SKIN January 2021 Volume 5 Issue 1 Copyright 2021 The National Society for Cutaneous Medicine 29 RISING DERM STARS® ABSTRACTS The Ongoing Impact of COVID-19 on US Dermatology Practices Graham H Litchman DO, MS1, Justin W. Marson, MD2, Darrell S. Rigel, MD, MS3 1Department of Dermatology, St. John’s Episcopal Hospital, Far Rockaway, NY 2National Society for Cutaneous Medicine, New York, NY 3Department of Dermatology, NYU Grossman School of Medicine, New York, NY COVID-19 is significantly impacting healthcare delivery worldwide.1 Chen et al anecdotally reported the impact on dermatology outpatient care at the outbreak epicenter in Wuhan, China, but nothing has yet been assessed for the US.2 The purpose of this study was to determine the magnitude of the ongoing impact of COVID- 19 on US dermatology outpatient care. After pre-validation, 2 surveys comparing outpatient volumes and scheduling issues for the weeks of February 17th versus the week of March 16th, 2020 (Survey 1) and April 13th, 2020 (Survey 2) and for estimation of trends in the next several weeks was emailed to 9,891 US Dermatologists on 3/21 (Survey 1) and 4/18 (Survey 2). Because of the importance of this information and the need for rapid dissemination, only data from the first 1,000 respondents (collected in the initial 36 hours) were included in each survey. In Survey 1, 30 responses were removed due to ineligible geography or errors in survey entry, leaving 970 for the analysis. Survey 2 consisted of 1,000 eligible respondents. Demographics (Table 1) representativeness with AAD membership was confirmed (Table 2). Statistical significance was calculated using chi-square, difference-of-proportions, and two-tailed independent t-tests. COVID-19 impact was material (Table 3). From the 3rd week in February to the 3rd week in March to the 3rd week in April, the average number of patients seen fell from 149.4 to 63.4 to 28.2(p<0.0001), practice days from 4.2 to 3.1 and then rose to 3.5(p<0.0001) and biopsies from 19.8 to 7.7 to 3.5(p<0.0001). Although by 3/16 there were only 24.5k cases nationally3, the early- phase decrease in patient volume and office days suggests the magnitude of disease concern impact was greater than actual prevalence. Postponement of non-essential appointments increased from 35.5% to 79.4% to 95.6%(p<0.0001). In Survey 1, 66.3% of respondents estimated a >50% decrease in patient volume in the coming 2 weeks (18.9% completely closing practices) and, disturbingly, 47.2% of respondents in the 2nd survey estimated an additional ≥50% decrease in patient volume in the next 2 weeks. 54.6% (Survey 1) of postponed appointments were for >4 weeks with an additional 25.4% not rescheduled. INTRODUCTION METHODS RESULTS SKIN January 2021 Volume 5 Issue 1 Copyright 2021 The National Society for Cutaneous Medicine 30 Table 1. Participant Demographics by Survey Versus AAD US Membership Data. Demographics (n=1000) Survey 1 (%, 95% CI) Survey 2 (%, 95% CI) Survey 3 (%, 95% CI) AAD US Membership* Practice type Private 89.1 (87.1-91.1) 89.7 (87.8-91.6) 89.7 87.6-91.8) University/Academic/ Government 10.9 (8.9-12.9) 10.3 (8.4-12.2) 10.3 (8.2-12.4) Years of experience 1-10 21.8 (19.1-24.5) 18.9 (16.4-21.4) 16.1 (13.6-18.6) 27.0% 11-20 26.6 (23.8-29.4) 25.7 (22.9-28.5) 22.3 (19.4-25.2) 27.5% 21-30 26.3 (23.5-29.1) 29.3 (26.4-32.2) 29.8 (26.6-33.0) 21.8% > 30 25.4 (22.6-28.2) 26.1 (23.3-28.9) 31.7 (28.5-34.9) 23.7% Practice mix AAD Practice Profile, 2017** Medical 63.0 (59.9-66.1) 60.4 (57.3-63.5) 61.5 (58.1-64.9) 63% Surgical/Oncology 26.7 (23.9-29.5) 25.8 (23.0-28.6) 23.2 (20.3-26.1) 25% Cosmetic 14.8 (12.5-17.1) 11.5 (9.5-13.5) 12.9 (10.6-15.2) 12% Dermatopathology 4.4 (3.1-5.7) 2.4 (1.4-3.4) 2.4 (1.3-3.5) *Source: American Academy of Dermatology. Practices mix/types not available. **Source: Margosian E. Medical vs. cosmetic dermatology: Who is doing what?. Dermatology World.2019. http://digitaleditions.walsworthprintgroup.com/publication/?m=12468&i=552514&view=articleBrowser&article_id=3267519&search=practice%20p rofile&ver=html5. No data available for dermatopathology. Table 2. Geographic and Practice Tenure Distribution of Survey Respondents versus American Academy of Dermatology US Membership 1st- digit zip (region) code AAD US Membership (%) 9.6% 12.8% 10.3% 13.8% 8.3% Survey 1 (%) 9.4% 14.0% 11.0% 12.3% 7.6% Survey 2 (%) 8.4% 15.8% 10.9% 12.4% 8.6% 1st- digit zip (region) code AAD US Membership (%) 4.8% 6.5% 10.0% 6.1% 17.1% Survey 1 (%) 3.9% 6.6% 10.0% 8.4% 16.3% Survey 2 (%) 4.2% 6.2% 8.7% 7.7% 16.5% SKIN January 2021 Volume 5 Issue 1 Copyright 2021 The National Society for Cutaneous Medicine 31 Table 3. Comparison of US Dermatology practice during February 17-21 versus March 16-20, April 13-18, and prospective practice estimates. Week of February 17, 2020 Week of March 16, 2020 Week of April 13, 2020 p-value How many days did you practice? (mean; 95%CI) 4.18 (4.11-4.26) 3.08 (2.95-3.21) 3.50 (3.385-3.59) <0.0001 How many patients were seen in your primary practice location? (mean; 95%CI) 149.74 (139.59-159.89) 63.50 (57.81-69.19) 28.24 (23.74-32.73) <0.0001 How many biopsies did you perform for suspicious pigmented skin lesions? (mean; 95%CI) 19.86 (18.02-21.70) 7.75 (6.73-8.78) 3.55 (2.74-4.36) <0.0001 Did you selectively postpone non-essential appointments? (%Yes; 95%CI) 35.42% (31.89% - 38.95%) 79.4% (76.01% - 82.51%) 95.6% (94.27% - 96.88%) <0.0001 How many biopsies were postponed? (mean; 95%CI) 3.89 (3.06-4.73) 10.75 (9.19-12.31) 7.84 (6.62-9.05) <0.0001 Prospective Estimates March 16-20 April 13-18 Relative to your practice during the week of March 16-20 (Survey 2: April 13-18; Survey 3: May 18-23), what do you anticipate your schedule for March 23-April 10 (Survey 2: April 20-May 10) will look like? (%; 95%CI) Similar schedule & patient load 6.1% 38.5% 0-25% reduction 8.3% 5.6% 26-50% reduction 19.4% 8.7% 51-75% reduction 13.3% 12.5% > 75% reduction (but still open) 34.1% 24.0% Completely closing practice 18.9% 10.7% What percentage of appointments did you do using telemedicine (0-100%)? (%; 95%CI) 0% 20.1% 10% 14.8% 20% 7.0% 30% 4.2% 40% 2.5% 50% 5.0% 60% 2.9% 70% 4.4% 80% 7.0% 90% 16.1% 100% 16.0% Overall (mean) 48.6% In the next month, what percentage of your patient visits will be done using telemedicine because of COVD-19? (mean; 95%CI) 37.8% 45.9% SKIN January 2021 Volume 5 Issue 1 Copyright 2021 The National Society for Cutaneous Medicine 32 Figure 1. Covid-19 Hotspots as of April 18, 2020. Section Codes Geographic Description Section Codes Geographic Description Section Codes Geographic Description Section Codes Geographic Description 018 Boston Metro Area 330 Miami Metro Area 780* San Antonio, TX 919* San Diego Metro Area 019 331 782 920 021 333 786 Austin, TX 921 024 334 787 922 070-071 New York Metro Area 480 Detroit Metro Area 800 Denver Metro Area 923 073* 481 801 925 076 483 802 926 Los Angeles Metro Area 085*-086 600 Chicago Metro Area 804 928 100-101* 601 816* Eagle County, CO 940 San Francisco Bay Area 103 602 900 Los Angeles Metro Area 941 104 604 901* 950 105 605 902 951 108* 606 904 956 Sacramento, CA 109 700* New Orleans, LA 905 957 110 701 906* 958 112 750 Dallas Metro Area 907 980 Seattle Metro Area 113 752 908 981 115 765* Waco, TX 910 983 117,119 766* 913 302 Atlanta, GA 770 Houston Metro Area 914* 303 774-775* 915 *Survey 1 only. Note: 36% (Survey 1) and 34% (Survey 2) of dermatologists (survey respondents) practiced in these high-density (“hotspot”) disease areas SKIN January 2021 Volume 5 Issue 1 Copyright 2021 The National Society for Cutaneous Medicine 33 A greater negative impact was found in US “hotspot” regions4 (36% (Survey 1) and 34% (Survey 2) of respondents-Figure 1) for week 3/16-20 for practice days (3.0 hotspots vs. 3.3 non-hotspots) and patients seen (56.2 in hotspots vs. 70.0 in non-hotspots); and for week 4/13-18 (3.4 in hotspots vs 3.5 in non-hotspots) and patients seen (25.3 in hotspots vs 29.7 in non-hotspots). No significant differing telemedicine usage (39.5% hotspots vs 37.2% non-hotspots) or practice closure (21.0% hotspots vs 17.6% non-hotspots) was found in Survey 1 (March); however, a significant difference in telemedicine usage (54.5% hotspots vs 45.5% non-hotspots) and practice closure (25.4% hotspots vs 16.4% non-hotspots, when compared to a typical April week) was found in Survey 2 (April). Mean estimated telemedicine visits overall for the next 2 weeks was 37.8% (Survey 1) and 45.9% (Survey 2). Academic/University/Institutional dermatologists were significantly more likely to use telemedicine (Survey 1=57.1%, Survey 2=68.6%) than private practitioners (Survey 1=35.5%, Survey 2=46.2%). Telemedicine usage was less likely for dermatologists with >30 practice years (>30=32.4% vs 40.0%) and this trend continued in April with only 37.2% of more experienced dermatologists using telemedicine. However, telemedicine usage does not have an impact on the deferred/postponed biopsies that had already occurred during the March (mean=10.7) or April (mean=7.9) weeks as well as those predicted to be subsequently postponed. Limitations include that this study reflects a “snapshot” which could materially change given the dynamically evolving situation. Estimations could have led to recall bias and the 10.1% response rate could have introduced sampling and non-response bias. Those with lower work volumes could have been more likely to have time to respond, but this bias was minimized by weekend-only data collection. However, the large sample size and representative distribution mitigate selection bias and standard statistical testing demonstrated significance. Our findings demonstrate the significant early impact of COVID-19 on US dermatologic care and can help better understand national trends. With an estimated 49.9 million annual US dermatology office visits5, the 50%+ decrease in predicted visits could be devastating. Beyond telemedicine, other innovative approaches will need to be developed and implemented to help delivery of essential dermatology care during this crisis. Conflict of Interest Disclosures: None Funding: None Corresponding Author: Graham H Litchman, DO, MS Department of Dermatology St. John’s Episcopal Hospital Far Rockaway, NY 11691 Email: graham.litchman@gmail.com References: 1. R Emanuel EJ, Persad G, Upshur R, et al. Fair Allocation of Scarce Medical Resources in the Time of Covid-19. New England Journal of Medicine. 2020. doi:10.1056/nejmsb2005114. 2. Chen Y, Pradhan S, Xue S. What are we doing in the dermatology outpatient department amidst the raging of the 2019 novel coronavirus? Journal of the American Academy of Dermatology. 2020;82(4):1034. doi:10.1016/j.jaad.2020.02.030. 3. Cases of Coronavirus Disease 2019 (COVID-19) in the U.S. by Centers for Disease Control and Prevention website. https://www.cdc.gov/coronavirus/2019- ncov/cases-updates/cases-in- us.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc. gov%2Fcoronavirus%2F2019-ncov%2Fcases-in- us.html#anchor_1586790730. Accessed April 23, 2020. 4. Coronavirus COVID-19 Global Cases by the Center for Systems Science and Engineering at Johns Hopkins University website. https://gisanddata.maps.arcgis.com/apps/opsdashboar d/index.html#/bda7594740fd40299423467b48e9ecf6. Updated March 24, 2020. Accessed March, 24, 2020. 5. Rui P, Okeyode T. National Ambulatory Medical Care Survey: 2016 National Summary Tables. Available from: https://www.cdc.gov/nchs/data/ahcd/namcs_summary/ 2016_namcs_web_tables.pdf DISCUSSION CONCLUSION https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fcases-in-us.html#anchor_1586790730 https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fcases-in-us.html#anchor_1586790730 https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fcases-in-us.html#anchor_1586790730 https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fcases-in-us.html#anchor_1586790730 https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fcases-in-us.html#anchor_1586790730 https://gisanddata.maps.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6 https://gisanddata.maps.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6 https://gisanddata.maps.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6