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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):1591-1592.

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.

Methods
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.

Results
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.

View this table: [in this window] [in a new window] [as a PowerPoint slide]   Table 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).

View this table: [in this window] [in a new window] [as a PowerPoint slide]   Table 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.

Comment
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

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

Financial Disclosure: None reported.

REFERENCES
1. Feldman SR, Fleischer AB Jr, Williford PM, White R, Byington 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. FULL TEXT | WEB OF SCIENCE | PUBMED 2. Clark AR, Monroe JR, Feldman SR, Fleischer AB Jr, Hauser DA, Hinds MA. The emerging role of physician assistants in the delivery of dermatologic health care. Dermatol Clin. 2000;18(2):297-302. FULL TEXT | WEB OF SCIENCE | PUBMED 3. Smith ES, Fleischer AB Jr, Feldman 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. FULL TEXT | WEB OF SCIENCE | PUBMED 4. Balkrishnan R, Cook JM, Shaffer MP, Saltzberg FB, Feldman SR, Fleischer 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. FULL TEXT | WEB OF SCIENCE | PUBMED 5. 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 28, 2007.6. Resneck J Jr, Kimball AB. The dermatology workforce shortage. J Am Acad Dermatol. 2004;50(1):50-54. FULL TEXT | WEB OF SCIENCE | PUBMED

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