Racial disparities in the management of acne: evidence from the National Ambulatory Medical Care Survey,

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1 Journal of Dermatological Treatment ISSN: (Print) (Online) Journal homepage: Racial disparities in the management of acne: evidence from the National Ambulatory Medical Care Survey, Andrew T. Rogers, Yevgeniy R. Semenov, Shawn G. Kwatra & Ginette A. Okoye To cite this article: Andrew T. Rogers, Yevgeniy R. Semenov, Shawn G. Kwatra & Ginette A. Okoye (2017): Racial disparities in the management of acne: evidence from the National Ambulatory Medical Care Survey, , Journal of Dermatological Treatment, DOI: / To link to this article: Accepted author version posted online: 23 Aug Submit your article to this journal Article views: 2 View related articles View Crossmark data Full Terms & Conditions of access and use can be found at Download by: [JAMES COOK UNIVERSITY] Date: 26 August 2017, At: 12:42

2 Racial disparities in the management of acne: evidence from the National Ambulatory Medical Care Survey, Andrew T. Rogers, BS 1, Yevgeniy R. Semenov, MD, MA 2, Shawn G. Kwatra, MD 1, Ginette A. Okoye, MD 1 1 Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, United States; 2 Division of Dermatology, Washington University School of Medicine, St. Louis, United States Andrew T. Rogers, BS Corresponding Author The Johns Hopkins Hospital Room 100, Tower Building Doctors' Lounge Baltimore, Maryland Tel: aroger32@jhmi.edu Yevgeniy R. Semenov, MD, MA, Washington University School of Medicine, Division of Dermatology, 660 S. Euclid, Campus Box 8123, St. Louis, MO 63110, Tel: , yevgeniy.semenov1@gmail.com Shawn G. Kwatra, MD, Johns Hopkins University School of Medicine, Cancer Research Building II, 1550 Orleans Street, Baltimore, MD 21231, Tel: skwatra1@jhmi.edu

3 Ginette A. Okoye, MD, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, Suite 2500, Baltimore, MD 21224, Tel: , Manuscript word count (not including title, abstract, acknowledgment, references, and tables): 713; Table count: 2; Figure count: 0

4 Racial disparities in the management of acne: evidence from the National Ambulatory Medical Care Survey, Purpose: Racial health disparities are widespread in the United States, but little is known about racial disparities in the management of dermatological conditions. Materials and Methods: Nationally representative data on the management of acne vulgaris were gathered from the National Ambulatory Medical Care Survey for the years Visits to any specialist were included. Rao-Scott chisquare tests and multivariate adjusted logistic regressions were used to identify differences in patient demographics, visit characteristics, and acne medications across races. Results: Black patients are less likely than white patients to visit a dermatologist (aor 0.48, P=.001), receive any acne medication (aor 0.64, P=.01), receive a combination acne medication (aor 0.52, P=.007), or receive isotretinoin (aor 0.46, P=.03). Adjusting for management by a dermatologist eliminated the association between race and the prescription of any acne medication as well as between race and the prescription of isotretinoin. Conclusions: Among outpatient visits for acne in the United States, racial disparities exist in the likelihood of seeing a dermatologist and receiving treatment. Treatment disparities are less common when care is provided by a dermatologist. More research is needed to better understand the causes of disparities in acne management and other dermatological conditions. Keywords: acne vulgaris; disparities; race; isotretinoin

5 Introduction Racial health disparities are widespread and have been targeted by many national health policy initiatives [1]. However, the disparities literature in dermatology remains limited [1]. We investigated racial disparities in the management of acne vulgaris, one of the most common dermatoses across all races [2]. Materials and Methods Data was gathered from the National Ambulatory Medical Care Survey, a nationally representative survey of U.S. office-based physicians [3]. After combining surveys from , we identified 2,514 sample visits for acne across all specialties, weighted to represent 61 million (95% CI 55 million 68 million) visits nationally. Patients identifying as white, black, or any other race comprised 84.4% (95% CI 81.9% %), 10.1% (95% CI 8.1% %), and 5.5% (95% CI 3.9% - 7.1%) of these visits, respectively. We performed Rao-Scott chi-square tests to identify differences in patient demographics, visit characteristics, and acne medications across races (Table 1). Variables for which the association with race had a P<.05 were further evaluated in multivariate logistic regressions after adjusting for potential confounders, including age, race, sex, location, number of chronic diseases, Medicaid coverage as a measure of socioeconomic status, and number of past visits as a proxy for acne severity (Table 2). This study was exploratory in nature, so P-values were not adjusted for multiple comparisons. All analyses were conducted in SAS 9.4 (SAS Institute). To adjust for the complex survey design of NAMCS, the SURVEY suite of commands in SAS was used, which incorporates all sampling strata, clusters, and weights. All frequencies, odds ratios, and variance estimates are presented from the weighted analyses. P-Values of

6 less than.05 were considered statistically significant. Since this study does not qualify as human subjects research, institutional review board approval is inapplicable. Results Black patients were less likely to visit a dermatologist than white patients (aor 0.48, P=.001). Across all specialties, black patients were less likely to have an acne prescription than white patients (aor 0.64, P=.01). This association lost statistical significance in a sensitivity analysis that further adjusted for management by a dermatologist, a variable associated with increased likelihood of prescription independent of race (aor 3.0, P<.001). When assessing individual drug classes, there were no significant differences in treatment with topical retinoids, antibiotics, or multiple acne medications (i.e., whether more than one acne medication was prescribed) across races. However, black patients were less likely to have a prescription for a combination acne medication (aor 0.52, P=.007) or isotretinoin (aor 0.46, P=.03). In a sensitivity analysis that further adjusted for dermatologist management, race was no longer associated with isotretinoin use. In that model, dermatologist management was independently associated with an increased likelihood of isotretinoin prescription (aor 12.7, P<.001). By contrast, adjusting for dermatologist management did not attenuate the association between race and combination acne medication. Discussion We find mixed evidence for disparities in acne management. We were encouraged to find many aspects of care were similar across races. However, racial disparities in the likelihood of seeing a dermatologist and treatment were notable. The aforementioned sensitivity analyses suggest treatment disparities may be less common among

7 dermatology visits, underscoring a potential need for improved education about acne therapies among generalists. Our finding that isotretinoin is less likely to be prescribed for black patients is consistent with Fleischer et al. [4], though adds to the literature in several ways. First, given that Fleischer et al. used data, our study suggests this disparity has persisted for over two decades. Second, we provide stronger evidence for this association by adjusting for confounders, which Fleischer et al. did not do. Finally, Fleischer et al. focus on medication cost as a potential explanation. However, this hypothesis is less compelling for , since we adjusted for socioeconomic status and use data after isotretinoin became generic in 2002 [5]. This study has several limitations, including its exploratory nature and lack of clinical data on acne severity. However, the literature suggests that, if anything, acne tends to be more severe in black patients, who have higher rates of dyspigmentation and scarring [6]. Additionally, past visits functioned appropriately as a proxy for acne severity, as isotretinoin was more likely to be prescribed with each prior visit (aor 1.15, P<.001). Further research is needed to validate our findings and better understand the cause of disparities in acne management. Acknowledgements: none. Funding/Support: None. Disclosure of interest: The authors report no conflicts of interest.

8 References 1. Buster KJ, Stevens EI, Elmets CA. Dermatologic health disparities. Dermatol Clin [Internet]. 2012;30(1):53 9. Available from: 2. Davis SA, Narahari S, Feldman SR, et al. Top dermatologic conditions in patients of color: an analysis of nationally representative data. J Drugs Dermatol Apr;11(4): National Center for Health Statistics. Ambulatory Health Care Data: Questionnaires, Datasets, and Related Documentation [Internet]. [cited 2017 May 26]. Available from: 4. Fleischer AB, Simpson JK, Mcmichael A, et al. Are there racial and sex differences in the use of oral isotretinoin for acne management in the United States? J Am Acad Dermatol. 2003;49(4): Koren G, Avner M, Shear N. Generic isotretinoin: a new risk for unborn children. C Can Med Assoc J [Internet] May 11;170(10): Available from: 6. Yin NC, McMichael AJ. Acne in patients with skin of color: practical management. Am J Clin Dermatol Feb;15(1):7 16.

9 Table 1: Summary Statistics Table 1. Summary Statistics. Characteristic Patient Information Age Gender Insurance Patient Race White (2,120 sample visits) Black (246 sample visits) Other (148 sample visits) N (95% CI) % (95% CI) N (95% CI) % (95% CI) N (95% CI) % (95% CI) < 18 years 22.1 ( ) 42.6 ( ) 2.3 ( ) 37.0 ( ) 1.3 ( ) 37.5 ( ) 18 years 29.8 ( ) 57.4 ( ) 3.9 ( ) 63.0 ( ) 2.1 ( ) 62.5 ( ) Male 19.5 ( ) 37.5 ( ) 1.8 ( ) 29.6 ( ) 1.1 ( ) 32.7 ( ) Female 32.4 ( ) 62.5 ( ) 4.4 ( ) 70.4 ( ) 2.3 ( ) 67.3 ( ) Private 42.1 ( ) 81.4 ( ) 4.0 ( ) 64.4 ( ) 2.3 ( ) 66.7 ( ) Medicaid 3.7 ( ) 7.7 ( ) 1.1 ( ) 17.8 ( ) 0.5 ( )* 14.5 ( )* Chronic Conditions ( ) 85.2 ( ) 4.5 ( ) 72.4 ( ) 2.9 ( ) 85.4 ( ) ( ) 11.3 ( ) 1.3 ( ) 21.3 ( ) 0.4 ( )* 12.2 ( )* ( ) 3.5 ( ) 0.4 ( )* 6.3 ( )* 0.1 ( )* 2.4 ( )* Visit Characteristics Visit with Dermatologist 34.2 ( ) 66.1 ( ) 3.3 ( ) 53.0 ( ) 1.8 ( ) 54.1 ( ).008 Documented Skin Exam 34.3 ( ) 66.1 ( ) 4.0 ( ) 63.8 ( ) 2.1 ( ) 63.1 ( ).77 New Medications Prescribed 30.7 ( ) 59.3 ( ) 3.7 ( ) 60.4 ( ) 2.0 ( ) 57.6 ( ).90 Medications Managed 46.6 ( ) 90.3 ( ) 5.7 ( ) 92.1 ( ) 2.8 ( ) 85.3 ( ).29 MD Seen 50.1 ( ) 96.6 ( ) 6.0 ( ) 96.6 ( ) 3.3 ( ) 97.1 ( ).98 Return Appointment Scheduled Solo Physician Practice Setting Fully Electronic Medical Record System Acne Medication Management 36.6 ( ) 70.5 ( ) 4.8 ( ) 77.0 ( ) 2.2 ( ) 65.5 ( ) ( ) 38.1 ( ) 3.0 ( ) 48.4 ( ) 1.7 ( ) 49.3 ( ) ( ) 37.4 ( ) 2.1 ( ) 33.2 ( ) 1.2 ( ) 34.8 ( ).72 Acne Medication Prescribed 36.2 ( ) 69.9 ( ) 3.7 ( ) 59.4 ( ) 2.5 ( ) 72.9 ( ).01 Multiple Acne Medications Prescribed Topical Benzoyl Peroxide Prescribed 16.6 ( ) 32.0 ( ) 1.5 ( ) 24.9 ( ) 1.1 ( ) 31.0 ( ) ( ) 12.9 ( ) 1.2 ( ) 19.5 ( ) 0.5 ( )* 15.2 ( )*.06 Topical Retinoid Prescribed 16.5 ( ) 31.9 ( ) 1.5 ( ) 24.7 ( ) 1.0 ( ) 29.4 ( ).10 Topical Antibiotic Prescribed 7.6 ( ) 14.6 ( ) 0.7 ( ) 11.0 ( ) 0.7 ( )* 20.7 ( )*.06 Oral Antibiotic Prescribed 15.6 ( ) 30.0 ( ) 1.7 ( ) 26.8 ( ) 1.0 ( ) 29.8 ( ).80 Combination Acne Medication Prescribed 7.8 ( ) 15.1 ( ) 0.5 ( )* 8.3 ( )* 0.3 ( )* 10.3 ( )*.01 Isotretinoin Prescribed 5.7 ( ) 11.0 ( ) 0.3 ( )* 4.9 ( )* 0.3 ( )* 10.1 ( )*.02 Data are reported as the national weighted number (percentage) of visits in millions. 'Other' includes patients of all other races, who were grouped due to sample sizes limitations. Indicates whether medications were ordered, supplied, administered, or continued. 25 visits were excluded from the analysis due to missing data. Acne medication included topical benzoyl peroxide, topical retinoids, topical antibiotics, oral antibiotics, and isotretinoin. Combination acne medications included medications with combined ingredients of benzoyl peroxide, topical retinoids, and/or topical antibiotics. *Estimates are based on <30 raw sample cases and may therefore be unreliable per NAMCS guidelines. P <.001 <.001

10 Table 2. Multivariate Adjusted Logistic Regression Analyses. Table 2: Multivariate Adjusted Logistic Regression Analyses Black Patients Patient Race* Other Patients Dependent Variable aor (95% CI) P aor (95% CI) P Visit with Dermatologist 0.48 ( ) ( ).38 Solo Practice Setting 1.51 ( ) ( ).12 Acne Medication Prescribed 0.64 ( ) ( ).50 Combination Acne Medication Prescribed 0.52 ( ) ( ).36 Isotretinoin Prescribed 0.46 ( ) ( ).64 *White patients served as the reference population for race. All models were adjusted for age, race, sex, region, number of chronic conditions, location in a metropolitan statistical area, and payment with Medicaid as a proxy for socioeconomic status. For models using acne medications as the dependent variable, the number of past visits was also included as a proxy for acne severity.

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