PracticalDermatology

The COVID-19 pandemic is an evolving public health crisis. States have experienced a fluctuating number of cases, requiring adjustments to social distancing recommendations. In July 2020, Texas experienced a surge of COVID-19 infections, while Oregon maintained a relatively low infection burden.¹ We sought to examine the impact of COVID-19 case incidence on dermatology practice responses by determining the percentage of open dermatology offices and their level of operation in Texas and Oregon in July 2020.

We selected 25 Texas and 25 Oregon dermatologists from the AAD member website at random.² Dermatology subspecialists, health systems requiring membership, and military centers were excluded. Practice websites and Crunchbase Pro were used to classify practices as private, private with private equity (PE) investment, academic, or health system.³

On the mornings of July 20 and July 21, 2020, practices were called by one author (AM). Phone call scripts were derived from previous studies.⁴ If an employee answered, a script about a patient seeking the next available appointment for the urgent condition of a bleeding mole was utilized. Offices accepting new patients received a second scripted call in the afternoon involving a patient interested in scheduling an appointment for botulinum toxin injections, a non-urgent appointment. All appointments offered were declined. If a recording was reached, the office was considered closed. If given a range of available appointment dates, the mid-point was selected for calculations. We performed two sample t-tests to compare mean wait times. The University of California, Riverside institutional review board deemed the study non-human subjects research.

Fifty offices were contacted (100 percent contact rate). Twenty-five practices (50 percent) were seeing urgent and non-urgent conditions, 18 (36 percent) were seeing only urgent conditions, four (eight percent) were closed, two (four percent) were operational but would only offer an appointment subsequent to registering for a patient account (which we declined), and one (two percent) was not accepting new patients (Figure I). A study by Muddasani, et al., conducted in March 2020 using different states, reported similar results. In this study, 53 percent and 31 percent of contacted practices were operating without restrictions and only seeing urgent conditions, respectively.⁴

Figure I. Percent of dermatologists open in Texas and Oregon in July 2020

At the time our study was conducted, Texas had 332,434 total cases, while Oregon had 14,847.¹ In Texas, 12/25 (48 percent) offices were operating without restrictions and 8/25 (32 percent) practices were only seeing urgent conditions, compared to 13/25 (52 percent) and 10/25 (40 percent) practices in Oregon, respectively (Table I). Three offices were closed in Texas (12 percent) compared to 1 in Oregon (four percent).

For the 50 offices, mean wait time for urgent conditions was 19.2±28.3 days, while mean wait time for non-urgent conditions was 28.2±43.1 days. There was no significant difference between mean wait time for urgent and nonurgent conditions (p = 0.365). Mean wait time for urgent conditions was 12.9±20.3 days and 24.7±33.2 days in Texas and Oregon, respectively. Mean wait time for non-urgent appointments was 24.9±45.8 days in Texas and 31.4±41.9 days in Oregon. There was a significant difference between the mean wait time for urgent conditions between the two states (p = 0.043) but not for non-urgent conditions (p=0.720).

Private practices with and without PE investment had the highest percentage of practices operating without restrictions (Table I). Private practices may be more incentivized to stay open without restrictions due to revenue loss. A Texas Medical Association poll from April reports 24 percent and 36 percent of respondents had lost 75-100 percent and 50-75 percent of revenue since the start of the pandemic, respectively.⁵

Despite larger cumulative incidence of COVID-19 cases, Texas had a significantly shorter wait time for urgent conditions compared to Oregon. Similarly, Muddasani, et al. found a shorter mean wait time in counties with a lower percentage of open practices, which tended to have a higher infection burden and suggested this may be due to a higher cancelation rate in these areas.⁴ Alternatively, dermatologists in areas with rising infection rates may be altering their practices to an urgent care dermatology clinic model.⁶ Although our study was conducted in different geographical areas and at a later time point than Muddasani, et al., we obtained similar findings.⁴ This suggests dermatologists are maintaining a steady response to COVID-19 regardless of fluctuations in infection levels.

1. United States COVID-19 Cases and Deaths by State over Time | Data | Centers for Disease Control and Prevention. https://data.cdc.gov/Case-Surveillance/United-States-COVID-19-Cases-and-Deaths-by-State-o/9mfq-cb36/data. Accessed September 22, 2020.

2. Find A Dermatologist. https://find-a-derm.aad.org/. Accessed September 21, 2020.

3. Crunchbase Pro: Company Search and Tracking Made Easy | Crunchbase. https://about.crunchbase.com/products/crunchbase-pro/. Accessed September 21, 2020.

4. Muddasani S, Housholder A, Fleischer AB. An assessment of United States dermatology practices during the COVID-19 outbreak. J Dermatolog Treat. 2020;31(5):436-438. doi:10.1080/09546634.2020.1750556

5. Road to Practice Recovery: A Guide for Reopening Your Practice Post-COVID-19 website; [cited 2020 Sep 22]. Available from: https://www.texmed.org/uploadedFiles/Current/2016_Public_Health/Infectious_Diseases/Road to Recovery.pdf.

6. Sempler J, Thomas F, Pettit J, Klein SZ. The value of urgent care dermatology. Int J Dermatol. 2019;58(1):80-85.