academy of Dermatology. We regret the error and any confusion that it may have caused.
From the Departments of Dermatology at University of Wales College of Medicine, Cardiff a and University of Miami School of Medicine.b and the Department of Epidemiology and Public Health, University of Miami School of Medicine.c Funding sources: None. Disclosure: Professor Finlay is joint copyright owner of the Dermatology Life Quality Index used in this study. Dr Kirsner was recipient of the Dermatology Foundation Health Care Policy Clinical Career Development Award from 1995 until 1998. The results have been presented at the British Association of Dermatologists Annual Meeting, Edinburgh, United Kingdom, July 1999 (Ayyalaraju RS, Finlay AY, Dykes PJ, Trent JT, Kirsner RS, Kerdel FA. Dermatology inpatient services: a UK/USA comparative study. Br J Dermatol 1999;141[Suppl 55]:79-80), and at the International Dermatoepidemiology Association annual meeting, Chicago, Ill, May 2000, (Ayyalaraju RS, Finlay AY, Dykes PJ, Trent JT, Kirsner RS, Kerdel FA. Dermatology inpatient services: a UK/USA compara-
F
inancial and administrative pressures have resulted in the rationalization of inpatient services in the United States and the United Kingdom. Although dermatology is predominantly an outpatient specialty, there has been a shift away
tive study. J Invest Dermatol 2000;114:886). Some of the data have been presented in the following article: Ayyalaraju RS, Finlay AY. Inpatient dermatology: United Kingdom and United States similarities. Dermatol Clin 2000;18:397-404. Accepted for publication December 2, 2002. Reprint requests: R. Sowjanya Ayyalaraju, MRCP, Department of Dermatology, University Hospital of Wales, Heath Park, Cardiff CF14 4XN, United Kingdom. Copyright © 2003 by the American Academy of Dermatology, Inc. 0190-9622/2003/$30.00 ⫹ 0 doi:10.1067/S0190-9622(03)00897-1
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from inpatient therapy toward outpatient-based treatment, which is viewed to be less expensive. In the United States, the number of academic units with dedicated dermatology beds has decreased, with a corresponding reduction in the number of patients admitted annually.1 In the United States, during the last few decades the payers have placed limitations on financial reimbursement for admissions. Recently in the United Kingdom, an overall reduction in the number of beds for all medical and surgical specialties has resulted in both ward closures and a reduction in bed numbers. This is particularly the case for dermatology. Accompanying these structural and administrative changes in the health services are alterations in the end points of inpatient treatment. Previously, the aim of inpatient care was complete clearance of skin disease. The goal has now changed. The aim is now for patient disease to improve sufficiently to allow outpatient treatment. This reflects changing medical practices and the need to accommodate patients’ personal and employment obligations. Despite this change in emphasis, ultimate treatment outcome aims remain similar. Although the preferred therapeutic regime may vary between differing countries, regions, and even between physicians within the same unit, a subset of patients remains for whom inpatient care remains essential, needing intensive nursing and medical care. For all patients, including this subset, in addition to the improvement in the skin disease, improvement in the patients’ quality of life,2 and levels of stress and anxiety are important outcomes as well.3 The aim of this study was to determine the effect of hospitalization for skin disease on patients’ quality of life at 2 teaching institutions. We assessed 2 teaching hospital inpatient dermatology units: the University Hospital of Wales (UHW), Cardiff, United Kingdom; and the University of Miami School of Medicine (UMSM), Miami, Fla, to determine whether there were any differences in the use and effectiveness of their inpatient service. These 2 hospitals operate in different health care systems in different countries but both have been subject to similar pressures of financial containment.4
METHODS Institutions Cardiff is the capital of Wales, United Kingdom, and has a population of 277,182. The population is predominantly white (93.7%) with minority groups of the Indian subcontinent (2.6%), blacks (1.3%), and Chinese and others (1.8%).5 The inpatient facility at UHW is the only unit for the city of Cardiff, United Kingdom. At the time of the study there were
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16 beds (now reduced to 10), 5 dermatology physicians (consultants), and 4 dermatology trainees (registrars). The city of Miami, Fla, is situated on the east coast of Florida. The city itself has a population of 362,470 and the greater Miami, Fla, area had a population of 3 million. The population is also predominantly white (66.6%) with minority groups of blacks (22.3%), Asians (0.9%), mixed (4.7%), and other (5.4%). Of the total population, 65.8% define themselves as being Latino or Hispanic in origin.6 The inpatient facility at UMSM is the only inpatient dermatology facility in southern Florida. There are 16 beds, 12 attending dermatology (2 full-time inpatient attending) physicians, and 20 dermatology trainees (residents). All patients admitted because of a skin condition to the above centers during a 12-month period were invited to participate in the study. Patients with dermatologic conditions admitted to beds in the same hospital but outside the unit were included in the study but patients without dermatologic conditions occupying beds on the unit were excluded. Patients not originally admitted by the dermatologists were invited to participate on the date of transfer to the dermatology unit. A number of scales have been devised to measure the clinical severity of specific skin diseases objectively but their results may not correlate with the patients’ subjective morbidity.7 Quality of life measures may be used to assess the impact of an illness on patients’ lives, and the response to treatment from the patients’ perspective.8 The Dermatology Life Quality Index (DLQI)9 was used to assess impact of inpatient therapy. The DLQI score ranges from 0 (no impairment) to 30 (maximum impairment). The DLQI has been validated in the United Kingdom,10-13 the United States,14,15 and other countries16,17 in a wide variety of skin diseases. Study design Data were collected prospectively. Patients were administered the DLQI on admission. A second DLQI was mailed to the patient 1 week after discharge with an additional section to obtain patients’ views about their inpatient stay. Questionnaires that were returned up to 4 weeks after discharge were accepted. The duration of admission, the source of referral for admission, the reason for admission, and the diagnosis were recorded for each patient. Data analysis Data were entered into a software spreadsheet (Excel, Microsoft), and means and SD of parameters calculated. Statistical analysis was carried out using software (Unistat for Windows, Version 4.5) in Excel (Microsoft) overlay mode. For independent vari-
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Table I. Most frequent diagnoses on admission in Cardiff, United Kingdom, and Miami, Florida Type of admission
Cardiff, UK
Totals
Psoriasis Atopic eczema Other eczema Leg ulcers Cellulitis Vasculitis Pustular eruption Varicose eczema Urticaria Blistering eruption Others (ⱕ3 per category)
No. of patients
109 60 44 8 8 7 5 5 3 3 43 295
ables the pooled variance t test was used with a level of significance of P ⫽ .05. For paired variables, such as before and after comparisons in the same patients, the paired t test was used at a level of significance of P ⫽ .05.
RESULTS Data were collected for 12 months, from January 1998 (UHW) and from March 1998 (UMSM). In all, 295 (154 men, 141 women) of 341 patients admitted to UHW and 366 (154 men, 212 women) of 508 admitted to UMSM consented to participate in the study. Average age for UHW was 50.6 years (SD ⫽ 20.1) and 58.8 years for UMSM (SD ⫽ 19.3, P ⬍ .0001). There was no significant difference between the mean ages of men and women at UHW and UMSM. The average duration of admission at UMSM was only 6.7 days (SD ⫽ 5.3) compared with 14.2 (SD ⫽ 14.4, P ⬍ .0001) at UHW. If the patients with mycosis fungoides were removed from the calculations, the average duration of admission at UMSM increased to 7.40 (SD ⫽ 5.29, n ⫽ 314). However, the difference between UMSM and UHW was still highly significant (P ⬍ .0001). At UMSM the most common reasons necessitating the admission were extensive disease (199, 54%), the patient being unwell (66, 18%), photophoresis (52, 14%), outpatient treatment failure (29, 8%), and acute deterioration of disease (15, 4%). At UHW, the common reasons were acute deterioration (104, 35%), extensive disease (84, 28%), outpatient treatment failure (65, 22%), and liver biopsy (11, 4%). The most common diagnoses at UHW were psoriasis and eczema, accounting for 72.2% of the total admissions (Table I). In contrast, the most common diagnoses at UMSM were psoriasis, leg ulcers, and mycosis fungoides, accounting for 50% of the total admissions (Table I). The sample numbers for bul-
Miami, Fla
Type of admission
No. of patients
Psoriasis Leg ulcers Mycosis fungoides Immunobullous disorders Cellulitis Atopic eczema Pyoderma gangrenosum Lupus Erythroderma Others (ⱕ6 per category)
71 61 51 18 16 13 13 12 8 103 366
lous disease may be inappropriately low, as these are more likely to be older patients, some of whom may not have been able to give consent to participate in the study. At UHW there is a separate specialist wound-healing unit, accounting for the low incidence of inpatients with leg ulcers compared with UMSM. Though both centers had a long list of less frequent diagnoses, UMSM had a broader range of common diagnoses but with lower individual figures. The admission figures for mycosis fungoides are high in the United States, most patients being admitted for a 2-day overnight admission for photophoresis, which is not in common for this condition in the United Kingdom. The mean DLQI value for all patients decreased after admission at UHW and UMSM (Table II) (P ⬍ .0001). The mean DLQI decreased for the common diseases with the exception of mycosis fungoides. Omitting the patients with mycosis fungoides made little difference to the first and second DLQI mean values (Table II). The mean DLQI scores for all the individual diseases improved after admission with the exception of mycosis fungoides. Psoriasis was the only condition for which disease-specific comparisons could be made between the 2 centers (Fig 1). The majority of patients thought that they benefited from their admission (87% UHW, 92% UMSM), that if they had not been admitted their skin condition would have deteriorated (91% UHW, 86% UMSM), that their admission would help their disease in the future (62% UHW, 80% UMSM), and that they had adequate information about their skin condition and treatment, respectively (68%, 73% UHW; 81%, 89% UMSM).
DISCUSSION Dermatology is predominantly an outpatientbased specialty. In recent years the scope of outpa-
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Table II. Changes in Dermatology Life Quality Index with treatment in Cardiff, United Kingdom, and Miami, Florida
Disease
Cardiff
Miami
All patients Psoriasis Atopic eczema Eczema Leg ulcers Cellulitis All patients All patients less patients with MF Psoriasis Leg ulcers MF Cellulitis Atopic eczema Lupus
Mean first DLQI
SD
Nⴝ
Mean second DLQI
14.9 13.7 18.5 15.9 11.4 13.0 12.0 12.9
7.2 6.8 5.3 5.9 3.8 5.9 6.9 6.5
283 109 60 44 8 8 366 315
14.6 12.8 6.3 13.3 13.9 13.6
6.4 6.8 6.7 6.1 5.0 5.5
71 61 51 16 13 12
SD
Nⴝ
Percentage Change
Pooled varience
8.2 6.2 11.1 8.4 5.3 6.8 8.5 8.9
6.5 5.1 6.9 4.3 3.0 8.2 7.7 7.9
253 99 58 38 7 8 292 241
⫺45.6 ⫺54.6 ⫺40.1 ⫺47.5 ⫺53.5 ⫺48.1 ⫺28.9 ⫺30.7
P ⬍.0001 P ⬍.0001 P ⬍.0001 P ⬍.0001 P ⫽ .0049 P ⫽ .1 P ⬍ .0001 P ⬍ .0001
8.2 8.6 6.2 7.9 5.8 12.2
8.3 7.7 5.8 8.2 4.6 10.6
56 44 51 10 9 12
⫺44.1 ⫺33.3 ⫺1.4 ⫺40.4 ⫺58.5 ⫺10.4
P ⬍ .0001 P ⫽ .003 P ⫽ .94 P ⫽ .07 P ⫽ .001 P ⫽ .69
DLQI, Dermatology Life Quality Index; MF, mycosis fungoides.
Fig 1. Improvement in Dermatology Life Quality Index (DLQI) for psoriasis in Cardiff, UK, and Miami, Fla.
tient care has widened with the advent of cosmetically more acceptable creams, outpatient-based day treatment, phototherapy, and the introduction of systemic immunosuppressive agents. However, inpatient treatment remains an important therapeutic option. Patterns of inpatient care are changing throughout medicine with all specialties trying to minimize the duration of admission. However, subsets of patients exist for whom inpatient care is essential. The reduction of bed numbers is continuing in the United States as in the United Kingdom. Despite the administrative and financial pressures driving these changes, every effort should be made to ensure that the quality of inpatient care is not compromised at the patients’ expense. Even though therapeutic options may vary, paramount importance
must be given to provide the treatment that is most appropriate for the patients. The optimal therapy for a condition is often the subject of debate. Objective assessment of the impact on disease needs to be correlated with the patients’ subjective morbidity. However, the two may not always concur.8 The 2 centers involved in this study operate in different health care systems, with different population bases and treatment practices. Access to the units and reasons for admission varied. Although there were limitations in the disease-specific comparisons as a result of insufficient numbers, there was a significant improvement in quality of life after inpatient care in both units. The majority of patients believed they benefited from their admission, in both the immediate postdischarge period and in the long term. A significant improvement in quality of life after hospitalization has been shown to persist at 3 months postdischarge.18 Inpatient therapy offers a number of advantages. The skin is a very visible organ. Often the symptoms requiring admission are chronic and may result in self-depreciation and low self-esteem.19 Patients who were admitted had higher DLQI scores than their outpatient counterparts, with the highest mean score on the question relating to their symptoms and feelings.3,18,20 The ward environment can provide social support and the opportunity for education from the staff and other patients. Topical therapies may be laborious, time-consuming, messy, and difficult to apply. As a skin condition becomes more extensive, more dedicated
J AM ACAD DERMATOL VOLUME 49, NUMBER 2
time and motivation is required with a subsequent decrease in compliance.21 During the period of intensive inpatient therapy, patients are not limited by their usual daily routine or the pressures of work and are assisted by trained staff to effect a rapid clinical improvement. When compared with day treatment, inpatient therapy results in a greater improvement over a shorter period of time.18 However, inpatients had greater disease severity and poorer quality of life at the start of the treatment period.22 We found extent or severity of disease to be the most common reason for admission in both centers. This was also found in a recent audit of admissions in the northwest United Kingdom, with a similar improvement in the quality of life after admission.23 Quality of life after discharge becomes similar to the corresponding outpatient population.18,22 Patients with a good quality of life and psychologic outlook, despite extensive skin disease, may cope better with an outpatient therapeutic regime. Though disease severity is cited as the most common reason for admission, the effect of skin disease on quality of life may be a confounding bias and the true reason for admission. Evidence of a patient’s life being severely affected by his or her skin disease may aid the physician in the decision process over whether to admit a patient. If quality of life measures were used routinely as 1 aspect of recording skin disease status, high scores indicating severe disability would provide an additional alert to a physician over the need for intervention. In the United Kingdom the dermatology units operate in a national health service, which is free for patients and funded by general taxation. In the United States the method of private funding, by traditional fee for service or by health maintenance organizations, may add another factor to the threshold for admission. Once admitted, however, there was no significant difference in the duration of stay, investigation, or treatment between patients on varying financial schemes.24 In recent years, a wealth of new treatment options has been introduced for skin conditions. The majority of these are outpatient-based and have only caused a small expansion in inpatient care.1 The patient profile in this study concurs with most previous publications1,19,21,25,26 but not all,27 reflecting regional variation in the patient population, dermatology practice, and specialty interests. Even though units deal with different patient profiles, the decision-making process on whether to deliver outpatient as opposed to inpatient treatment for an individual is the same. Inpatient therapy remains an important and essential option of dermatologic treatment. In the majority of patients who have been admitted, inpatient care is thought to be the pre-
Ayyalaraju et al 253
ferred therapeutic option even if optimal outpatient facilities were available.23 Since the introduction of patient information services and the ease of access to the Internet, patients can keep up to date with the latest medical advances. In this study the majority of patients had adequate information about their skin condition and treatment, but still believed they wanted more. Though available, information and education may not always lead to greater patient understanding. Physicians no longer dictate therapy but serve as a guide, allowing the patient to make an informed choice of the available therapeutic options. The advancement of dermatology, with continuing research and the advent of newer treatments, will allow the scope of both inpatient and outpatient therapies to broaden further. New treatments are often expensive. Therapies that are most cost-effective are more likely to be adopted, providing that a high standard of quality of care and patient satisfaction is maintained. We thank all the patients who participated in this study in Cardiff, UK, and Miami, Fla. REFERENCES 1. Kirsner RS, Yang DG, Kerdel FA. The changing status of inpatient dermatology at American academic dermatology programs. J Am Acad Dermatol 1999;40:755-7. 2. Kurwa H, Finlay AY. Dermatology inpatient admission greatly improves life quality. Br J Dermatol 1995;133:575-8. 3. Hurwitz D, Kerdel FA, Kirsner RS. Hospitalization for skin disease improves quality of life. Arch Dermatol 1997;133:797-8. 4. Ayyalaraju RS, Finlay AY. Inpatient dermatology: United Kingdom and United States similarities. Dermatol Clin 2000;18:397404. 5. Office of Population and Census Surveys. 1991 census county report: South Glamorgan part 1. London: HMSO Books; 1992. 6. US Census Bureau. Census 2000. Geographic comparison table: race, Hispanic or Latino. Redistricting data, public law 94-171 summary file. Generated by American fact finder. Available from: www.census.gov. Accessed: September 2001. 7. Finlay AY, Khan GK. Dermatology life quality index (DLQI): a simple practical measure for routine clinical use. Clin Exp Dermatol 1994;19:210-6. 8. Jemec GB, Wulf HC. Patient-physician consensus on quality of life in dermatology. Clin Exp Dermatol 1996;21:177-9. 9. Finlay AY. Quality of life measurement in dermatology: a practical guide. Br J Dermatol 1997;136:305-14. 10. Hutchings CV, Shum KW, Gawkrodger DJ. Occupational contact dermatitis has an appreciable impact on quality of life. Contact Dermatitis 2001;45:17-20. 11. Mallon E, Newton JN, Klassen A, Stewart-Brown SL, Ryan TJ, Finlay AY. The quality of life in acne: a comparison with general medical conditions using generic questionnaires. Br J Dermatol 1999;140:672-6. 12. Klassen AF, Newton JN, Mallon E. Measuring quality of life in people referred for specialist care of acne: comparing generic and disease–specific measures. J Am Acad Dermatol 2000;43: 229-33.
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13. Kent G, Al-Abadie M. Factors affecting responses on dermatology life quality index items among vitiligo sufferers. Clin Exp Dermatol 1996;21:330-3. 14. Nichol MB, Margoilies JE, Lippa E, Rowe M, Quell J. The application of multiple quality of life instruments in individuals with mild-to-moderate psoriasis. Pharmacoeconomics 1996;10:64453. 15. Drake L, Prendergast M, Maher R, Korman N, Satoi Y, Beusterien KM, et al. The impact of tacrolimus ointment on health-related quality of life of adult and pediatric patients with atopic dermatitis. J Am Acad Dermatol 2001;44(Suppl):S65-72. 16. Von der Werth JM, Jemec GBE. Morbidity in patients with hidradenitis suppurativa. Br J Dermatol 2001;144:809-13. 17. Lundberg L, Johannesson M, Silverdahl M, Hermansson C, Lindberg M. Health-related quality of life in patients with psoriasis and atopic dermatitis measured with SF-36, DLQI and a subjective measure of disease activity. Acta Derm Venereol 2000;80: 430-4. 18. Vensel E, Hilley T, Trent J, Taylor JR, Kirsner RS, Kerdel FA, et al. Sustained improvement of the quality of life of patients with psoriasis after hospitalization. J Am Acad Dermatol 2000;43:85860. 19. Zachariae R, Zachariae C, Ibsen H, Mortensen JT, Wulf HC. Der-
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CORRECTION Management of Acne: A Report From a Global Alliance to Improve Outcomes in Acne (J Am Acad Dermatol 2003;49:S1-38) In the July supplement to the Journal, an incorrect attribution was made in the footnotes on page S1. The attribution should have read: ⬙Author affiliations are listed on pages 1A and 2A (blind folios) of the supplement.⬙ Production and publication of the supplement was made possible by an educational grant from Galderma. It represents the work and opinions of the guest editors and authors. It was not produced by the American Academy of Dermatology. We regret the error and any confusion that it may have caused.