SKIN January 2019 Volume 3 Issue 1 Copyright 2018 The National Society for Cutaneous Medicine 28 RESEARCH LETTER Rapid Access Clinic Expedites Patient Connection with Dermatologic Services and Improves Productivity TN Canavan, MD1, RL Pearlman, MD1, BE Elewski, MD1, LV Graham, MD, PhD1 1Department of Dermatology, University of Alabama at Birmingham, Birmingham, AL Access to dermatologic care, especially for urgent complaints, poses an ongoing challenge. To address long scheduling wait times and acute dermatologic complaints, institutions have sought innovative solutions to patient access problems.1-5 To improve access at the University of Alabama at Birmingham, a twice weekly Rapid Access Clinic (RAC) was implemented in 2017 where up to 60 patients are scheduled on Tuesday. On Fridays, 40 patients were scheduled for the first month with 50 scheduled the subsequent months. These clinics are staffed by 6 dermatology residents plus 2 attendings. Referrals are not required. Most appointments are scheduled within 2 weeks. This clinic has been in place for around one year and we continue to see a similar number of patients. Visits are intended to be limited to a single dermatologic complaint, and patients are informed of this policy. A retrospective review was conducted for all RAC patients seen over a 4-month period (9/1/2017-12/31/2017). Twenty-seven clinics with 1018 visits were reviewed for demographics, diagnosis, and follow-up recommendations (Table 1). The average patient age was 51.5 (range 5-100), 60.1% were female, and 89.7% were new patients. Despite our intent to limit visits to 1 complaint, most patients had several complains addressed. Seventy eight new cutaneous malignancies were diagnosed, including six melanomas (Table 1). RAC implementation reduced appointment wait times considerably. Our department’s scheduling wait times before RAC were 96 and 87 days for new and return patients, respectively (Table 2). After 10 months of RAC, the wait times were 35 and 32 days for Table 1: Characterizing patient population, patient diagnoses, and follow-up recommendations from RAC. Patient Demographics (n=1018) Mean (± SD) or n (%) Age 51.5 (+/- 18.6) Female gender 612 (60.1%) New patient 913 (89.7%) Return patient with new complaint 49 (4.8%) Total Eruptions Diagnosed 712 (47.9%) Total Neoplasms Diagnosed 784 (52.1%) Follow-up required 611 (60.0%) Biopsy results Number of patients (total number detected) BCC 39 (45) SCC SCC in situ 19 (23) 3 (3) Melanoma 5 (6) Adenocarcinoma 1 (1) SKIN January 2019 Volume 3 Issue 1 Copyright 2018 The National Society for Cutaneous Medicine 29 new, and returns. The no-show rate for RAC was 17.3%. Implementation of the biweekly RAC model resulted in dramatic departmental productivity enhancement (Table 2). The average RAC encounter generated approximately 55% more wRVUs on average than non-RAC clinic visits due to a high proportion of new patients and procedures performed in RAC vs non-RAC clinic. By replacing one regular clinic with a RAC, one faculty member noted an increase of over 1000 wRVUs in a 5-month period. The change in wRVUs could not be assessed for the other RAC attending as they joined the department around the time RAC was implemented. The most frequently used billing codes in RAC were for skin biopsies, followed closely by destruction of benign lesions (Table 2). RAC significantly augmented our procedural referrals. RAC resulted in 116 procedural referrals, including 54 distinct lesions referred for Mohs surgery (Table 2). Table 2: Identifying patient services and assessing productivity gains associated with RAC. Productivity Measures Metrics Difference in RAC vs non-RAC wRVUS (%) per encounter +55% Change in wait times for new patients 61 days shorter Change in wait times for return patients 55 days shorter No-show rate (% of RAC appointments) 17.3% Procedural referrals Number of patients (total number of lesions to treat) Excision 54 (58) MMS 43 (54) Laser treatment 4 (4) Total 101 (116) Table 2: Continued. Procedure code % of patients (n) Skin biopsy (11100) 14.7 (150) Destruction of benign lesions (17110) 12.3 (125) Destruction of 1st premalignant lesion (17000) 10.2 (104) Destruction of premalignant lesions 2-14 (17003) 7.0 (71) Distinct procedural services (59 modifier) 4.6 (47) Injection 1-7 lesions (11900) 2.2 (22) Acne surgery (10040) 1.1 (11) Implementing the RAC model helped us achieve our goals of shortening wait times, enhancing department revenue, and diagnosing more cutaneous malignancies, especially melanomas. Limitations of this study include its retrospective nature and short time frame. The RAC was implemented at a large tertiary care academic center staffed by a sizeable department with a broad referral base, thus results may not be generalizable to all clinic settings. Improving access to dermatologic care is complex; however, the RAC model accomplishes this goal for patients with acute complaints. Future studies are needed to assess the flexibility of implementing this model in different practice settings. Conflict of Interest Disclosures: Dr. Elewski has been a consultant, in which she received honoraria, for the following companies: Celgene, Leo, Lilly, Novartis, Pfizer, Sun, and Valeant. Dr. Elewski has received clinical research support (funds paid to The University of Alabama at Birmingham) from the following companies: Abbvie, Boehringer Ingelheim, Celgene, Incyte, Leo, Lilly, Merck, Novartis, Pfizer, Regeneron, Sun, and Valeant. Dr. Graham has received clinical research support (funds paid to The University of Alabama at Birmingham) from Pfizer and served as a consultant to UCB. The remaining authors have no conflicts of interest. Funding: None. IRB Status: Approved (IRB-300000327) SKIN January 2019 Volume 3 Issue 1 Copyright 2018 The National Society for Cutaneous Medicine 30 Corresponding Author: Lauren Graham, MD, PhD Department of Dermatology University of Alabama at Birmingham Birmingham, AL lvgraham@uabmc.edu References: 1. Suneja T, Smith ED, Chen GJ, Zipperstein KJ, Fleischer AB, Feldman SR. Waiting times to see a dermatologist are perceived as too long by dermatologists: implications for the dermatology workforce. Arch Dermatol 2001;137(10):1303–7. 2. Tsang MW, Resneck JS. Even patients with changing moles face long dermatology appointment wait-times: a study of simulated patient calls to dermatologists. J Am Acad Dermatol 2006;55(1):54–8. 3. Kimball AB, Resneck JS. The US dermatology workforce: a specialty remains in shortage. J Am Acad Dermatol 2008;59(5):741–5. 4. Murray M, Berwick DM. Advanced access: reducing waiting and delays in primary care. JAMA 2003;289(8):1035–40. 5. Anderson BE, Marks JG, Downs E, et al. The Hershey access clinic: a model for improving patient access. J Am Acad Dermatol 2007;57(4):601–3. mailto:lvgraham@uabmc.edu