Satyaprakash A, Balkrishnan R, Camacho FT, Jayawant SS, Fleischer AB, Feldman SR. Quality of Dermatologic Care Delivered by Physician Assistants: An Analysis of Prescribing Behavior for the Combination Antifungal Agent Clotrimazole-Betamethasone. Arch Dermatol. 2007;143(12):1589-1603. doi:10.1001/archderm.143.12.1591-b
Most patients with skin disease do not see a dermatologist.1 In an effort to better meet patients' needs, there is growing use of physician assistants in dermatology.2 The quality of dermatologic care offered by physician assistants is not well characterized. Our group has used clotrimazole-betamethasone dipropionate prescribing behavior as a measure of the quality of dermatologic services provided by practitioners in different specialties.3,4 Herein, to assess the quality of dermatologic care provided by physician assistants, we analyze clotrimazole-betamethasone prescribing behavior of 4 practitioner groups: dermatologists, dermatology physician assistants, primary care providers, and primary care physician assistants.
Data on the use of the combination antifungal agent clotrimazole-betamethasone were obtained from the 1995-2004 National Ambulatory Medical Care Survey5 and analyzed as previously described.3,4 First, we identified the 5 most common diagnoses that were treated with clotrimazole-betamethasone at least some of the time. Then we determined the percentage of visits for those 5 conditions at which clotrimazole-betamethasone was prescribed. Each patient visit was analyzed according to whether a physician, physician assistant, or both were involved in the visit. Direct supervision is defined as visits where patients were seen by both the physician assistant and the physician.
There were an estimated 301 million outpatient visits for inflammatory or fungal skin conditions for which clotrimazole-betamethasone was sometimes prescribed. Most of the visits for these skin diseases were to primary care physicians (44.7%) and dermatologists (38.8%) (Table 1). Other subspecialty physicians accounted for 16.5% of these visits. In 95% of the visits, a physician was the only provider to see the patient. Both a physician and physician assistant were seen during 1.4% of these visits, and a physician assistant was the sole health care provider during 0.9% of visits.
In multivariate logistic regression analyses of clotrimazole-betamethasone prescriptions, primary care providers prescribed clotrimazole-betamethasone at a rate of 4.9% compared with the dermatologist prescription rate of 0.2%; other subspecialty physicians prescribed the drug at a rate of 1.7%. Clotrimazole-betamethasone was more likely to be prescribed at visits to physician assistants (regardless of specialty) when the physician assistant was the sole provider of dermatologic care vs when the physician assistant was under direct supervision by a physician (odds ratio [OR], 4.3; 95% confidence interval [CI], 0.7-25.6 vs OR, 1.8; 95% CI, 0.4-8.0) (Table 2).
The highest rate of clotrimazole-betamethasone use, 16.9%, was by physician assistants practicing in primary care and seeing patients without direct supervision. Physician assistants practicing under dermatologists and seeing patients without direct supervision prescribed clotrimazole-betamethasone at a much lower rate of 3.8% compared with their primary care counterparts. For both primary care physician assistants and dermatology physician assistants, however, seeing patients under physician supervision decreased the rate of clotrimazole-betamethasone prescription to 8.3% and 1.1%, respectively.
Physician assistants practicing in a dermatology office are much less likely to prescribe clotrimazole-betamethasone than are physician assistants working in primary care specialties. Even without direct supervision, dermatology physician assistants' clotrimazole-betamethasone prescribing behavior is no worse than that of primary care physicians. When supervised by a dermatologist, physician assistants' clotrimazole-betamethasone prescribing behavior comes closer to that of the dermatologists.
When clotrimazole-betamethasone prescribing behavior is used as the measure of quality, physician assistants provide dermatologic care more comparable to that of primary care physicians than to that of dermatologists. However, these are pilot data that only begin to assess a very complex issue. The growing demand for dermatologic care and the limited availability of dermatologists require that additional attention be paid to the quality of care offered by physician extenders.6
Correspondence: Dr Feldman, Department of Dermatology, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157-1071 (firstname.lastname@example.org).
Financial Disclosure: None reported.