J AM ACAD DERMATOL
730 Letters
APRIL 2015
Nucleo de Medicina Tropical, Universidade Federal do Para,a and Centro de Ciencias Biologicas e da Saude, Universidade do Estado do Para,b Belem-PA, Brazil Funding sources: Conselho Nacional de Pesquisa (Grant Number 481020/2012-8)/CNPq - Brazil. Conflicts of interest: None declared. Correspondence to: Juarez Antonio Sim~ oes Quaresma, PhD, Nucleo de Medicina Tropical-UFPA, Av Generalissimo Deodoro 92, Umarizal, Belem, Brazil, 66055-240 E-mail: [email protected] REFERENCES 1. Degang Y, Nakamura K, Akama T, Ishido Y, Luo Y, Ishii N, Suzuki K. Leprosy as a model of immunity. Future Microbiol. 2014;9:43-54. 2. Hsu SM, Raine L, Fanger H. Use of avidin-biotin-peroxidase complex (ABC) in immunoperoxidase techniques: a comparison between ABC and unlabeled antibody (PAP) procedures. J Histochem Cytochem. 1981;29:577-580. 3. Saini C, Ramesh V, Nath I. CD41 Th17 cells discriminate clinical types and constitute a third subset of non Th1, non Th2 T cells in human leprosy. PLoS Negl Trop Dis. 2013;25: 2338. 4. Eyerich S, Eyerich K, Pennino D, et al. Th22 cells represent a distinct human T cell subset involved in epidermal immunity and remodeling. J Clin Invest. 2009;119:3573-3585. 5. Teraki Y, Sakurai A, Izaki S. IL-13/IL-22-coproducing T cells, a novel subset, are increased in atopic dermatitis. J Allergy Clin Immunol. 2013;132:971-974. http://dx.doi.org/10.1016/j.jaad.2014.11.023
Awareness and engagement in political advocacy among dermatology residents: A needs assessment To the Editor: In a changing health care environment, where legislation may negatively impact dermatology practice and patient care, many dermatologists have become informed and engaged in political advocacy. While opportunities exist to involve dermatology residents in this process, little is known about their attitudes, competencies, or participation in this arena, factors that could impact the direction of the specialty. In this IRB-approved (Baylor Research Institute IRB Number 014-012) cross-sectional survey of dermatology residents and fellows, the authors sought to assess dermatology residents’ experiences and views on political advocacy in order to later identify ways of increasing awareness and involvement in advocacy opportunities. Survey development began with key informant interviews of dermatology residents representing various
Table I. Survey responder demographics # (%)
Gender Male Female Stage of training Resident e PGY2 Resident e PGY3 Resident e PGY4 Fellow Other Political affiliation Very conservative Conservative Centralist Liberal Very liberal None
158 (35.5) 287 (64.5) 158 122 127 34 4
(35.5) (27.4) (28.5) (7.6) (0.9)
12 133 111 142 25 18
(2.7) (3.2) (25.1) (32.2) (5.7) (4.1)
backgrounds and practice settings. It was reviewed for content and face validity by residents from 2 programs in Texas as well as leaders in dermatology political advocacy from 3 states. Of the 1441 residents and fellows in the 2013-2014 academic year (Terry Barrett, MD, written communication, October 20, 2014), 1342 were e-mailed an anonymous, voluntary electronic survey. Surveys were sent between March and May of 2014 to e-mail addresses identified through internet searches and personal contacts. Of the 446 respondents (33.2%) representing 37 of the 40 states with training programs, demographics reflected a distribution of training levels and diverse political affiliations (Table I). Among respondents, 99.3% considered political advocacy in dermatology important, and 98.6% believed health care policies will affect their career. However, many reported having no understanding of Medicare billing (26.9%) or the Patient Protection and Affordable Care Act (PPACA) (51.6%), and no formal residency education on Medicare (57.9%) or the PPACA (92.3%). Only 41.8% believed their training programs encouraged political advocacy, while 90.6% of residents thought health care policy should be a part of residency training and 66.8% endorsed greater likelihood to learn about health care policy if it was tested on American Board of Dermatology (ABD) exams (Fig 1). With respect to Medicare patients, 95.3% anticipated caring for these patients after residency; however, 69.4% indicated they would see fewer Medicare patients if reimbursement decreased. Regarding involvement in political organizations, 40.7% of respondents reported membership in the
J AM ACAD DERMATOL
Letters 731
VOLUME 72, NUMBER 4
Fig 1. Bar graph of survey response data.
American Medical Association (AMA) and 14.2% in SkinPAC. The most common reason for not joining the AMA was cost, followed by not seeing the value of membership. For SkinPAC, lack of awareness, reported by 47.4%, was the major barrier to membership. Of those not interested in dermatology advocacy, time and lack of interest in political conversation were the major barriers to involvement. After taking this survey, 47.2% of respondents indicated they would speak to their co-residents and faculty
members about policy issues and 39.2% indicated increased interest in political advocacy. Limitations of this study include potential reporting bias, incomplete response rate, and potential selection bias toward more engaged or opinionated individuals more likely to take a voluntary, non-incentivized survey. Also, there are no prior data against which results could be compared. These findings suggest that dermatology residents largely value advocacy and would appreciate
J AM ACAD DERMATOL
732 Letters
APRIL 2015
education on health care policy in their training, and that many would become involved if given more opportunities for education and participation.
Table I. Visual analog scores for patient satisfaction with vitiligo treatments Treatment
N
Mean VAS score
95% Confidence interval
Mary E. Horner, MD,a A. Shadi Kourosh, MD,b and M. Alan Menter, MDa
NBUVB phototherapy Topical corticosteroids Topical 0.1% tacrolimus Skin grafting
78 82 51 20
78 52 41 64
73-83 46-59 32-50 48-80
Division of Dermatology, Baylor University Medical Center,a Dallas, Texas, and Department of Dermatology, Massachusetts General Hospital,b Boston Funding sources: None. Conflicts of interest: None declared. Correspondence to: Mary E. Horner, MD, Baylor University Medical Center, Division of Dermatology, 3900 Junius St. 145, Dallas, TX 75246 E-mail: [email protected] http://dx.doi.org/10.1016/j.jaad.2014.12.011
Patient satisfaction with different treatment modalities for vitiligo To the Editor: Vitiligo often has a negative effect on quality of life and several treatments are available; however, patient satisfaction with treatment is a seldom used outcome measure in trials, with a recent systematic review reporting only 7% of studies measuring patient satisfaction in the past 40 years.1-3 The goal of this cross-sectional study was to determine overall patient satisfaction with commonly used treatments for vitiligo. All patients enrolled in the Dallas Vitiligo Registry (DVR) at UT Southwestern Medical Center, Dallas, Texas, from April 2013 to August 2014 were surveyed regarding satisfaction with treatment. The DVR is approved by a local institutional review board and all patients gave informed consent. Treatments included narrowband ultraviolet B (NBUVB) phototherapy, topical corticosteroids, topical tacrolimus, and 1.5-mm punch grafts. Most patients were on combination therapy with at least 2 of the aforementioned treatments at the same time. All had been exposed to each therapy alone for at least 1 month. Patients were asked to assess overall satisfaction with each treatment they had received. Taking into account time commitment, cost, distance traveled, repigmentation achieved, and associated side effects, each patient marked a visual analog scale (VAS) in which 0 indicated extreme dissatisfaction and 100 indicated extreme satisfaction.
Phototherapy had the highest satisfaction score of 78, while topical tacrolimus had the lowest score of 41 (Table I). A one-way analysis of variance showed a statistically significant difference between the means (P \ .001). A multiple comparison analysis using a Tamhane post hoc test to determine which pairs of the group were significantly different showed a significant difference between phototherapy and topical corticosteroids (P \ .001) as well as between phototherapy and topical tacrolimus (P \.001). Although the size of the study was too small to compare topical therapies and grafting, it is clear that NBUVB phototherapy is the most satisfactory treatment to patients. Patients were not queried directly regarding the reasons for their choices, although many stated that NBUVB had superior efficacy in repigmenting their vitiligo lesions compared to topical therapies. A limitation of the study is that most of the patients were on combination therapy and all of the potential treatments were not an option in every patient, making comparison difficult. Another limitation is the lack of uniform duration of treatment for all patients and inclusion of all types of vitiligo. Additionally, 1 month of treatment may be too short a duration of treatment to expect a response. Future studies should control for these factors and compare satisfaction with individual treatments in a larger number of patients used over a longer period of time. Satisfaction with treatment should also be compared to disease severity. Although satisfaction with treatment is not often measured, there is a recent emphasis for more patient-centered approaches to the practice of medicine.4 Patient satisfaction can play an integral role in patient outcome measures and quality of care. As new payment models focusing on patient satisfaction to determine reimbursement rates for physicians and hospitals are developed, these studies will become even more important. Study data were collected and managed using REDCap electronic data capture tools hosted at the
730 Letters
APRIL 2015
Nucleo de Medicina Tropical, Universidade Federal do Para,a and Centro de Ciencias Biologicas e da Saude, Universidade do Estado do Para,b Belem-PA, Brazil Funding sources: Conselho Nacional de Pesquisa (Grant Number 481020/2012-8)/CNPq - Brazil. Conflicts of interest: None declared. Correspondence to: Juarez Antonio Sim~ oes Quaresma, PhD, Nucleo de Medicina Tropical-UFPA, Av Generalissimo Deodoro 92, Umarizal, Belem, Brazil, 66055-240 E-mail: [email protected] REFERENCES 1. Degang Y, Nakamura K, Akama T, Ishido Y, Luo Y, Ishii N, Suzuki K. Leprosy as a model of immunity. Future Microbiol. 2014;9:43-54. 2. Hsu SM, Raine L, Fanger H. Use of avidin-biotin-peroxidase complex (ABC) in immunoperoxidase techniques: a comparison between ABC and unlabeled antibody (PAP) procedures. J Histochem Cytochem. 1981;29:577-580. 3. Saini C, Ramesh V, Nath I. CD41 Th17 cells discriminate clinical types and constitute a third subset of non Th1, non Th2 T cells in human leprosy. PLoS Negl Trop Dis. 2013;25: 2338. 4. Eyerich S, Eyerich K, Pennino D, et al. Th22 cells represent a distinct human T cell subset involved in epidermal immunity and remodeling. J Clin Invest. 2009;119:3573-3585. 5. Teraki Y, Sakurai A, Izaki S. IL-13/IL-22-coproducing T cells, a novel subset, are increased in atopic dermatitis. J Allergy Clin Immunol. 2013;132:971-974. http://dx.doi.org/10.1016/j.jaad.2014.11.023
Awareness and engagement in political advocacy among dermatology residents: A needs assessment To the Editor: In a changing health care environment, where legislation may negatively impact dermatology practice and patient care, many dermatologists have become informed and engaged in political advocacy. While opportunities exist to involve dermatology residents in this process, little is known about their attitudes, competencies, or participation in this arena, factors that could impact the direction of the specialty. In this IRB-approved (Baylor Research Institute IRB Number 014-012) cross-sectional survey of dermatology residents and fellows, the authors sought to assess dermatology residents’ experiences and views on political advocacy in order to later identify ways of increasing awareness and involvement in advocacy opportunities. Survey development began with key informant interviews of dermatology residents representing various
Table I. Survey responder demographics # (%)
Gender Male Female Stage of training Resident e PGY2 Resident e PGY3 Resident e PGY4 Fellow Other Political affiliation Very conservative Conservative Centralist Liberal Very liberal None
158 (35.5) 287 (64.5) 158 122 127 34 4
(35.5) (27.4) (28.5) (7.6) (0.9)
12 133 111 142 25 18
(2.7) (3.2) (25.1) (32.2) (5.7) (4.1)
backgrounds and practice settings. It was reviewed for content and face validity by residents from 2 programs in Texas as well as leaders in dermatology political advocacy from 3 states. Of the 1441 residents and fellows in the 2013-2014 academic year (Terry Barrett, MD, written communication, October 20, 2014), 1342 were e-mailed an anonymous, voluntary electronic survey. Surveys were sent between March and May of 2014 to e-mail addresses identified through internet searches and personal contacts. Of the 446 respondents (33.2%) representing 37 of the 40 states with training programs, demographics reflected a distribution of training levels and diverse political affiliations (Table I). Among respondents, 99.3% considered political advocacy in dermatology important, and 98.6% believed health care policies will affect their career. However, many reported having no understanding of Medicare billing (26.9%) or the Patient Protection and Affordable Care Act (PPACA) (51.6%), and no formal residency education on Medicare (57.9%) or the PPACA (92.3%). Only 41.8% believed their training programs encouraged political advocacy, while 90.6% of residents thought health care policy should be a part of residency training and 66.8% endorsed greater likelihood to learn about health care policy if it was tested on American Board of Dermatology (ABD) exams (Fig 1). With respect to Medicare patients, 95.3% anticipated caring for these patients after residency; however, 69.4% indicated they would see fewer Medicare patients if reimbursement decreased. Regarding involvement in political organizations, 40.7% of respondents reported membership in the
J AM ACAD DERMATOL
Letters 731
VOLUME 72, NUMBER 4
Fig 1. Bar graph of survey response data.
American Medical Association (AMA) and 14.2% in SkinPAC. The most common reason for not joining the AMA was cost, followed by not seeing the value of membership. For SkinPAC, lack of awareness, reported by 47.4%, was the major barrier to membership. Of those not interested in dermatology advocacy, time and lack of interest in political conversation were the major barriers to involvement. After taking this survey, 47.2% of respondents indicated they would speak to their co-residents and faculty
members about policy issues and 39.2% indicated increased interest in political advocacy. Limitations of this study include potential reporting bias, incomplete response rate, and potential selection bias toward more engaged or opinionated individuals more likely to take a voluntary, non-incentivized survey. Also, there are no prior data against which results could be compared. These findings suggest that dermatology residents largely value advocacy and would appreciate
J AM ACAD DERMATOL
732 Letters
APRIL 2015
education on health care policy in their training, and that many would become involved if given more opportunities for education and participation.
Table I. Visual analog scores for patient satisfaction with vitiligo treatments Treatment
N
Mean VAS score
95% Confidence interval
Mary E. Horner, MD,a A. Shadi Kourosh, MD,b and M. Alan Menter, MDa
NBUVB phototherapy Topical corticosteroids Topical 0.1% tacrolimus Skin grafting
78 82 51 20
78 52 41 64
73-83 46-59 32-50 48-80
Division of Dermatology, Baylor University Medical Center,a Dallas, Texas, and Department of Dermatology, Massachusetts General Hospital,b Boston Funding sources: None. Conflicts of interest: None declared. Correspondence to: Mary E. Horner, MD, Baylor University Medical Center, Division of Dermatology, 3900 Junius St. 145, Dallas, TX 75246 E-mail: [email protected] http://dx.doi.org/10.1016/j.jaad.2014.12.011
Patient satisfaction with different treatment modalities for vitiligo To the Editor: Vitiligo often has a negative effect on quality of life and several treatments are available; however, patient satisfaction with treatment is a seldom used outcome measure in trials, with a recent systematic review reporting only 7% of studies measuring patient satisfaction in the past 40 years.1-3 The goal of this cross-sectional study was to determine overall patient satisfaction with commonly used treatments for vitiligo. All patients enrolled in the Dallas Vitiligo Registry (DVR) at UT Southwestern Medical Center, Dallas, Texas, from April 2013 to August 2014 were surveyed regarding satisfaction with treatment. The DVR is approved by a local institutional review board and all patients gave informed consent. Treatments included narrowband ultraviolet B (NBUVB) phototherapy, topical corticosteroids, topical tacrolimus, and 1.5-mm punch grafts. Most patients were on combination therapy with at least 2 of the aforementioned treatments at the same time. All had been exposed to each therapy alone for at least 1 month. Patients were asked to assess overall satisfaction with each treatment they had received. Taking into account time commitment, cost, distance traveled, repigmentation achieved, and associated side effects, each patient marked a visual analog scale (VAS) in which 0 indicated extreme dissatisfaction and 100 indicated extreme satisfaction.
Phototherapy had the highest satisfaction score of 78, while topical tacrolimus had the lowest score of 41 (Table I). A one-way analysis of variance showed a statistically significant difference between the means (P \ .001). A multiple comparison analysis using a Tamhane post hoc test to determine which pairs of the group were significantly different showed a significant difference between phototherapy and topical corticosteroids (P \ .001) as well as between phototherapy and topical tacrolimus (P \.001). Although the size of the study was too small to compare topical therapies and grafting, it is clear that NBUVB phototherapy is the most satisfactory treatment to patients. Patients were not queried directly regarding the reasons for their choices, although many stated that NBUVB had superior efficacy in repigmenting their vitiligo lesions compared to topical therapies. A limitation of the study is that most of the patients were on combination therapy and all of the potential treatments were not an option in every patient, making comparison difficult. Another limitation is the lack of uniform duration of treatment for all patients and inclusion of all types of vitiligo. Additionally, 1 month of treatment may be too short a duration of treatment to expect a response. Future studies should control for these factors and compare satisfaction with individual treatments in a larger number of patients used over a longer period of time. Satisfaction with treatment should also be compared to disease severity. Although satisfaction with treatment is not often measured, there is a recent emphasis for more patient-centered approaches to the practice of medicine.4 Patient satisfaction can play an integral role in patient outcome measures and quality of care. As new payment models focusing on patient satisfaction to determine reimbursement rates for physicians and hospitals are developed, these studies will become even more important. Study data were collected and managed using REDCap electronic data capture tools hosted at the
