Differences in Face-to-Face Time Spent With a Dermatologist Among Patients With Psoriasis Based on Race and Ethnicity

Abstract

This cross-sectional study examines whether a physician’s time spent with a patient with psoriasis differs based on the patient’s race and ethnicity.

Psoriasis is a chronic inflammatory skin condition frequently managed by dermatologists. Dermatologists have an obligation to provide each patient with psoriasis with adequate time to address their concerns and develop strong communication and trust. Ineffective physician-patient communication can mean poor treatment adherence, comprehension, satisfaction, and outcomes for the patient.¹ It is unclear whether differences exist in the amount of time a dermatologist spends with a patient with psoriasis based on race or ethnicity. We aimed to evaluate the association between a patient’s race and ethnicity and time spent with a dermatologist for psoriasis treatment.

Methods

We performed a cross-sectional study of data from the National Ambulatory Medical Care Survey from 2010 through 2016.² Data were analyzed January 3 to April 24, 2022. We conducted multivariable linear regression analyses adjusted for age, sex, type of visit (follow-up or new patient), visit complexity based on the number of reasons for visit, insurance status, psoriasis severity on the basis of systemic psoriasis treatment or phototherapy, and complex topical regimen (3 or more topical agents) to evaluate the association between patient race and ethnicity and visit duration for psoriasis treatment with a dermatologist. Race and ethnicity were self-reported by patients. The eMethods in the Supplement provides further details. This study was categorized as exempt by the University of Southern California Institutional Review Board, and the requirement for informed consent was waived because only deidentified data were used. We followed the STROBE reporting guideline. Statistical tests were 2-tailed, and a 2-sided P < .05 was considered statistically significant.

Results

A weighted estimate of 4 201 745 (95% CI, 3 688 629-4 714 862) patient visits for psoriasis was identified. Of the tabulated demographic characteristics, a significant difference existed in age (37.2 [95% CI, 32.0-42.4] years for Asian patients vs 44.7 [95% CI, 33.4-56.0] years for Hispanic patients vs 33.3 [95% CI, 16.9-49.7] years for Black patients vs 54.8 [95% CI, 51.6-58.0] years for White patients; P = .001) and complex topical regimen (11.8% among Asian patients vs 1.5% among Black patients vs 1.1% among White patients; P = .03) among the groups (Table 1). Mean duration of visits was 9.2 (95% CI, 4.4-14.1) minutes with Asian patients, 15.7 (95% CI, 14.2-17.3) minutes with Hispanic or Latino patients, 20.7 (95% CI, 14.5-26.9) minutes with non-Hispanic Black patients, and 15.4 (95% CI, 13.5-17.3) minutes with non-Hispanic White patients. Visits with Asian patients had a 39.9% shorter mean duration compared with visits with White patients (β coefficient, −5.747 [95% CI, −11.026 to −0.469]; P = .03) and a 40.6% shorter mean duration compared with visits with non-Asian patients as a single group (β coefficient, −5.908 [95% CI, −11.147 to −0.669]; P = .03) (Table 2).

Table 1. Characteristics of Dermatologist Visits Among Patients With Psoriasis Based on Their Race and Ethnicity.

Characteristic	Weighted estimate (%) [95% CI]				P value
	Asian patients	Hispanic or Latino patients	Non-Hispanic Black patients	Non-Hispanic White patients
No. of visits	153 283 (3.6) [75 834-230 733]	278 453 (6.6) [121 266-435 640]	110 797 (2.6) [20 199-201 395]	3 659 212 (87.1) [3 189 041-4 129 382]
Patient age, mean (95% CI), y	37.2 (32.0-42.4)	44.7 (33.4-56.0)	33.3 (16.9-49.7)	54.8 (51.6-58.0)	.001
Sex
Male	56 914 (37.1) [26 466-87 365]	122 769 (44.1) [43-245 494]	32 543 (29.4) [16 888-48 199]	1 913 999 (52.3) [1 568 126-2 259 872]	.49
Female	96 369 (62.9) [37 020-155 715]	155 684 (55.9) [45 179-266 189]	78 254 (70.6) [2636-153 872]	1 745 213 (47.7) [1 428 431-2 061 995]
Type of visit
Follow-up	100 609 (65.6) [36 297-164 921]	255 145 (91.6) [97 225-413 064]	56 711 (51.2) [1555-111 867]	3 044 018 (83.2) [2 595 640-3 492 396]	.10
New patient	52 674 (34.4) [13 831-91 518]	23 308 (8.4) [Not applicable]	54 086 (48.8)	615 194 (16.8) [476 838-753 550]
Complexity of visit
1 Reason for visit	90 358 (58.9) [43 819-136 897]	116 218 (41.7) [81 129-151 307]	95 125 (85.9) [14 518-175 731]	2 492 441 (68.1) [2 083 785-2 901 096]	.64
2 Reasons for visit	21 451 (14.0) [4360-38 543]	162 235 (58.3) [17 117-307 353]	5968 (5.4) [711-11 224]	873 326 (23.9) [678 839-1 067 812]
3 Reasons for visit	41 474 (27.1) [Not applicable]	Not applicable	9704 (8.8)	293 445 (8.0) [191 914-394 978]
Prescribed a systemic agent or phototherapya	104 778 (68.4) [60 288-149 268]	174 415 (62.6) [46 265-302 565]	11 894 (10.7) [1908-21 879]	1 081 249 (29.5) [861 372-1 301 126]	.06
Prescribed a complex topical regimenb	18 102 (11.8) [3149-33 056]	Not applicable	1643 (1.5) [Not applicable]	41 001 (1.1) [26 921-55 082]	.03

^a Systemic agents include etanercept, adalimumab, infliximab, ustekinumab, methotrexate, acitretin, mycophenolate mofetil, apremilast, and systemic corticosteroids.

^b Topical agents include clobetasol, tacrolimus, pimecrolimus, desonide, desoximetasone, fluocinolone, halobetasol, triamcinolone, hydrocortisone, calcipotriene, fluocinonide, halcinonide, tazarotene, betamethasone, betamethasone with calcipotriene, and alclometasone.

Table 2. Multivariable Linear Regressions Evaluating Race and Ethnicity on Time Spent With Dermatologist.

Independent variables	Face-to-face time with dermatologist
	β Coefficient (95% CI)	P value
Race or ethnicitya
Asian	−5.747 (−11.026 to −0.469)	.03
Hispanic or Latino	1.273 (−1.952 to 4.498)	.43
Non-Hispanic Black	0.595 (−4.329 to 5.520)	.81
Non-Hispanic White	1 [Reference]	1 [Reference]
Age	0.018 (−0.051 to 0.088)	.60
Sex
Female	1 [Reference]	1 [Reference]
Male	−1.516 (−3.803 to 0.772)	.19
Type of visit
Follow-up	1 [Reference]	1 [Reference]
New patient	2.600 (0.385 to 4.814)	.02
Complexity of visit
1 Reason for visit	1 [Reference]	1 [Reference]
2 Reasons for visit	−0.392 (−2.439 to 1.655)	.70
3 Reasons for visit	−1.001 (−4.592 to 2.590)	.58
Insurance status
Private insurance	1 [Reference]	1 [Reference]
Medicare	0.916 (−1.159 to 2.991)	.38
Medicaid	1.380 (−1.258 to 4.018)	.30
Self-pay	16.088 (−1.616 to 33.792)	.07
No charge	13.396 (7.820 to 18.973)	<.001
Systemic treatment or phototherapy?b
No	1 [Reference]	1 [Reference]
Yes	−0.435 (−2.759 to 1.890)	.71
A complex topical regimen (≥3 topical agents prescribed)?c
No	1 [Reference]	1 [Reference]
Yes	1.468 (−3.200 to 6.137)	.53

^a Race and ethnicity were self-reported by patients. Racial and ethnic groups included Asian, Hispanic or Latino, non-Hispanic Black, and non-Hispanic White. Other racial and ethnic groups were excluded owing to small sample sizes. Individuals in the Asian race category of the National Ambulatory Medical Care Survey included Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, and “Other Asian racial groups,” which were not identified in the survey.

^b Systemic agents include etanercept, adalimumab, infliximab, ustekinumab, methotrexate, acitretin, mycophenolate mofetil, apremilast, and systemic corticosteroids.

^c Topical agents include clobetasol, tacrolimus, pimecrolimus, desonide, desoximetasone, fluocinolone, halobetasol, triamcinolone, hydrocortisone, calcipotriene, fluocinonide, halcinonide, tazarotene, betamethasone, betamethasone with calcipotriene, and alclometasone.

Discussion

Results of the present study suggest that Asian patients with psoriasis receive significantly less face-to-face time with a dermatologist compared with patients of other races and ethnicities. This study supports the results of previous studies in which Asian patients were found to be less likely to receive counseling from physicians compared with White patients.^3,4 Paradoxically, Asian individuals tend to present with more severe psoriasis compared with individuals of other races and ethnicities.⁵

The etiology of these differences is unclear. It is possible that factors, such as unconscious bias, cultural differences in communication, or residual confounding may be responsible for the observed findings.^3,6 Further research is needed to understand the underlying factors responsible for the differences observed in this study.

This study has limitations. Visit duration was self-reported by the physician or their staff and had been studied in other fields; formal validation studies are pending. Missing data on race and ethnicity were imputed using a sequential regression method.² It is possible that those patients who did not report race and ethnicity may have different characteristics affecting visit duration vs those who did report this information.

Dermatologists spend less time with Asian patients with psoriasis compared with patients of other races and ethnicities. Dermatologists need to allow sufficient time to develop strong physician-patient communication regardless of patient background.

Supplement.

eMethods. Further Details on Methodology