0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Research Letter |

Quality of Dermatologic Care Delivered by Physician Assistants: An Analysis of Prescribing Behavior for the Combination Antifungal Agent Clotrimazole-Betamethasone FREE

Anita Satyaprakash, BS; Rajesh Balkrishnan, PhD; Fabian T. Camacho, MS; Sujata S. Jayawant, MS; Alan B. Fleischer Jr, MD; Steven R. Feldman, MD, PhD
Arch Dermatol. 2007;143(12):1589-1603. doi:10.1001/archderm.143.12.1591-b.
Text Size: A A A
Published online

Most patients with skin disease do not see a dermatologist.1 In an effort to better meet patients' needs, there is growing use of physician assistants in dermatology.2 The quality of dermatologic care offered by physician assistants is not well characterized. Our group has used clotrimazole-betamethasone dipropionate prescribing behavior as a measure of the quality of dermatologic services provided by practitioners in different specialties.3,4 Herein, to assess the quality of dermatologic care provided by physician assistants, we analyze clotrimazole-betamethasone prescribing behavior of 4 practitioner groups: dermatologists, dermatology physician assistants, primary care providers, and primary care physician assistants.

Data on the use of the combination antifungal agent clotrimazole-betamethasone were obtained from the 1995-2004 National Ambulatory Medical Care Survey5 and analyzed as previously described.3,4 First, we identified the 5 most common diagnoses that were treated with clotrimazole-betamethasone at least some of the time. Then we determined the percentage of visits for those 5 conditions at which clotrimazole-betamethasone was prescribed. Each patient visit was analyzed according to whether a physician, physician assistant, or both were involved in the visit. Direct supervision is defined as visits where patients were seen by both the physician assistant and the physician.

There were an estimated 301 million outpatient visits for inflammatory or fungal skin conditions for which clotrimazole-betamethasone was sometimes prescribed. Most of the visits for these skin diseases were to primary care physicians (44.7%) and dermatologists (38.8%) (Table 1). Other subspecialty physicians accounted for 16.5% of these visits. In 95% of the visits, a physician was the only provider to see the patient. Both a physician and physician assistant were seen during 1.4% of these visits, and a physician assistant was the sole health care provider during 0.9% of visits.

Table Graphic Jump LocationTable 1. Proportion of Outpatient Visits Managed by Different Specialties for Inflammatory or Fungal Skin Conditions for Which Clotrimazole-Betamethasone Was Sometimes Prescribeda

In multivariate logistic regression analyses of clotrimazole-betamethasone prescriptions, primary care providers prescribed clotrimazole-betamethasone at a rate of 4.9% compared with the dermatologist prescription rate of 0.2%; other subspecialty physicians prescribed the drug at a rate of 1.7%. Clotrimazole-betamethasone was more likely to be prescribed at visits to physician assistants (regardless of specialty) when the physician assistant was the sole provider of dermatologic care vs when the physician assistant was under direct supervision by a physician (odds ratio [OR], 4.3; 95% confidence interval [CI], 0.7-25.6 vs OR, 1.8; 95% CI, 0.4-8.0) (Table 2).

Table Graphic Jump LocationTable 2. Multivariate Analysis Examining Predictors of Clotrimazole-Betamethasone Prescriptiona

The highest rate of clotrimazole-betamethasone use, 16.9%, was by physician assistants practicing in primary care and seeing patients without direct supervision. Physician assistants practicing under dermatologists and seeing patients without direct supervision prescribed clotrimazole-betamethasone at a much lower rate of 3.8% compared with their primary care counterparts. For both primary care physician assistants and dermatology physician assistants, however, seeing patients under physician supervision decreased the rate of clotrimazole-betamethasone prescription to 8.3% and 1.1%, respectively.

Physician assistants practicing in a dermatology office are much less likely to prescribe clotrimazole-betamethasone than are physician assistants working in primary care specialties. Even without direct supervision, dermatology physician assistants' clotrimazole-betamethasone prescribing behavior is no worse than that of primary care physicians. When supervised by a dermatologist, physician assistants' clotrimazole-betamethasone prescribing behavior comes closer to that of the dermatologists.

When clotrimazole-betamethasone prescribing behavior is used as the measure of quality, physician assistants provide dermatologic care more comparable to that of primary care physicians than to that of dermatologists. However, these are pilot data that only begin to assess a very complex issue. The growing demand for dermatologic care and the limited availability of dermatologists require that additional attention be paid to the quality of care offered by physician extenders.6

ARTICLE INFORMATION

Correspondence: Dr Feldman, Department of Dermatology, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157-1071 (sfeldman@wfubmc.edu).

Financial Disclosure: None reported.

Feldman  SRFleischer  AB  JrWilliford  PMWhite  RByington  R Increasing utilization of dermatologists by managed care: an analysis of the National Ambulatory Medical Care survey, 1990-1994. J Am Acad Dermatol 1997;37 (5 pt 1) 784- 788
PubMed Link to Article
Clark  ARMonroe  JRFeldman  SRFleischer  AB  JrHauser  DAHinds  MA The emerging role of physician assistants in the delivery of dermatologic health care. Dermatol Clin 2000;18 (2) 297- 302
PubMed
Smith  ESFleischer  AB  JrFeldman  SR Nondermatologists are more likely than dermatologists to prescribe antifungal/corticosteroid products: an analysis of office visits for cutaneous fungal infections, 1990-1994. J Am Acad Dermatol 1998;39 (1) 43- 47
PubMed Link to Article
Balkrishnan  RCook  JMShaffer  MPSaltzberg  FBFeldman  SRFleischer  AB  Jr Analysis of factors associated with prescription of a potentially inappropriate combination dermatological medication among US outpatient physicians. Pharmacoepidemiol Drug Saf 2004;13 (3) 133- 138
PubMed Link to Article
Centers for Disease Control and Prevention; National Center for Health Statistics, National Ambulatory Medical Care Survey. http://www.cdc.gov/nchs/about/major/ahcd/namcsdes.htm[registration required]Accessed August 2, 2007
Resneck  J  JrKimball  AB The dermatology workforce shortage. J Am Acad Dermatol 2004;50 (1) 50- 54
PubMed Link to Article

Figures

Tables

Table Graphic Jump LocationTable 1. Proportion of Outpatient Visits Managed by Different Specialties for Inflammatory or Fungal Skin Conditions for Which Clotrimazole-Betamethasone Was Sometimes Prescribeda
Table Graphic Jump LocationTable 2. Multivariate Analysis Examining Predictors of Clotrimazole-Betamethasone Prescriptiona

References

Feldman  SRFleischer  AB  JrWilliford  PMWhite  RByington  R Increasing utilization of dermatologists by managed care: an analysis of the National Ambulatory Medical Care survey, 1990-1994. J Am Acad Dermatol 1997;37 (5 pt 1) 784- 788
PubMed Link to Article
Clark  ARMonroe  JRFeldman  SRFleischer  AB  JrHauser  DAHinds  MA The emerging role of physician assistants in the delivery of dermatologic health care. Dermatol Clin 2000;18 (2) 297- 302
PubMed
Smith  ESFleischer  AB  JrFeldman  SR Nondermatologists are more likely than dermatologists to prescribe antifungal/corticosteroid products: an analysis of office visits for cutaneous fungal infections, 1990-1994. J Am Acad Dermatol 1998;39 (1) 43- 47
PubMed Link to Article
Balkrishnan  RCook  JMShaffer  MPSaltzberg  FBFeldman  SRFleischer  AB  Jr Analysis of factors associated with prescription of a potentially inappropriate combination dermatological medication among US outpatient physicians. Pharmacoepidemiol Drug Saf 2004;13 (3) 133- 138
PubMed Link to Article
Centers for Disease Control and Prevention; National Center for Health Statistics, National Ambulatory Medical Care Survey. http://www.cdc.gov/nchs/about/major/ahcd/namcsdes.htm[registration required]Accessed August 2, 2007
Resneck  J  JrKimball  AB The dermatology workforce shortage. J Am Acad Dermatol 2004;50 (1) 50- 54
PubMed Link to Article

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.

Multimedia

Some tools below are only available to our subscribers or users with an online account.

435 Views
7 Citations
×

Related Content

Customize your page view by dragging & repositioning the boxes below.

Jobs