Contact email

klaskowski@bwh.harvard.edu

Overview

This program at an academic medical center utilized early dermatological consultation to decrease unnecessary antibiotic use, prevent misdiagnosis of cellulitis, and to lower healthcare costs. 

Department

Department of Medicine

Collaborators

David Li, BS
Fan Di Xia, AB
Hasan Khosravi, MD
Anna Dewan, MD, MHS
Daniel Pallin, MD, MPH
Christopher Baugh, MD, MBA
Karl Laskowski, MD, MBA
Cara Joyce, PhD

Status/Stage of Development

Planning

Funding Sources

Project funding came from the NIH National Center for Advancing Translational Sciences grant TL1TR001062 and the Brigham and Women’s Physicians Organization Brigham Care Redesign Incubator and Startup Program.

Practice Setting

Academic Medical Center

National/Policy Context

• Unnecessary hospitalizations and prescriptions lead to both increased morbidity and increased healthcare spending. 
  • Intervening to prevent false diagnoses of cellulitis has the potential to lower healthcare spending through decreased antibiotic use and hospital admissions.
• Dermatology screenings could decrease unnecessary antibiotic use and hospitalizations by 74.4% and 85%, respectively. Such a reduction could translate to up to 91,000 patients protected from unnecessary antibiotic use and up to 256,000 unnecessary hospitalizations avoided.

Local/Organizational Context

• Many patients visit the emergency department with presumed diagnoses of cellulitis, which, if not confirmed, can lead to inpatient hospital admissions and improper use of antibiotics. This intervention was enacted to mitigate these healthcare costs and other negative outcomes and confirm that patients either had cellulitis or a different inflammatory skin condition that had presented similarly. 

Patient Population Served and Payor Information

• Enrolled patients had presumed diagnoses of cellulitis in the emergency department (ED), in the ED observation unit, or within 24 hours of admission at a large, urban academic medical center.
• The population served was 78% non-Hispanic White, 54% female, and on average, 58 years old.

Leadership

• The study concept and design were created by David Li, Fan Di Xia, Dr. Daniel Pallin, Dr. Christopher Baugh, Dr. Karl Laskowski, and Dr. Arash Mostaghimi, while other members of the study team provided support with data acquisition/analysis, statistics, and supervision.

Project Research + Planning

• As the intervention was a dermatology consultation built into the existing inpatient admission protocol, no restructuring of the hospital’s admission process was required. 
• However, dermatologists needed to be present in the hospital, have availability in their schedules, and be compensated for their time to be involved in this intervention. This required altering dermatologists’ schedules to ensure their availability.

Training

• Clinical research fellows were trained to perform patient-intake screens to enroll patients into the program.

Tech Involved

• Electronic medical record

Team Members Involved

• Clinical Trainee or Student
• Physicians

Workflow Steps

• A patient with presumed cellulitis gets admitted to the ED, ED observation unit, or inpatient unit.
• Patients are screened by trained research fellows to determine their eligibility for program enrollment based on whether or not they present with cellulitis-like conditions. 
• Admitted patients given a primary diagnosis of cellulitis by the ED or inpatient unit physicians are enrolled in the program. The study team then checks the records of these patients to see if they received a formal diagnosis of cellulitis. 
• Dermatologists either confirmed the diagnosis of cellulitis or re-diagnosed the patient with pseudocellulitis.
• Dermatologists provided recommendations to patients with pseudocellulitis for stopping antibiotics and for the next appropriate steps in treatment. 
• All patients were scheduled for cellulitis follow-up appointments or follow-up phone calls post-discharge.

Outcomes

• Patient disposition: Patients diagnosed with pseudocellulitis had an overall in-clinic or telephone follow-up response rate of 77%, while patients with cellulitis had a response rate of 74%.
• Antibiotic use: 87% of patients were using antibiotics at enrollment. Of this group, 82% were advised to discontinue antibiotic use, and 93% stopped using antibiotics. 
• Rate of adverse events or worsening pseudo/cellulitis 30-days post discharge: Patients with pseudocellulitis and cellulitis said their condition resolved, improved, or stayed the same.

Future Outcomes

• Efficacy of alternative delivery models (i.e. telemedicine) to ensure dermatologic consultation access for patients could be considered.

Benefits

• Correct diagnoses of cellulitis can lower healthcare costs incurred by incorrect diagnosis, subsequent hospital admissions, and antibiotic treatment. 
  • The authors predict that the intervention may result in up to 250,000 avoided inpatient hospitalization days and up to 91,000 patients avoiding unnecessary antibiotic use. 
• The intervention also has potential to improve patient education about their dermatological condition.
• Up to $210 million in healthcare costs were saved by this project, accounting for the costs of the consultation intervention.

Intervention-Specific Challenges

• Finding funding to support wide scale dermatology consultations for a condition as common as cellulitis was challenging. 
• This intervention is unable to account for different aspects of hospital triage and flow that could continue to contribute to the inappropriate prescribing and utilization of antibiotic therapy.

Glossary

• Pseudocellulitis: inflammatory skin diseases that mimic cellulitis

Sources

• Li, David G, Fan Di Xia, Hasan Khosravi, Anna K Dewan, Daniel J Pallin, Christopher W Baugh, Karl Laskowski, Cara Joyce, and Arash Mostaghimi. “Outcomes of Early Dermatology Consultation for Inpatients Diagnosed With Cellulitis.” JAMA Dermatology 154.5 (2018): 537-43. Web.