Underuse of Early Follow-up Visits: A Missed Opportunity to Improve Patients’ Adherence

July 2014 | Volume 13 | Issue 7 | Original Article | 833 | Copyright © July 2014


Scott A. Davis MA,a Hsien-Chang Lin PhD,b Cheng-Han Yu MA,c
Rajesh Balkrishnan PhD,d and Steven R. Feldman MD PhDa,e,f

aDepartment of Dermatology, Wake Forest School of Medicine, Winston-Salem, NC
bDepartment of Applied Health Science, School of Public Health, Indiana University, Bloomington, IN
cDepartment of Applied Mathematics and Statistics, University of California, Santa Cruz, CA
dDepartment of Clinical, Social and Administrative Sciences, College of Pharmacy, University of Michigan, Ann Arbor, MI
eDepartment of Pathology, Wake Forest School of Medicine, Winston-Salem, NC
fDepartment of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC

Abstract
BACKGROUND: Early follow-up visits improve patient adherence, but the actual scheduling behavior of physicians is not known.
PURPOSE: To characterize the timing of first follow-up visits in US dermatologic practice.
Methods: Patients with a diagnosis of psoriasis, acne, or atopic dermatitis were identified in the 2003-2007 MarketScan Medicaid database. Factors affecting the length of time before first follow-up were assessed using a Cox proportional hazards model.
RESULTS: Mean length of time to the first follow-up visit was 153 days for adults and 142 days for children with psoriasis; 151 days for adults and 218 days for children with acne; and 161 days for adults and 209 days for children with atopic dermatitis. Black and those other than white patients were less likely than whites to receive early follow-up in psoriasis and acne, but more likely in atopic dermatitis. Dermatologists were more likely to schedule early follow-up visits than nondermatologists.
LIMITATIONS: The database includes only Medicaid patients. The rate of non-attendance at scheduled visits could not be determined.
CONCLUSIONS: Most physicians are missing the opportunity to maximize patient adherence by scheduling early follow-up visits. Contact by email or phone may be beneficial for physicians who cannot schedule early follow-up.

J Drugs Dermatol. 2014;13(7):833-836.

INTRODUCTION

Good patient adherence is increasingly being recognized as essential to the success of dermatologic treatment regimens. Adherence to dermatologic treatment improves around the time of office visits.1 Visits induce “whitecoat compliance,” in which the expectation of monitoring leads to better use of the medication.2 The effect is similar to people flossing their teeth just before a visit to the dentist, or practicing piano just before a lesson. Although the mechanism of whitecoat compliance is not well understood, frequent visits may enhance feelings of trust and make the patient feel a greater sense of being cared for. Scheduling an early return visit improves patients’ use of medication, perhaps in part by reducing the perceived burden of treatment, as patients find it easier to take a medication consistently over a shorter period of time.3,4
Despite the benefits of early follow-up, there is little data on the timing of follow-up visits in US medical practice. Given that many research studies report primary outcomes at 6-8 weeks, many physicians may tend to schedule the first followup visit at 6-8 weeks after the initial visit. However, clinical trials may show initial improvement at earlier times, and the visits done to assess that improvement may be contributing to good adherence in the study and better outcomes than would have been achieved had the earlier follow up not been done.5 Although some areas of medicine are dominated by slowacting treatments, the majority of dermatologic treatments can be expected to induce improvement in symptoms within a week or less, provided they are used correctly. Therefore, in dermatology, scheduling a return visit at one to two weeks after the initial visit may be valuable.
The present study aims to provide data on the typical practice of dermatologic treatment in regard to follow-up visits. This information enables assessment of how frequently physicians are having patients return for follow-up visits within the ideal interval of time to optimize adherence, and whether guidelines are needed to encourage earlier follow-up.

METHODS

We analyzed data from the MarketScan Medicaid database from 2003-2007 to determine the timing of first follow-up skin disease visits. We identified first visits for patients with three common dermatologic diagnoses– psoriasis, acne, and atopic dermatitis, creating separate data sets for adults and children. We determined the length of time before the first follow up visit for each patient with at least one follow-up visit. A Cox
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