To the Editor:
Acne vulgaris is common and is seen clinically by both pediatricians and dermatologists. Approximately 70%–87% of teenagers >12 years of age have acne.1 Effective treatment often involves use of several medications that target different types of pathomechanisms.2 A practice gap has been identified among pediatricians treating acne when compared with their dermatologist colleagues. The prescribing behavior of dermatologists and pediatricians differs considerably, with topical retinoids prescribed 46.1% and 12.1% of the time among dermatologists and pediatricians, respectively.3 The opportunity exists for pediatricians to treat acne more effectively. In this intervention study, whether an educational program and electronic medical record (EMR) ordering tool could improve pediatrician acne care and decrease referrals to dermatologists was assessed.
A guidelines-based educational program was administered to 116 pediatricians. An EMR ordering tool was created that provided recommendations on medication based on severity with customized care plans and educational materials. Physicians were surveyed on their attitudes about and perceived work burden relating to this acne care tool.
After training and implementation, pediatricians used the EMR ordering tool 546 (43.03%) times over the course of 4 months (Table I). Acne-coded visits increased from 1078 to 1269 compared with the year prior (odds ratio [OR] 1.18, 95% confidence interval [CI] 1.08–1.28; P < .001). The absolute decrease in percentage of acne referrals to dermatologists was 26.3% (P =.017). After the intervention, pediatricians prescribed significantly more retinoids (P = .003) and less topical clindamycin (Table II). The odds of pediatricians prescribing a retinoid were 4.96 times higher with use of the EMR tool than without (3.73–6.57; P <.001); after controlling for confounding factors, such as sex and insurance status, the odds were 5.13 (3.83–6.92; P < .001). Pediatricians reported a decreased burden of acne care, with 75% assessing this care as minimal to no work.
Table I.
Demographics of preintervention and postintervention acne patient populations
| Characteristic | Preintervention population, n = 1078 | Postintervention population, n = 1269 |
|---|---|---|
| Age, y, mean (SD) | 16.0 (1.89) | 15.0 (1.94) |
| Age range, y | 7.2–20.6 | 10.0–20.6 |
| Female, n (%) | 608 (56.40) | 716 (56.42) |
| Total acne-coded visits by pediatricians, n (%) | 1078 (2.94) | 1269 (3.47) |
| Smart set use, n (%) | 546 (43.03) | |
| Total referrals to dermatologists, n | 295 | 214 |
| Referrals with acne code, n (%) | 120 (11.13) | 104 (8.20) |
| Referrals without acne code, n | 175 | 110 |
The preintervention period before pediatricians had easy access to guidelines was December 31, 2015-April 30, 2016, and the postintervention period when pediatricians had easy access to guidelines was December 31, 2016-April 30, 2017.
SD, Standard deviation.
Table II.
Acne medications prescribed during preintervention and postintervention periods
| Intervention |
|||||
|---|---|---|---|---|---|
| Medication | Pre, N = 1078, n (%) | Post, N = 1269, n (%) | OR* | 95% CI | P value |
| Topical retinoids | 620 (57.51) | 894 (70.45) | 1.22 | 1.07–1.40 | .003† |
| Topical clindamycin | 399 (37.01) | 279 (21.99) | 0.59 | 0.50–0.71 | <.001† |
| Doxycycline | 159 (14.75) | 206 (16.23) | 1.10 | 0.88–1.38 | .43 |
| Minocycline | 77 (7.14) | 118 (9.30) | 1.30 | 0.96–1.78 | .090 |
| Hormone therapy | 39 (3.62) | 56 (4.41) | 1.22 | 0.79–1.90 | .40 |
CI, Confidence interval; OR, odds ratio.
OR calculation of postintervention versus preintervention.
Indicates statistical significance at P < .01.
Pediatricians adhering to guidelines improves the treatment provided in the primary care setting and patient satisfaction. The educational program and EMR ordering tool use enabled patients with more severe acne and conditions other than acne to have greater access to pediatric dermatologists. In a previous intervention study, in which practice gaps in acne treatment were examined, pediatricians were found to have increased confidence and improved ability to choose medications in accordance with treatment guidelines after employing a case-based educational intervention that was based on national guidelines.4 In another study, an acne treatment algorithm model that assessed prescribing patterns among primary care providers of adult patients referred to dermatologists for acne care was examined.5 When primary care providers followed an acne treatment algorithm that initiated topical treatments, the model predicted that referrals would decrease by 48%, and if the algorithm initiated topical and systemic antibiotics, the model predicted that referrals would decrease by 86.7%.5
Our intervention narrowed the practice gap in acne treatment between dermatologists and pediatricians through the implementation of EMR-embedded guidelines, in conjunction with brief, live educational sessions. The EMR tool increased acne care delivery and management consistent with clinical guidelines, decreased referrals to dermatologists, and did not increase the perceived burden of work for pediatricians. Limitations of our study include the short study period. Future research will aim to determine the impact of this combined guidelines-based educational program and EMR ordering tool on patient acne outcomes.
Acknowledgments
Funding sources: Centers for Medicare and Medicaid Services Transforming Clinical Practices Initiative and The American Acne and Rosacea Society.
Footnotes
Conflicts of interest: None disclosed.
REFERENCES
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