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The changing status of inpatient dermatology at American academic dermatology programs
SPECIAL ARTICLE The changing status of inpatient dermatology at American academic dermatology programs Robert S. Kirsner, MD,a,b Doris G. Yang, MD,a and Francisco A. Kerdel, BSc, MBBSa Miami, Florida Background: Changes in health care delivery financing such as the adoption of the diagnosis-related groups (DRG) in 1983 has affected inpatient services of dermatology programs across the United States. Objective: The purpose of this study was to define the present status of inpatient dermatology at academic medical centers compared with 1982. Methods: Questionnaires inquiring about the state of inpatient service were sent to the chairpersons of each dermatology residency program in the United States. Results: Of the 71 programs responding, 79% reported a reduction in inpatient activity. Nearly half of the dermatology programs with dedicated dermatology beds in 1982 reported not continuing to have these in 1997 (41 to 24). The average number of patients admitted for skin disease decreased from 119 in 1982 to 36.5 in 1997, and the average daily census decreased from 8.9 to 2.2. Conclusion: There has been a decline in the number of patients hospitalized by academic dermatology departments and a shift of some patients hospitalized to beds where the attending is other than a dermatologist. (J Am Acad Dermatol 1999;40:755-7.)
Diagnosis-related groups (DRG) were originated to provide product definitions for the output of hospitals and were adopted by Medicare in 1983 to serve as a basis for a prospective payment system (PPS) for US hospitals. Subsequently many other payers of hospital care have adopted the DRG system.1 These and other changes in the health care delivery as well as advances in outpatient therapy have had a profound effect on the inpatient services of all medical specialties. It has been observed that some academic dermatology programs have decreased the number of hospitalized patients or have discontinued hospitalizing dermatology patients.2 The present trend
From the Departments of Dermatology and Cutaneous Surgery,a and Epidemiology and Public Health,b University of Miami School of Medicine. Dr Kirsner is a recipient of the Dermatology Foundation’s Clinical Career Development Award in Health Care Policy supported by the Leaders Society. Reprint requests: Robert S. Kirsner, MD, Cedars Medical Center, University of Miami, 1400 NW 12th Ave, 6 S Derm, Miami, FL 33136. Copyright © 1999 by the American Academy of Dermatology, Inc. 0190-9622/99/$8.00 + 0 16/1/97318
seems to be one of “closing shop.” The purpose of this study was to determine the present status of inpatient dermatology and compare it with 1982, the year before adoption of the DRG system. Defining the current state of inpatient dermatology at academic medical centers might be of value for future strategies. METHODS A list of the dermatology residency programs (1997) within the United States was obtained from the American Academy of Dermatology. Questionnaires were faxed to the chairpersons of those programs. Each chairperson was asked a series of questions regarding the status of their inpatient dermatology service as well as demographic data regarding their program such as the number of residents in training and full-time clinical faculty. These questions specifically focused on whether or not there had been changes in inpatient activity as compared with 1982 and the possible reasons for any such changes. After 2 to 3 weeks a second survey was sent to the nonrespondents, followed by a phone call. Pearson Correlation Coefficient was used to determine whether any association exists between the size of the residency programs and the number of patients admitted.
755
756 Kirsner, Yang, and Kerdel
Journal of the American Academy of Dermatology May 1999
Table I. Responsibility for the care of hospitalized dermatology patients 1982
Rotating attending dermatologist Patient’s dermatologist Designated attending dermatologist (> 6 mos) Other physician with dermatologist acting as consultant Others No answer
1997
45 (63%)
41 (58%)
13 (18%) 11 (15.5%)
13 (18%) 13 (18%)
11 (15.5%)
23 (32.4%)
3 (4%) 6 (8.5%)
2 (3%) 3 (4%)
Fig 1. Percentage of patients admitted for each specific skin disorder in 1982 and 1997.
RESULTS
Of the 101 dermatology residency programs in the United States listed in the American Academy of Dermatology, surveys were sent to the chairpersons of 97 programs. The National Institutes of Health was not included, nor were 3 other programs that could not be reached. Of the 97 programs, 71 responded (response rate 73%). Of these respondents, 79% reported a reduction in inpatient activity. The number of institutions with dedicated dermatology beds decreased from 41 (58%) in 1982 to 24 (34%) in 1997. The average number of patients admitted annually for dermatologic conditions decreased from 119 ± 22 SE to 36.5 ± 14 SE, and the average daily census also decreased from 8.9 to 2.2. The mechanism through which programs care for hospitalized dermatology patients was also evaluated. Forty-one (58%) of the current programs have a rotating attending dermatologist compared with 45 (63%) in 1982 as the person responsible for the care of the hospitalized patients with skin diseases. Many programs however now rely on other physicians (nondermatologists) to care for inpatients. The number of programs doing so has increased from 11 (15.5%) to 23 (32.4%) (Table I). Despite a decrease in dermatology inpatient activity, advanced therapeutic regimens used in treating inpatients were identified. In 1997, 87% centers had inpatient Goeckerman therapy, 38% had extracorporeal photochemotherapy, 72% performed skin grafts, 83% had patients treated with pulse steroids or pulse immunosuppressants, and
Table II. Implicated factors leading to reduced inpatient activity %
Problems with DRGs Insurance issues Too few patients for admission Better outpatient treatment Lack of interest Inadequate facilities Inadequate manpower
66 41 41 30 7 4 2
66% administered intravenous immunoglobulin treatment. The types of diseases for which patients are hospitalized have not changed significantly, but the relative frequency of their diseases has (Fig 1). Patients with psoriasis, as a percentage of all patients admitted, decreased from 46.5% to 32.7%, whereas hospitalized patients with malignancy and bullous diseases increased from 5.5% to 8.8% and 9.5% to 18.3% respectively. The average number of residents in training in each program increased only slightly from 8.18 in 1982 to 9.02 in 1997, whereas the average number of full-time clinical faculty increased from 4.86 in 1982 to 7.84 in 1997. There was no correlation between the size of the residency training program and the number of patients hospitalized. Of respondents, 66% reported that problems adhering to the DRG system was an important factor in the reduction of admissions. Other factors given were insurance issues (41%), too few patients for admission (41%), and better outpatient treatment (30%; Table II).
Journal of the American Academy of Dermatology Volume 40, Number 5, Part 1
DISCUSSION
We report a dramatic decrease in the number of hospitalized dermatology patients at academic medical centers. Of the respondents, 79% reported a reduction in inpatient activity. The average number of patients admitted for skin disease decreased as did the average daily census. One of the reasons for the reduced admissions may be because of implementation of the DRG system. The DRG system results in a reduction of lengths of stay often requiring different end points for hospitalization than in the past. For example, patients often complete a course of intravenous antibiotics at home whereas in the past the complete course was administered during hospitalization. In a similar fashion hospital end points, for example, for psoriasis may no longer be complete clearing of disease but only improvement, a hospital end point academic dermatologists may not be used to or comfortable with. The emergence of HMOs as an important health care delivery system may have led to reduced number of patients admitted, but this may be a function of patient selection.3 Nearly half of the dermatology programs with dedicated dermatology beds had discontinued their inpatient service completely between the years compared (41 in 1982 to 24 in 1997). Although limited by recall bias this survey confirms the observation that changes in the health care delivery have forced dermatology to exit the hospital wards in many parts of the country.4 Despite this, many centers reported offering advanced therapeutic modalities for inpatients such as light treatment, photopheresis, skin grafting, pulse steroids/immunosuppressants, and pulse intravenous immunoglobulins. It appears that a select minority of patients receive these modalities. New advanced outpatient therapies are also available. As was the case in 1982, most programs now rely on a rotating attending dermatologist as the person responsible for the care of hospitalized patients with skin disease (Table I). However the most dramatic adaptation reported, in addition to reducing the number of admissions, was to shift care to nondermatologists, reflected by the doubling in the number of other physicians taking
Kirsner, Yang, and Kerdel 757 responsibility for inpatients with the dermatologist acting as a consultant (11 [15.5%] in 1982 to 23 [32.4%] in 1997). Whether quality of hospital care has changed in these situations is not known. Although the types of conditions requiring admission has not changed significantly, their relative frequency has (Fig 1). The reported decrease in the percentage of psoriatic patients may be a result of the availability of more effective outpatient regimens for this condition. The increase in the percentage of patients with malignancy and bullous diseases may be attributed to longer life span or advanced inpatient therapies. The average number of residents in training increased slightly from 8.18 in 1982 to 9.02 in 1997. Interestingly, there was an increase in the average number of full-time clinical faculty from 4.86 to 7.84. Both of these suggest that manpower is not a cause for reduction of inpatient activity, although reduced training in the care of hospitalized patients with severe skin disease is a consequence. The factors that have been identified as a cause for the reduced admissions are shown in Table II. As mentioned, the availability of newer and better outpatient regimens was reported as important with the potential outcome being fewer patients requiring admission. In addition, often patients may be admitted to a nondermatologist with a dermatologist serving as a consultant. Fiscal issues such as problems with adhering to the reduced lengths of stays implied by the DRG system and problems with insurers may have also led to decreased inpatient activity. When fiscal issues are involved, unfortunately for patients with severe skin disease, the decision to be hospitalized may not be controlled by disease extent or severity but by nonclinical factors. REFERENCES 1. Fetter RB. Diagnosis related groups: understanding hospital performance. Interfaces 1991;21:1 Jan-Feb: 6-26. 2. Kirsner RS, Freedberg I, Kerdel FA. Inpatient dermatology: Should we let it die or should we work towards regional centers? J Am Acad Dermatol 1997;36:276-8. 3. Morgan RO, Vernig BA, DeVito CA, Persily NA. The Medicare-HMO revolving door: the healthy go in and the sick go out. N Engl J Med 1997;337:169-75. 4. Lynch PJ. Academic dermatology in a changing health care environment. Arch Dermatol 1997;133:509-13.
Diagnosis-related groups (DRG) were originated to provide product definitions for the output of hospitals and were adopted by Medicare in 1983 to serve as a basis for a prospective payment system (PPS) for US hospitals. Subsequently many other payers of hospital care have adopted the DRG system.1 These and other changes in the health care delivery as well as advances in outpatient therapy have had a profound effect on the inpatient services of all medical specialties. It has been observed that some academic dermatology programs have decreased the number of hospitalized patients or have discontinued hospitalizing dermatology patients.2 The present trend
From the Departments of Dermatology and Cutaneous Surgery,a and Epidemiology and Public Health,b University of Miami School of Medicine. Dr Kirsner is a recipient of the Dermatology Foundation’s Clinical Career Development Award in Health Care Policy supported by the Leaders Society. Reprint requests: Robert S. Kirsner, MD, Cedars Medical Center, University of Miami, 1400 NW 12th Ave, 6 S Derm, Miami, FL 33136. Copyright © 1999 by the American Academy of Dermatology, Inc. 0190-9622/99/$8.00 + 0 16/1/97318
seems to be one of “closing shop.” The purpose of this study was to determine the present status of inpatient dermatology and compare it with 1982, the year before adoption of the DRG system. Defining the current state of inpatient dermatology at academic medical centers might be of value for future strategies. METHODS A list of the dermatology residency programs (1997) within the United States was obtained from the American Academy of Dermatology. Questionnaires were faxed to the chairpersons of those programs. Each chairperson was asked a series of questions regarding the status of their inpatient dermatology service as well as demographic data regarding their program such as the number of residents in training and full-time clinical faculty. These questions specifically focused on whether or not there had been changes in inpatient activity as compared with 1982 and the possible reasons for any such changes. After 2 to 3 weeks a second survey was sent to the nonrespondents, followed by a phone call. Pearson Correlation Coefficient was used to determine whether any association exists between the size of the residency programs and the number of patients admitted.
755
756 Kirsner, Yang, and Kerdel
Journal of the American Academy of Dermatology May 1999
Table I. Responsibility for the care of hospitalized dermatology patients 1982
Rotating attending dermatologist Patient’s dermatologist Designated attending dermatologist (> 6 mos) Other physician with dermatologist acting as consultant Others No answer
1997
45 (63%)
41 (58%)
13 (18%) 11 (15.5%)
13 (18%) 13 (18%)
11 (15.5%)
23 (32.4%)
3 (4%) 6 (8.5%)
2 (3%) 3 (4%)
Fig 1. Percentage of patients admitted for each specific skin disorder in 1982 and 1997.
RESULTS
Of the 101 dermatology residency programs in the United States listed in the American Academy of Dermatology, surveys were sent to the chairpersons of 97 programs. The National Institutes of Health was not included, nor were 3 other programs that could not be reached. Of the 97 programs, 71 responded (response rate 73%). Of these respondents, 79% reported a reduction in inpatient activity. The number of institutions with dedicated dermatology beds decreased from 41 (58%) in 1982 to 24 (34%) in 1997. The average number of patients admitted annually for dermatologic conditions decreased from 119 ± 22 SE to 36.5 ± 14 SE, and the average daily census also decreased from 8.9 to 2.2. The mechanism through which programs care for hospitalized dermatology patients was also evaluated. Forty-one (58%) of the current programs have a rotating attending dermatologist compared with 45 (63%) in 1982 as the person responsible for the care of the hospitalized patients with skin diseases. Many programs however now rely on other physicians (nondermatologists) to care for inpatients. The number of programs doing so has increased from 11 (15.5%) to 23 (32.4%) (Table I). Despite a decrease in dermatology inpatient activity, advanced therapeutic regimens used in treating inpatients were identified. In 1997, 87% centers had inpatient Goeckerman therapy, 38% had extracorporeal photochemotherapy, 72% performed skin grafts, 83% had patients treated with pulse steroids or pulse immunosuppressants, and
Table II. Implicated factors leading to reduced inpatient activity %
Problems with DRGs Insurance issues Too few patients for admission Better outpatient treatment Lack of interest Inadequate facilities Inadequate manpower
66 41 41 30 7 4 2
66% administered intravenous immunoglobulin treatment. The types of diseases for which patients are hospitalized have not changed significantly, but the relative frequency of their diseases has (Fig 1). Patients with psoriasis, as a percentage of all patients admitted, decreased from 46.5% to 32.7%, whereas hospitalized patients with malignancy and bullous diseases increased from 5.5% to 8.8% and 9.5% to 18.3% respectively. The average number of residents in training in each program increased only slightly from 8.18 in 1982 to 9.02 in 1997, whereas the average number of full-time clinical faculty increased from 4.86 in 1982 to 7.84 in 1997. There was no correlation between the size of the residency training program and the number of patients hospitalized. Of respondents, 66% reported that problems adhering to the DRG system was an important factor in the reduction of admissions. Other factors given were insurance issues (41%), too few patients for admission (41%), and better outpatient treatment (30%; Table II).
Journal of the American Academy of Dermatology Volume 40, Number 5, Part 1
DISCUSSION
We report a dramatic decrease in the number of hospitalized dermatology patients at academic medical centers. Of the respondents, 79% reported a reduction in inpatient activity. The average number of patients admitted for skin disease decreased as did the average daily census. One of the reasons for the reduced admissions may be because of implementation of the DRG system. The DRG system results in a reduction of lengths of stay often requiring different end points for hospitalization than in the past. For example, patients often complete a course of intravenous antibiotics at home whereas in the past the complete course was administered during hospitalization. In a similar fashion hospital end points, for example, for psoriasis may no longer be complete clearing of disease but only improvement, a hospital end point academic dermatologists may not be used to or comfortable with. The emergence of HMOs as an important health care delivery system may have led to reduced number of patients admitted, but this may be a function of patient selection.3 Nearly half of the dermatology programs with dedicated dermatology beds had discontinued their inpatient service completely between the years compared (41 in 1982 to 24 in 1997). Although limited by recall bias this survey confirms the observation that changes in the health care delivery have forced dermatology to exit the hospital wards in many parts of the country.4 Despite this, many centers reported offering advanced therapeutic modalities for inpatients such as light treatment, photopheresis, skin grafting, pulse steroids/immunosuppressants, and pulse intravenous immunoglobulins. It appears that a select minority of patients receive these modalities. New advanced outpatient therapies are also available. As was the case in 1982, most programs now rely on a rotating attending dermatologist as the person responsible for the care of hospitalized patients with skin disease (Table I). However the most dramatic adaptation reported, in addition to reducing the number of admissions, was to shift care to nondermatologists, reflected by the doubling in the number of other physicians taking
Kirsner, Yang, and Kerdel 757 responsibility for inpatients with the dermatologist acting as a consultant (11 [15.5%] in 1982 to 23 [32.4%] in 1997). Whether quality of hospital care has changed in these situations is not known. Although the types of conditions requiring admission has not changed significantly, their relative frequency has (Fig 1). The reported decrease in the percentage of psoriatic patients may be a result of the availability of more effective outpatient regimens for this condition. The increase in the percentage of patients with malignancy and bullous diseases may be attributed to longer life span or advanced inpatient therapies. The average number of residents in training increased slightly from 8.18 in 1982 to 9.02 in 1997. Interestingly, there was an increase in the average number of full-time clinical faculty from 4.86 to 7.84. Both of these suggest that manpower is not a cause for reduction of inpatient activity, although reduced training in the care of hospitalized patients with severe skin disease is a consequence. The factors that have been identified as a cause for the reduced admissions are shown in Table II. As mentioned, the availability of newer and better outpatient regimens was reported as important with the potential outcome being fewer patients requiring admission. In addition, often patients may be admitted to a nondermatologist with a dermatologist serving as a consultant. Fiscal issues such as problems with adhering to the reduced lengths of stays implied by the DRG system and problems with insurers may have also led to decreased inpatient activity. When fiscal issues are involved, unfortunately for patients with severe skin disease, the decision to be hospitalized may not be controlled by disease extent or severity but by nonclinical factors. REFERENCES 1. Fetter RB. Diagnosis related groups: understanding hospital performance. Interfaces 1991;21:1 Jan-Feb: 6-26. 2. Kirsner RS, Freedberg I, Kerdel FA. Inpatient dermatology: Should we let it die or should we work towards regional centers? J Am Acad Dermatol 1997;36:276-8. 3. Morgan RO, Vernig BA, DeVito CA, Persily NA. The Medicare-HMO revolving door: the healthy go in and the sick go out. N Engl J Med 1997;337:169-75. 4. Lynch PJ. Academic dermatology in a changing health care environment. Arch Dermatol 1997;133:509-13.