The immediate impact of COVID-19 on US dermatology practices
Authors: Graham H. Litchman, Darrell S. Rigel
Journal: Journal of the American Academy of Dermatology (2020)

To the Editor: COVID-19 is significantly affecting health care delivery worldwide.1Emanuel E.J. Persad G. Upshur R. et al.Fair allocation of scarce medical resources in the time of Covid-19.N Engl Med J. 2020; 382: 2049-2055Crossref PubMed Scopus (2114) Google Scholar Chen et al2Chen Y. Pradhan S. Xue S. What are we doing in the dermatology outpatient department amidst the raging of the 2019 novel coronavirus?.J Am Acad Dermatol. 2020; 82: 1034Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar anecdotally reported the impact on dermatology outpatient care at the outbreak epicenter in Wuhan, China, but nothing has yet been assessed for the United States. The purpose of this study was to determine the magnitude of the initial impact of COVID-19 on US dermatology outpatient care. After prevalidation, a survey comparing outpatient volumes and scheduling issues for the week of February 17 versus the week of March 16, 2020 and for estimation of trends in the next several weeks was e-mailed to US dermatologists on March 21, 2020 (Supplemental Table I; available via Mendeley at https://doi.org/10.17632/cwzhng62w9.1), and the first 1000 responses were tabulated. Thirty responses were removed because of ineligible geography or errors in survey entry, leaving 970 for the analysis. Respondent demographics were analyzed (Table I). Representativeness with regard to geographic location and practice experience compared to American Academy of Dermatology membership data was confirmed (Supplemental Table II; available via Mendeley at https://doi.org/10.17632/cwzhng62w9.1). Statistical significance was calculated using chi-square, difference-of-proportions, and 2-tailed independent t tests.Table ISurvey respondent demographics (n = 970)Demographics%Practice type Private89.1 University/academic/government10.9Years of experience 1-1021.8 11-2026.6 21-3026.3 >3025.4Practice mix Medical63.0 Surgical/oncology26.7 Cosmetic14.8 Dermatopathology4.4 Open table in a new tab The COVID-19 impact was material (Table II). From the third week in February to the third week in March, the average number of patients seen fell from 149.4 to 63.4 (P < .0001), practice days fell from 4.2 to 3.1 (P < .0001), and number of biopsies fell from 19.8 to 7.7 (P < .0001). Although by March 16 there were only 24,600 cases nationally,3Centers for Disease Control and PreventionCases of coronavirus disease 2019 (COVID-19).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_1586790730Date accessed: April 23, 2020Google Scholar the early-phase decreases in patient volume and office days suggest that the magnitude of disease concern impact was greater than actual prevalence. Postponement of nonessential appointments increased from 35.5% to 79.4% (P < .00001). Of respondents, 66.3% estimated a greater than 50% decrease in patient volume in the coming 2 weeks (with 18.9% completely closing practices). In addition, 54.6% of postponed appointments were for longer than 4 weeks, with an additional 25.4% not rescheduled.Table IIComparison of US dermatology practices, February 17 to 21 versus March 16 to 20 and future practice estimatesQuestionsWeek of February 17, 2020, meanWeek of March 16, 2020, meanP valueHow many days did you practice?4.23.1<.0001How many patients were seen in your primary practice location?149.463.4<.0001How many biopsies did you perform for suspicious pigmented skin lesions?19.87.7<.0001Did you selectively postpone nonessential appointments?Yes: 35.5%No: 64.5%Yes: 79.4%No: 20.6%<.00001How many biopsies were postponed?3.910.7<.0001Prospective estimate questionsEstimate%If appointments were postponed during the week of March 16 to 20, when did you primarily reschedule them?None were postponed12.8March 23 to April 157.0April 16 to 3026.9May 1 to 3115.5June 1 to 308.8After July 13.4Not rescheduled at this time25.6If biopsies were postponed during the week of March 16 to 20, when did you primarily reschedule them?None were postponed0March 23 to April 156.4April 16 to 3020.3May 1 to 3111.4June 1 to 305.6After July 11.9Not rescheduled at this time54.7Relative to your practice during the week of March 16 to 20, what do you anticipate your schedule for March 23 to April 10 will look like?Similar schedule and patient load6.10% to 25% reduction8.326% to 50% reduction19.451% to 75% reduction13.3>5% reduction (but still open)34.1Completely closing practice18.9In the next month, what percentage of your patient visits will be done using telemedicine because of COVID-19?Mean: 37.8 Open table in a new tab A greater negative impact was found in US hotspot regions4COVID-19 Dashboard by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University (JHU).https://gisanddata.maps.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6Date: 2020Date accessed: March 24, 2020Google Scholar (36% of respondents; see Supplemental Fig 1; available via Mendeley at https://doi.org/10.17632/cwzhng62w9.1) for the week from March 16 to 20 for practice days (3.0 in hotspots vs 3.3 in non-hotspots) and patients seen (56.2 in hotspots vs. 70.0 in non-hotspots). No significant differences in telemedicine usage (39.5% in hotspots vs 37.2% in non-hotspots) or practice closure (21.0% in hotspots vs 17.6% in non-hotspots) were found. Mean estimated telemedicine visits overall for the next 2 weeks was 37.8%. University/academic/government dermatologists were significantly more likely to use telemedicine (57.1%) than private practitioners (35.5%). Telemedicine usage was less likely for dermatologists with more than 30 practice years (>30 years, 32.4% vs <30 years, 40.0%). However, telemedicine usage does not have an impact on the deferred/postponed biopsies that had already occurred during the March week (mean, 10.7) or 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 methodology could have introduced sampling and nonresponse 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 showed significance. Our findings show the significant early impact of COVID-19 on US dermatologic care and can help with better understanding of national trends. With an estimated 49.9 million annual US dermatology office visits,5Rui P. Okeyode T. National ambulatory medical care survey: 2016 national summary tables.https://www.cdc.gov/nchs/data/ahcd/namcs_summary/2016_namcs_web_tables.pdfDate accessed: March 24, 2020Google Scholar the greater than 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. We would like to thank Cindy Kuhn, Rosie Balk, Jeff Miller, and the American Academy of Dermatology (AAD) staff for their help with AAD data collection.