Diversity in Medicine

Therapeutic inertia regarding intensification of blood pressure treatment has been shown to be more of an issue in Black patients, but this was not the case in the SPRINT trial, which involved a strict standardized approach to blood pressure management, a new analysis shows.

Ingram Publishing/ThinkStock

“Overall, we found that therapeutic inertia was similar in different races in the SPRINT trial. We did not see disparities that have been reported in previous observational studies,” lead author, Alexander Zheutlin, MD, University of Utah School of Medicine, Salt Lake City, told this news organization.

“These results show that a well-resourced approach in which a standardized approach to blood pressure measurement and treatment intensification is followed can overcome the racial disparity that is seen in therapeutic inertia and the treatment of blood pressure,” he added.

The study was published online in JAMA Network Open on Jan. 10.

The authors explain that hypertension remains a leading modifiable cause of racial disparities in cardiovascular disease. Despite similar treatment rates and increased availability of safe, effective, and affordable antihypertensive medications, blood pressure control rates among Black and Hispanic adults remain significantly lower than among White adults in the United States, and one of the factors contributing to this is thought to be therapeutic inertia – the phenomenon of clinicians not initiating or up-titrating clinically indicated therapy in the setting of unmet treatment goals.

The current analysis of the SPRINT trial was conducted to investigate whether racial and ethnic differences in therapeutic inertia in hypertension were present when blood pressure care was standardized and protocolized.

The landmark SPRINT trial compared intensive (<120 mm Hg) with standard (<140 mm Hg) systolic blood pressure treatment goals in adults 50 years and older at high risk for cardiovascular disease. The present analysis was restricted to participant visits with measured blood pressure above the target goal and included 4,141 patients in the standard group and 4,415 patients in the intensive group.

Results showed that the overall prevalence of therapeutic inertia – defined as no antihypertensive medication intensification at each study visit where the blood pressure was above target goal – was either similar or lower for Black and Hispanic participants than for White participants. This pattern was observed whether participants were randomized to the standard or intensive treatment group.

“These findings support the idea that a standardized approach to blood pressure management, as implemented in SPRINT, may help ensure equitable care is provided to all patients and could reduce the contribution of therapeutic inertia to disparities in uncontrolled blood pressure,” the authors say.

They point out that therapeutic inertia has been identified as a key clinician-level barrier to blood pressure control and is estimated to be present in more than 80% of clinic visits in community practice, whereas in the current analysis of the SPRINT trial, therapeutic inertia was present in 50% to 60% of participant visits with uncontrolled blood pressure.

“In SPRINT, blood pressure had to be measured at defined intervals with a specific method, and there were clear instructions on intensifying treatment if blood pressure was above a certain goal,” Dr. Zheutlin noted. “Our results show that within such strict confines, therapeutic inertia does not seem to be different between different racial groups. This suggests that we could make better gains in blood pressure control and more equitable treatment if we adopted a standardized approach to hypertension management.”

He added: “Many guidelines have been published on when to start treatment and the targets for blood pressure, but there is a lot of variation in how we turn these guidelines into protocols. We need to bring in more consistent protocols on blood pressure measurement and intensification and ensure they are followed. In practice, if the BP is 5 or 10 mm Hg above target, a clinician may defer a decision to intensify treatment and intensification never gets done. But if there was a strict protocol to follow, there would be less chance of this happening.”
 

Therapeutic inertia still high

In an accompanying commentary, Matthew Rivara, MD, Nisha Bansal, MD, and Bessie Young, MD, University of Washington, Seattle, say the current SPRINT analysis has broad implications for reducing racial and ethnic disparities in achievement of evidence-based treatment targets in the general population.

“In hypertension management, standardized protocols for medication adjustments may limit clinician practice heterogeneity to ultimately reduce differences in blood pressure control among racial and ethnic minority populations,” they write. But they add that such protocols must be implemented thoughtfully to incorporate individualized clinical assessment and clinician-patient shared decision-making.

Dr. Rivara et al. point out that the rates of therapeutic inertia in SPRINT, while lower than community-based estimates, were still very high. They suggest reasons for this could include clinician concerns about medication efficacy, adverse effects, and patient mistrust of medical professionals. Outside the clinical trial environment, additional considerations may include prescription drug and laboratory test costs, pharmacy access, and competing demands during busy clinic visits.

To address these challenges, they say that clinicians need education on current clinical practice guidelines, managing complications of intensified antihypertensive therapies, and shared decisionmaking, including culturally sensitive collaborative care. Similarly, care systems must support patients on how to address concerns about treatments.

Finally, further research is needed to better define the specific factors associated with therapeutic inertia to allow tailored interventions to overcome this inertia.

“In designing and performing such research, it is vital that investigators engage with racial and ethnic minority groups to better explore the intersection of race, ethnicity, therapeutic decision-making, trust, and shared decisionmaking,” they add.

The SPRINT trial was funded with federal funds from the National Institutes of Health. Dr. Zheutlin reported receiving grants from the NIH during the conduct of the study.

A version of this article first appeared on Medscape.com.

Therapeutic inertia regarding intensification of blood pressure treatment has been shown to be more of an issue in Black patients, but this was not the case in the SPRINT trial, which involved a strict standardized approach to blood pressure management, a new analysis shows.

Ingram Publishing/ThinkStock

“Overall, we found that therapeutic inertia was similar in different races in the SPRINT trial. We did not see disparities that have been reported in previous observational studies,” lead author, Alexander Zheutlin, MD, University of Utah School of Medicine, Salt Lake City, told this news organization.

“These results show that a well-resourced approach in which a standardized approach to blood pressure measurement and treatment intensification is followed can overcome the racial disparity that is seen in therapeutic inertia and the treatment of blood pressure,” he added.

The study was published online in JAMA Network Open on Jan. 10.

The authors explain that hypertension remains a leading modifiable cause of racial disparities in cardiovascular disease. Despite similar treatment rates and increased availability of safe, effective, and affordable antihypertensive medications, blood pressure control rates among Black and Hispanic adults remain significantly lower than among White adults in the United States, and one of the factors contributing to this is thought to be therapeutic inertia – the phenomenon of clinicians not initiating or up-titrating clinically indicated therapy in the setting of unmet treatment goals.

The current analysis of the SPRINT trial was conducted to investigate whether racial and ethnic differences in therapeutic inertia in hypertension were present when blood pressure care was standardized and protocolized.

The landmark SPRINT trial compared intensive (<120 mm Hg) with standard (<140 mm Hg) systolic blood pressure treatment goals in adults 50 years and older at high risk for cardiovascular disease. The present analysis was restricted to participant visits with measured blood pressure above the target goal and included 4,141 patients in the standard group and 4,415 patients in the intensive group.

Results showed that the overall prevalence of therapeutic inertia – defined as no antihypertensive medication intensification at each study visit where the blood pressure was above target goal – was either similar or lower for Black and Hispanic participants than for White participants. This pattern was observed whether participants were randomized to the standard or intensive treatment group.

“These findings support the idea that a standardized approach to blood pressure management, as implemented in SPRINT, may help ensure equitable care is provided to all patients and could reduce the contribution of therapeutic inertia to disparities in uncontrolled blood pressure,” the authors say.

They point out that therapeutic inertia has been identified as a key clinician-level barrier to blood pressure control and is estimated to be present in more than 80% of clinic visits in community practice, whereas in the current analysis of the SPRINT trial, therapeutic inertia was present in 50% to 60% of participant visits with uncontrolled blood pressure.

“In SPRINT, blood pressure had to be measured at defined intervals with a specific method, and there were clear instructions on intensifying treatment if blood pressure was above a certain goal,” Dr. Zheutlin noted. “Our results show that within such strict confines, therapeutic inertia does not seem to be different between different racial groups. This suggests that we could make better gains in blood pressure control and more equitable treatment if we adopted a standardized approach to hypertension management.”

He added: “Many guidelines have been published on when to start treatment and the targets for blood pressure, but there is a lot of variation in how we turn these guidelines into protocols. We need to bring in more consistent protocols on blood pressure measurement and intensification and ensure they are followed. In practice, if the BP is 5 or 10 mm Hg above target, a clinician may defer a decision to intensify treatment and intensification never gets done. But if there was a strict protocol to follow, there would be less chance of this happening.”
 

Therapeutic inertia still high

In an accompanying commentary, Matthew Rivara, MD, Nisha Bansal, MD, and Bessie Young, MD, University of Washington, Seattle, say the current SPRINT analysis has broad implications for reducing racial and ethnic disparities in achievement of evidence-based treatment targets in the general population.

“In hypertension management, standardized protocols for medication adjustments may limit clinician practice heterogeneity to ultimately reduce differences in blood pressure control among racial and ethnic minority populations,” they write. But they add that such protocols must be implemented thoughtfully to incorporate individualized clinical assessment and clinician-patient shared decision-making.

Dr. Rivara et al. point out that the rates of therapeutic inertia in SPRINT, while lower than community-based estimates, were still very high. They suggest reasons for this could include clinician concerns about medication efficacy, adverse effects, and patient mistrust of medical professionals. Outside the clinical trial environment, additional considerations may include prescription drug and laboratory test costs, pharmacy access, and competing demands during busy clinic visits.

To address these challenges, they say that clinicians need education on current clinical practice guidelines, managing complications of intensified antihypertensive therapies, and shared decisionmaking, including culturally sensitive collaborative care. Similarly, care systems must support patients on how to address concerns about treatments.

Finally, further research is needed to better define the specific factors associated with therapeutic inertia to allow tailored interventions to overcome this inertia.

“In designing and performing such research, it is vital that investigators engage with racial and ethnic minority groups to better explore the intersection of race, ethnicity, therapeutic decision-making, trust, and shared decisionmaking,” they add.

The SPRINT trial was funded with federal funds from the National Institutes of Health. Dr. Zheutlin reported receiving grants from the NIH during the conduct of the study.

A version of this article first appeared on Medscape.com.

Therapeutic inertia regarding intensification of blood pressure treatment has been shown to be more of an issue in Black patients, but this was not the case in the SPRINT trial, which involved a strict standardized approach to blood pressure management, a new analysis shows.

Ingram Publishing/ThinkStock

“Overall, we found that therapeutic inertia was similar in different races in the SPRINT trial. We did not see disparities that have been reported in previous observational studies,” lead author, Alexander Zheutlin, MD, University of Utah School of Medicine, Salt Lake City, told this news organization.

“These results show that a well-resourced approach in which a standardized approach to blood pressure measurement and treatment intensification is followed can overcome the racial disparity that is seen in therapeutic inertia and the treatment of blood pressure,” he added.

The study was published online in JAMA Network Open on Jan. 10.

The authors explain that hypertension remains a leading modifiable cause of racial disparities in cardiovascular disease. Despite similar treatment rates and increased availability of safe, effective, and affordable antihypertensive medications, blood pressure control rates among Black and Hispanic adults remain significantly lower than among White adults in the United States, and one of the factors contributing to this is thought to be therapeutic inertia – the phenomenon of clinicians not initiating or up-titrating clinically indicated therapy in the setting of unmet treatment goals.

The current analysis of the SPRINT trial was conducted to investigate whether racial and ethnic differences in therapeutic inertia in hypertension were present when blood pressure care was standardized and protocolized.

The landmark SPRINT trial compared intensive (<120 mm Hg) with standard (<140 mm Hg) systolic blood pressure treatment goals in adults 50 years and older at high risk for cardiovascular disease. The present analysis was restricted to participant visits with measured blood pressure above the target goal and included 4,141 patients in the standard group and 4,415 patients in the intensive group.

Results showed that the overall prevalence of therapeutic inertia – defined as no antihypertensive medication intensification at each study visit where the blood pressure was above target goal – was either similar or lower for Black and Hispanic participants than for White participants. This pattern was observed whether participants were randomized to the standard or intensive treatment group.

“These findings support the idea that a standardized approach to blood pressure management, as implemented in SPRINT, may help ensure equitable care is provided to all patients and could reduce the contribution of therapeutic inertia to disparities in uncontrolled blood pressure,” the authors say.

They point out that therapeutic inertia has been identified as a key clinician-level barrier to blood pressure control and is estimated to be present in more than 80% of clinic visits in community practice, whereas in the current analysis of the SPRINT trial, therapeutic inertia was present in 50% to 60% of participant visits with uncontrolled blood pressure.

“In SPRINT, blood pressure had to be measured at defined intervals with a specific method, and there were clear instructions on intensifying treatment if blood pressure was above a certain goal,” Dr. Zheutlin noted. “Our results show that within such strict confines, therapeutic inertia does not seem to be different between different racial groups. This suggests that we could make better gains in blood pressure control and more equitable treatment if we adopted a standardized approach to hypertension management.”

He added: “Many guidelines have been published on when to start treatment and the targets for blood pressure, but there is a lot of variation in how we turn these guidelines into protocols. We need to bring in more consistent protocols on blood pressure measurement and intensification and ensure they are followed. In practice, if the BP is 5 or 10 mm Hg above target, a clinician may defer a decision to intensify treatment and intensification never gets done. But if there was a strict protocol to follow, there would be less chance of this happening.”
 

Therapeutic inertia still high

In an accompanying commentary, Matthew Rivara, MD, Nisha Bansal, MD, and Bessie Young, MD, University of Washington, Seattle, say the current SPRINT analysis has broad implications for reducing racial and ethnic disparities in achievement of evidence-based treatment targets in the general population.

“In hypertension management, standardized protocols for medication adjustments may limit clinician practice heterogeneity to ultimately reduce differences in blood pressure control among racial and ethnic minority populations,” they write. But they add that such protocols must be implemented thoughtfully to incorporate individualized clinical assessment and clinician-patient shared decision-making.

Dr. Rivara et al. point out that the rates of therapeutic inertia in SPRINT, while lower than community-based estimates, were still very high. They suggest reasons for this could include clinician concerns about medication efficacy, adverse effects, and patient mistrust of medical professionals. Outside the clinical trial environment, additional considerations may include prescription drug and laboratory test costs, pharmacy access, and competing demands during busy clinic visits.

To address these challenges, they say that clinicians need education on current clinical practice guidelines, managing complications of intensified antihypertensive therapies, and shared decisionmaking, including culturally sensitive collaborative care. Similarly, care systems must support patients on how to address concerns about treatments.

Finally, further research is needed to better define the specific factors associated with therapeutic inertia to allow tailored interventions to overcome this inertia.

“In designing and performing such research, it is vital that investigators engage with racial and ethnic minority groups to better explore the intersection of race, ethnicity, therapeutic decision-making, trust, and shared decisionmaking,” they add.

The SPRINT trial was funded with federal funds from the National Institutes of Health. Dr. Zheutlin reported receiving grants from the NIH during the conduct of the study.

A version of this article first appeared on Medscape.com.

A new document from the American Heart Association summarizes the latest research on cardiovascular risk factor management in type 2 diabetes, including medications, lifestyle, and social determinants of health.

Despite the availability of effective therapies for improving cardiovascular risk, in the United States fewer than one in five people with type 2 diabetes and without known cardiovascular disease meet control targets for a combination of A1c, blood pressure, LDL cholesterol, and nonsmoking status.

Volkan Ünalan/Thinkstock

That proportion drops to less than 1 in 10 if body mass index less than 30 kg/m² is included among the targets, and even less than that among individuals with established atherosclerotic cardiovascular disease, Joshua J. Joseph, MD, and colleagues point out in their paper, published online Jan. 10 in Circulation.

“This new scientific statement is an urgent call to action to follow the latest evidence-based approaches and to develop new best practices to advance type 2 diabetes treatment and care and reduce cardiovascular disease risk,” wrote Dr. Joseph, assistant professor of medicine in the division of endocrinology, diabetes, and metabolism at The Ohio State University, Columbus, Ohio, and coauthors.

The statement is not a guideline but an expert analysis that may inform future clinical practice guidelines, according to a press release from the AHA.

The new statement reviews evidence through June 2020 for lifestyle management of diabetes and weight, glycemic targets and control, blood pressure management, lipid management, antithrombotic therapy, and screening for cardiovascular and renal complications, including imaging. It also discusses the clinical implications of recent cardiovascular outcomes trials of newer glucose-lowering medications.

However, Dr. Joseph and colleagues point out, clinical care and treatment account for just 10%-20% of modifiable contributors to health outcomes. The other 80%-90% relate to social determinants of health, including health-related behaviors, socioeconomic factors, environmental factors, and racism.

“If we are to continue to advance the management of cardiovascular risk factors, we must also address the [social determinants of health] in the delivery of health care,” they noted.

Overall, they advise a patient-centered approach, meaning “reframing our clinical encounters to think about patients as people who live in families, communities, and societies that must be considered in their cardiovascular risk management.”

“People with [type 2 diabetes] face numerous barriers to health including access to care and equitable care, which must be considered when developing individualized care plans with our patients,” Dr. Joseph said in the AHA press release.
 

Lifestyle, medications for lowering A1c, BP, lipids

For lifestyle management, the authors say, “culturally appropriate recommendations through diabetes self-management education and support and medical nutrition therapy are key to meeting individualized goals for behavioral change and diabetes self-management.”

The document summarizes recommendations from other professional societies regarding glycemic targets and glucose lowering medications, i.e., target A1c levels of either < 7% or < 6.5% for the majority, with adjustments based on individual factors, such as life expectancy. It advises on use of metformin as first-line therapy followed by a sodium-glucose cotransporter-2 inhibitor or a glucagon-like peptide-1 agonist for those with established cardiovascular disease or risk factors.

“Cost may be a barrier to taking some [type 2 diabetes] medications as prescribed; however, many of these medications are now more commonly covered by more health insurance plans,” Dr. Joseph said.

“Another barrier is recognition by patients that these newer [type 2 diabetes] medications are also effective in reducing the risk of heart disease, stroke, heart failure, and kidney disease.”

Blood pressure treatment guidelines differ between those of the AHA/American College of Cardiology (ACC) and the American Diabetes Association (ADA), most notably that the AHA/ACC guidelines advise a general target of < 130/80 mm Hg, whereas ADA advises < 140/90 mm Hg or < 130/80 mm Hg for those with high risk if it can be safely achieved.

The decision should be “patient-centered with shared decision-making,” Dr. Joseph and colleagues advised.

For lipid-lowering, the document cites the 2018 ACC/AHA cholesterol guidelines, which include advising statins as first-line therapy for both primary and secondary prevention in diabetes, with highest intensity statins used in those at highest risk. But again, treatment should be individualized, and other agents should be used for patients in whom statins don’t work or aren’t tolerated.

And while use of antiplatelets – that is, aspirin – is well established as secondary prevention in type 2 diabetes, given new data suggesting that the risk for major bleeding could outweigh the benefits for primary prevention, “the relative benefits of antithrombotic approaches need to be weighed carefully against risks using a patient-centered approach,” the authors advised.

Among the many imaging tests available to facilitate cardiovascular risk stratification in type 2 diabetes, coronary artery calcification (CAC) CT screening is one of the few with sufficient data to support routine use in selected patients. The National Lipid Association, for example, recommends escalation to high-intensity statin for CAC > 100.

“One avenue to continue to address and advance diabetes management is through breaking down the four walls of the clinic or hospital through community engagement, clinic-to-community connections, and academic-community-government partnerships that may help address and support modifiable lifestyle behaviors such as physical activity, nutrition, smoking cessation and stress management,” Dr. Joseph concluded.

The AHA receives funding primarily from individuals. Foundations and corporations, including pharmaceutical, device manufacturers, and other companies, also make donations and fund AHA programs and events. The AHA’s strict policies prevent these relationships from influencing the science content. Revenues from pharmaceutical and biotech companies, device manufacturers, and health insurance providers and the AHA’s financial information are available on the association’s website. Dr. Joseph has disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

A new document from the American Heart Association summarizes the latest research on cardiovascular risk factor management in type 2 diabetes, including medications, lifestyle, and social determinants of health.

Despite the availability of effective therapies for improving cardiovascular risk, in the United States fewer than one in five people with type 2 diabetes and without known cardiovascular disease meet control targets for a combination of A1c, blood pressure, LDL cholesterol, and nonsmoking status.

Volkan Ünalan/Thinkstock

That proportion drops to less than 1 in 10 if body mass index less than 30 kg/m² is included among the targets, and even less than that among individuals with established atherosclerotic cardiovascular disease, Joshua J. Joseph, MD, and colleagues point out in their paper, published online Jan. 10 in Circulation.

“This new scientific statement is an urgent call to action to follow the latest evidence-based approaches and to develop new best practices to advance type 2 diabetes treatment and care and reduce cardiovascular disease risk,” wrote Dr. Joseph, assistant professor of medicine in the division of endocrinology, diabetes, and metabolism at The Ohio State University, Columbus, Ohio, and coauthors.

The statement is not a guideline but an expert analysis that may inform future clinical practice guidelines, according to a press release from the AHA.

The new statement reviews evidence through June 2020 for lifestyle management of diabetes and weight, glycemic targets and control, blood pressure management, lipid management, antithrombotic therapy, and screening for cardiovascular and renal complications, including imaging. It also discusses the clinical implications of recent cardiovascular outcomes trials of newer glucose-lowering medications.

However, Dr. Joseph and colleagues point out, clinical care and treatment account for just 10%-20% of modifiable contributors to health outcomes. The other 80%-90% relate to social determinants of health, including health-related behaviors, socioeconomic factors, environmental factors, and racism.

“If we are to continue to advance the management of cardiovascular risk factors, we must also address the [social determinants of health] in the delivery of health care,” they noted.

Overall, they advise a patient-centered approach, meaning “reframing our clinical encounters to think about patients as people who live in families, communities, and societies that must be considered in their cardiovascular risk management.”

“People with [type 2 diabetes] face numerous barriers to health including access to care and equitable care, which must be considered when developing individualized care plans with our patients,” Dr. Joseph said in the AHA press release.
 

Lifestyle, medications for lowering A1c, BP, lipids

For lifestyle management, the authors say, “culturally appropriate recommendations through diabetes self-management education and support and medical nutrition therapy are key to meeting individualized goals for behavioral change and diabetes self-management.”

The document summarizes recommendations from other professional societies regarding glycemic targets and glucose lowering medications, i.e., target A1c levels of either < 7% or < 6.5% for the majority, with adjustments based on individual factors, such as life expectancy. It advises on use of metformin as first-line therapy followed by a sodium-glucose cotransporter-2 inhibitor or a glucagon-like peptide-1 agonist for those with established cardiovascular disease or risk factors.

“Cost may be a barrier to taking some [type 2 diabetes] medications as prescribed; however, many of these medications are now more commonly covered by more health insurance plans,” Dr. Joseph said.

“Another barrier is recognition by patients that these newer [type 2 diabetes] medications are also effective in reducing the risk of heart disease, stroke, heart failure, and kidney disease.”

Blood pressure treatment guidelines differ between those of the AHA/American College of Cardiology (ACC) and the American Diabetes Association (ADA), most notably that the AHA/ACC guidelines advise a general target of < 130/80 mm Hg, whereas ADA advises < 140/90 mm Hg or < 130/80 mm Hg for those with high risk if it can be safely achieved.

The decision should be “patient-centered with shared decision-making,” Dr. Joseph and colleagues advised.

For lipid-lowering, the document cites the 2018 ACC/AHA cholesterol guidelines, which include advising statins as first-line therapy for both primary and secondary prevention in diabetes, with highest intensity statins used in those at highest risk. But again, treatment should be individualized, and other agents should be used for patients in whom statins don’t work or aren’t tolerated.

And while use of antiplatelets – that is, aspirin – is well established as secondary prevention in type 2 diabetes, given new data suggesting that the risk for major bleeding could outweigh the benefits for primary prevention, “the relative benefits of antithrombotic approaches need to be weighed carefully against risks using a patient-centered approach,” the authors advised.

Among the many imaging tests available to facilitate cardiovascular risk stratification in type 2 diabetes, coronary artery calcification (CAC) CT screening is one of the few with sufficient data to support routine use in selected patients. The National Lipid Association, for example, recommends escalation to high-intensity statin for CAC > 100.

“One avenue to continue to address and advance diabetes management is through breaking down the four walls of the clinic or hospital through community engagement, clinic-to-community connections, and academic-community-government partnerships that may help address and support modifiable lifestyle behaviors such as physical activity, nutrition, smoking cessation and stress management,” Dr. Joseph concluded.

The AHA receives funding primarily from individuals. Foundations and corporations, including pharmaceutical, device manufacturers, and other companies, also make donations and fund AHA programs and events. The AHA’s strict policies prevent these relationships from influencing the science content. Revenues from pharmaceutical and biotech companies, device manufacturers, and health insurance providers and the AHA’s financial information are available on the association’s website. Dr. Joseph has disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

A new document from the American Heart Association summarizes the latest research on cardiovascular risk factor management in type 2 diabetes, including medications, lifestyle, and social determinants of health.

Despite the availability of effective therapies for improving cardiovascular risk, in the United States fewer than one in five people with type 2 diabetes and without known cardiovascular disease meet control targets for a combination of A1c, blood pressure, LDL cholesterol, and nonsmoking status.

Volkan Ünalan/Thinkstock

That proportion drops to less than 1 in 10 if body mass index less than 30 kg/m² is included among the targets, and even less than that among individuals with established atherosclerotic cardiovascular disease, Joshua J. Joseph, MD, and colleagues point out in their paper, published online Jan. 10 in Circulation.

“This new scientific statement is an urgent call to action to follow the latest evidence-based approaches and to develop new best practices to advance type 2 diabetes treatment and care and reduce cardiovascular disease risk,” wrote Dr. Joseph, assistant professor of medicine in the division of endocrinology, diabetes, and metabolism at The Ohio State University, Columbus, Ohio, and coauthors.

The statement is not a guideline but an expert analysis that may inform future clinical practice guidelines, according to a press release from the AHA.

The new statement reviews evidence through June 2020 for lifestyle management of diabetes and weight, glycemic targets and control, blood pressure management, lipid management, antithrombotic therapy, and screening for cardiovascular and renal complications, including imaging. It also discusses the clinical implications of recent cardiovascular outcomes trials of newer glucose-lowering medications.

However, Dr. Joseph and colleagues point out, clinical care and treatment account for just 10%-20% of modifiable contributors to health outcomes. The other 80%-90% relate to social determinants of health, including health-related behaviors, socioeconomic factors, environmental factors, and racism.

“If we are to continue to advance the management of cardiovascular risk factors, we must also address the [social determinants of health] in the delivery of health care,” they noted.

Overall, they advise a patient-centered approach, meaning “reframing our clinical encounters to think about patients as people who live in families, communities, and societies that must be considered in their cardiovascular risk management.”

“People with [type 2 diabetes] face numerous barriers to health including access to care and equitable care, which must be considered when developing individualized care plans with our patients,” Dr. Joseph said in the AHA press release.
 

Lifestyle, medications for lowering A1c, BP, lipids

For lifestyle management, the authors say, “culturally appropriate recommendations through diabetes self-management education and support and medical nutrition therapy are key to meeting individualized goals for behavioral change and diabetes self-management.”

The document summarizes recommendations from other professional societies regarding glycemic targets and glucose lowering medications, i.e., target A1c levels of either < 7% or < 6.5% for the majority, with adjustments based on individual factors, such as life expectancy. It advises on use of metformin as first-line therapy followed by a sodium-glucose cotransporter-2 inhibitor or a glucagon-like peptide-1 agonist for those with established cardiovascular disease or risk factors.

“Cost may be a barrier to taking some [type 2 diabetes] medications as prescribed; however, many of these medications are now more commonly covered by more health insurance plans,” Dr. Joseph said.

“Another barrier is recognition by patients that these newer [type 2 diabetes] medications are also effective in reducing the risk of heart disease, stroke, heart failure, and kidney disease.”

Blood pressure treatment guidelines differ between those of the AHA/American College of Cardiology (ACC) and the American Diabetes Association (ADA), most notably that the AHA/ACC guidelines advise a general target of < 130/80 mm Hg, whereas ADA advises < 140/90 mm Hg or < 130/80 mm Hg for those with high risk if it can be safely achieved.

The decision should be “patient-centered with shared decision-making,” Dr. Joseph and colleagues advised.

For lipid-lowering, the document cites the 2018 ACC/AHA cholesterol guidelines, which include advising statins as first-line therapy for both primary and secondary prevention in diabetes, with highest intensity statins used in those at highest risk. But again, treatment should be individualized, and other agents should be used for patients in whom statins don’t work or aren’t tolerated.

And while use of antiplatelets – that is, aspirin – is well established as secondary prevention in type 2 diabetes, given new data suggesting that the risk for major bleeding could outweigh the benefits for primary prevention, “the relative benefits of antithrombotic approaches need to be weighed carefully against risks using a patient-centered approach,” the authors advised.

Among the many imaging tests available to facilitate cardiovascular risk stratification in type 2 diabetes, coronary artery calcification (CAC) CT screening is one of the few with sufficient data to support routine use in selected patients. The National Lipid Association, for example, recommends escalation to high-intensity statin for CAC > 100.

“One avenue to continue to address and advance diabetes management is through breaking down the four walls of the clinic or hospital through community engagement, clinic-to-community connections, and academic-community-government partnerships that may help address and support modifiable lifestyle behaviors such as physical activity, nutrition, smoking cessation and stress management,” Dr. Joseph concluded.

The AHA receives funding primarily from individuals. Foundations and corporations, including pharmaceutical, device manufacturers, and other companies, also make donations and fund AHA programs and events. The AHA’s strict policies prevent these relationships from influencing the science content. Revenues from pharmaceutical and biotech companies, device manufacturers, and health insurance providers and the AHA’s financial information are available on the association’s website. Dr. Joseph has disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Photographs courtesy of Richard P. Usatine, MD.

THE COMPARISON

A Pink, elevated, granulomatous, indurated plaques on the face, including the nasal alae, of a 52-year-old woman with a darker skin tone.

B Orange and pink, elevated, granulomatous, indurated plaques on the face of a 55-year-old woman with a lighter skin tone.

Sarcoidosis is a granulomatous disease that may affect the skin in addition to multiple body organ systems, including the lungs. Bilateral hilar adenopathy on a chest radiograph is the most common finding. Sarcoidosis also has a variety of cutaneous manifestations. Early diagnosis is vital, as patients with with sarcoidosis and pulmonary fibrosis have a shortened life span compared to the overall population.¹ With a growing skin of color population, it is important to recognize sarcoidosis as soon as possible.²

Epidemiology

People of African descent have the highest sarcoidosis prevalence in the United States.³ In the United States, the incidence of sarcoidosis in Black individuals peaks in the fourth decade of life. A 5-year study in a US health maintenance organization found that the age-adjusted annual incidence was 10.9 per 100,000 cases among Whites and 35.5 per 100,000 cases among Blacks.⁴

Key clinical features in people with darker skin tones:

• Papules are seen in sarcoidosis, primarily on the face, and may start as orange hued or yellow-brown and then become brown-red or pink to violaceous before involuting into faint macules.^5-7

• When round or oval sarcoid plaques appear, they often are more erythematous. In skin of color, plaques may become hypopigmented.⁸

• Erythema nodosum, the most common nonspecific cutaneous lesion seen in sarcoidosis, is less commonly seen in those of African and Asian descent.^9-11 This is in contrast to distinctive forms of specific sarcoid skin lesions such as lupus pernio and scar sarcoidosis, as well as papules and plaques and minor forms of specific sarcoid skin lesions including subcutaneous nodules; hypopigmented macules; psoriasiform lesions; and ulcerative, localized erythrodermic, ichthyosiform, scalp, and nail lesions.

• Lupus pernio is a cutaneous manifestation of sarcoidosis that appears on the face. It looks similar to lupus erythematosus and occurs most commonly in women of African descent.^8,12

• Hypopigmented lesions are more common in those with darker skin tones.⁹

• Ulcerative lesions are more common in those of African descent and women.¹³

• Scalp sarcoidosis is more common in patients of African descent.¹⁴

• Sarcoidosis may develop at sites of trauma, such as scars and tattoos.^15-17

Worth noting

The cutaneous lesions seen in sarcoidosis may be emotionally devastating and disfiguring. Due to the variety of clinical manifestations, sarcoidosis may be misdiagnosed, leading to delays in treatment.¹⁸

Health disparity highlight

Patients older than 40 years presenting with sarcoidosis and those of African descent have a worse prognosis.¹⁹ Despite adjusting for race, ethnic group, age, and sex, patients with low income and financial barriers present with more severe sarcoidosis.²⁰

Photographs courtesy of Richard P. Usatine, MD.

THE COMPARISON

A Pink, elevated, granulomatous, indurated plaques on the face, including the nasal alae, of a 52-year-old woman with a darker skin tone.

B Orange and pink, elevated, granulomatous, indurated plaques on the face of a 55-year-old woman with a lighter skin tone.

Sarcoidosis is a granulomatous disease that may affect the skin in addition to multiple body organ systems, including the lungs. Bilateral hilar adenopathy on a chest radiograph is the most common finding. Sarcoidosis also has a variety of cutaneous manifestations. Early diagnosis is vital, as patients with with sarcoidosis and pulmonary fibrosis have a shortened life span compared to the overall population.¹ With a growing skin of color population, it is important to recognize sarcoidosis as soon as possible.²

Epidemiology

People of African descent have the highest sarcoidosis prevalence in the United States.³ In the United States, the incidence of sarcoidosis in Black individuals peaks in the fourth decade of life. A 5-year study in a US health maintenance organization found that the age-adjusted annual incidence was 10.9 per 100,000 cases among Whites and 35.5 per 100,000 cases among Blacks.⁴

Key clinical features in people with darker skin tones:

• Papules are seen in sarcoidosis, primarily on the face, and may start as orange hued or yellow-brown and then become brown-red or pink to violaceous before involuting into faint macules.^5-7

• When round or oval sarcoid plaques appear, they often are more erythematous. In skin of color, plaques may become hypopigmented.⁸

• Erythema nodosum, the most common nonspecific cutaneous lesion seen in sarcoidosis, is less commonly seen in those of African and Asian descent.^9-11 This is in contrast to distinctive forms of specific sarcoid skin lesions such as lupus pernio and scar sarcoidosis, as well as papules and plaques and minor forms of specific sarcoid skin lesions including subcutaneous nodules; hypopigmented macules; psoriasiform lesions; and ulcerative, localized erythrodermic, ichthyosiform, scalp, and nail lesions.

• Lupus pernio is a cutaneous manifestation of sarcoidosis that appears on the face. It looks similar to lupus erythematosus and occurs most commonly in women of African descent.^8,12

• Hypopigmented lesions are more common in those with darker skin tones.⁹

• Ulcerative lesions are more common in those of African descent and women.¹³

• Scalp sarcoidosis is more common in patients of African descent.¹⁴

• Sarcoidosis may develop at sites of trauma, such as scars and tattoos.^15-17

Worth noting

The cutaneous lesions seen in sarcoidosis may be emotionally devastating and disfiguring. Due to the variety of clinical manifestations, sarcoidosis may be misdiagnosed, leading to delays in treatment.¹⁸

Health disparity highlight

Patients older than 40 years presenting with sarcoidosis and those of African descent have a worse prognosis.¹⁹ Despite adjusting for race, ethnic group, age, and sex, patients with low income and financial barriers present with more severe sarcoidosis.²⁰

Photographs courtesy of Richard P. Usatine, MD.

THE COMPARISON

A Pink, elevated, granulomatous, indurated plaques on the face, including the nasal alae, of a 52-year-old woman with a darker skin tone.

B Orange and pink, elevated, granulomatous, indurated plaques on the face of a 55-year-old woman with a lighter skin tone.

Sarcoidosis is a granulomatous disease that may affect the skin in addition to multiple body organ systems, including the lungs. Bilateral hilar adenopathy on a chest radiograph is the most common finding. Sarcoidosis also has a variety of cutaneous manifestations. Early diagnosis is vital, as patients with with sarcoidosis and pulmonary fibrosis have a shortened life span compared to the overall population.¹ With a growing skin of color population, it is important to recognize sarcoidosis as soon as possible.²

Epidemiology

People of African descent have the highest sarcoidosis prevalence in the United States.³ In the United States, the incidence of sarcoidosis in Black individuals peaks in the fourth decade of life. A 5-year study in a US health maintenance organization found that the age-adjusted annual incidence was 10.9 per 100,000 cases among Whites and 35.5 per 100,000 cases among Blacks.⁴

Key clinical features in people with darker skin tones:

• Papules are seen in sarcoidosis, primarily on the face, and may start as orange hued or yellow-brown and then become brown-red or pink to violaceous before involuting into faint macules.^5-7

• When round or oval sarcoid plaques appear, they often are more erythematous. In skin of color, plaques may become hypopigmented.⁸

• Erythema nodosum, the most common nonspecific cutaneous lesion seen in sarcoidosis, is less commonly seen in those of African and Asian descent.^9-11 This is in contrast to distinctive forms of specific sarcoid skin lesions such as lupus pernio and scar sarcoidosis, as well as papules and plaques and minor forms of specific sarcoid skin lesions including subcutaneous nodules; hypopigmented macules; psoriasiform lesions; and ulcerative, localized erythrodermic, ichthyosiform, scalp, and nail lesions.

• Lupus pernio is a cutaneous manifestation of sarcoidosis that appears on the face. It looks similar to lupus erythematosus and occurs most commonly in women of African descent.^8,12

• Hypopigmented lesions are more common in those with darker skin tones.⁹

• Ulcerative lesions are more common in those of African descent and women.¹³

• Scalp sarcoidosis is more common in patients of African descent.¹⁴

• Sarcoidosis may develop at sites of trauma, such as scars and tattoos.^15-17

Worth noting

The cutaneous lesions seen in sarcoidosis may be emotionally devastating and disfiguring. Due to the variety of clinical manifestations, sarcoidosis may be misdiagnosed, leading to delays in treatment.¹⁸

Health disparity highlight

Patients older than 40 years presenting with sarcoidosis and those of African descent have a worse prognosis.¹⁹ Despite adjusting for race, ethnic group, age, and sex, patients with low income and financial barriers present with more severe sarcoidosis.²⁰

With a majority-minority population expected in the United States by 2044, improving diversity and cultural competency in the dermatology workforce is now more important than ever. A more diverse workforce increases the cultural competence of all providers, provides greater opportunities for mentorship and sponsorship of underrepresented minority (URM) trainees, establishes a more inclusive environment for learners, and enhances the knowledge and productivity of the workforce.^1-3 Additionally, it is imperative to address clinical care disparities seen in minority patients in dermatology, including treatment of skin cancer, psoriasis, acne, atopic dermatitis, and other diseases.^4-7

Despite the attention that has been devoted to improving diversity in medicine,^8-10 dermatology remains one of the least diverse specialties, prompting additional calls to action within the field.¹¹ Why does the lack of diversity still exist in dermatology, and what is the path to correcting this problem? In this article, we review the evidence of diversity barriers at different stages of medical education training that may impede academic advancement for minority learners pursuing careers in dermatology.

Undergraduate Medical Education

The term leaky pipeline refers to the progressive decline in the number of URMs along a given career path, including in dermatology. The Association of American Medical Colleges defines URMs as racial/ethnic populations that are “underrepresented in the medical profession relative to their numbers in the general population.”⁹ The first leak in the pipeline is that URMs are not applying to medical school. From 2002 and 2017, rates of both application and matriculation to medical school were lower by 30% to 70% in URM groups compared to White students, including Hispanic, Black, and American Indian/Alaska Native students.^12,13 The decision not to apply to medical school was greater in URM undergraduate students irrespective of scholastic ability as measured by SAT scores.¹⁴

A striking statistic is that the number of Black men matriculating into medical school in 2014 was less than it was in 1978 despite the increase in the number of US medical schools and efforts to recruit more diverse student populations. The Association of American Medical Colleges identified potential reasons for this decline, including poor early education, lack of mentorship, negative perceptions of Black men due to racial stereotypes, and lack of financial and academic resources to support the application process.^8,13,15-17 Implicit racial bias by admission committees also may play a role.

Medical School Matriculation and Applying to Dermatology Residency

There is greater representation of URM students in medical school than in dermatology residency, which means URM students are either not applying to dermatology programs or they are not matching into the specialty. In the Electronic Residency Application Service’s 2016-2017 application cycle (N=776), there were 76 (9.8%) URM dermatology residency applicants.¹⁸ In 2018, there was a notable decline in representation of Black students among residency applicants (4.9%) to matched residents (3.7%), and there were only 133 (9.3%) URM dermatology residents in total (PGY2-PGY4 classes).¹⁹ The lack of exposure to medical subspecialties and the recommendation by medical schools for URM medical students to pursue careers in primary care have been cited as reasons that these students may not apply to residency programs in specialty care.^20,21 The presence of an Accreditation Council for Graduate Medical Education dermatology residency program, fellowships, and dermatology interest groups at their medical schools correlated with higher proportions of URM students applying to dermatology programs.²⁰

Underrepresented minority students face critical challenges during medical school, including receiving lower grades in both standardized and school-designated assessments and clerkship grades.^21,22 A 2019 National Board of Medical Examiners study found that Hispanic and Black test takers scored 12.1 and 16.6 points lower than White men, respectively, on the US Medical Licensing Examination (USMLE) Step 1.²³ Black and Asian students also were less likely than White students to be selected as members of the Alpha Omega Alpha Honor Medical Society (AΩA), even after accounting for USMLE Step 1 scores, research productivity, community service, leadership, and Gold Humanism Honor Society membership.²⁴ Taken together, the emphasis on clinical grades, USMLE scores, and AΩA status as recruitment and selection criteria likely deters URM students from applying to and may preclude them from successfully matching into highly selective specialties such as dermatology.²⁵

A recent cross-sectional study showed that lack of equitable resources, lack of support, financial constrictions, and lack of group identity were 4 barriers to URM students matching into dermatology.²⁶ Dermatology is a competitive specialty with the highest median Electronic Residency Application Service applications submitted per US applicant (n=90)²⁷ and an approximate total cost per US applicant of $10,781.^28,29 Disadvantaged URM applicants noted relying on loans while non-URM applicants cited family financial support as being beneficial.²⁶ In addition, an increasing number of applicants take gap years for research, which pose additional costs for finances and resources. In contrast, mentorship and participation in pipeline/enrichment programs were factors associated with URM students matching into dermatology.²⁶

 

 

Dermatology Residency and the Transition to Advanced Dermatology Fellowships

Similar to the transition from medical school into dermatology residency, URM dermatology residents are either not applying to fellowships or are not getting in. In the 2018-2019 academic year, there were no Black, Hispanic, Native Hawaiian/Pacific Islander, or American Indian/Alaska Native Mohs micrographic surgery and dermatologic oncology fellows.¹⁹ Similarly, there were no Black, Native Hawaiian/Pacific Islander, or American Indian/Alaska Native dermatopathology fellows. There were 4 (6%) Hispanic dermatopathology fellows.¹⁹

There also is marked underrepresentation of minority groups—and minimal growth over time—in the dermatology procedural subspecialty. Whereas the percentage of female Mohs surgeons increased considerably from 1985 to 2005 (12.7% to 40.9%, respectively), the percentage of URM Mohs surgeons remained steady from 4.2% to 4.6%, respectively, and remained at 4.5% in 2014.³⁰

There are no available data on the race/ethnicity of fellowship applicants, as these demographic data for the application process have not been consistently or traditionally collected. The reasons why there are so few URM dermatology fellows is not known; whether this is due to a lack of mentorship or whether other factors lead to residents not applying for advanced training needs further study. Financial factors related to prolonged training, which include lower salaries and delayed loan repayment, may present barriers to applying to fellowships.

Lack of URM Academic Faculty in Dermatology

At the academic faculty level, URM representation continues to worsen. Lett et al³¹ found that there is declining racial and ethnic representation in clinical academic medicine relative to US census data for 16 US medical specialties, including dermatology, with growing underrepresentation of Black and Hispanic faculty at the associate professor and full professor levels and underrepresentation in all faculty ranks. From 1970 to 2018, URM faculty in dermatology only increased from 4.8% to 7.4%, respectively. Non-URM female and male faculty members increased by 13.8 and 10.8 faculty members per year, respectively, while URM female and male faculty members increased by 1.2 and 0.8 faculty members per year, respectively.³²

Underrepresentation of minorities seen in dermatology faculty may result from clinical demands, minority taxation (defined as the extensive service requirements uniquely experienced by URM faculty to disproportionately serve as representatives on academic committees and to mentor URM students), and barriers to academic promotion, which are challenges uniquely encountered by URMs in academic dermatology.³³ Increased clinical demand may result from the fact that URM physicians are more likely to care for underserved populations, those of lower socioeconomic status, non-English–speaking patients, those on Medicaid, and those who are uninsured, which may impact renumeration. Minority tax experienced by URM faculty includes mentoring URM medical students, providing cultural expertise to departments and institutions, and participating in community service projects and outreach programs. Specifically, many institutional committees require the participation of a URM member, resulting in URM faculty members experiencing higher committee service burden. Many, if not all, of these responsibilities often are not compensated through salary or academic promotion.

A Call to Action

There are several steps that can be taken to create a pathway to dermatology that is inclusive, flexible, and supportive of URMs.

• Increase early exposure to dermatology in medical school. Early exposure and mentorship opportunities are associated with higher rates of students pursuing specialty field careers.³⁴ Increased early opportunities allow for URM students to consider and explore a career in dermatology; receive mentorship; and ensure that dermatology, including topics related to skin of color (SOC), is incorporated into their learning. The American Academy of Dermatology has contributed to these efforts by its presence at every national meeting of the Student National Medical Association and Latino Medical Student Association, as well as its involvement with Nth Dimensions, which offers various educational opportunities for URM medical students.

• Implement equitable grading and holistic review processes in medical school. Racial/ethnic differences in clinical grading and standardized test scores in medical school demonstrate why holistic review of dermatology residency applicants is needed and why other metrics such as USMLE scores and AΩA status should be de-emphasized or eliminated when evaluating candidates. To support equity, many medical schools have eliminated honors grading, and some schools have eliminated AΩA distinction.

• Increase diversity of dermatology residents and residency programs. Implicit bias training for a medical school admissions committee has been shown to increase diversity in medical school enrollment.³⁵ Whether implicit bias training and other diversity training may benefit dermatology residency selection must be examined, including study of unintended consequences, such as reduced diversity, increased microaggressions toward minority colleagues, and the illusion of fairness.^36-39 Increasing representation is not sufficient—creating inclusive residency training environments is a critical parallel aim. Prioritizing diversity in dermatology residency recruitment is imperative. Creating dermatology residency positions specifically for URM residents may be an important option, as done at the University of Pennsylvania (Philadelphia, Pennsylvania) and Duke University (Durham, North Carolina).

• Create effective programs for URM mentorship. Due to the competitive nature of dermatology residency, the need for mentors in dermatology is critically vital for URM medical students, especially those without a home dermatology program at their medical school. Further development of formal mentorship and pipeline programs is essential at both the local and national levels. Some national examples of these initiatives include diversity mentorship programs offered by the American Academy of Dermatology, Skin of Color Society, Women’s Dermatologic Society, and Student National Medical Association. Many institutional programs also offer invaluable opportunities, such as the summer research fellowship at the University of California, San Francisco (UCSF); visiting clerkship grants for URMs at the University of Pennsylvania (Philadelphia, Pennsylvania) and Johns Hopkins University (Baltimore, Maryland); and integrated programs, such as the Visiting Elective Scholarship Program at UCSF, which provides funding and faculty mentorship for URM students completing an away rotation at UCSF.

• Establish longitudinal skin-of-color curricula and increased opportunities for research. More robust SOC training may lead to an increasingly diverse workforce. It is important that medical student and dermatology resident and fellow education include training on SOC to ensure high-quality care to diverse patient populations, which also may enhance the knowledge of trainees, encourage clinical and research interest in this field, and reduce health care disparities. Increasing research opportunities and offering formalized longitudinal training in SOC as well as incorporating more diverse images in medical school education may foster greater interest in this field at a time when trainees are establishing their career interests. At present, there is considerable room for improvement. Nijhawan et al⁴⁰ surveyed 63 dermatology chief residents and 41 program directors and found only 14.3% and 14.6%, respectively, reported having an expert who conducts clinic specializing in SOC. Only 52.4% and 65.9% reported having didactic sessions or lectures focused on SOC diseases, and 30.2% and 12.2% reported having a dedicated rotation for residents to gain experience in SOC.⁴⁰ A more recent study showed that when faculty were asked to incorporate more SOC content into lectures, the most commonly identified barrier to implementation was a lack of SOC images.⁴¹ Additionally, there remains a paucity of published research on this topic, with SOC articles representing only 2.7% of the literature.⁴² These numbers demonstrate the continued need for a more inclusive and comprehensive curriculum in dermatology residency programs and more robust funding for SOC research.

• Recruit and support URM faculty. Increasing diversity in dermatology residency programs likely will increase the number of potential URMs pursuing additional fellowship training and academic dermatology with active career mentorship and support. In addition, promoting faculty retention by combatting the progressive loss of URMs at all faculty levels is paramount. Mentorship for URM physicians has been shown to play a key role in the decision to pursue academic medicine as well as academic productivity and job satisfaction.^43,44 The visibility, cultural competency, clinical work, academic productivity, and mentorship efforts that URM faculty provide are essential to enhancing patient care, teaching diverse groups of learners, and recruiting more diverse trainees. Protected time to participate in professional development opportunities has been shown to improve recruitment and retention of URM faculty and offer additional opportunities for junior faculty to find mentors.^35,36 Incentivizing clinical care of underserved populations also may augment financial stability for URM physicians who choose to care for these patients. Finally, diversity work and community service should be legitimized and count toward faculty promotion.

Conclusion

There are numerous factors that contribute to the leaky pipeline in dermatology (eFigure). Many challenges that are unique to the URM population disadvantage these students from entering medical school, applying to dermatology residency, matching into dermatology fellowships, pursuing and staying in faculty positions, and achieving faculty advancement into leadership positions. With each progressive step along this trajectory, there is less minority representation. All dermatologists, regardless of race/ethnicity, need to play an active role and must prioritize diversity, equity, and inclusion efforts at all levels of education and training for the betterment of the specialty.

With a majority-minority population expected in the United States by 2044, improving diversity and cultural competency in the dermatology workforce is now more important than ever. A more diverse workforce increases the cultural competence of all providers, provides greater opportunities for mentorship and sponsorship of underrepresented minority (URM) trainees, establishes a more inclusive environment for learners, and enhances the knowledge and productivity of the workforce.^1-3 Additionally, it is imperative to address clinical care disparities seen in minority patients in dermatology, including treatment of skin cancer, psoriasis, acne, atopic dermatitis, and other diseases.^4-7

Despite the attention that has been devoted to improving diversity in medicine,^8-10 dermatology remains one of the least diverse specialties, prompting additional calls to action within the field.¹¹ Why does the lack of diversity still exist in dermatology, and what is the path to correcting this problem? In this article, we review the evidence of diversity barriers at different stages of medical education training that may impede academic advancement for minority learners pursuing careers in dermatology.

Undergraduate Medical Education

The term leaky pipeline refers to the progressive decline in the number of URMs along a given career path, including in dermatology. The Association of American Medical Colleges defines URMs as racial/ethnic populations that are “underrepresented in the medical profession relative to their numbers in the general population.”⁹ The first leak in the pipeline is that URMs are not applying to medical school. From 2002 and 2017, rates of both application and matriculation to medical school were lower by 30% to 70% in URM groups compared to White students, including Hispanic, Black, and American Indian/Alaska Native students.^12,13 The decision not to apply to medical school was greater in URM undergraduate students irrespective of scholastic ability as measured by SAT scores.¹⁴

A striking statistic is that the number of Black men matriculating into medical school in 2014 was less than it was in 1978 despite the increase in the number of US medical schools and efforts to recruit more diverse student populations. The Association of American Medical Colleges identified potential reasons for this decline, including poor early education, lack of mentorship, negative perceptions of Black men due to racial stereotypes, and lack of financial and academic resources to support the application process.^8,13,15-17 Implicit racial bias by admission committees also may play a role.

Medical School Matriculation and Applying to Dermatology Residency

There is greater representation of URM students in medical school than in dermatology residency, which means URM students are either not applying to dermatology programs or they are not matching into the specialty. In the Electronic Residency Application Service’s 2016-2017 application cycle (N=776), there were 76 (9.8%) URM dermatology residency applicants.¹⁸ In 2018, there was a notable decline in representation of Black students among residency applicants (4.9%) to matched residents (3.7%), and there were only 133 (9.3%) URM dermatology residents in total (PGY2-PGY4 classes).¹⁹ The lack of exposure to medical subspecialties and the recommendation by medical schools for URM medical students to pursue careers in primary care have been cited as reasons that these students may not apply to residency programs in specialty care.^20,21 The presence of an Accreditation Council for Graduate Medical Education dermatology residency program, fellowships, and dermatology interest groups at their medical schools correlated with higher proportions of URM students applying to dermatology programs.²⁰

Underrepresented minority students face critical challenges during medical school, including receiving lower grades in both standardized and school-designated assessments and clerkship grades.^21,22 A 2019 National Board of Medical Examiners study found that Hispanic and Black test takers scored 12.1 and 16.6 points lower than White men, respectively, on the US Medical Licensing Examination (USMLE) Step 1.²³ Black and Asian students also were less likely than White students to be selected as members of the Alpha Omega Alpha Honor Medical Society (AΩA), even after accounting for USMLE Step 1 scores, research productivity, community service, leadership, and Gold Humanism Honor Society membership.²⁴ Taken together, the emphasis on clinical grades, USMLE scores, and AΩA status as recruitment and selection criteria likely deters URM students from applying to and may preclude them from successfully matching into highly selective specialties such as dermatology.²⁵

A recent cross-sectional study showed that lack of equitable resources, lack of support, financial constrictions, and lack of group identity were 4 barriers to URM students matching into dermatology.²⁶ Dermatology is a competitive specialty with the highest median Electronic Residency Application Service applications submitted per US applicant (n=90)²⁷ and an approximate total cost per US applicant of $10,781.^28,29 Disadvantaged URM applicants noted relying on loans while non-URM applicants cited family financial support as being beneficial.²⁶ In addition, an increasing number of applicants take gap years for research, which pose additional costs for finances and resources. In contrast, mentorship and participation in pipeline/enrichment programs were factors associated with URM students matching into dermatology.²⁶

 

 

Dermatology Residency and the Transition to Advanced Dermatology Fellowships

Similar to the transition from medical school into dermatology residency, URM dermatology residents are either not applying to fellowships or are not getting in. In the 2018-2019 academic year, there were no Black, Hispanic, Native Hawaiian/Pacific Islander, or American Indian/Alaska Native Mohs micrographic surgery and dermatologic oncology fellows.¹⁹ Similarly, there were no Black, Native Hawaiian/Pacific Islander, or American Indian/Alaska Native dermatopathology fellows. There were 4 (6%) Hispanic dermatopathology fellows.¹⁹

There also is marked underrepresentation of minority groups—and minimal growth over time—in the dermatology procedural subspecialty. Whereas the percentage of female Mohs surgeons increased considerably from 1985 to 2005 (12.7% to 40.9%, respectively), the percentage of URM Mohs surgeons remained steady from 4.2% to 4.6%, respectively, and remained at 4.5% in 2014.³⁰

There are no available data on the race/ethnicity of fellowship applicants, as these demographic data for the application process have not been consistently or traditionally collected. The reasons why there are so few URM dermatology fellows is not known; whether this is due to a lack of mentorship or whether other factors lead to residents not applying for advanced training needs further study. Financial factors related to prolonged training, which include lower salaries and delayed loan repayment, may present barriers to applying to fellowships.

Lack of URM Academic Faculty in Dermatology

At the academic faculty level, URM representation continues to worsen. Lett et al³¹ found that there is declining racial and ethnic representation in clinical academic medicine relative to US census data for 16 US medical specialties, including dermatology, with growing underrepresentation of Black and Hispanic faculty at the associate professor and full professor levels and underrepresentation in all faculty ranks. From 1970 to 2018, URM faculty in dermatology only increased from 4.8% to 7.4%, respectively. Non-URM female and male faculty members increased by 13.8 and 10.8 faculty members per year, respectively, while URM female and male faculty members increased by 1.2 and 0.8 faculty members per year, respectively.³²

Underrepresentation of minorities seen in dermatology faculty may result from clinical demands, minority taxation (defined as the extensive service requirements uniquely experienced by URM faculty to disproportionately serve as representatives on academic committees and to mentor URM students), and barriers to academic promotion, which are challenges uniquely encountered by URMs in academic dermatology.³³ Increased clinical demand may result from the fact that URM physicians are more likely to care for underserved populations, those of lower socioeconomic status, non-English–speaking patients, those on Medicaid, and those who are uninsured, which may impact renumeration. Minority tax experienced by URM faculty includes mentoring URM medical students, providing cultural expertise to departments and institutions, and participating in community service projects and outreach programs. Specifically, many institutional committees require the participation of a URM member, resulting in URM faculty members experiencing higher committee service burden. Many, if not all, of these responsibilities often are not compensated through salary or academic promotion.

A Call to Action

There are several steps that can be taken to create a pathway to dermatology that is inclusive, flexible, and supportive of URMs.

• Increase early exposure to dermatology in medical school. Early exposure and mentorship opportunities are associated with higher rates of students pursuing specialty field careers.³⁴ Increased early opportunities allow for URM students to consider and explore a career in dermatology; receive mentorship; and ensure that dermatology, including topics related to skin of color (SOC), is incorporated into their learning. The American Academy of Dermatology has contributed to these efforts by its presence at every national meeting of the Student National Medical Association and Latino Medical Student Association, as well as its involvement with Nth Dimensions, which offers various educational opportunities for URM medical students.

• Implement equitable grading and holistic review processes in medical school. Racial/ethnic differences in clinical grading and standardized test scores in medical school demonstrate why holistic review of dermatology residency applicants is needed and why other metrics such as USMLE scores and AΩA status should be de-emphasized or eliminated when evaluating candidates. To support equity, many medical schools have eliminated honors grading, and some schools have eliminated AΩA distinction.

• Increase diversity of dermatology residents and residency programs. Implicit bias training for a medical school admissions committee has been shown to increase diversity in medical school enrollment.³⁵ Whether implicit bias training and other diversity training may benefit dermatology residency selection must be examined, including study of unintended consequences, such as reduced diversity, increased microaggressions toward minority colleagues, and the illusion of fairness.^36-39 Increasing representation is not sufficient—creating inclusive residency training environments is a critical parallel aim. Prioritizing diversity in dermatology residency recruitment is imperative. Creating dermatology residency positions specifically for URM residents may be an important option, as done at the University of Pennsylvania (Philadelphia, Pennsylvania) and Duke University (Durham, North Carolina).

• Create effective programs for URM mentorship. Due to the competitive nature of dermatology residency, the need for mentors in dermatology is critically vital for URM medical students, especially those without a home dermatology program at their medical school. Further development of formal mentorship and pipeline programs is essential at both the local and national levels. Some national examples of these initiatives include diversity mentorship programs offered by the American Academy of Dermatology, Skin of Color Society, Women’s Dermatologic Society, and Student National Medical Association. Many institutional programs also offer invaluable opportunities, such as the summer research fellowship at the University of California, San Francisco (UCSF); visiting clerkship grants for URMs at the University of Pennsylvania (Philadelphia, Pennsylvania) and Johns Hopkins University (Baltimore, Maryland); and integrated programs, such as the Visiting Elective Scholarship Program at UCSF, which provides funding and faculty mentorship for URM students completing an away rotation at UCSF.

• Establish longitudinal skin-of-color curricula and increased opportunities for research. More robust SOC training may lead to an increasingly diverse workforce. It is important that medical student and dermatology resident and fellow education include training on SOC to ensure high-quality care to diverse patient populations, which also may enhance the knowledge of trainees, encourage clinical and research interest in this field, and reduce health care disparities. Increasing research opportunities and offering formalized longitudinal training in SOC as well as incorporating more diverse images in medical school education may foster greater interest in this field at a time when trainees are establishing their career interests. At present, there is considerable room for improvement. Nijhawan et al⁴⁰ surveyed 63 dermatology chief residents and 41 program directors and found only 14.3% and 14.6%, respectively, reported having an expert who conducts clinic specializing in SOC. Only 52.4% and 65.9% reported having didactic sessions or lectures focused on SOC diseases, and 30.2% and 12.2% reported having a dedicated rotation for residents to gain experience in SOC.⁴⁰ A more recent study showed that when faculty were asked to incorporate more SOC content into lectures, the most commonly identified barrier to implementation was a lack of SOC images.⁴¹ Additionally, there remains a paucity of published research on this topic, with SOC articles representing only 2.7% of the literature.⁴² These numbers demonstrate the continued need for a more inclusive and comprehensive curriculum in dermatology residency programs and more robust funding for SOC research.

• Recruit and support URM faculty. Increasing diversity in dermatology residency programs likely will increase the number of potential URMs pursuing additional fellowship training and academic dermatology with active career mentorship and support. In addition, promoting faculty retention by combatting the progressive loss of URMs at all faculty levels is paramount. Mentorship for URM physicians has been shown to play a key role in the decision to pursue academic medicine as well as academic productivity and job satisfaction.^43,44 The visibility, cultural competency, clinical work, academic productivity, and mentorship efforts that URM faculty provide are essential to enhancing patient care, teaching diverse groups of learners, and recruiting more diverse trainees. Protected time to participate in professional development opportunities has been shown to improve recruitment and retention of URM faculty and offer additional opportunities for junior faculty to find mentors.^35,36 Incentivizing clinical care of underserved populations also may augment financial stability for URM physicians who choose to care for these patients. Finally, diversity work and community service should be legitimized and count toward faculty promotion.

Conclusion

There are numerous factors that contribute to the leaky pipeline in dermatology (eFigure). Many challenges that are unique to the URM population disadvantage these students from entering medical school, applying to dermatology residency, matching into dermatology fellowships, pursuing and staying in faculty positions, and achieving faculty advancement into leadership positions. With each progressive step along this trajectory, there is less minority representation. All dermatologists, regardless of race/ethnicity, need to play an active role and must prioritize diversity, equity, and inclusion efforts at all levels of education and training for the betterment of the specialty.

With a majority-minority population expected in the United States by 2044, improving diversity and cultural competency in the dermatology workforce is now more important than ever. A more diverse workforce increases the cultural competence of all providers, provides greater opportunities for mentorship and sponsorship of underrepresented minority (URM) trainees, establishes a more inclusive environment for learners, and enhances the knowledge and productivity of the workforce.^1-3 Additionally, it is imperative to address clinical care disparities seen in minority patients in dermatology, including treatment of skin cancer, psoriasis, acne, atopic dermatitis, and other diseases.^4-7

Despite the attention that has been devoted to improving diversity in medicine,^8-10 dermatology remains one of the least diverse specialties, prompting additional calls to action within the field.¹¹ Why does the lack of diversity still exist in dermatology, and what is the path to correcting this problem? In this article, we review the evidence of diversity barriers at different stages of medical education training that may impede academic advancement for minority learners pursuing careers in dermatology.

Undergraduate Medical Education

The term leaky pipeline refers to the progressive decline in the number of URMs along a given career path, including in dermatology. The Association of American Medical Colleges defines URMs as racial/ethnic populations that are “underrepresented in the medical profession relative to their numbers in the general population.”⁹ The first leak in the pipeline is that URMs are not applying to medical school. From 2002 and 2017, rates of both application and matriculation to medical school were lower by 30% to 70% in URM groups compared to White students, including Hispanic, Black, and American Indian/Alaska Native students.^12,13 The decision not to apply to medical school was greater in URM undergraduate students irrespective of scholastic ability as measured by SAT scores.¹⁴

A striking statistic is that the number of Black men matriculating into medical school in 2014 was less than it was in 1978 despite the increase in the number of US medical schools and efforts to recruit more diverse student populations. The Association of American Medical Colleges identified potential reasons for this decline, including poor early education, lack of mentorship, negative perceptions of Black men due to racial stereotypes, and lack of financial and academic resources to support the application process.^8,13,15-17 Implicit racial bias by admission committees also may play a role.

Medical School Matriculation and Applying to Dermatology Residency

There is greater representation of URM students in medical school than in dermatology residency, which means URM students are either not applying to dermatology programs or they are not matching into the specialty. In the Electronic Residency Application Service’s 2016-2017 application cycle (N=776), there were 76 (9.8%) URM dermatology residency applicants.¹⁸ In 2018, there was a notable decline in representation of Black students among residency applicants (4.9%) to matched residents (3.7%), and there were only 133 (9.3%) URM dermatology residents in total (PGY2-PGY4 classes).¹⁹ The lack of exposure to medical subspecialties and the recommendation by medical schools for URM medical students to pursue careers in primary care have been cited as reasons that these students may not apply to residency programs in specialty care.^20,21 The presence of an Accreditation Council for Graduate Medical Education dermatology residency program, fellowships, and dermatology interest groups at their medical schools correlated with higher proportions of URM students applying to dermatology programs.²⁰

Underrepresented minority students face critical challenges during medical school, including receiving lower grades in both standardized and school-designated assessments and clerkship grades.^21,22 A 2019 National Board of Medical Examiners study found that Hispanic and Black test takers scored 12.1 and 16.6 points lower than White men, respectively, on the US Medical Licensing Examination (USMLE) Step 1.²³ Black and Asian students also were less likely than White students to be selected as members of the Alpha Omega Alpha Honor Medical Society (AΩA), even after accounting for USMLE Step 1 scores, research productivity, community service, leadership, and Gold Humanism Honor Society membership.²⁴ Taken together, the emphasis on clinical grades, USMLE scores, and AΩA status as recruitment and selection criteria likely deters URM students from applying to and may preclude them from successfully matching into highly selective specialties such as dermatology.²⁵

A recent cross-sectional study showed that lack of equitable resources, lack of support, financial constrictions, and lack of group identity were 4 barriers to URM students matching into dermatology.²⁶ Dermatology is a competitive specialty with the highest median Electronic Residency Application Service applications submitted per US applicant (n=90)²⁷ and an approximate total cost per US applicant of $10,781.^28,29 Disadvantaged URM applicants noted relying on loans while non-URM applicants cited family financial support as being beneficial.²⁶ In addition, an increasing number of applicants take gap years for research, which pose additional costs for finances and resources. In contrast, mentorship and participation in pipeline/enrichment programs were factors associated with URM students matching into dermatology.²⁶

 

 

Dermatology Residency and the Transition to Advanced Dermatology Fellowships

Similar to the transition from medical school into dermatology residency, URM dermatology residents are either not applying to fellowships or are not getting in. In the 2018-2019 academic year, there were no Black, Hispanic, Native Hawaiian/Pacific Islander, or American Indian/Alaska Native Mohs micrographic surgery and dermatologic oncology fellows.¹⁹ Similarly, there were no Black, Native Hawaiian/Pacific Islander, or American Indian/Alaska Native dermatopathology fellows. There were 4 (6%) Hispanic dermatopathology fellows.¹⁹

There also is marked underrepresentation of minority groups—and minimal growth over time—in the dermatology procedural subspecialty. Whereas the percentage of female Mohs surgeons increased considerably from 1985 to 2005 (12.7% to 40.9%, respectively), the percentage of URM Mohs surgeons remained steady from 4.2% to 4.6%, respectively, and remained at 4.5% in 2014.³⁰

There are no available data on the race/ethnicity of fellowship applicants, as these demographic data for the application process have not been consistently or traditionally collected. The reasons why there are so few URM dermatology fellows is not known; whether this is due to a lack of mentorship or whether other factors lead to residents not applying for advanced training needs further study. Financial factors related to prolonged training, which include lower salaries and delayed loan repayment, may present barriers to applying to fellowships.

Lack of URM Academic Faculty in Dermatology

At the academic faculty level, URM representation continues to worsen. Lett et al³¹ found that there is declining racial and ethnic representation in clinical academic medicine relative to US census data for 16 US medical specialties, including dermatology, with growing underrepresentation of Black and Hispanic faculty at the associate professor and full professor levels and underrepresentation in all faculty ranks. From 1970 to 2018, URM faculty in dermatology only increased from 4.8% to 7.4%, respectively. Non-URM female and male faculty members increased by 13.8 and 10.8 faculty members per year, respectively, while URM female and male faculty members increased by 1.2 and 0.8 faculty members per year, respectively.³²

Underrepresentation of minorities seen in dermatology faculty may result from clinical demands, minority taxation (defined as the extensive service requirements uniquely experienced by URM faculty to disproportionately serve as representatives on academic committees and to mentor URM students), and barriers to academic promotion, which are challenges uniquely encountered by URMs in academic dermatology.³³ Increased clinical demand may result from the fact that URM physicians are more likely to care for underserved populations, those of lower socioeconomic status, non-English–speaking patients, those on Medicaid, and those who are uninsured, which may impact renumeration. Minority tax experienced by URM faculty includes mentoring URM medical students, providing cultural expertise to departments and institutions, and participating in community service projects and outreach programs. Specifically, many institutional committees require the participation of a URM member, resulting in URM faculty members experiencing higher committee service burden. Many, if not all, of these responsibilities often are not compensated through salary or academic promotion.

A Call to Action

There are several steps that can be taken to create a pathway to dermatology that is inclusive, flexible, and supportive of URMs.

• Increase early exposure to dermatology in medical school. Early exposure and mentorship opportunities are associated with higher rates of students pursuing specialty field careers.³⁴ Increased early opportunities allow for URM students to consider and explore a career in dermatology; receive mentorship; and ensure that dermatology, including topics related to skin of color (SOC), is incorporated into their learning. The American Academy of Dermatology has contributed to these efforts by its presence at every national meeting of the Student National Medical Association and Latino Medical Student Association, as well as its involvement with Nth Dimensions, which offers various educational opportunities for URM medical students.

• Implement equitable grading and holistic review processes in medical school. Racial/ethnic differences in clinical grading and standardized test scores in medical school demonstrate why holistic review of dermatology residency applicants is needed and why other metrics such as USMLE scores and AΩA status should be de-emphasized or eliminated when evaluating candidates. To support equity, many medical schools have eliminated honors grading, and some schools have eliminated AΩA distinction.

• Increase diversity of dermatology residents and residency programs. Implicit bias training for a medical school admissions committee has been shown to increase diversity in medical school enrollment.³⁵ Whether implicit bias training and other diversity training may benefit dermatology residency selection must be examined, including study of unintended consequences, such as reduced diversity, increased microaggressions toward minority colleagues, and the illusion of fairness.^36-39 Increasing representation is not sufficient—creating inclusive residency training environments is a critical parallel aim. Prioritizing diversity in dermatology residency recruitment is imperative. Creating dermatology residency positions specifically for URM residents may be an important option, as done at the University of Pennsylvania (Philadelphia, Pennsylvania) and Duke University (Durham, North Carolina).

• Create effective programs for URM mentorship. Due to the competitive nature of dermatology residency, the need for mentors in dermatology is critically vital for URM medical students, especially those without a home dermatology program at their medical school. Further development of formal mentorship and pipeline programs is essential at both the local and national levels. Some national examples of these initiatives include diversity mentorship programs offered by the American Academy of Dermatology, Skin of Color Society, Women’s Dermatologic Society, and Student National Medical Association. Many institutional programs also offer invaluable opportunities, such as the summer research fellowship at the University of California, San Francisco (UCSF); visiting clerkship grants for URMs at the University of Pennsylvania (Philadelphia, Pennsylvania) and Johns Hopkins University (Baltimore, Maryland); and integrated programs, such as the Visiting Elective Scholarship Program at UCSF, which provides funding and faculty mentorship for URM students completing an away rotation at UCSF.

• Establish longitudinal skin-of-color curricula and increased opportunities for research. More robust SOC training may lead to an increasingly diverse workforce. It is important that medical student and dermatology resident and fellow education include training on SOC to ensure high-quality care to diverse patient populations, which also may enhance the knowledge of trainees, encourage clinical and research interest in this field, and reduce health care disparities. Increasing research opportunities and offering formalized longitudinal training in SOC as well as incorporating more diverse images in medical school education may foster greater interest in this field at a time when trainees are establishing their career interests. At present, there is considerable room for improvement. Nijhawan et al⁴⁰ surveyed 63 dermatology chief residents and 41 program directors and found only 14.3% and 14.6%, respectively, reported having an expert who conducts clinic specializing in SOC. Only 52.4% and 65.9% reported having didactic sessions or lectures focused on SOC diseases, and 30.2% and 12.2% reported having a dedicated rotation for residents to gain experience in SOC.⁴⁰ A more recent study showed that when faculty were asked to incorporate more SOC content into lectures, the most commonly identified barrier to implementation was a lack of SOC images.⁴¹ Additionally, there remains a paucity of published research on this topic, with SOC articles representing only 2.7% of the literature.⁴² These numbers demonstrate the continued need for a more inclusive and comprehensive curriculum in dermatology residency programs and more robust funding for SOC research.

• Recruit and support URM faculty. Increasing diversity in dermatology residency programs likely will increase the number of potential URMs pursuing additional fellowship training and academic dermatology with active career mentorship and support. In addition, promoting faculty retention by combatting the progressive loss of URMs at all faculty levels is paramount. Mentorship for URM physicians has been shown to play a key role in the decision to pursue academic medicine as well as academic productivity and job satisfaction.^43,44 The visibility, cultural competency, clinical work, academic productivity, and mentorship efforts that URM faculty provide are essential to enhancing patient care, teaching diverse groups of learners, and recruiting more diverse trainees. Protected time to participate in professional development opportunities has been shown to improve recruitment and retention of URM faculty and offer additional opportunities for junior faculty to find mentors.^35,36 Incentivizing clinical care of underserved populations also may augment financial stability for URM physicians who choose to care for these patients. Finally, diversity work and community service should be legitimized and count toward faculty promotion.

Conclusion

There are numerous factors that contribute to the leaky pipeline in dermatology (eFigure). Many challenges that are unique to the URM population disadvantage these students from entering medical school, applying to dermatology residency, matching into dermatology fellowships, pursuing and staying in faculty positions, and achieving faculty advancement into leadership positions. With each progressive step along this trajectory, there is less minority representation. All dermatologists, regardless of race/ethnicity, need to play an active role and must prioritize diversity, equity, and inclusion efforts at all levels of education and training for the betterment of the specialty.

Practice Gap

In accordance with World Health Organization guidelines on social distancing to limit transmission of SARS-CoV-2, dermatologists have relied on teledermatology (TD) to develop novel adaptations of traditional workflows, optimize patient care, and limit in-person appointments during the COVID-19 pandemic. Pandemic-induced physical and emotional stress were anticipated to increase the incidence of dermatologic diseases with psychologic triggers. 

The connection between hair loss and emotional stress is well documented for telogen effluvium and alopecia areata.^1,2 As anticipated, dermatology visits increased during the COVID-19 pandemic for the diagnosis of alopecia^1-4; a survey performed during the pandemic found that alopecia was one of the most common diagnoses dermatologists made through telehealth platforms.⁵

This article provides a practical guide for dermatology practitioners to efficiently and accurately assess alopecia by TD in all patients, with added considerations for skin of color patients.

Diagnostic Tools

The intersection of TD, as an effective mechanism for the diagnosis and treatment of dermatologic disorders, and the increase in alopecia observed during the COVID-19 pandemic prompted us to develop a workflow for conducting virtual scalp examinations. Seven dermatologists (A.M., A.A., O.A., N.E., V.C., C.M.B., S.C.T.) who are experts in hair disorders contributed to developing workflows to optimize the assessment of alopecia through a virtual scalp examination, with an emphasis on patients of color. These experts completed a 7-question survey (Table) detailing their approach to the virtual scalp examination. One author (B.N.W.) served as an independent reviewer and collated responses into the following workflows.

Telemedicine Previsit Workflow

Components of the previsit workflow include:

• Instruct patients to provide all laboratory values and biopsy reports before the appointment.

• Test for a stable Wi-Fi connection using a speed test (available at https://www.speedtest.net/). A speed of 10 megabits/second or more is required for high-quality video via TD.⁶

• Provide a handout illustrating the required photographs of the anterior hairline; the mid scalp, including vertex, bilateral parietal, and occipital scalp; and posterior hairline. Photographs should be uploaded 2 hours before the visit. Figures 1 and 2 are examples of photographs that should be requested.

• Request images with 2 or 3 different angles of the area of the scalp with the greatest involvement to help appreciate primary and secondary characteristics.

• Encourage patients to present with clean, recently shampooed, dried, and detangled natural hair, unless they have an itchy or flaky scalp.

• For concerns of scalp, hairline, eyebrow, or facial flaking and scaling, instruct the patient to avoid applying a moisturizer before the visit.

• Instruct the patient to remove false eyelashes, eyelash extensions, eyebrow pencil, hair camouflage, hair accessories, braids, extensions, weaves, twists, and other hairstyles so that the hair can be maneuvered to expose the scalp surface.

• Instruct the patient to have a comb, pic, or brush, or more than one of these implements, available during the visit.

Telemedicine Visit Workflow

Components of the visit workflow include:

• If a stable Wi-Fi connection cannot be established, switch to an audio-only visit to collect a pertinent history. Advise the patient that in-person follow-up must be scheduled.

• Confirm that (1) the patient is in a private setting where the scalp can be viewed and (2) lighting is positioned in front of the patient.

• Ensure that the patient’s hairline, full face, eyebrows, and eyelashes and, upon request, the vertex and posterior scalp, are completely visible.

• Initiate the virtual scalp examination by instructing the patient how to perform a hair pull test. Then, examine the pattern and distribution of hair loss alongside supplemental photographs.

• Instruct the patient to apply pressure with the fingertips throughout the scalp to help localize tenderness, which, in combination with the pattern of hair loss observed, might inform the diagnosis.

• Instruct the patient to scan the scalp with the fingertips for “bumps” to locate papules, pustules, and keloidal scars.

Diagnostic Pearls

Distribution of Alopecia—The experts noted that the pattern, distribution, and location of hair loss determined from the telemedicine alopecia assessment provided important clues to distinguish the type of alopecia.

Diagnostic clues for diffuse or generalized alopecia include:

• Either of these findings might be indicative of telogen effluvium or acquired trichorrhexis nodosa. Results of the hair pull test can help distinguish between these diagnoses.

• Recent stressful life events along with the presence of telogen hairs extracted during a hair pull test support the diagnosis of telogen effluvium.

• A history of external stress on the hair—thermal, traction, or chemical—along with broken hair shafts following the hair pull test support the diagnosis of acquired trichorrhexis nodosa.

Diagnostic clues for focal or patchy alopecia include:

• Alopecia areata generally presents as focal hair loss in an annular distribution; pruritus, erythema, and scale are absent.

• Seborrheic dermatitis can present as pruritic erythematous patches with scale distributed on the scalp and, in some cases, in the eyebrows, nasolabial folds, or paranasal skin.⁷ Some skin of color patients present with petaloid seborrheic dermatitis—pink or hypopigmented polycyclic coalescing rings with minimal scale.^7,8

• Discoid lupus erythematosus, similar to seborrheic dermatitis, might present as pruritic, scaly, hypopigmented patches. However, in the experience of the experts, a more common presentation is tender erythematous patches of hair loss with central hypopigmentation and surrounding hyperpigmentation.

Diagnostic clues for vertex and mid scalp alopecia include:

• Androgenetic alopecia typically presents as a reduction of terminal hair density in the vertex and mid scalp regions (with widening through the midline part) and fine hair along the anterior hairline.⁹ Signs of concomitant hyperandrogenism, including facial hirsutism, acne, and obesity, might be observed.¹⁰

• Central centrifugal cicatricial alopecia typically affects the vertex and mid scalp with a shiny scalp appearance and follicular dropout.

Diagnostic clues for frontotemporal alopecia include:

• Frontal fibrosing alopecia (FFA) often presents with spared single terminal hairs (lonely hair sign).

• Traction alopecia commonly presents with the fringe hair sign.

Scalp Symptoms—The experts noted that the presence of symptoms (eg, pain, tenderness, pruritus) in conjunction with the pattern of hair loss might support the diagnosis of an inflammatory scarring alopecia.

When do symptoms raise suspicion of central centrifugal cicatricial alopecia?

• Suspected in the setting of vertex alopecia associated with tenderness, pain, or itching.

When do symptoms raise suspicion of FFA?

• Suspected when patients experience frontotemporal tenderness, pain, or burning associated with alopecia.

• The skin hue of the affected area might be lighter in color than, and contrast with, the darker hue of the photoaged upper forehead.¹¹

• The lonely hair sign can aid in diagnosing FFA and distinguish it from the fringe sign of traction alopecia.

• Concurrent madarosis, flesh-colored papules on the cheeks, or lichen planus pigmentosus identified by visual inspection of the face confirms the diagnosis.^9,12 Madarosis of the eyebrow was frequently cited by the experts as an associated symptom of FFA.

When do symptoms raise suspicion of lichen planopilaris?

• Suspected in the presence of pruritus, burning, tenderness, or pain associated with perifollicular erythema and scale in the setting of vertex and parietal alopecia.¹³

• Anagen hair release is observed during the hair pull test.^11,14• The experts cited flesh-colored papules and lichen planus pigmentosus as frequently associated symptoms of lichen planopilaris.

Practice Implications

There are limitations to a virtual scalp examination—the inability to perform a scalp biopsy or administer certain treatments—but the consensus of the expert panel is that an initial alopecia assessment can be completed successfully utilizing TD. Although TD is not a replacement for an in-person dermatology visit, this technology has allowed for the diagnosis, treatment, and continuing care of many common dermatologic conditions without the patient needing to travel to the office.⁵

With the increased frequency of hair loss concerns documented over the last year and more patients seeking TD, it is imperative that dermatologists feel confident performing a virtual hair and scalp examination on all patients.^1,3,4

Practice Gap

In accordance with World Health Organization guidelines on social distancing to limit transmission of SARS-CoV-2, dermatologists have relied on teledermatology (TD) to develop novel adaptations of traditional workflows, optimize patient care, and limit in-person appointments during the COVID-19 pandemic. Pandemic-induced physical and emotional stress were anticipated to increase the incidence of dermatologic diseases with psychologic triggers. 

The connection between hair loss and emotional stress is well documented for telogen effluvium and alopecia areata.^1,2 As anticipated, dermatology visits increased during the COVID-19 pandemic for the diagnosis of alopecia^1-4; a survey performed during the pandemic found that alopecia was one of the most common diagnoses dermatologists made through telehealth platforms.⁵

This article provides a practical guide for dermatology practitioners to efficiently and accurately assess alopecia by TD in all patients, with added considerations for skin of color patients.

Diagnostic Tools

The intersection of TD, as an effective mechanism for the diagnosis and treatment of dermatologic disorders, and the increase in alopecia observed during the COVID-19 pandemic prompted us to develop a workflow for conducting virtual scalp examinations. Seven dermatologists (A.M., A.A., O.A., N.E., V.C., C.M.B., S.C.T.) who are experts in hair disorders contributed to developing workflows to optimize the assessment of alopecia through a virtual scalp examination, with an emphasis on patients of color. These experts completed a 7-question survey (Table) detailing their approach to the virtual scalp examination. One author (B.N.W.) served as an independent reviewer and collated responses into the following workflows.

Telemedicine Previsit Workflow

Components of the previsit workflow include:

• Instruct patients to provide all laboratory values and biopsy reports before the appointment.

• Test for a stable Wi-Fi connection using a speed test (available at https://www.speedtest.net/). A speed of 10 megabits/second or more is required for high-quality video via TD.⁶

• Provide a handout illustrating the required photographs of the anterior hairline; the mid scalp, including vertex, bilateral parietal, and occipital scalp; and posterior hairline. Photographs should be uploaded 2 hours before the visit. Figures 1 and 2 are examples of photographs that should be requested.

• Request images with 2 or 3 different angles of the area of the scalp with the greatest involvement to help appreciate primary and secondary characteristics.

• Encourage patients to present with clean, recently shampooed, dried, and detangled natural hair, unless they have an itchy or flaky scalp.

• For concerns of scalp, hairline, eyebrow, or facial flaking and scaling, instruct the patient to avoid applying a moisturizer before the visit.

• Instruct the patient to remove false eyelashes, eyelash extensions, eyebrow pencil, hair camouflage, hair accessories, braids, extensions, weaves, twists, and other hairstyles so that the hair can be maneuvered to expose the scalp surface.

• Instruct the patient to have a comb, pic, or brush, or more than one of these implements, available during the visit.

Telemedicine Visit Workflow

Components of the visit workflow include:

• If a stable Wi-Fi connection cannot be established, switch to an audio-only visit to collect a pertinent history. Advise the patient that in-person follow-up must be scheduled.

• Confirm that (1) the patient is in a private setting where the scalp can be viewed and (2) lighting is positioned in front of the patient.

• Ensure that the patient’s hairline, full face, eyebrows, and eyelashes and, upon request, the vertex and posterior scalp, are completely visible.

• Initiate the virtual scalp examination by instructing the patient how to perform a hair pull test. Then, examine the pattern and distribution of hair loss alongside supplemental photographs.

• Instruct the patient to apply pressure with the fingertips throughout the scalp to help localize tenderness, which, in combination with the pattern of hair loss observed, might inform the diagnosis.

• Instruct the patient to scan the scalp with the fingertips for “bumps” to locate papules, pustules, and keloidal scars.

Diagnostic Pearls

Distribution of Alopecia—The experts noted that the pattern, distribution, and location of hair loss determined from the telemedicine alopecia assessment provided important clues to distinguish the type of alopecia.

Diagnostic clues for diffuse or generalized alopecia include:

• Either of these findings might be indicative of telogen effluvium or acquired trichorrhexis nodosa. Results of the hair pull test can help distinguish between these diagnoses.

• Recent stressful life events along with the presence of telogen hairs extracted during a hair pull test support the diagnosis of telogen effluvium.

• A history of external stress on the hair—thermal, traction, or chemical—along with broken hair shafts following the hair pull test support the diagnosis of acquired trichorrhexis nodosa.

Diagnostic clues for focal or patchy alopecia include:

• Alopecia areata generally presents as focal hair loss in an annular distribution; pruritus, erythema, and scale are absent.

• Seborrheic dermatitis can present as pruritic erythematous patches with scale distributed on the scalp and, in some cases, in the eyebrows, nasolabial folds, or paranasal skin.⁷ Some skin of color patients present with petaloid seborrheic dermatitis—pink or hypopigmented polycyclic coalescing rings with minimal scale.^7,8

• Discoid lupus erythematosus, similar to seborrheic dermatitis, might present as pruritic, scaly, hypopigmented patches. However, in the experience of the experts, a more common presentation is tender erythematous patches of hair loss with central hypopigmentation and surrounding hyperpigmentation.

Diagnostic clues for vertex and mid scalp alopecia include:

• Androgenetic alopecia typically presents as a reduction of terminal hair density in the vertex and mid scalp regions (with widening through the midline part) and fine hair along the anterior hairline.⁹ Signs of concomitant hyperandrogenism, including facial hirsutism, acne, and obesity, might be observed.¹⁰

• Central centrifugal cicatricial alopecia typically affects the vertex and mid scalp with a shiny scalp appearance and follicular dropout.

Diagnostic clues for frontotemporal alopecia include:

• Frontal fibrosing alopecia (FFA) often presents with spared single terminal hairs (lonely hair sign).

• Traction alopecia commonly presents with the fringe hair sign.

Scalp Symptoms—The experts noted that the presence of symptoms (eg, pain, tenderness, pruritus) in conjunction with the pattern of hair loss might support the diagnosis of an inflammatory scarring alopecia.

When do symptoms raise suspicion of central centrifugal cicatricial alopecia?

• Suspected in the setting of vertex alopecia associated with tenderness, pain, or itching.

When do symptoms raise suspicion of FFA?

• Suspected when patients experience frontotemporal tenderness, pain, or burning associated with alopecia.

• The skin hue of the affected area might be lighter in color than, and contrast with, the darker hue of the photoaged upper forehead.¹¹

• The lonely hair sign can aid in diagnosing FFA and distinguish it from the fringe sign of traction alopecia.

• Concurrent madarosis, flesh-colored papules on the cheeks, or lichen planus pigmentosus identified by visual inspection of the face confirms the diagnosis.^9,12 Madarosis of the eyebrow was frequently cited by the experts as an associated symptom of FFA.

When do symptoms raise suspicion of lichen planopilaris?

• Suspected in the presence of pruritus, burning, tenderness, or pain associated with perifollicular erythema and scale in the setting of vertex and parietal alopecia.¹³

• Anagen hair release is observed during the hair pull test.^11,14• The experts cited flesh-colored papules and lichen planus pigmentosus as frequently associated symptoms of lichen planopilaris.

Practice Implications

There are limitations to a virtual scalp examination—the inability to perform a scalp biopsy or administer certain treatments—but the consensus of the expert panel is that an initial alopecia assessment can be completed successfully utilizing TD. Although TD is not a replacement for an in-person dermatology visit, this technology has allowed for the diagnosis, treatment, and continuing care of many common dermatologic conditions without the patient needing to travel to the office.⁵

With the increased frequency of hair loss concerns documented over the last year and more patients seeking TD, it is imperative that dermatologists feel confident performing a virtual hair and scalp examination on all patients.^1,3,4

Practice Gap

In accordance with World Health Organization guidelines on social distancing to limit transmission of SARS-CoV-2, dermatologists have relied on teledermatology (TD) to develop novel adaptations of traditional workflows, optimize patient care, and limit in-person appointments during the COVID-19 pandemic. Pandemic-induced physical and emotional stress were anticipated to increase the incidence of dermatologic diseases with psychologic triggers. 

The connection between hair loss and emotional stress is well documented for telogen effluvium and alopecia areata.^1,2 As anticipated, dermatology visits increased during the COVID-19 pandemic for the diagnosis of alopecia^1-4; a survey performed during the pandemic found that alopecia was one of the most common diagnoses dermatologists made through telehealth platforms.⁵

This article provides a practical guide for dermatology practitioners to efficiently and accurately assess alopecia by TD in all patients, with added considerations for skin of color patients.

Diagnostic Tools

The intersection of TD, as an effective mechanism for the diagnosis and treatment of dermatologic disorders, and the increase in alopecia observed during the COVID-19 pandemic prompted us to develop a workflow for conducting virtual scalp examinations. Seven dermatologists (A.M., A.A., O.A., N.E., V.C., C.M.B., S.C.T.) who are experts in hair disorders contributed to developing workflows to optimize the assessment of alopecia through a virtual scalp examination, with an emphasis on patients of color. These experts completed a 7-question survey (Table) detailing their approach to the virtual scalp examination. One author (B.N.W.) served as an independent reviewer and collated responses into the following workflows.

Telemedicine Previsit Workflow

Components of the previsit workflow include:

• Instruct patients to provide all laboratory values and biopsy reports before the appointment.

• Test for a stable Wi-Fi connection using a speed test (available at https://www.speedtest.net/). A speed of 10 megabits/second or more is required for high-quality video via TD.⁶

• Provide a handout illustrating the required photographs of the anterior hairline; the mid scalp, including vertex, bilateral parietal, and occipital scalp; and posterior hairline. Photographs should be uploaded 2 hours before the visit. Figures 1 and 2 are examples of photographs that should be requested.

• Request images with 2 or 3 different angles of the area of the scalp with the greatest involvement to help appreciate primary and secondary characteristics.

• Encourage patients to present with clean, recently shampooed, dried, and detangled natural hair, unless they have an itchy or flaky scalp.

• For concerns of scalp, hairline, eyebrow, or facial flaking and scaling, instruct the patient to avoid applying a moisturizer before the visit.

• Instruct the patient to remove false eyelashes, eyelash extensions, eyebrow pencil, hair camouflage, hair accessories, braids, extensions, weaves, twists, and other hairstyles so that the hair can be maneuvered to expose the scalp surface.

• Instruct the patient to have a comb, pic, or brush, or more than one of these implements, available during the visit.

Telemedicine Visit Workflow

Components of the visit workflow include:

• If a stable Wi-Fi connection cannot be established, switch to an audio-only visit to collect a pertinent history. Advise the patient that in-person follow-up must be scheduled.

• Confirm that (1) the patient is in a private setting where the scalp can be viewed and (2) lighting is positioned in front of the patient.

• Ensure that the patient’s hairline, full face, eyebrows, and eyelashes and, upon request, the vertex and posterior scalp, are completely visible.

• Initiate the virtual scalp examination by instructing the patient how to perform a hair pull test. Then, examine the pattern and distribution of hair loss alongside supplemental photographs.

• Instruct the patient to apply pressure with the fingertips throughout the scalp to help localize tenderness, which, in combination with the pattern of hair loss observed, might inform the diagnosis.

• Instruct the patient to scan the scalp with the fingertips for “bumps” to locate papules, pustules, and keloidal scars.

Diagnostic Pearls

Distribution of Alopecia—The experts noted that the pattern, distribution, and location of hair loss determined from the telemedicine alopecia assessment provided important clues to distinguish the type of alopecia.

Diagnostic clues for diffuse or generalized alopecia include:

• Either of these findings might be indicative of telogen effluvium or acquired trichorrhexis nodosa. Results of the hair pull test can help distinguish between these diagnoses.

• Recent stressful life events along with the presence of telogen hairs extracted during a hair pull test support the diagnosis of telogen effluvium.

• A history of external stress on the hair—thermal, traction, or chemical—along with broken hair shafts following the hair pull test support the diagnosis of acquired trichorrhexis nodosa.

Diagnostic clues for focal or patchy alopecia include:

• Alopecia areata generally presents as focal hair loss in an annular distribution; pruritus, erythema, and scale are absent.

• Seborrheic dermatitis can present as pruritic erythematous patches with scale distributed on the scalp and, in some cases, in the eyebrows, nasolabial folds, or paranasal skin.⁷ Some skin of color patients present with petaloid seborrheic dermatitis—pink or hypopigmented polycyclic coalescing rings with minimal scale.^7,8

• Discoid lupus erythematosus, similar to seborrheic dermatitis, might present as pruritic, scaly, hypopigmented patches. However, in the experience of the experts, a more common presentation is tender erythematous patches of hair loss with central hypopigmentation and surrounding hyperpigmentation.

Diagnostic clues for vertex and mid scalp alopecia include:

• Androgenetic alopecia typically presents as a reduction of terminal hair density in the vertex and mid scalp regions (with widening through the midline part) and fine hair along the anterior hairline.⁹ Signs of concomitant hyperandrogenism, including facial hirsutism, acne, and obesity, might be observed.¹⁰

• Central centrifugal cicatricial alopecia typically affects the vertex and mid scalp with a shiny scalp appearance and follicular dropout.

Diagnostic clues for frontotemporal alopecia include:

• Frontal fibrosing alopecia (FFA) often presents with spared single terminal hairs (lonely hair sign).

• Traction alopecia commonly presents with the fringe hair sign.

Scalp Symptoms—The experts noted that the presence of symptoms (eg, pain, tenderness, pruritus) in conjunction with the pattern of hair loss might support the diagnosis of an inflammatory scarring alopecia.

When do symptoms raise suspicion of central centrifugal cicatricial alopecia?

• Suspected in the setting of vertex alopecia associated with tenderness, pain, or itching.

When do symptoms raise suspicion of FFA?

• Suspected when patients experience frontotemporal tenderness, pain, or burning associated with alopecia.

• The skin hue of the affected area might be lighter in color than, and contrast with, the darker hue of the photoaged upper forehead.¹¹

• The lonely hair sign can aid in diagnosing FFA and distinguish it from the fringe sign of traction alopecia.

• Concurrent madarosis, flesh-colored papules on the cheeks, or lichen planus pigmentosus identified by visual inspection of the face confirms the diagnosis.^9,12 Madarosis of the eyebrow was frequently cited by the experts as an associated symptom of FFA.

When do symptoms raise suspicion of lichen planopilaris?

• Suspected in the presence of pruritus, burning, tenderness, or pain associated with perifollicular erythema and scale in the setting of vertex and parietal alopecia.¹³

• Anagen hair release is observed during the hair pull test.^11,14• The experts cited flesh-colored papules and lichen planus pigmentosus as frequently associated symptoms of lichen planopilaris.

Practice Implications

There are limitations to a virtual scalp examination—the inability to perform a scalp biopsy or administer certain treatments—but the consensus of the expert panel is that an initial alopecia assessment can be completed successfully utilizing TD. Although TD is not a replacement for an in-person dermatology visit, this technology has allowed for the diagnosis, treatment, and continuing care of many common dermatologic conditions without the patient needing to travel to the office.⁵

With the increased frequency of hair loss concerns documented over the last year and more patients seeking TD, it is imperative that dermatologists feel confident performing a virtual hair and scalp examination on all patients.^1,3,4

To the Editor:

Securing a dermatology residency position is extraordinarily competitive. The match rate for US allopathic seniors for dermatology is 84.7%, among the lowest of all medical specialties. Matched dermatology applicants boast a mean US Medical Licensing Examination (USMLE) Step 1 score of 248, the second highest of all specialties.¹ To gain an edge, applicants are faced with decisions regarding pursuit of dedicated research time and additional professional degrees.

We conducted a cross-sectional study to determine how many dermatology residency applicants pursue additional years of training and how this decision relates to USMLE scores and other metrics. This study was approved by the University of Michigan institutional review board. Using Electronic Residency Application Service applicant data, all applicants to the University of Michigan Medical School (Ann Arbor, Michigan) dermatology residency program for the 2018-2019 application cycle were included.

Analysis of variance was performed to determine differences in mean USMLE Step 1 scores, Step 2 Clinical Knowledge scores, and number of research experiences (eg, presentations, publications) between groups. A 2-tailed z test of independent samples was performed for individual pairwise subgroup analyses.

There were 608 (377 female, 231 male; mean age, 27.9 years) applicants from 199 different medical schools; 550 graduated with an MD degree, 40 with a DO degree, and 18 were international medical graduates (IMGs)(eg, MBBS, MBBCh, BAO, MBChB). One hundred eighty-four applicants (30.2%) pursued either a second professional degree or a dedicated research period lasting at least 12 months. Twenty-eight applicants (4.6%) obtained a master’s degree, 21 (3.5%) obtained a doctorate, and 135 (22.2%) pursued dedicated research.

Of the 40 DO applicants, 1 (2.5%) pursued dedicated research time; 0 (zero) completed a dual degree. None (zero) of the 18 IMGs pursued a dual degree or dedicated research time. When the scores of applicants who pursued additional training and the scores of applicants who did not were compared, neither mean USMLE Step 1 scores nor mean USMLE Step 2 Clinical Knowledge scores were statistically different (P=.31 and P=.44, respectively). Applicants who completed medical school in 4 years had fewer research experiences (mean [SD] experiences, 13.9 [13.2]) than students with a master’s degree (18.5 [8.4]), doctorate (24.5 [17.5]), or dedicated research time (23.9 [14.9])(P<.001).

Utilizing US News & World Report rankings (2019 Best Medical Schools: Research), we determined that 146 applicants (24.0%) attended a top 25 medical school in 2019.² Of those 146 applicants, 77 (52.7%) pursued additional training through dedicated research or a second professional degree. Only 107 of the 462 applicants (23.2%) from medical schools that were not in the top 25 as determined by the US News & World Report pursued additional training (P<.0001)(Figure).

There is sentiment among applicants that a weaker dermatology residency application can be bolstered through a dedicated research year or a second professional degree. Whether this additional training has an impact on an applicant’s chances of matching is unclear and requires further investigation. Our data showed that applicants from the top 25 medical schools were more likely to pursue additional training than graduates at other institutions. These highly ranked academic institutions might encourage students to pursue a dual degree or research fellowship. In addition, year-long research opportunities might be more available through top medical schools; these schools might be more likely to offer dual-degree programs or provide funding to support student research opportunities.

It is important to comment on the potential importance of funding to support research years; the unpaid nature of many research fellowships in dermatology tends to favor applicants from a higher socioeconomic background. In that respect, the pervasive trend of encouraging research years in dermatology might widen already apparent disparities in our field, likely impacting underrepresented minorities disproportionately.³ Importantly, students with an MD degree represent nearly all applicants who completed a dual degree or dedicated research time. This might be due to fewer opportunities available to IMGs and DO students or secondary to incentivization by MD institutions.

Our data also suggest that students who pursue additional training have academic achievement metrics similar to those who do not. Additional training might increase medical students’ debt burden, thus catering to more affluent applicants, which, in turn, might have an impact on the diversity of the dermatology residency applicant pool.

Our data come from a single institution during a single application cycle, comprising 608 applicants. Nationwide, there were 701 dermatology residency applicants for the 2018-2019 application cycle; our pool therefore represents most (86.7%) but not all applicants.

We decided to use the US News & World Report 2019 rankings to identify top medical schools. Although this ranking system is imperfect and inherently subjective, it is widely utilized by prospective applicants and administrative faculty; we deemed it the best ranking that we could utilize to identify top medical schools. Because the University of Michigan Medical School was in the top 25 of Best Medical Schools: Research, according to the US News & World Report 2019 rankings, our applicant pool might be skewed to applicants interested in a more academic, research-focused residency program.

Our study revealed that 30% (n=184) of dermatology residency applicants pursued a second professional degree or dedicated research time. There was no difference in UMLE Step 1 and Step 2 scores for those who pursued additional training compared to those who did not.

To the Editor:

Securing a dermatology residency position is extraordinarily competitive. The match rate for US allopathic seniors for dermatology is 84.7%, among the lowest of all medical specialties. Matched dermatology applicants boast a mean US Medical Licensing Examination (USMLE) Step 1 score of 248, the second highest of all specialties.¹ To gain an edge, applicants are faced with decisions regarding pursuit of dedicated research time and additional professional degrees.

We conducted a cross-sectional study to determine how many dermatology residency applicants pursue additional years of training and how this decision relates to USMLE scores and other metrics. This study was approved by the University of Michigan institutional review board. Using Electronic Residency Application Service applicant data, all applicants to the University of Michigan Medical School (Ann Arbor, Michigan) dermatology residency program for the 2018-2019 application cycle were included.

Analysis of variance was performed to determine differences in mean USMLE Step 1 scores, Step 2 Clinical Knowledge scores, and number of research experiences (eg, presentations, publications) between groups. A 2-tailed z test of independent samples was performed for individual pairwise subgroup analyses.

There were 608 (377 female, 231 male; mean age, 27.9 years) applicants from 199 different medical schools; 550 graduated with an MD degree, 40 with a DO degree, and 18 were international medical graduates (IMGs)(eg, MBBS, MBBCh, BAO, MBChB). One hundred eighty-four applicants (30.2%) pursued either a second professional degree or a dedicated research period lasting at least 12 months. Twenty-eight applicants (4.6%) obtained a master’s degree, 21 (3.5%) obtained a doctorate, and 135 (22.2%) pursued dedicated research.

Of the 40 DO applicants, 1 (2.5%) pursued dedicated research time; 0 (zero) completed a dual degree. None (zero) of the 18 IMGs pursued a dual degree or dedicated research time. When the scores of applicants who pursued additional training and the scores of applicants who did not were compared, neither mean USMLE Step 1 scores nor mean USMLE Step 2 Clinical Knowledge scores were statistically different (P=.31 and P=.44, respectively). Applicants who completed medical school in 4 years had fewer research experiences (mean [SD] experiences, 13.9 [13.2]) than students with a master’s degree (18.5 [8.4]), doctorate (24.5 [17.5]), or dedicated research time (23.9 [14.9])(P<.001).

Utilizing US News & World Report rankings (2019 Best Medical Schools: Research), we determined that 146 applicants (24.0%) attended a top 25 medical school in 2019.² Of those 146 applicants, 77 (52.7%) pursued additional training through dedicated research or a second professional degree. Only 107 of the 462 applicants (23.2%) from medical schools that were not in the top 25 as determined by the US News & World Report pursued additional training (P<.0001)(Figure).

There is sentiment among applicants that a weaker dermatology residency application can be bolstered through a dedicated research year or a second professional degree. Whether this additional training has an impact on an applicant’s chances of matching is unclear and requires further investigation. Our data showed that applicants from the top 25 medical schools were more likely to pursue additional training than graduates at other institutions. These highly ranked academic institutions might encourage students to pursue a dual degree or research fellowship. In addition, year-long research opportunities might be more available through top medical schools; these schools might be more likely to offer dual-degree programs or provide funding to support student research opportunities.

It is important to comment on the potential importance of funding to support research years; the unpaid nature of many research fellowships in dermatology tends to favor applicants from a higher socioeconomic background. In that respect, the pervasive trend of encouraging research years in dermatology might widen already apparent disparities in our field, likely impacting underrepresented minorities disproportionately.³ Importantly, students with an MD degree represent nearly all applicants who completed a dual degree or dedicated research time. This might be due to fewer opportunities available to IMGs and DO students or secondary to incentivization by MD institutions.

Our data also suggest that students who pursue additional training have academic achievement metrics similar to those who do not. Additional training might increase medical students’ debt burden, thus catering to more affluent applicants, which, in turn, might have an impact on the diversity of the dermatology residency applicant pool.

Our data come from a single institution during a single application cycle, comprising 608 applicants. Nationwide, there were 701 dermatology residency applicants for the 2018-2019 application cycle; our pool therefore represents most (86.7%) but not all applicants.

We decided to use the US News & World Report 2019 rankings to identify top medical schools. Although this ranking system is imperfect and inherently subjective, it is widely utilized by prospective applicants and administrative faculty; we deemed it the best ranking that we could utilize to identify top medical schools. Because the University of Michigan Medical School was in the top 25 of Best Medical Schools: Research, according to the US News & World Report 2019 rankings, our applicant pool might be skewed to applicants interested in a more academic, research-focused residency program.

Our study revealed that 30% (n=184) of dermatology residency applicants pursued a second professional degree or dedicated research time. There was no difference in UMLE Step 1 and Step 2 scores for those who pursued additional training compared to those who did not.

To the Editor:

Securing a dermatology residency position is extraordinarily competitive. The match rate for US allopathic seniors for dermatology is 84.7%, among the lowest of all medical specialties. Matched dermatology applicants boast a mean US Medical Licensing Examination (USMLE) Step 1 score of 248, the second highest of all specialties.¹ To gain an edge, applicants are faced with decisions regarding pursuit of dedicated research time and additional professional degrees.

We conducted a cross-sectional study to determine how many dermatology residency applicants pursue additional years of training and how this decision relates to USMLE scores and other metrics. This study was approved by the University of Michigan institutional review board. Using Electronic Residency Application Service applicant data, all applicants to the University of Michigan Medical School (Ann Arbor, Michigan) dermatology residency program for the 2018-2019 application cycle were included.

Analysis of variance was performed to determine differences in mean USMLE Step 1 scores, Step 2 Clinical Knowledge scores, and number of research experiences (eg, presentations, publications) between groups. A 2-tailed z test of independent samples was performed for individual pairwise subgroup analyses.

There were 608 (377 female, 231 male; mean age, 27.9 years) applicants from 199 different medical schools; 550 graduated with an MD degree, 40 with a DO degree, and 18 were international medical graduates (IMGs)(eg, MBBS, MBBCh, BAO, MBChB). One hundred eighty-four applicants (30.2%) pursued either a second professional degree or a dedicated research period lasting at least 12 months. Twenty-eight applicants (4.6%) obtained a master’s degree, 21 (3.5%) obtained a doctorate, and 135 (22.2%) pursued dedicated research.

Of the 40 DO applicants, 1 (2.5%) pursued dedicated research time; 0 (zero) completed a dual degree. None (zero) of the 18 IMGs pursued a dual degree or dedicated research time. When the scores of applicants who pursued additional training and the scores of applicants who did not were compared, neither mean USMLE Step 1 scores nor mean USMLE Step 2 Clinical Knowledge scores were statistically different (P=.31 and P=.44, respectively). Applicants who completed medical school in 4 years had fewer research experiences (mean [SD] experiences, 13.9 [13.2]) than students with a master’s degree (18.5 [8.4]), doctorate (24.5 [17.5]), or dedicated research time (23.9 [14.9])(P<.001).

Utilizing US News & World Report rankings (2019 Best Medical Schools: Research), we determined that 146 applicants (24.0%) attended a top 25 medical school in 2019.² Of those 146 applicants, 77 (52.7%) pursued additional training through dedicated research or a second professional degree. Only 107 of the 462 applicants (23.2%) from medical schools that were not in the top 25 as determined by the US News & World Report pursued additional training (P<.0001)(Figure).

There is sentiment among applicants that a weaker dermatology residency application can be bolstered through a dedicated research year or a second professional degree. Whether this additional training has an impact on an applicant’s chances of matching is unclear and requires further investigation. Our data showed that applicants from the top 25 medical schools were more likely to pursue additional training than graduates at other institutions. These highly ranked academic institutions might encourage students to pursue a dual degree or research fellowship. In addition, year-long research opportunities might be more available through top medical schools; these schools might be more likely to offer dual-degree programs or provide funding to support student research opportunities.

It is important to comment on the potential importance of funding to support research years; the unpaid nature of many research fellowships in dermatology tends to favor applicants from a higher socioeconomic background. In that respect, the pervasive trend of encouraging research years in dermatology might widen already apparent disparities in our field, likely impacting underrepresented minorities disproportionately.³ Importantly, students with an MD degree represent nearly all applicants who completed a dual degree or dedicated research time. This might be due to fewer opportunities available to IMGs and DO students or secondary to incentivization by MD institutions.

Our data also suggest that students who pursue additional training have academic achievement metrics similar to those who do not. Additional training might increase medical students’ debt burden, thus catering to more affluent applicants, which, in turn, might have an impact on the diversity of the dermatology residency applicant pool.

Our data come from a single institution during a single application cycle, comprising 608 applicants. Nationwide, there were 701 dermatology residency applicants for the 2018-2019 application cycle; our pool therefore represents most (86.7%) but not all applicants.

We decided to use the US News & World Report 2019 rankings to identify top medical schools. Although this ranking system is imperfect and inherently subjective, it is widely utilized by prospective applicants and administrative faculty; we deemed it the best ranking that we could utilize to identify top medical schools. Because the University of Michigan Medical School was in the top 25 of Best Medical Schools: Research, according to the US News & World Report 2019 rankings, our applicant pool might be skewed to applicants interested in a more academic, research-focused residency program.

Our study revealed that 30% (n=184) of dermatology residency applicants pursued a second professional degree or dedicated research time. There was no difference in UMLE Step 1 and Step 2 scores for those who pursued additional training compared to those who did not.

Federal officials will allow some flexibility in meeting new requirements on covering the costs of clinical trials for people enrolled in Medicaid, seeking to accommodate states where legislatures will not meet in time to make needed changes in rules.

Congress in 2020 ordered U.S. states to have their Medicaid programs cover expenses related to participation in certain clinical trials, a move that was hailed by the American Society of Clinical Oncology (ASCO) and other groups as a boost to trials as well as to patients with serious illness who have lower incomes.

The mandate went into effect on Jan. 1, but the Centers for Medicare & Medicaid Services will allow accommodations in terms of implementation time for states that have not yet been able to make needed legislative changes, Daniel Tsai, deputy administrator and director of the Center for Medicaid and CHIP Services, wrote in a Dec. 7 letter. Mr. Tsai’s letter doesn’t mention specific states. The CMS did not immediately respond to a request seeking information on the states expected to apply for waivers.

Medicaid has in recent years been a rare large U.S. insurance program that does not cover the costs of clinical trials. The Affordable Care Act of 2010 mandated this coverage for people in private insurance plans. The federal government in 2000 decided that Medicare would do so.

‘A hidden opportunity’

A perspective article last May in the New England Journal of Medicine referred to the new Medicaid mandate on clinical trials as a “hidden opportunity,” referring to its genesis as an add-on in a massive federal spending package enacted in December 2020.

In the article, Samuel U. Takvorian, MD, MSHP, of the University of Pennsylvania, Philadelphia, and coauthors noted that rates of participation in clinical trials remain low for racial and ethnic minority groups, due in part to the lack of Medicaid coverage.

“For example, non-Hispanic White patients are nearly twice as likely as Black patients and three times as likely as Hispanic patients to enroll in cancer clinical trials – a gap that has widened over time,” Dr. Takvorian and coauthors wrote. “Inequities in enrollment have also manifested during the COVID-19 pandemic, which has disproportionately affected non-White patients, without their commensurate representation in trials of COVID-19 therapeutics.”

In October, researchers from the Arthur G. James Cancer Hospital and Ohio State University, Columbus, published results of a retrospective study of patients with stage I-IV pancreatic cancer that also found inequities in enrollment. Mariam F. Eskander, MD, MPH, and coauthors reported what they found by examining records for 1,127 patients (0.4%) enrolled in clinical trials and 301,340 (99.6%) who did not enroll. They found that enrollment in trials increased over the study period, but not for Black patients or patients on Medicaid.

In an interview, Dr. Eskander said the new Medicaid policy will remove a major obstacle to participation in clinical trials. An oncologist, Dr. Eskander said she is looking forward to being able to help more of her patients get access to experimental medicines and treatments.

But that may not be enough to draw more people with low incomes into these studies, said Dr. Eskander, who is now at Rutgers Cancer Institute of New Jersey in New Brunswick. She urges greater use of patient navigators to help people on Medicaid understand the resources available to them, as well as broad use of Medicaid’s nonemergency medical transportation (NEMT) benefit.

“Some patients will be offered clinical trial enrollment and some will accept, but I really worry about the challenges low-income people face with things like transportation and getting time off work,” she said.

A version of this article first appeared on Medscape.com.

Federal officials will allow some flexibility in meeting new requirements on covering the costs of clinical trials for people enrolled in Medicaid, seeking to accommodate states where legislatures will not meet in time to make needed changes in rules.

Congress in 2020 ordered U.S. states to have their Medicaid programs cover expenses related to participation in certain clinical trials, a move that was hailed by the American Society of Clinical Oncology (ASCO) and other groups as a boost to trials as well as to patients with serious illness who have lower incomes.

The mandate went into effect on Jan. 1, but the Centers for Medicare & Medicaid Services will allow accommodations in terms of implementation time for states that have not yet been able to make needed legislative changes, Daniel Tsai, deputy administrator and director of the Center for Medicaid and CHIP Services, wrote in a Dec. 7 letter. Mr. Tsai’s letter doesn’t mention specific states. The CMS did not immediately respond to a request seeking information on the states expected to apply for waivers.

Medicaid has in recent years been a rare large U.S. insurance program that does not cover the costs of clinical trials. The Affordable Care Act of 2010 mandated this coverage for people in private insurance plans. The federal government in 2000 decided that Medicare would do so.

‘A hidden opportunity’

A perspective article last May in the New England Journal of Medicine referred to the new Medicaid mandate on clinical trials as a “hidden opportunity,” referring to its genesis as an add-on in a massive federal spending package enacted in December 2020.

In the article, Samuel U. Takvorian, MD, MSHP, of the University of Pennsylvania, Philadelphia, and coauthors noted that rates of participation in clinical trials remain low for racial and ethnic minority groups, due in part to the lack of Medicaid coverage.

“For example, non-Hispanic White patients are nearly twice as likely as Black patients and three times as likely as Hispanic patients to enroll in cancer clinical trials – a gap that has widened over time,” Dr. Takvorian and coauthors wrote. “Inequities in enrollment have also manifested during the COVID-19 pandemic, which has disproportionately affected non-White patients, without their commensurate representation in trials of COVID-19 therapeutics.”

In October, researchers from the Arthur G. James Cancer Hospital and Ohio State University, Columbus, published results of a retrospective study of patients with stage I-IV pancreatic cancer that also found inequities in enrollment. Mariam F. Eskander, MD, MPH, and coauthors reported what they found by examining records for 1,127 patients (0.4%) enrolled in clinical trials and 301,340 (99.6%) who did not enroll. They found that enrollment in trials increased over the study period, but not for Black patients or patients on Medicaid.

In an interview, Dr. Eskander said the new Medicaid policy will remove a major obstacle to participation in clinical trials. An oncologist, Dr. Eskander said she is looking forward to being able to help more of her patients get access to experimental medicines and treatments.

But that may not be enough to draw more people with low incomes into these studies, said Dr. Eskander, who is now at Rutgers Cancer Institute of New Jersey in New Brunswick. She urges greater use of patient navigators to help people on Medicaid understand the resources available to them, as well as broad use of Medicaid’s nonemergency medical transportation (NEMT) benefit.

“Some patients will be offered clinical trial enrollment and some will accept, but I really worry about the challenges low-income people face with things like transportation and getting time off work,” she said.

A version of this article first appeared on Medscape.com.

Federal officials will allow some flexibility in meeting new requirements on covering the costs of clinical trials for people enrolled in Medicaid, seeking to accommodate states where legislatures will not meet in time to make needed changes in rules.

Congress in 2020 ordered U.S. states to have their Medicaid programs cover expenses related to participation in certain clinical trials, a move that was hailed by the American Society of Clinical Oncology (ASCO) and other groups as a boost to trials as well as to patients with serious illness who have lower incomes.

The mandate went into effect on Jan. 1, but the Centers for Medicare & Medicaid Services will allow accommodations in terms of implementation time for states that have not yet been able to make needed legislative changes, Daniel Tsai, deputy administrator and director of the Center for Medicaid and CHIP Services, wrote in a Dec. 7 letter. Mr. Tsai’s letter doesn’t mention specific states. The CMS did not immediately respond to a request seeking information on the states expected to apply for waivers.

Medicaid has in recent years been a rare large U.S. insurance program that does not cover the costs of clinical trials. The Affordable Care Act of 2010 mandated this coverage for people in private insurance plans. The federal government in 2000 decided that Medicare would do so.

‘A hidden opportunity’

A perspective article last May in the New England Journal of Medicine referred to the new Medicaid mandate on clinical trials as a “hidden opportunity,” referring to its genesis as an add-on in a massive federal spending package enacted in December 2020.

In the article, Samuel U. Takvorian, MD, MSHP, of the University of Pennsylvania, Philadelphia, and coauthors noted that rates of participation in clinical trials remain low for racial and ethnic minority groups, due in part to the lack of Medicaid coverage.

“For example, non-Hispanic White patients are nearly twice as likely as Black patients and three times as likely as Hispanic patients to enroll in cancer clinical trials – a gap that has widened over time,” Dr. Takvorian and coauthors wrote. “Inequities in enrollment have also manifested during the COVID-19 pandemic, which has disproportionately affected non-White patients, without their commensurate representation in trials of COVID-19 therapeutics.”

In October, researchers from the Arthur G. James Cancer Hospital and Ohio State University, Columbus, published results of a retrospective study of patients with stage I-IV pancreatic cancer that also found inequities in enrollment. Mariam F. Eskander, MD, MPH, and coauthors reported what they found by examining records for 1,127 patients (0.4%) enrolled in clinical trials and 301,340 (99.6%) who did not enroll. They found that enrollment in trials increased over the study period, but not for Black patients or patients on Medicaid.

In an interview, Dr. Eskander said the new Medicaid policy will remove a major obstacle to participation in clinical trials. An oncologist, Dr. Eskander said she is looking forward to being able to help more of her patients get access to experimental medicines and treatments.

But that may not be enough to draw more people with low incomes into these studies, said Dr. Eskander, who is now at Rutgers Cancer Institute of New Jersey in New Brunswick. She urges greater use of patient navigators to help people on Medicaid understand the resources available to them, as well as broad use of Medicaid’s nonemergency medical transportation (NEMT) benefit.

“Some patients will be offered clinical trial enrollment and some will accept, but I really worry about the challenges low-income people face with things like transportation and getting time off work,” she said.

A version of this article first appeared on Medscape.com.

Women with physical, intellectual, and sensory disabilities had higher risk for almost all pregnancy complications, obstetric interventions, and adverse outcomes, including severe maternal morbidity (SMM) and mortality compared to women without disabilities, according to an analysis of a large, retrospective cohort.

The findings, published in JAMA Network Open (2021;4[12]:e2138414 doi: 10.1001/jamanetworkopen.2021.38414), “may be a direct reflection of the challenges women with all types of disabilities face when accessing and receiving care, which is likely compounded by poorer preconception health,” suggested lead author Jessica L. Gleason, PhD, MPH, and co-authors, all from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Md.

“Women with disabilities have long been ignored in obstetric research and clinical practice,” added Hilary K. Brown, PhD, from the University of Toronto, in an accompanying editorial. “Inclusion of disability indicators needs to be the norm – not the exception – in health administrative data so that these disparities can be regularly tracked and addressed.”

The investigators used data from the Consortium on Safe Labor (CSL), a retrospective cohort of deliveries from 12 U.S. clinical centers between Jan. 2002 and Jan. 2008, to analyze obstetric interventions and adverse maternal outcomes in women with and without disabilities.

The analysis included a total of 223,385 women, mean age 27.6 years, of whom 2,074 (0.9%) had a disability, and 221,311 did not. Among those with disabilities, 1,733 (83.5%) were physical, 91 (4.4%) were intellectual, and 250 (12.1%) were sensory. While almost half (49.4%) of the women were White, 22.5% were Black, 17.5% were Hispanic, and 4.1% were Asian or Pacific Islander.

Outcomes were analyzed with three composite measures:

• Pregnancy-related complications (pregnancy-related hypertensive diseases, gestational diabetes, placental abruption, placenta previa, premature rupture of membranes, preterm PROM);
• All labor, delivery, and postpartum complications (chorioamnionitis, hemorrhage, blood transfusion, thromboembolism, postpartum fever, infection, cardiovascular events, cardiomyopathy, and maternal death);
• SMM only, including severe pre-eclampsia/eclampsia, hemorrhage, thromboembolism, fever, infection, cardiomyopathy, and cardiovascular events during labor and delivery.

After adjustment for covariates, women with disabilities had higher risk of pregnancy-related complications. This included a 48% higher risk of mild pre-eclampsia and double the risk of severe pre-eclampsia/eclampsia. The composite risk of any pregnancy complication was 27% higher for women with physical disabilities, 49% higher for women with intellectual disabilities, and 53% higher for women with sensory disabilities.

The findings were similar for labor, delivery, and postpartum complications, showing women with disabilities had higher risk for a range of obstetrical interventions, including cesarean delivery – both planned and intrapartum (aRR, 1.34). Additionally, women with disabilities were less likely to have a cesarean delivery that was “solely clinically indicated” (aRR, 0.79), and more likely to have a cesarean delivery for “softer” mixed indication (aRR, 1.16), “supporting a possible overuse of cesarean delivery among women with disability,” they suggested.

Women with disabilities also had a higher risk of postpartum hemorrhage (aRR, 1.27), blood transfusion (aRR, 1.64), and maternal mortality (aRR, 11.19), as well as individual markers of severe maternal morbidity, such as cardiovascular events (aRR, 4.02), infection (aRR, 2.69), and venous thromboembolism (aRR, 6.08).

The authors speculate that the increased risks for women with disabilities “may be the result of a combination of independent risk factors, including the higher rate of obstetric intervention via cesarean delivery, under-recognition of women with disabilities as a population with higher-risk pregnancies, and lack of health care practitioner knowledge or comfort in managing pregnancies among women with disabilities.”

Dr. Brown noted in her commentary that there is a need for better education of health care professionals in this area. “Given that 12% of reproductive-aged women have a disability, that pregnancy rates are similar among women with and without disabilities, and that women with disabilities are at elevated risk of a range of adverse maternal outcomes, including severe maternal morbidity and maternal mortality, disability modules should be a mandatory component of education for obstetricians and midwives as well as other obstetrical health care professionals.”

Calling the study “a serious wake-up call,” Monika Mitra, PhD, told this publication that the findings highlight the need for “urgent attention” on improving obstetric care for people with disabilities “with a focus on accessibility and inclusion, changing clinical practice to better serve disabled people, integrating disability-related training for health care practitioners, and developing evidence-based interventions to support people with disabilities during this time.” The associate professor and director of the Lurie Institute for Disability Policy, in Brandeis University, Waltham, Mass. said the risk factors for poor outcomes are present early in pregnancy or even preconception. “We know that disabled women report barriers in accessing health care and receive lower-quality care compared to nondisabled women and are more likely to experience poverty, housing and food insecurity, educational and employment barriers, abuse, chronic health conditions, and mental illness than women without disabilities.”

She noted that the study’s sample of people with disabilities was small, and the measure of disability used was based on ICD-9 codes, which captures only severe disabilities. “As noted in the commentary by [Dr.] Brown, our standard sources of health administrative data do not give us the full picture on disability, and we need other, more equitable ways of identifying disability based, for example, on self-reports of activity or participation limitations if we are to be able to understand the effects on obstetric outcomes of health and health care disparities and of social determinants of health. Moreover, researchers have generally not yet begun to incorporate knowledge of the experiences of transgender people during pregnancy, which will impact our measures and study of obstetric outcomes among people with disabilities as well as the language we use.”

The study was supported by the Intramural Research Program of the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD). The study authors and Dr. Brown reported no conflicts of interest. Dr. Mitra receives funding from the NICHD and the National Institute on Disability, Independent Living for research on pregnancy outcomes among people with disabilities.

obnews@mdedge.com

Women with physical, intellectual, and sensory disabilities had higher risk for almost all pregnancy complications, obstetric interventions, and adverse outcomes, including severe maternal morbidity (SMM) and mortality compared to women without disabilities, according to an analysis of a large, retrospective cohort.

The findings, published in JAMA Network Open (2021;4[12]:e2138414 doi: 10.1001/jamanetworkopen.2021.38414), “may be a direct reflection of the challenges women with all types of disabilities face when accessing and receiving care, which is likely compounded by poorer preconception health,” suggested lead author Jessica L. Gleason, PhD, MPH, and co-authors, all from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Md.

“Women with disabilities have long been ignored in obstetric research and clinical practice,” added Hilary K. Brown, PhD, from the University of Toronto, in an accompanying editorial. “Inclusion of disability indicators needs to be the norm – not the exception – in health administrative data so that these disparities can be regularly tracked and addressed.”

The investigators used data from the Consortium on Safe Labor (CSL), a retrospective cohort of deliveries from 12 U.S. clinical centers between Jan. 2002 and Jan. 2008, to analyze obstetric interventions and adverse maternal outcomes in women with and without disabilities.

The analysis included a total of 223,385 women, mean age 27.6 years, of whom 2,074 (0.9%) had a disability, and 221,311 did not. Among those with disabilities, 1,733 (83.5%) were physical, 91 (4.4%) were intellectual, and 250 (12.1%) were sensory. While almost half (49.4%) of the women were White, 22.5% were Black, 17.5% were Hispanic, and 4.1% were Asian or Pacific Islander.

Outcomes were analyzed with three composite measures:

• Pregnancy-related complications (pregnancy-related hypertensive diseases, gestational diabetes, placental abruption, placenta previa, premature rupture of membranes, preterm PROM);
• All labor, delivery, and postpartum complications (chorioamnionitis, hemorrhage, blood transfusion, thromboembolism, postpartum fever, infection, cardiovascular events, cardiomyopathy, and maternal death);
• SMM only, including severe pre-eclampsia/eclampsia, hemorrhage, thromboembolism, fever, infection, cardiomyopathy, and cardiovascular events during labor and delivery.

After adjustment for covariates, women with disabilities had higher risk of pregnancy-related complications. This included a 48% higher risk of mild pre-eclampsia and double the risk of severe pre-eclampsia/eclampsia. The composite risk of any pregnancy complication was 27% higher for women with physical disabilities, 49% higher for women with intellectual disabilities, and 53% higher for women with sensory disabilities.

The findings were similar for labor, delivery, and postpartum complications, showing women with disabilities had higher risk for a range of obstetrical interventions, including cesarean delivery – both planned and intrapartum (aRR, 1.34). Additionally, women with disabilities were less likely to have a cesarean delivery that was “solely clinically indicated” (aRR, 0.79), and more likely to have a cesarean delivery for “softer” mixed indication (aRR, 1.16), “supporting a possible overuse of cesarean delivery among women with disability,” they suggested.

Women with disabilities also had a higher risk of postpartum hemorrhage (aRR, 1.27), blood transfusion (aRR, 1.64), and maternal mortality (aRR, 11.19), as well as individual markers of severe maternal morbidity, such as cardiovascular events (aRR, 4.02), infection (aRR, 2.69), and venous thromboembolism (aRR, 6.08).

The authors speculate that the increased risks for women with disabilities “may be the result of a combination of independent risk factors, including the higher rate of obstetric intervention via cesarean delivery, under-recognition of women with disabilities as a population with higher-risk pregnancies, and lack of health care practitioner knowledge or comfort in managing pregnancies among women with disabilities.”

Dr. Brown noted in her commentary that there is a need for better education of health care professionals in this area. “Given that 12% of reproductive-aged women have a disability, that pregnancy rates are similar among women with and without disabilities, and that women with disabilities are at elevated risk of a range of adverse maternal outcomes, including severe maternal morbidity and maternal mortality, disability modules should be a mandatory component of education for obstetricians and midwives as well as other obstetrical health care professionals.”

Calling the study “a serious wake-up call,” Monika Mitra, PhD, told this publication that the findings highlight the need for “urgent attention” on improving obstetric care for people with disabilities “with a focus on accessibility and inclusion, changing clinical practice to better serve disabled people, integrating disability-related training for health care practitioners, and developing evidence-based interventions to support people with disabilities during this time.” The associate professor and director of the Lurie Institute for Disability Policy, in Brandeis University, Waltham, Mass. said the risk factors for poor outcomes are present early in pregnancy or even preconception. “We know that disabled women report barriers in accessing health care and receive lower-quality care compared to nondisabled women and are more likely to experience poverty, housing and food insecurity, educational and employment barriers, abuse, chronic health conditions, and mental illness than women without disabilities.”

She noted that the study’s sample of people with disabilities was small, and the measure of disability used was based on ICD-9 codes, which captures only severe disabilities. “As noted in the commentary by [Dr.] Brown, our standard sources of health administrative data do not give us the full picture on disability, and we need other, more equitable ways of identifying disability based, for example, on self-reports of activity or participation limitations if we are to be able to understand the effects on obstetric outcomes of health and health care disparities and of social determinants of health. Moreover, researchers have generally not yet begun to incorporate knowledge of the experiences of transgender people during pregnancy, which will impact our measures and study of obstetric outcomes among people with disabilities as well as the language we use.”

The study was supported by the Intramural Research Program of the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD). The study authors and Dr. Brown reported no conflicts of interest. Dr. Mitra receives funding from the NICHD and the National Institute on Disability, Independent Living for research on pregnancy outcomes among people with disabilities.

obnews@mdedge.com

Women with physical, intellectual, and sensory disabilities had higher risk for almost all pregnancy complications, obstetric interventions, and adverse outcomes, including severe maternal morbidity (SMM) and mortality compared to women without disabilities, according to an analysis of a large, retrospective cohort.

The findings, published in JAMA Network Open (2021;4[12]:e2138414 doi: 10.1001/jamanetworkopen.2021.38414), “may be a direct reflection of the challenges women with all types of disabilities face when accessing and receiving care, which is likely compounded by poorer preconception health,” suggested lead author Jessica L. Gleason, PhD, MPH, and co-authors, all from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Md.

“Women with disabilities have long been ignored in obstetric research and clinical practice,” added Hilary K. Brown, PhD, from the University of Toronto, in an accompanying editorial. “Inclusion of disability indicators needs to be the norm – not the exception – in health administrative data so that these disparities can be regularly tracked and addressed.”

The investigators used data from the Consortium on Safe Labor (CSL), a retrospective cohort of deliveries from 12 U.S. clinical centers between Jan. 2002 and Jan. 2008, to analyze obstetric interventions and adverse maternal outcomes in women with and without disabilities.

The analysis included a total of 223,385 women, mean age 27.6 years, of whom 2,074 (0.9%) had a disability, and 221,311 did not. Among those with disabilities, 1,733 (83.5%) were physical, 91 (4.4%) were intellectual, and 250 (12.1%) were sensory. While almost half (49.4%) of the women were White, 22.5% were Black, 17.5% were Hispanic, and 4.1% were Asian or Pacific Islander.

Outcomes were analyzed with three composite measures:

• Pregnancy-related complications (pregnancy-related hypertensive diseases, gestational diabetes, placental abruption, placenta previa, premature rupture of membranes, preterm PROM);
• All labor, delivery, and postpartum complications (chorioamnionitis, hemorrhage, blood transfusion, thromboembolism, postpartum fever, infection, cardiovascular events, cardiomyopathy, and maternal death);
• SMM only, including severe pre-eclampsia/eclampsia, hemorrhage, thromboembolism, fever, infection, cardiomyopathy, and cardiovascular events during labor and delivery.

After adjustment for covariates, women with disabilities had higher risk of pregnancy-related complications. This included a 48% higher risk of mild pre-eclampsia and double the risk of severe pre-eclampsia/eclampsia. The composite risk of any pregnancy complication was 27% higher for women with physical disabilities, 49% higher for women with intellectual disabilities, and 53% higher for women with sensory disabilities.

The findings were similar for labor, delivery, and postpartum complications, showing women with disabilities had higher risk for a range of obstetrical interventions, including cesarean delivery – both planned and intrapartum (aRR, 1.34). Additionally, women with disabilities were less likely to have a cesarean delivery that was “solely clinically indicated” (aRR, 0.79), and more likely to have a cesarean delivery for “softer” mixed indication (aRR, 1.16), “supporting a possible overuse of cesarean delivery among women with disability,” they suggested.

Women with disabilities also had a higher risk of postpartum hemorrhage (aRR, 1.27), blood transfusion (aRR, 1.64), and maternal mortality (aRR, 11.19), as well as individual markers of severe maternal morbidity, such as cardiovascular events (aRR, 4.02), infection (aRR, 2.69), and venous thromboembolism (aRR, 6.08).

The authors speculate that the increased risks for women with disabilities “may be the result of a combination of independent risk factors, including the higher rate of obstetric intervention via cesarean delivery, under-recognition of women with disabilities as a population with higher-risk pregnancies, and lack of health care practitioner knowledge or comfort in managing pregnancies among women with disabilities.”

Dr. Brown noted in her commentary that there is a need for better education of health care professionals in this area. “Given that 12% of reproductive-aged women have a disability, that pregnancy rates are similar among women with and without disabilities, and that women with disabilities are at elevated risk of a range of adverse maternal outcomes, including severe maternal morbidity and maternal mortality, disability modules should be a mandatory component of education for obstetricians and midwives as well as other obstetrical health care professionals.”

Calling the study “a serious wake-up call,” Monika Mitra, PhD, told this publication that the findings highlight the need for “urgent attention” on improving obstetric care for people with disabilities “with a focus on accessibility and inclusion, changing clinical practice to better serve disabled people, integrating disability-related training for health care practitioners, and developing evidence-based interventions to support people with disabilities during this time.” The associate professor and director of the Lurie Institute for Disability Policy, in Brandeis University, Waltham, Mass. said the risk factors for poor outcomes are present early in pregnancy or even preconception. “We know that disabled women report barriers in accessing health care and receive lower-quality care compared to nondisabled women and are more likely to experience poverty, housing and food insecurity, educational and employment barriers, abuse, chronic health conditions, and mental illness than women without disabilities.”

She noted that the study’s sample of people with disabilities was small, and the measure of disability used was based on ICD-9 codes, which captures only severe disabilities. “As noted in the commentary by [Dr.] Brown, our standard sources of health administrative data do not give us the full picture on disability, and we need other, more equitable ways of identifying disability based, for example, on self-reports of activity or participation limitations if we are to be able to understand the effects on obstetric outcomes of health and health care disparities and of social determinants of health. Moreover, researchers have generally not yet begun to incorporate knowledge of the experiences of transgender people during pregnancy, which will impact our measures and study of obstetric outcomes among people with disabilities as well as the language we use.”

The study was supported by the Intramural Research Program of the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD). The study authors and Dr. Brown reported no conflicts of interest. Dr. Mitra receives funding from the NICHD and the National Institute on Disability, Independent Living for research on pregnancy outcomes among people with disabilities.

obnews@mdedge.com

The clinical presentation of atopic dermatitis (AD) in skin of color varies widely, which may create a challenge for clinicians.

“We see very heterogenous and broad clinical presentations across the diverse patient populations that we see,” Andrew F. Alexis, MD, MPH, said at the Revolutionizing Atopic Dermatitis symposium. “Some of these differences might be related to population variations in skin barrier function, immunologic factors, genetic factors, and environmental factors, which all interplay to produce variations in the clinical presentation and overall impact of AD. Many nongenetic factors also contribute to differences that we see, including some socioeconomic and other factors that feed into health disparities.”

Dr. Alexis, professor of clinical dermatology at Weill Cornell Medicine, New York, discussed four main clinical features of AD in skin of color.
 

Erythema is less visible because it is masked by pigment

“There can be some masking of the redness and alteration of that color such that it doesn’t look bright red as it would in the background of lightly pigmented skin,” Dr. Alexis said. “Instead, the [AD lesions] have shades of grayish-red or grayish-brown or reddish-brown. It’s important to recognize this clinical presentation and look carefully and assess the patient – not just visually but with palpation and take into consideration symptomatology so that you don’t fall into the trap of calling an AD lesion postinflammatory hyperpigmentation. It’s also helpful to isolate the islands of normal or nonlesional skin and contrast that with the areas of lesional skin, to get a sense of how active and inflamed the areas are. Palpation really helps to appreciate the elevation of the lesions that are involved.”

Follicular accentuation

Morphological variants common in skin of color include the follicular variant or micropapular variant of AD. “You might just see a collection of papules that are 1-2 mm in size and pruritic and in typical sites of predilection [for] eczema,” he said. Prurigo nodularis–like lesions or prurigo nodularis in association with AD are also seen more frequently in skin of color.

Lichenification

The lichenoid variant of AD is characterized by a violaceous hue and other features that resemble lichen planus and has been reported to be more common in individuals of African descent. A prospective study of about 1,000 patients with AD seen over 2 years at a dermatology clinic in southeastern Nigeria found that 54% of patients had papular lichenoid lesions. In addition, 51% had elevated blood eosinophil counts, especially those with severe disease.

Dr. Alexis added that psoriasiform features have been reported in studies of East Asian populations with AD. These plaques may be more well demarcated and have clinical and histologic features that resemble psoriasis.
 

Dyspigmentation

One common feature across the spectrum of patients with skin of color “is the risk of longstanding pigmentary sequelae in the form of hyperpigmentation or hypopigmentation,” said Dr. Alexis, who is also vice chair for diversity and inclusion for the department of dermatology at Weill Cornell Medicine. “In very severe longstanding areas with chronic excoriation to the point of breaking of the skin, eroding of the skin, causing permanent damage to the melanocytes, dyspigmentation that resembles vitiligo can be seen. We can also see hypopigmentation as a consequence of topical corticosteroids, particularly those that are class I or class II and are used for prolonged periods of time.”

Dr. Alexis noted that delays in treatment and undertreatment can contribute to a higher risk of pigmentary and other long-term sequelae. “New therapies show promise in improving outcomes in AD patients with skin of color. When it comes to therapeutic responses, there are some post hoc studies that have investigated potential differences in safety and efficacy of the agents that have been recently approved. We clearly need more data to better understand if there are potential racial or ethnic differences.”

Dr. Alexis reported no relevant financial relationships.

Commentary by Lawrence F. Eichenfield, MD

Atopic dermatitis (AD) is highly heterogenous, with tremendous variations in extent, qualities of eczema, symptom complex, and physical presentation. Prior studies have reported disparities of care delivered to racial and ethnic minorities in the United States, as well as higher susceptibility to AD and odds of persistent disease into adulthood from child-onset AD. Recognizing some differences in presentation of AD in patients with skin of color is important as we select our therapeutic interventions, including assessing new treatments being added to our armamentarium. Erythema may be harder to notice in darker skin, but attempting to blanch the skin with pressure can help to assess the color and inflammation. Appreciating lichenoid changes, including papular and “micropapular” AD, and psoriasiform-like thickening in certain patients (reportedly more common in East Asian populations) are important as well. And dyspigmentation is an important aspect of the disease presentation and patient and parental concern, given both hypopigmentaton and hyperpigmentation commonly seen over the course of AD.

Dr. Eichenfield is chief of pediatric and adolescent dermatology at Rady Children's Hospital-San Diego. He is vice chair of the department of dermatology and professor of dermatology and pediatrics at the University of California, San Diego. He disclosed that he has served as an investigator and/or consultant to AbbVie, Lilly, Pfizer, Regeneron, Sanofi-Genzyme, and Verrica.

A version of this article first appeared on Medscape.com.

This article was updated 6/18/22.

The clinical presentation of atopic dermatitis (AD) in skin of color varies widely, which may create a challenge for clinicians.

“We see very heterogenous and broad clinical presentations across the diverse patient populations that we see,” Andrew F. Alexis, MD, MPH, said at the Revolutionizing Atopic Dermatitis symposium. “Some of these differences might be related to population variations in skin barrier function, immunologic factors, genetic factors, and environmental factors, which all interplay to produce variations in the clinical presentation and overall impact of AD. Many nongenetic factors also contribute to differences that we see, including some socioeconomic and other factors that feed into health disparities.”

Dr. Alexis, professor of clinical dermatology at Weill Cornell Medicine, New York, discussed four main clinical features of AD in skin of color.
 

Erythema is less visible because it is masked by pigment

“There can be some masking of the redness and alteration of that color such that it doesn’t look bright red as it would in the background of lightly pigmented skin,” Dr. Alexis said. “Instead, the [AD lesions] have shades of grayish-red or grayish-brown or reddish-brown. It’s important to recognize this clinical presentation and look carefully and assess the patient – not just visually but with palpation and take into consideration symptomatology so that you don’t fall into the trap of calling an AD lesion postinflammatory hyperpigmentation. It’s also helpful to isolate the islands of normal or nonlesional skin and contrast that with the areas of lesional skin, to get a sense of how active and inflamed the areas are. Palpation really helps to appreciate the elevation of the lesions that are involved.”

Follicular accentuation

Morphological variants common in skin of color include the follicular variant or micropapular variant of AD. “You might just see a collection of papules that are 1-2 mm in size and pruritic and in typical sites of predilection [for] eczema,” he said. Prurigo nodularis–like lesions or prurigo nodularis in association with AD are also seen more frequently in skin of color.

Lichenification

The lichenoid variant of AD is characterized by a violaceous hue and other features that resemble lichen planus and has been reported to be more common in individuals of African descent. A prospective study of about 1,000 patients with AD seen over 2 years at a dermatology clinic in southeastern Nigeria found that 54% of patients had papular lichenoid lesions. In addition, 51% had elevated blood eosinophil counts, especially those with severe disease.

Dr. Alexis added that psoriasiform features have been reported in studies of East Asian populations with AD. These plaques may be more well demarcated and have clinical and histologic features that resemble psoriasis.
 

Dyspigmentation

One common feature across the spectrum of patients with skin of color “is the risk of longstanding pigmentary sequelae in the form of hyperpigmentation or hypopigmentation,” said Dr. Alexis, who is also vice chair for diversity and inclusion for the department of dermatology at Weill Cornell Medicine. “In very severe longstanding areas with chronic excoriation to the point of breaking of the skin, eroding of the skin, causing permanent damage to the melanocytes, dyspigmentation that resembles vitiligo can be seen. We can also see hypopigmentation as a consequence of topical corticosteroids, particularly those that are class I or class II and are used for prolonged periods of time.”

Dr. Alexis noted that delays in treatment and undertreatment can contribute to a higher risk of pigmentary and other long-term sequelae. “New therapies show promise in improving outcomes in AD patients with skin of color. When it comes to therapeutic responses, there are some post hoc studies that have investigated potential differences in safety and efficacy of the agents that have been recently approved. We clearly need more data to better understand if there are potential racial or ethnic differences.”

Dr. Alexis reported no relevant financial relationships.

Commentary by Lawrence F. Eichenfield, MD

Atopic dermatitis (AD) is highly heterogenous, with tremendous variations in extent, qualities of eczema, symptom complex, and physical presentation. Prior studies have reported disparities of care delivered to racial and ethnic minorities in the United States, as well as higher susceptibility to AD and odds of persistent disease into adulthood from child-onset AD. Recognizing some differences in presentation of AD in patients with skin of color is important as we select our therapeutic interventions, including assessing new treatments being added to our armamentarium. Erythema may be harder to notice in darker skin, but attempting to blanch the skin with pressure can help to assess the color and inflammation. Appreciating lichenoid changes, including papular and “micropapular” AD, and psoriasiform-like thickening in certain patients (reportedly more common in East Asian populations) are important as well. And dyspigmentation is an important aspect of the disease presentation and patient and parental concern, given both hypopigmentaton and hyperpigmentation commonly seen over the course of AD.

Dr. Eichenfield is chief of pediatric and adolescent dermatology at Rady Children's Hospital-San Diego. He is vice chair of the department of dermatology and professor of dermatology and pediatrics at the University of California, San Diego. He disclosed that he has served as an investigator and/or consultant to AbbVie, Lilly, Pfizer, Regeneron, Sanofi-Genzyme, and Verrica.

A version of this article first appeared on Medscape.com.

This article was updated 6/18/22.

The clinical presentation of atopic dermatitis (AD) in skin of color varies widely, which may create a challenge for clinicians.

“We see very heterogenous and broad clinical presentations across the diverse patient populations that we see,” Andrew F. Alexis, MD, MPH, said at the Revolutionizing Atopic Dermatitis symposium. “Some of these differences might be related to population variations in skin barrier function, immunologic factors, genetic factors, and environmental factors, which all interplay to produce variations in the clinical presentation and overall impact of AD. Many nongenetic factors also contribute to differences that we see, including some socioeconomic and other factors that feed into health disparities.”

Dr. Alexis, professor of clinical dermatology at Weill Cornell Medicine, New York, discussed four main clinical features of AD in skin of color.
 

Erythema is less visible because it is masked by pigment

“There can be some masking of the redness and alteration of that color such that it doesn’t look bright red as it would in the background of lightly pigmented skin,” Dr. Alexis said. “Instead, the [AD lesions] have shades of grayish-red or grayish-brown or reddish-brown. It’s important to recognize this clinical presentation and look carefully and assess the patient – not just visually but with palpation and take into consideration symptomatology so that you don’t fall into the trap of calling an AD lesion postinflammatory hyperpigmentation. It’s also helpful to isolate the islands of normal or nonlesional skin and contrast that with the areas of lesional skin, to get a sense of how active and inflamed the areas are. Palpation really helps to appreciate the elevation of the lesions that are involved.”

Follicular accentuation

Morphological variants common in skin of color include the follicular variant or micropapular variant of AD. “You might just see a collection of papules that are 1-2 mm in size and pruritic and in typical sites of predilection [for] eczema,” he said. Prurigo nodularis–like lesions or prurigo nodularis in association with AD are also seen more frequently in skin of color.

Lichenification

The lichenoid variant of AD is characterized by a violaceous hue and other features that resemble lichen planus and has been reported to be more common in individuals of African descent. A prospective study of about 1,000 patients with AD seen over 2 years at a dermatology clinic in southeastern Nigeria found that 54% of patients had papular lichenoid lesions. In addition, 51% had elevated blood eosinophil counts, especially those with severe disease.

Dr. Alexis added that psoriasiform features have been reported in studies of East Asian populations with AD. These plaques may be more well demarcated and have clinical and histologic features that resemble psoriasis.
 

Dyspigmentation

One common feature across the spectrum of patients with skin of color “is the risk of longstanding pigmentary sequelae in the form of hyperpigmentation or hypopigmentation,” said Dr. Alexis, who is also vice chair for diversity and inclusion for the department of dermatology at Weill Cornell Medicine. “In very severe longstanding areas with chronic excoriation to the point of breaking of the skin, eroding of the skin, causing permanent damage to the melanocytes, dyspigmentation that resembles vitiligo can be seen. We can also see hypopigmentation as a consequence of topical corticosteroids, particularly those that are class I or class II and are used for prolonged periods of time.”

Dr. Alexis noted that delays in treatment and undertreatment can contribute to a higher risk of pigmentary and other long-term sequelae. “New therapies show promise in improving outcomes in AD patients with skin of color. When it comes to therapeutic responses, there are some post hoc studies that have investigated potential differences in safety and efficacy of the agents that have been recently approved. We clearly need more data to better understand if there are potential racial or ethnic differences.”

Dr. Alexis reported no relevant financial relationships.

Commentary by Lawrence F. Eichenfield, MD

Atopic dermatitis (AD) is highly heterogenous, with tremendous variations in extent, qualities of eczema, symptom complex, and physical presentation. Prior studies have reported disparities of care delivered to racial and ethnic minorities in the United States, as well as higher susceptibility to AD and odds of persistent disease into adulthood from child-onset AD. Recognizing some differences in presentation of AD in patients with skin of color is important as we select our therapeutic interventions, including assessing new treatments being added to our armamentarium. Erythema may be harder to notice in darker skin, but attempting to blanch the skin with pressure can help to assess the color and inflammation. Appreciating lichenoid changes, including papular and “micropapular” AD, and psoriasiform-like thickening in certain patients (reportedly more common in East Asian populations) are important as well. And dyspigmentation is an important aspect of the disease presentation and patient and parental concern, given both hypopigmentaton and hyperpigmentation commonly seen over the course of AD.

Dr. Eichenfield is chief of pediatric and adolescent dermatology at Rady Children's Hospital-San Diego. He is vice chair of the department of dermatology and professor of dermatology and pediatrics at the University of California, San Diego. He disclosed that he has served as an investigator and/or consultant to AbbVie, Lilly, Pfizer, Regeneron, Sanofi-Genzyme, and Verrica.

A version of this article first appeared on Medscape.com.

This article was updated 6/18/22.

In the United States, nearly 4 million women a year prepare to give birth, looking forward to the joy to come. But for some, the dream turns tragic. About 700 women die each year either during their pregnancy or in the weeks after the birth. And another 60,000 have pregnancy-related or childbirth-related health issues.

Causes of death vary greatly, including hemorrhage during pregnancy or during delivery, heart conditions, and mental health issues such as substance abuse and suicide after the birth.

In 2019, the U.S. maternal death rate was 20.1 per 100,000 women, according to the CDC, significantly higher than the 17.4 per 100,000 recorded in 2018. For Black women, the maternal death rate was more than double the overall – 44 per 100,000 in 2019.

“We have to address our horrendous maternal health care system and also need to address the inequities,” says Laurie Zephyrin, MD, vice president for advancing health equity for the Commonwealth Fund, a foundation supporting independent research on health care issues. “This is an issue that has needed national attention for a long time.”

“If we look overall, our maternal death rate is more than twice that of more than 10 other high-income countries,” she said.

As sobering as the problem is, recent developments have sparked hope that reversing the course is possible. Among them:

U.S. News & World Report, long known for its rankings of hospitals, issued its first ever “Best Hospitals for Maternity” rankings Dec. 7, highlighting facilities that perform well on key quality indicators. It plans to update the report annually.

At the first-ever White House Maternal Health Day of Action on Dec. 7, Vice President Kamala Harris urged a call to action to reduce maternal deaths and pregnancy-related health problems, with extension of postpartum coverage through Medicaid programs, among other actions.

A new hospital designation called ‘’Birthing Friendly” will be established by the Centers for Medicare & Medicaid Services. The label will be given to facilities that take part in a program aimed at improving maternal outcomes and that use patient safety practices.

President Joe Biden’s proposed Build Back Better plan includes maternal health provisions, including $3 billion in new maternal health funding. The money will aim to grow and diversify the workforce caring for pregnant women, coordinate care better, and step up research on maternal health, among other projects.

Ongoing efforts in Congress are aimed at fixing the wide disparities in maternal health affecting Black women. Regardless of income level or education, Black women are at a higher risk of maternal death and other health issues than are White women. A Black woman with a college education is at 60% higher risk of maternal death than a White or Hispanic woman who didn’t graduate high school, according to the Commonwealth Fund.
 

Best hospitals for maternity

For its rankings, U.S. News and World Report reached out to the 2,700 U.S. hospitals that offer maternity services, said Ben Harder, chief of health analysis and managing editor at U.S. News & World Report.

To be recognized, a hospital had to submit data from 2019 and meet the publication’s maternity care standards. The publication received responses from just 571 hospitals, representing about two of every five births in the country.

Of those, 237 were identified as best for maternity.

As to why the response rate was not higher, Mr. Harder cited the reporting burden and says it is understandable. Some hospitals likely did not have the staff available, especially during the pandemic, to gather the data needed to be evaluated by U.S. News & World Report.

On their other evaluations, the rankings are based on Medicare data, “so hospitals don’t have to lift a finger.” He expects more hospitals will respond for their future evaluations of maternity care.

The evaluators focused on five quality measures, making a score based on the cesarean section delivery rate among first-time mothers, early elective delivery rates, unexpected newborn complication rates, breastfeeding rates, and option for vaginal birth after C-section.
 

A call to action: Expand coverage

Speaking at the White House Maternal Health Day of Action, Mrs. Harris told participants: “The challenge is urgent, and it is important, and it will take all of us.”

Being pregnant and giving birth, she said, should not carry such great risks. She zeroed in on systemic inequities in the way women are treated and the dramatic impact maternal death and health issues have on the economy.

“A healthy economy requires healthy mothers and healthy babies,” Mrs. Harris said.

“Before, during, and after childbirth, women in our nation are dying at a higher rate than any other developed nation in our world,” she said, noting that research shows that Black women, Native Americans, and women in rural America more likely to suffer.

A major strategy in the call to action, according to Mrs. Harris, is encouraging states to expand postpartum coverage to pregnant women enrolled in Medicaid or the Children’s Health Insurance Program from the existing 60 days to a full year. Together, these two programs cover over 42% of births in the country, so expanding the coverage is expected to have a great impact.

The 60 days of coverage is not enough, as many deaths and complications happen more than 60 days after childbirth, Mrs. Harris said. The logistics for states to extend coverage were established by the American Rescue Plan and will become available by April 2022. Some states have already extended the postpartum coverage.

According to the Centers for Medicare and Medicaid Services, if every state did adopt an extension, as the Build Back Better Act proposes, the number of Americans getting coverage for a full year after childbirth would about double, extending the coverage for about 720,000 each year.
 

Congressional actions

Congress is working on the issue as well. The Black Maternal Health Momnibus Act of 2021, for instance, proposes several measures, including improving maternal nutrition, expanding affordable housing, and extending the maternal workforce to include more doulas and midwives.

“And for so many women, let’s note doulas are literally a lifeline,” Mrs. Harris said at the White House event.

Doulas are trained to offer women physical, emotional, and informational support before, during, and after childbirth. No reliable statistics are available on their numbers in the United States, but a March of Dimes report estimates that about 9,000 were included in a registration database in 2018.
 

Explaining and fixing the disparities

No one can explain for sure why Black women, in particular, are at higher risk of dying from pregnancy-related complications. Systemic inequity is one likely reason, Mrs. Harris said, noting there are differences in how people are treated based on who they are.

Inherent and unconscious bias in offering women treatment plays a role, experts say. Training could reverse or reduce that bias. Some women of color also may have less access to care, as do women in some rural areas.

According to Mrs. Harris, more than 20 companies and nonprofits have pledged to invest more than $20 million in maternal health efforts in the United States and more than $150 million globally. Among the proposed programs: remote-care monitors in rural areas, better care models for the postpartum period, and improved education programs for maternal health providers.
 

When statistics hit home

Many who work to improve maternal health have gone through issues themselves or had loved ones who did.

Jill Arnold, founder of the Maternal Safety Foundation in Bentonville, Ark., became a consumer advocate after giving birth to her two daughters, now teenagers. With the first birth, Ms. Arnold said she was intensely pressured at the last minute to have a C-section. She held out, resisted, and delivered a healthy baby vaginally.

For her second childbirth, she chose an accredited birth center that allowed her to have a doula and a midwife.

“The care I received was night and day,” she said. “The overwhelming pressure to consent to a C-section wasn’t there.”

She welcomes the information provided by the new U.S. News & World Report rankings as well as the upcoming “Birthing Friendly” designations.

“The onus shouldn’t be on patients, on individuals, on pregnant people to do the research,” Ms. Arnold said.

Rather, women and their partners need information at their fingertips so they can make an informed decision about how to give birth and where.

U.S. Rep. Lauren Underwood (D-Ill.), who cofounded the Black Maternal Health Caucus in April 2019, with Rep. Alma Adams (D-N.C.), wrote a touching blog in the journal Health Affairs to explain her passion in improving maternal health.

Her former classmate, Shalon Irving, who went on to become a CDC epidemiologist, died in February 2017 at age 36, just 3 weeks after giving birth, when she developed complications from high blood pressure.

In the blog, Ms. Underwood cited statistics and provides details of the Black Maternal Health Momnibus Act of 2021, then ends the blog, published in 2020, with an update on how Ms. Irving’s then 3-year-old daughter, raised by her grandmother, is doing. While Soleil is “curious, joyful, and brilliant,” the grandmother told Ms. Underwood that she has also walked into a room and found the little girl clutching a framed photograph of her mother.

The child’s question is understandable and heartbreaking: She wants to know where her mommy is.

“Soleil’s question is my motivation,” Ms. Underwood wrote. “To honor Shalon, and all the women like her who we have lost, let us take the serious and urgent action that is required to save our moms.”

A version of this article first appeared on WebMD.com.

In the United States, nearly 4 million women a year prepare to give birth, looking forward to the joy to come. But for some, the dream turns tragic. About 700 women die each year either during their pregnancy or in the weeks after the birth. And another 60,000 have pregnancy-related or childbirth-related health issues.

Causes of death vary greatly, including hemorrhage during pregnancy or during delivery, heart conditions, and mental health issues such as substance abuse and suicide after the birth.

In 2019, the U.S. maternal death rate was 20.1 per 100,000 women, according to the CDC, significantly higher than the 17.4 per 100,000 recorded in 2018. For Black women, the maternal death rate was more than double the overall – 44 per 100,000 in 2019.

“We have to address our horrendous maternal health care system and also need to address the inequities,” says Laurie Zephyrin, MD, vice president for advancing health equity for the Commonwealth Fund, a foundation supporting independent research on health care issues. “This is an issue that has needed national attention for a long time.”

“If we look overall, our maternal death rate is more than twice that of more than 10 other high-income countries,” she said.

As sobering as the problem is, recent developments have sparked hope that reversing the course is possible. Among them:

U.S. News & World Report, long known for its rankings of hospitals, issued its first ever “Best Hospitals for Maternity” rankings Dec. 7, highlighting facilities that perform well on key quality indicators. It plans to update the report annually.

At the first-ever White House Maternal Health Day of Action on Dec. 7, Vice President Kamala Harris urged a call to action to reduce maternal deaths and pregnancy-related health problems, with extension of postpartum coverage through Medicaid programs, among other actions.

A new hospital designation called ‘’Birthing Friendly” will be established by the Centers for Medicare & Medicaid Services. The label will be given to facilities that take part in a program aimed at improving maternal outcomes and that use patient safety practices.

President Joe Biden’s proposed Build Back Better plan includes maternal health provisions, including $3 billion in new maternal health funding. The money will aim to grow and diversify the workforce caring for pregnant women, coordinate care better, and step up research on maternal health, among other projects.

Ongoing efforts in Congress are aimed at fixing the wide disparities in maternal health affecting Black women. Regardless of income level or education, Black women are at a higher risk of maternal death and other health issues than are White women. A Black woman with a college education is at 60% higher risk of maternal death than a White or Hispanic woman who didn’t graduate high school, according to the Commonwealth Fund.
 

Best hospitals for maternity

For its rankings, U.S. News and World Report reached out to the 2,700 U.S. hospitals that offer maternity services, said Ben Harder, chief of health analysis and managing editor at U.S. News & World Report.

To be recognized, a hospital had to submit data from 2019 and meet the publication’s maternity care standards. The publication received responses from just 571 hospitals, representing about two of every five births in the country.

Of those, 237 were identified as best for maternity.

As to why the response rate was not higher, Mr. Harder cited the reporting burden and says it is understandable. Some hospitals likely did not have the staff available, especially during the pandemic, to gather the data needed to be evaluated by U.S. News & World Report.

On their other evaluations, the rankings are based on Medicare data, “so hospitals don’t have to lift a finger.” He expects more hospitals will respond for their future evaluations of maternity care.

The evaluators focused on five quality measures, making a score based on the cesarean section delivery rate among first-time mothers, early elective delivery rates, unexpected newborn complication rates, breastfeeding rates, and option for vaginal birth after C-section.
 

A call to action: Expand coverage

Speaking at the White House Maternal Health Day of Action, Mrs. Harris told participants: “The challenge is urgent, and it is important, and it will take all of us.”

Being pregnant and giving birth, she said, should not carry such great risks. She zeroed in on systemic inequities in the way women are treated and the dramatic impact maternal death and health issues have on the economy.

“A healthy economy requires healthy mothers and healthy babies,” Mrs. Harris said.

“Before, during, and after childbirth, women in our nation are dying at a higher rate than any other developed nation in our world,” she said, noting that research shows that Black women, Native Americans, and women in rural America more likely to suffer.

A major strategy in the call to action, according to Mrs. Harris, is encouraging states to expand postpartum coverage to pregnant women enrolled in Medicaid or the Children’s Health Insurance Program from the existing 60 days to a full year. Together, these two programs cover over 42% of births in the country, so expanding the coverage is expected to have a great impact.

The 60 days of coverage is not enough, as many deaths and complications happen more than 60 days after childbirth, Mrs. Harris said. The logistics for states to extend coverage were established by the American Rescue Plan and will become available by April 2022. Some states have already extended the postpartum coverage.

According to the Centers for Medicare and Medicaid Services, if every state did adopt an extension, as the Build Back Better Act proposes, the number of Americans getting coverage for a full year after childbirth would about double, extending the coverage for about 720,000 each year.
 

Congressional actions

Congress is working on the issue as well. The Black Maternal Health Momnibus Act of 2021, for instance, proposes several measures, including improving maternal nutrition, expanding affordable housing, and extending the maternal workforce to include more doulas and midwives.

“And for so many women, let’s note doulas are literally a lifeline,” Mrs. Harris said at the White House event.

Doulas are trained to offer women physical, emotional, and informational support before, during, and after childbirth. No reliable statistics are available on their numbers in the United States, but a March of Dimes report estimates that about 9,000 were included in a registration database in 2018.
 

Explaining and fixing the disparities

No one can explain for sure why Black women, in particular, are at higher risk of dying from pregnancy-related complications. Systemic inequity is one likely reason, Mrs. Harris said, noting there are differences in how people are treated based on who they are.

Inherent and unconscious bias in offering women treatment plays a role, experts say. Training could reverse or reduce that bias. Some women of color also may have less access to care, as do women in some rural areas.

According to Mrs. Harris, more than 20 companies and nonprofits have pledged to invest more than $20 million in maternal health efforts in the United States and more than $150 million globally. Among the proposed programs: remote-care monitors in rural areas, better care models for the postpartum period, and improved education programs for maternal health providers.
 

When statistics hit home

Many who work to improve maternal health have gone through issues themselves or had loved ones who did.

Jill Arnold, founder of the Maternal Safety Foundation in Bentonville, Ark., became a consumer advocate after giving birth to her two daughters, now teenagers. With the first birth, Ms. Arnold said she was intensely pressured at the last minute to have a C-section. She held out, resisted, and delivered a healthy baby vaginally.

For her second childbirth, she chose an accredited birth center that allowed her to have a doula and a midwife.

“The care I received was night and day,” she said. “The overwhelming pressure to consent to a C-section wasn’t there.”

She welcomes the information provided by the new U.S. News & World Report rankings as well as the upcoming “Birthing Friendly” designations.

“The onus shouldn’t be on patients, on individuals, on pregnant people to do the research,” Ms. Arnold said.

Rather, women and their partners need information at their fingertips so they can make an informed decision about how to give birth and where.

U.S. Rep. Lauren Underwood (D-Ill.), who cofounded the Black Maternal Health Caucus in April 2019, with Rep. Alma Adams (D-N.C.), wrote a touching blog in the journal Health Affairs to explain her passion in improving maternal health.

Her former classmate, Shalon Irving, who went on to become a CDC epidemiologist, died in February 2017 at age 36, just 3 weeks after giving birth, when she developed complications from high blood pressure.

In the blog, Ms. Underwood cited statistics and provides details of the Black Maternal Health Momnibus Act of 2021, then ends the blog, published in 2020, with an update on how Ms. Irving’s then 3-year-old daughter, raised by her grandmother, is doing. While Soleil is “curious, joyful, and brilliant,” the grandmother told Ms. Underwood that she has also walked into a room and found the little girl clutching a framed photograph of her mother.

The child’s question is understandable and heartbreaking: She wants to know where her mommy is.

“Soleil’s question is my motivation,” Ms. Underwood wrote. “To honor Shalon, and all the women like her who we have lost, let us take the serious and urgent action that is required to save our moms.”

A version of this article first appeared on WebMD.com.

In the United States, nearly 4 million women a year prepare to give birth, looking forward to the joy to come. But for some, the dream turns tragic. About 700 women die each year either during their pregnancy or in the weeks after the birth. And another 60,000 have pregnancy-related or childbirth-related health issues.

Causes of death vary greatly, including hemorrhage during pregnancy or during delivery, heart conditions, and mental health issues such as substance abuse and suicide after the birth.

In 2019, the U.S. maternal death rate was 20.1 per 100,000 women, according to the CDC, significantly higher than the 17.4 per 100,000 recorded in 2018. For Black women, the maternal death rate was more than double the overall – 44 per 100,000 in 2019.

“We have to address our horrendous maternal health care system and also need to address the inequities,” says Laurie Zephyrin, MD, vice president for advancing health equity for the Commonwealth Fund, a foundation supporting independent research on health care issues. “This is an issue that has needed national attention for a long time.”

“If we look overall, our maternal death rate is more than twice that of more than 10 other high-income countries,” she said.

As sobering as the problem is, recent developments have sparked hope that reversing the course is possible. Among them:

U.S. News & World Report, long known for its rankings of hospitals, issued its first ever “Best Hospitals for Maternity” rankings Dec. 7, highlighting facilities that perform well on key quality indicators. It plans to update the report annually.

At the first-ever White House Maternal Health Day of Action on Dec. 7, Vice President Kamala Harris urged a call to action to reduce maternal deaths and pregnancy-related health problems, with extension of postpartum coverage through Medicaid programs, among other actions.

A new hospital designation called ‘’Birthing Friendly” will be established by the Centers for Medicare & Medicaid Services. The label will be given to facilities that take part in a program aimed at improving maternal outcomes and that use patient safety practices.

President Joe Biden’s proposed Build Back Better plan includes maternal health provisions, including $3 billion in new maternal health funding. The money will aim to grow and diversify the workforce caring for pregnant women, coordinate care better, and step up research on maternal health, among other projects.

Ongoing efforts in Congress are aimed at fixing the wide disparities in maternal health affecting Black women. Regardless of income level or education, Black women are at a higher risk of maternal death and other health issues than are White women. A Black woman with a college education is at 60% higher risk of maternal death than a White or Hispanic woman who didn’t graduate high school, according to the Commonwealth Fund.
 

Best hospitals for maternity

For its rankings, U.S. News and World Report reached out to the 2,700 U.S. hospitals that offer maternity services, said Ben Harder, chief of health analysis and managing editor at U.S. News & World Report.

To be recognized, a hospital had to submit data from 2019 and meet the publication’s maternity care standards. The publication received responses from just 571 hospitals, representing about two of every five births in the country.

Of those, 237 were identified as best for maternity.

As to why the response rate was not higher, Mr. Harder cited the reporting burden and says it is understandable. Some hospitals likely did not have the staff available, especially during the pandemic, to gather the data needed to be evaluated by U.S. News & World Report.

On their other evaluations, the rankings are based on Medicare data, “so hospitals don’t have to lift a finger.” He expects more hospitals will respond for their future evaluations of maternity care.

The evaluators focused on five quality measures, making a score based on the cesarean section delivery rate among first-time mothers, early elective delivery rates, unexpected newborn complication rates, breastfeeding rates, and option for vaginal birth after C-section.
 

A call to action: Expand coverage

Speaking at the White House Maternal Health Day of Action, Mrs. Harris told participants: “The challenge is urgent, and it is important, and it will take all of us.”

Being pregnant and giving birth, she said, should not carry such great risks. She zeroed in on systemic inequities in the way women are treated and the dramatic impact maternal death and health issues have on the economy.

“A healthy economy requires healthy mothers and healthy babies,” Mrs. Harris said.

“Before, during, and after childbirth, women in our nation are dying at a higher rate than any other developed nation in our world,” she said, noting that research shows that Black women, Native Americans, and women in rural America more likely to suffer.

A major strategy in the call to action, according to Mrs. Harris, is encouraging states to expand postpartum coverage to pregnant women enrolled in Medicaid or the Children’s Health Insurance Program from the existing 60 days to a full year. Together, these two programs cover over 42% of births in the country, so expanding the coverage is expected to have a great impact.

The 60 days of coverage is not enough, as many deaths and complications happen more than 60 days after childbirth, Mrs. Harris said. The logistics for states to extend coverage were established by the American Rescue Plan and will become available by April 2022. Some states have already extended the postpartum coverage.

According to the Centers for Medicare and Medicaid Services, if every state did adopt an extension, as the Build Back Better Act proposes, the number of Americans getting coverage for a full year after childbirth would about double, extending the coverage for about 720,000 each year.
 

Congressional actions

Congress is working on the issue as well. The Black Maternal Health Momnibus Act of 2021, for instance, proposes several measures, including improving maternal nutrition, expanding affordable housing, and extending the maternal workforce to include more doulas and midwives.

“And for so many women, let’s note doulas are literally a lifeline,” Mrs. Harris said at the White House event.

Doulas are trained to offer women physical, emotional, and informational support before, during, and after childbirth. No reliable statistics are available on their numbers in the United States, but a March of Dimes report estimates that about 9,000 were included in a registration database in 2018.
 

Explaining and fixing the disparities

No one can explain for sure why Black women, in particular, are at higher risk of dying from pregnancy-related complications. Systemic inequity is one likely reason, Mrs. Harris said, noting there are differences in how people are treated based on who they are.

Inherent and unconscious bias in offering women treatment plays a role, experts say. Training could reverse or reduce that bias. Some women of color also may have less access to care, as do women in some rural areas.

According to Mrs. Harris, more than 20 companies and nonprofits have pledged to invest more than $20 million in maternal health efforts in the United States and more than $150 million globally. Among the proposed programs: remote-care monitors in rural areas, better care models for the postpartum period, and improved education programs for maternal health providers.
 

When statistics hit home

Many who work to improve maternal health have gone through issues themselves or had loved ones who did.

Jill Arnold, founder of the Maternal Safety Foundation in Bentonville, Ark., became a consumer advocate after giving birth to her two daughters, now teenagers. With the first birth, Ms. Arnold said she was intensely pressured at the last minute to have a C-section. She held out, resisted, and delivered a healthy baby vaginally.

For her second childbirth, she chose an accredited birth center that allowed her to have a doula and a midwife.

“The care I received was night and day,” she said. “The overwhelming pressure to consent to a C-section wasn’t there.”

She welcomes the information provided by the new U.S. News & World Report rankings as well as the upcoming “Birthing Friendly” designations.

“The onus shouldn’t be on patients, on individuals, on pregnant people to do the research,” Ms. Arnold said.

Rather, women and their partners need information at their fingertips so they can make an informed decision about how to give birth and where.

U.S. Rep. Lauren Underwood (D-Ill.), who cofounded the Black Maternal Health Caucus in April 2019, with Rep. Alma Adams (D-N.C.), wrote a touching blog in the journal Health Affairs to explain her passion in improving maternal health.

Her former classmate, Shalon Irving, who went on to become a CDC epidemiologist, died in February 2017 at age 36, just 3 weeks after giving birth, when she developed complications from high blood pressure.

In the blog, Ms. Underwood cited statistics and provides details of the Black Maternal Health Momnibus Act of 2021, then ends the blog, published in 2020, with an update on how Ms. Irving’s then 3-year-old daughter, raised by her grandmother, is doing. While Soleil is “curious, joyful, and brilliant,” the grandmother told Ms. Underwood that she has also walked into a room and found the little girl clutching a framed photograph of her mother.

The child’s question is understandable and heartbreaking: She wants to know where her mommy is.

“Soleil’s question is my motivation,” Ms. Underwood wrote. “To honor Shalon, and all the women like her who we have lost, let us take the serious and urgent action that is required to save our moms.”

A version of this article first appeared on WebMD.com.