Outcomes of Early Dermatology Consultation for Inpatients Diagnosed With Cellulitis

Abstract

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.

Dermatology consultation service at a large metropolitan hospital system serving minority populations

“…Other studies have shown that immediate consultation, within 24 h of hospitalization, led to shorter duration of treatment and decreased length of stay. 18,19 Figure 1 (a-j). This graph summarizes the collected data, including age at time of consultation (a), reason for admission (b), admission length prior to dermatology consult (c), number of inpatient visits by dermatology consultant (d), primary team (e), dermatology recommended testing (f), number of dermatologic diagnoses (g), whether or not the primary team followed dermatology's treatment plan (h), whether outpatient dermatology follow-up was needed after discharge (i) and whether or not the patient was lot to dermatology follow-up after discharge (j).…”

Inpatient dermatology: a paradigm shift in the management of skin disease in the hospital

“…Multiple studies show the admitting hospital service misdiagnoses skin disease at rates of between 45% and 78% of the time . Length of stay was reduced with inpatient consultation for dermatological disease by 2.64 days in one study and 2.1 days in another study . The same study by Milan‐Nejad et al .…”

“…also found a decrease in hospital readmission rates in this cohort of patients. Li et al . used their study results to attempt to quantify the economics of dermatology consultation, and found that employing early and universal dermatology consultation for presumed cellulitis could save up to 256 000 inpatient days and $210 million annually in the U.S.A. alone.…”

A case of exemestane induced pseudocellulitis

“…9 It is important to recognize pseudocellulitis early as they are com- showed that early consultation by dermatologists for patients with presumed cellulitis is a cost-effective intervention to reduce inappropriate antibiotic use and hospitalization. 10 This intervention may be a worthwhile consideration for hospitals with sufficient dermatological support.…”