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The value of in-patient dermatology: a survey of in-patients in Scotland and northern England

(British Journal of Dermatology 1999; 140: 474-479)

CS Munro, JG Lowe*, PM Cloone†, MI White‡ and JAA Hunter§ on behalf of the Scottish Dermatological Society In-Patient Survey Group
Southern General Hospital, Glasgow G51 4TF, UK
*Ninewells Hospital, Dundee DD1 9SY, UK
†Public Health Research Unit, University of Glasgow, Glasgow G12 8RZ, UK
‡Aberdeen Royal Infirmary, Forresterhill, Aberdeen AB25 2ZN, UK
§Royal Infirmary, Edinburgh EH3 9YW, UK

Accepted for publication 15 September 1998

Summary

Dermatology in-patient units are frequently threatened with reduction or closure, yet there are few objective data regarding the nature and use of in-patient management with which to assess their value.  We have surveyed 300 patients admitted during March 1997 to dermatology units throughout Scotland and Northern England, to establish their clinical and social profile, and the outcome of admission.  All departments provided phototherapy and out-patient treatment services, and 84% of those admitted lived within an hour's travel of one of these.  Three diagnostic groups (psoriasis, eczema and leg ulcers) accounted for 83% of in-patient days.  Patients were admitted principally because of disease severity but many, including half of those with psoriasis, had concurrent medical problems such as alcohol abuse, psychiatric disorder or arthropathy.  Many patients with psoriasis and leg ulcers were from socially deprived areas, as defined by low Carstairs index scores, and a similar proportion received income support.  Eighteen per cent of patients, mainly those with acute disorders, would have needed admission irrespective of dermatology bed availability.  Out-patient management was considered the next best alternative for only 28% of patients, and many patients would have been expected to treat themselves.  By contrast, 84% of patients admitted were cleared or substantially improved, or had procedures completed as planned, and another 12% were partially improved.  Outcomes were particularly good in psoriasis, eczema and infection groups.  We have demonstrated that in-patient management is highly effective in providing remission in chronic skin disease, and our survey also suggests that concomitant disability or social factors mean that for many such patients ambulatory care cannot replace this service.

Key words: dermatology, eczema, in-patients, leg ulcers, northern England, psoriasis, Scotland

Evolving therapies such as PUVA or narrow-band ultra-violet (UV) B phototherapy, and increasing skills and numbers of specialised dermatology nurses, have led to widespread use of ambulatory care for patients with major chronic skin diseases¹.  New drugs for psoriasis and eczema have been licensed.  Multilayer graduated compression bandaging has improved the management of leg ulcers.  In parallel with these developments, and despite increasing numbers of referrals to out-patient departments^2,3, there have been a reduction in the number of in-patient beds committed to dermatology in the UK⁴ and other countries⁵.  In-patient care is significantly more expensive than ambulatory care, and in reality reduction in bed provision has been driven by cost pressures rather than led by therapeutic advances.  It is tempting to believe that innovation and development will permit this process to continue indefinitely without prejudice to quality of care.  However, the choice of treatment is not determined solely by availability of ambulatory care.

Dermatologists know that out-patient treatment may be neither feasible nor appropriate for a variety of reasons, but there is little published work documenting these factors.  Moreover, until two recent studies using quality of life measures^6,7; objective data on the success of in-patient treatment have been sparse.  To seek further evidence about the use and value of in-patient resources, we have conducted an observational study of adults admitted to dermatology beds throughout Scotland and northern England during a 1-month period.  In particular, we have sought to identify clinical and social factors relevant to admission, and to assess outcome.

Materials and methods

A questionnaire was completed by local medical staff for adults admitted to dermatology beds of all 14 departments (15 in-patient units) in Scotland, Newcastle-upon-Tyne and Carlisle during March 1997.  March was chosen as a representative month, which would avoid mid-winter periods when medical patients overflow onto specialty beds, and service disruptions during statutory and summer holidays.  Dermatologists from these departments provide services for approximately 6.6 million people, conducting out-patient clinics at varying frequencies in a total of 75 locations.  In 21 locations, phototherapy (20) and out-patient dermatology treatments (21) were also provided.  Two departments also had community liaison nurses.  One in-patient unit had only 5-day beds, one centre had both 5- and 7-day beds, and the remainder were 7-day units.  The beds were dedicated to dermatology in all but one single-consultant department.

Questionnaires were identified by centre and unit number.  In order to keep the process as simple as possible, most data were gathered using tick-box choices, but there was scope for more information to be added.  The data collected at admission and discharge are shown in Table 1.  The Carstairs index⁸ is a summary measure of deprivation in electoral wards based on unemployment, overcrowding, access to a car and social class.  For patients in Scotland, each patient's postcode was subsequently used to obtain the value of the Carstairs index based on the 1991 census small area statistics⁹.   The completing dermatologist was also asked to indicate, first, the most likely course of action had it not been possible to admit to a dedicated dermatology bed and, secondly, the most likely outcome had it not been possible to admit the patient at all.  No comparison between units was made.  For all in-patients and individual disease groups, the numbers in each of the seven deprivation groups of the Carstairs index were combined into most affluent (1 and 2), average (2 - 5) and most deprived (6 and 7) and compared with the Scottish population as a whole using the X²-test.

^a Dependency status on admission graded by nursing staff on a four-point scale used in the Royal Infirmary of Edinburgh, which can be summarised as: 1, independence in all activities; 2, some help needed; 3, help needed with most activities; 4, total dependence.

Results

By chance, data were obtained on exactly 300 patients (Table 2).  For analysis, seven diagnostic groups were identified. Psoriasis included both acute and chronic forms and eczema included atopic and other forms.

^a rate of discharge or transfer not available for four patients

Leg ulcer and (immuno)bullous disease groups are self-evident.  The neoplasia group included patients admitted for surgery or chemotherapy, and cutaneous lymphoma.  The infection group included viral and bacterial infections e.g. eczema herpeticum and primary cellulitis.  The remaining group included drug erythemas, vasculitis, urticaria, pruritis and miscellaneous conditions.  Psoriasis accounted for 48% of admissions and 58% of in-patient days (Table 2), and for this group, results below are reported in particular detail.  Eczema and leg ulceration accounted for another quarter of in-patient days, with the remaining four groups each accounting for <_ 6%.

Age, disability and coexisting disease
About a third (32%) of patients were aged over 65 years (36% of in-patient days).  This age group included 84% of patients with leg ulcers, but only 17% with psoriasis and 25% of those with eczema.  Coexisting medical problems were present in 43% overall (psoriasis 50%), notably arthritis (9%; psoriasis 13%), alcohol abuse (6%; 10%), psychiatric disorder (6%; 9%) and cardiac disease (5%; 5%).  Fifteen per cent of patients (19% of bed use) had some degree of dependency, 11% requiring some supervision, 4% help with most activities and 0.3% total care.

Geographic and social factors
Sixteen per cent of patients (19% with psoriasis) lived more than 1h travelling time from the nearest out-patient treatment centre.  Most patients lived with a partner, parent or other adult family member, but 10% were elderly living alone and 14% other adults living alone.  Two per cent were single parents.  Thirty-six per cent of patients were retired, and the same percentage was in full or part-time employment or education, or housewives.  However, 17% of patients of working age (24% of those with psoriasis) were unable to work due to disability, occupying 19% of in-patient days (28% of those for psoriasis).  Another 9% were unemployed (17% with psoriasis).  Twenty-one per cent of patients (31.5% of those with psoriasis) stated that their household received income support.  Postcodes could be mapped to a value for the Carstairs index of deprivation for 213 of 226 in-patients living in Scotland.  In the Scottish population as a whole, 18% live in the most socially deprived areas (Carstairs groups 6 and 7).  In the dermatology in-patient population there was a trend to an increased proportion in groups 6 and 7: 23.5% of mapped postcodes (22% of all postcodes); X²=5.7,P=0.06 compared with Scottish population).  This trend to more deprived groups was seen in psoriasis (26%; X²=5.56,P=0.06 compared with the Scottish population) and leg ulcer patients (36%; X²=5.50,P=0.06), but not in other groups.  Of patients with psoriasis who were not geographically isolated (living within 10miles of a treatment unit), 31% were in groups 6 and 7.

Admission
Prior to admission, 11% of patients (14% of psoriasis; 24% of leg ulcers) had received treatment by dermatology nurses in out-patient departments.  Overall 9% of patients (48% of leg ulcer patients) had received nursing home, community or liaison nurse treatment prior to admission.  Almost all admissions were from out-patients referral clinics (76%) or as a result of acute general practitioner 8%).  The principle reason given for admission is shown in Table 3.  Only one choice was permitted and despite the high levels of concomitant factors, the reason given was severity of disease in 71% of cases.  Most of the rest were admitted because in-patient management was considered mandatory for the condition, or because out-patient management had failed.  About half of admissions were as emergencies or urgent cases (Table 4).  Treatment given was primarily topical (56% overall; 65% of psoriasis), although combined with phototherapy or systemic treatment in another 30% of psoriasis patients.

a Investigations, associated disease, social problems and miscellaneous reasons

Outcomes of admission and discharge arrangements
Overall, 84% of patients were either cleared or substantially improved, or treatment completed as planned and another 12% were partially improved.  The best out-comes (patients clear or substantially improved) were seen in psoriasis (87%), eczema (97%) and infection (92%) groups.  These outcomes were less frequent in leg ulcer (48%) and neoplasia (61%) groups, but in many cases the objectives would have been palliative, and the partial improvement recorded in another third of each group is important.  Following discharge, it was planned to review most cases (84%) in out-patient clinics or treatment units.  Twenty-two per cent of patients with psoriasis, 17% of those with eczema and 28% of those with leg ulcers were to have continuing treatment in out-patient units.  Of those with leg ulcers, 16% were to have treatment from community nurses and another 12% were transferred to other units.

Alternatives to admission
The suggested most likely alternative management, had dermatology admission not been possible, is shown in Table 4.  Eighteen per cent of patients would otherwise have needed admission to another medical or surgical specialty (psoriasis 8%).  Despite the availability of treatment services in all units, out-patient treatment was considered the likeliest alternative management in only 28% (psoriasis 36%).  Thirty-six per cent would have had no support, which was felt in practice to have meant no treatment at all in 11% (psoriasis 16%).  Had admission to any in-patient bed not been possible, it was felt that serious complications or death would have ensued in 12% (psoriasis 3%) an that the condition would have persisted without improvement or deteriorated in another 71% (psoriasis 85%).  Only 1.5% were expected to have shown comparable improvement or recovery irrespective of admission.

Discussion

Dermatology patients admitted to hospitals in Scotland and northern England are often those with multiple, complex or potentially serious disease, or with social disadvantage.  Concomitant disease, disability and psychiatric disorder contribute disproportionately to an in-patient bed occupancy.  Despite these adverse factors, the overall success of admission is very high.

Psoriasis, eczema and leg ulceration accounted 83% of dermatology bed usage surveyed, and with psoriasis alone almost 60%: proportions consistent with previous British studies^3,6.  Psoriasis affects 1-3% of the population¹, but severity and hence appropriate treatment varies greatly^10,11.  Of the relatively small proportion of patients seen by dermatologists, many have disease whose periodic relapses are sufficiently disabling or extensive to necessitate recurrent clearance treatments.  In addition to topical prescriptions, all the departments surveyed provided phototherapy and out-patient treatment, often in more than one site.  Phototherapy, using PUVA or narrow-band UVB, is the mainstay of out-patient treatment for severe psoriasis but, particularly for those patients requiring recurrent treatment, photo-carcinogenesis is a major concern¹².  For in-patients, use of the safer topical tar or dithranol preparations still predominates.

Medical factors and social circumstances appear most important in determining admission, but geographical factors also contribute.  However, while some departments served particularly sparsely populated areas, 80% of all in-patients with psoriasis lived within an hour's travel of an out-patient treatment unit.  In some of these cases, out-patient management had failed, but in others would not have been used even if dermatology beds were not available.  Of the concomitant medical factors, the most common were psychiatric or alcohol-related disease, and arthritis.  Despite the relative youth of the psoriasis in-patient population, unemployment due to disability was common.  These characteristics need to be borne in mind when considering hostel accommodation as an alternative to in-patient beds.

The psoriasis and leg ulcer in-patient groups showed trends to increased social deprivation relative to the Scottish population.  These were also the groups with the smallest proportions of urgent admissions (Table 3), indicating disease of a more chronic nature.  In urban areas, many in-patient groups are relatively deprived¹³, but this trend was not seen in our other dermatology groups.  The trend in psoriasis may in part be an association of disease and severity with low social status, but several of the parameters used in calculating the Carstairs index⁸ (lack of car ownership, over-crowded accommodation and unemployment) are themselves handicaps to home or ambulatory management.  The financial impact of psoriasis increases with increasing severity¹⁴, and disability due to psoriasis is greater in lower social classes¹⁵.   Patients with chronic skin disease need to bathe and wash clothing more often.  The additional costs are significant for poorer patients.  Travel by public transport, daily or several times weekly, may be disproportionately time-consuming and difficult, even over relatively short distances.

For dermatology in-patients as a whole, the outcomes of admission recorded were excellent, consistent with recent findings using quality of life measures^6,7; but outcome and duration of admission varied between disease groups.  For plaque psoriasis, affected skin returns to normal gradually, and the achievement of remission by whatever means implies a certain duration of admission.  Many patients believe that complete clearance gives the best hope of sustained remission, and as we assessed outcome only at the time of discharge, figures for duration of remission would be of further value.  The median duration of admission for patients with eczema was only half that for psoriasis, reflecting more rapid normalisation of affected skin and, again, almost all patients had complete or substantial clearance.  By contrast, admissions for leg ulceration, occurring in an older age group than either of the others, had the greatest length of stay of any group and the poorest outcome in terms of clearance.  However, the primary reasons for admission may have been complications such as acute infection or eczema⁶, and the true objectives the resolution of these rather than healing of the ulcer.

Had dermatology beds not been available, about a fifth of patients would, in the opinion of the local surveyor, have needed admission to medical, surgical or other beds.  This group included a high proportion of those with infectious, bullous or other acute disorders. The figure is probably an underestimate, as chronic conditions might also eventually necessitate admission elsewhere, e.g. an elderly patient whose leg ulcers are only one of several problems, or a psoriatic with disabling arthropathy.  For those with psoriasis, out-patient treatment was the most likely alternative for only about a third, and had already failed with some.  Despite a severity considered to necessitate admission, many would have been expected to treat themselves at home, or in reality would not have received treatment.  Relatively few would have been given systemic drugs (corticosteroids, retinoids, immunosuppresives or cyto-toxics), although in the majority of cases of psoriasis, the condition was expected to have persisted or deteriorated had admission not been possible.  It seems likely that the question of systemic treatment would rise again later, often despite adverse factors such as other diseases, drug treatment or alcohol abuse.

We conclude that in-patient management is highly successful in remitting acute and chronic skin disorders. In the absence of dermatology beds, some patients would be diverted to other specialties, and some managed in ways presently thought less satisfactory.  However, a significant proportion of patients, many of whom already suffer from psychological adverse affects¹⁶, and with multiple other disabilities or social disadvantage, would be obliged to tolerate their chronic skin disease with inadequate or no treatment.  Lack of provision for groups least able to articulate their distress may occur in countries whose health care is biased towards the private sector, but is contrary to the principle of equality of access to health care.  Dermatology in-patient services must provide not only for acute illness, but also for those patients with chronic skin disease and concomitant problems, for whom in-patient treatment is of proven value.

Acknowledgements

We are grateful to members of the survey team, and to all dermatologists in Scotland and Northern England who permitted us to study their patients.  Funding: none.  Conflict of interest: none.

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