IMPORTANCE Many inflammatory skin dermatoses mimic cellulitis (pseudocellulitis) and are treated with antibiotics and/or hospitalization, leading to unnecessary patient morbidity and substantial health care spending. OBJECTIVE To evaluate the impact of early dermatology consultation on clinical and economic outcomes associated with misdiagnosed cellulitis. DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study enrolled patients with presumed diagnosis of cellulitis in the emergency department, in the emergency department observation unit, or within 24 hours of admission to an inpatient unit of a large urban teaching hospital between February and September 2017. Patients were provided with telephone and clinic follow-up during the 30-day postdischarge period. We screened 165 patients with the primary concern of cellulitis. Of these, we excluded 44 who required antibiotics for cutaneous, soft-tissue, and deeper-tissue and/or bone infections irrespective of cellulitis status, and 5 who were scheduled to be discharged by the emergency department. INTERVENTIONS Early dermatology consultation for presumed cellulitis. MAIN OUTCOMES AND MEASURES Primary outcomes were patient disposition and rates of antibiotic use. RESULTS Of 116 patients (63 [54.3%] women; 91 [78.4%] non-Hispanic white; mean [SD] age, 58.4 [19.1] years), 39 (33.6%) were diagnosed with pseudocellulitis by dermatologists. Of these, 34 (87.2%) had started using antibiotics for presumed cellulitis as prescribed by the primary team at the time of enrollment. The dermatology team recommended antibiotic discontinuation in 28 of 34 patients (82.4%), and antibiotics were stopped in 26 of 28 cases (92.9%). The dermatologists also recommended discharge from planned observation or inpatient admission in 20 of 39 patients with pseudocellulitis (51.3%), and the primary team acted on this recommendation in 17 of 20 cases (85.0%). No patients diagnosed with pseudocellulitis experienced worsening condition after discharge based on phone and clinic follow-up (30 of 39 [76.9%] follow-up rate). Extrapolating the impact of dermatology consultation for presumed cellulitis nationally, we estimate 97 000 to 256 000 avoided hospitalization days, 34 000 to 91 000 patients avoiding unnecessary antibiotic exposure, and $80 million to $210 million in net cost savings annually. CONCLUSIONS AND RELEVANCE Early consultation by dermatologists for patients with presumed cellulitis represents a cost-effective intervention to improve health-related outcomes through the reduction of inappropriate antibiotic use and hospitalization.
recently graduated, and involved with teaching residents. 4 The reported reasons for dermoscopy nonuse are consistently due to lack of dedicated training.Our study examines the use of dermoscopy (whereby clinical documentation is a marker for use) for melanoma diagnosis at the Miami VA Medical Center and suggests that dermoscopy learners have a positive impact on the secondary prevention of melanoma, by way of identifying thinner lesions at diagnosis. Our findings also illustrate the actual rates of dermoscopy use among physicians-in-training in a longitudinal fashion. Physicians-in-training under the supervision of an attending physician are the key health care providers performing skin cancer screenings of patients in the VA system. The present strengths of our study include consistent record keeping by electronic medical record, reliable pathologic thresholds, and relative uniformity of thresholds for biopsy.This study has some limitations that have to be acknowledged. Average Breslow depth has been skewed toward thinner tumors over time due to multifactorial factors including increased biopsy rates, improved early detection, and changes in histopathologic measures for borderline lesions. 5 Second, we only included those cases with verified documentation of dermoscopy use, so the actual rates of use may be higher. Finally, the homogenous demographics of the VA study population who have equalized access to care may limit the generalizability of this study.It is known that dermoscopy use improves the malignantto-benign ratio for melanocytic lesions in dermoscopy users compared with nonusers. 6 We advocate for providing devices to residents along with structured dermoscopy education to encourage postresidency use.
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