Abstract
This cross-sectional study examines sunburn in claims data as well as the clinical settings and demographic characteristics of patients who receive sunburn diagnoses.
Sunburn is a preventable risk factor for skin cancer, which is increasing in incidence in the US.1 Prior investigations of sunburn have been primarily survey based,2 and those in health care settings have focused on emergency department visits.3,4 We aimed to investigate sunburn in claims data, which to our knowledge has not previously been done, and characterize the clinical settings and demographic characteristics of patients who receive sunburn diagnoses.
Methods
We used Truven MarketScan, a deidentified database of commercially insured patients, to identify sunburn visits from January 2009 to December 2018 using diagnosis codes (International Classification of Diseases, Ninth Revision [ICD-9] codes 692.71, 692.76, and 692.77; ICD-10 codes L55, L55.0, L55.1, L55.2, and L55.9). We included medical encounters with a sunburn diagnosis code (encounters on the same day for the same patient were considered 1 encounter). The primary outcomes were patient demographic characteristics, clinical settings, clinician specialties, management provided, and geographic location, which were presented with descriptive statistics. The study was approved by the institutional review board at MD Anderson Cancer Center, which also waived informed consent, and followed Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines.5 Statistical analysis was conducted using SAS, version 7.15 (SAS Institute).
Results
There were nearly 123 million eligible patients. We included 186 168 patients (0.15%) with 208 777 encounters with sunburn diagnoses. Most patients had a single encounter with sunburn diagnosis: 170 463 (91.6%) had 1 encounter; 12 131 (6.5%) had 2; and 3574 (1.9%) had 3 or more. Patients with a sunburn diagnosis were more likely to be female and to be younger than patients in MarketScan overall (Table 1). Approximately 20% of encounters were in the emergency or urgent care setting. Encounters with sunburn diagnoses were most commonly with dermatologists (26.0%), followed by family medicine clinicians (22.0%; Table 2). When we considered every ICD code entered (n = 235 015), 179 887 (76.5%) were nonspecific sunburn (692.71, L55.9), 14 594 (6.2%) were first degree (L55.0, no code in ICD-9), 39 838 (17.0%) were second degree (692.76, L55.1), and 696 (0.3%) were third degree (692.77, L55.2). Most patients (83.5%) did not receive medical treatment that was consistent with sunburn treatment. Treatment that may have been for sunburn was more likely in emergency/urgent care settings overall and for each category except topical steroids (Table 2).
Table 1. Patient Demographic Characteristics.
| Characteristic | No. (%) | P valuea | |
|---|---|---|---|
| Patients with a sunburn diagnosis | MarketScan population | ||
| Total patients | 186 168 | 122 988 324 | |
| Sex | |||
| Female | 102 882 (55.3) | 66 086 547 (53.7) | <.001 |
| Male | 83 286 (44.7) | 56 901 777 (46.3) | |
| Age, y | |||
| At MarketScan entry, median (IQR) | 27 (29) | 34 (34) | <.001 |
| At first encounter with sunburn diagnosis, median (IQR) | 28 (30) | NA | NA |
| At first encounter with sunburn diagnosis | |||
| <18 | 50 042 (26.9) | NA | NA |
| 18-24 | 32 280 (17.3) | ||
| 25-34 | 27 912 (15.0) | ||
| 35-44 | 24 302 (13.1) | ||
| 45-54 | 23 320 (12.5) | ||
| 55-64 | 19 524 (10.5) | ||
| 65-74 | 5479 (2.9) | ||
| 75-84 | 2557 (1.4) | ||
| ≥85 | 752 (0.4) | ||
| Census region | |||
| Midwest | 39 877 (21.4) | 28 111 889 (22.9) | <.001 |
| South | 71 517 (38.4) | 48 131 347 (39.1) | |
| Northeast | 43 245 (23.2) | 22 632 941 (18.4) | |
| West | 27 481 (14.8) | 21 793 450 (17.7) | |
| Other/unknown | 4048 (2.2) | 2 318 697 (1.9) | |
Abbreviations: IQR, interquartile range; NA, not applicable.
χ2 test for proportions, Mann-Whitney U test for medians.
Table 2. Characteristics of Encounters With Sunburn Codes.
| Characteristic | No. (%) | Encounters, No. (%)a | |
|---|---|---|---|
| Emergency or urgent care | Outpatient | ||
| Total No. of patient encounters | 208 777 | ||
| Season | |||
| Spring (March-May) | 62 310 (29.85) | NA | NA |
| Summer (June-August) | 118 915 (56.96) | ||
| Fall (September-November) | 17 529 (8.4) | ||
| Winter (December-February) | 10 023 (4.8) | ||
| Clinical setting | |||
| Emergency department | 28 611 (13.7) | NA | NA |
| Urgent care | 14 855 (7.12) | ||
| Outpatient office visit | 166 780 (79.88) | ||
| Other | 487 (0.23) | ||
| Clinician specialtyb | |||
| Emergency medicine | 16 249 (7.78) | NA | NA |
| Internal medicine | 13 065 (6.26) | ||
| Family medicine | 45 956 (22.01) | ||
| Dermatology | 54 198 (25.96) | ||
| Pediatrics | 19 608 (9.39) | ||
| Other | 62 034 (29.71) | ||
| Unknown | 14 170 (6.79) | ||
| Encounters that included possible sunburn managementb | |||
| Intravenous fluids | 1623 (0.78) | 1511 (3.51) | 112 (0.07) |
| Nonsteroidal anti-inflammatory drugs | 5201 (2.49) | 2174 (5.04) | 3027 (1.83) |
| Opioids | 184 (0.09) | 68 (0.16) | 116 (0.07) |
| Steroids | |||
| Topical | 11 621 (5.57) | 1137 (2.64) | 10 484 (6.34) |
| Systemic | 14 967 (7.17) | 4554 (10.57) | 10 413 (6.3) |
| Antihistamines | 283 (0.14) | 128 (0.3) | 155 (0.09) |
| None of the previously mentioned management | 17 9427 (85.94) | 35 230 (81.74) | 144 197 (87.24) |
Abbreviation: NA, not applicable.
χ2 comparing emergency or urgent care encounters with outpatient encounters were all P < .001.
Categories can overlap, as 1 encounter may include multiple clinicians or management strategies listed.
Discussion
Sunburn that is coded in medical encounters is uncommon but not negligible: we found 0.15% of eligible patients had an encounter with a sunburn diagnosis. We observed sunburn diagnoses in pediatric and adult patients, with approximately a quarter in patients 18 years or younger. Our results indicate that sunburn diagnoses occur across the lifespan, highlighting the need for sun protection for all. Our study findings suggest that sunburn is seen in various clinical settings, with an approximately 4:1 ratio of outpatient to emergency/urgent care and with dermatology and family medicine as the most common specialties. Most encounters with sunburn diagnoses did not appear to include sunburn medical management.
Our study has limitations. MarketScan includes patients with commercial insurance and is not designed to be nationally representative. However, the nearly 123 million eligible patients have similar demographic characteristics to the US population in terms of sex and geography. Additionally, we reported on encounters in which a sunburn diagnosis was entered, but we do not know whether a patient was seeking care for sunburn or if it was an incidental finding. When sunburn is an incidental finding, we may be overestimating patients who are seeking medical care for sunburn. However, we may also be underestimating patients who present with a physical examination finding of sunburn, as clinicians may not code diagnoses that are not being actively managed.
We found that sunburn is most commonly seen in the outpatient setting by dermatologists. Our results suggest that administrative data can be used to expand our ability to study sunburn beyond self-reported surveys and may represent a resource for public health initiatives in skin cancer prevention and detection.
References
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