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Original Article
ARTICLE IN PRESS
doi:
10.25259/IJDVL_711_20

Profile of dermatology inpatients and admissions over a four year period in a tertiary level government teaching hospital in North India

Department of Dermatology and Venereology, New Delhi, India
Biostatistics, All India Institute of Medical Sciences, New Delhi, India
Corresponding author: Dr Vinod Kumar Sharma, Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi, India. vksiadvl@gmail.com
Licence
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Gupta V, Gupta S, Kharghoria G, Pathak M, Sharma VK. Profile of Dermatology Inpatients and Admissions Over a Four Year Period in a Tertiary Level Government Teaching Hospital in North India. Indian J Dermatol Venereol Leprol. doi: 10.25259/IJDVL_711_20

Abstract

Background:

Although dermatology is mostly an outpatient specialty, some patients with severe skin disease need hospital admission for management. There is a paucity of data regarding the profile of these dermatology in-patient admissions.

Aims:

We studied the profile of patients admitted to the dermatology ward of our tertiary care government hospital in North India.

Methods:

This was a retrospective analysis of discharge sheets of patients admitted in the dermatology ward from January 1, 2014 to December 31, 2017.

Results:

Discharge sheets of 2032 admissions for 1664 patients were analyzed. The most common diagnoses in the admitted patients were immunobullous disorders (576, 28%), connective tissue diseases (409, 20%), infections, including leprosy and sexually transmitted infections (179, 8.8%), psoriasis (153, 7.5%) and reactive arthritis (92, 4.5%). The mean duration of admission was 13.95±11.67 days (range 1-118 days). Two hundred and fifty-six patients (15.38%) were re-admitted, accounting for 368 (18.11%) re-admissions. Patients with immunobullous disorders (OR 1.72, 95% CI 1.29-2.28) and psoriasis (OR 1.62, 95% CI 1.02-2.55) were more likely to be re-admitted. Adult patients, those who were admitted for more than four weeks, those who had comorbidities, and those who developed a complication during the hospital stay also had a greater likelihood of being re-admitted.

Limitations:

The retrospective design of the study, and the non-availability of data regarding transfers to other specialties or intensive care units and deaths were the main limitations of this study.

Conclusion:

This study describes the profile of patients admitted in a dermatology ward of a tertiary care centre center in North India. The patient profile and admission characteristics associated with a higher probability of re-admission were identified.

Plain Language Summary

Although dermatology is primarily an out-patient specialty, a subset of patients needs hospital admission for management. We retrospectively reviewed the characteristics of 1664 patients who were admitted a total of 2032 times to the dermatology ward of the All India Institute of Medical Sciences, New Delhi, over a period of four years (2014-2017). The most common diagnoses were immunobullous disorders and connective tissue diseases accounting for roughly half of the admissions, followed by infections, psoriasis and reactive arthritis. The average duration of admission was about two weeks and complications developed in about 10% of the admissions during hospital stay. Re-admission was needed in 15% of the patients, especially those with immunobullous disorders and psoriasis. Adult patients, those who were admitted for more than four weeks, those who had comorbidities, and those who developed a complication during the hospital stay also had a greater chance of being re-admitted.

Introduction

Dermatology is primarily an out-patient clinical specialty. Although skin diseases are generally non-life threatening, they are associated with significant morbidity and a negative impact on the quality of life. Many hospitals do not have dedicated in-patient services for patients with severe skin diseases, and such patients are often admitted under the care of internists with dermatologists providing consultation services.1 There is a paucity of literature regarding the profile of patients with skin diseases requiring hospital admission. This study reviews the characteristics of patients admitted over a four-year period to the dermatology ward of our institute.

Methods

We did a retrospective chart analysis of the discharge sheets of patients admitted in the dermatology inpatient ward of the All India Institute of Medical Sciences, New Delhi, India, a government tertiary care teaching hospital that caters largely to the population of North India. The dermatology ward has 29 beds, four of which are earmarked for providing isolation facilities for patients with extensive skin barrier loss. The ward is also equipped with two mechanical ventilators.

Discharge summaries of patients admitted in the dermatology ward between January 1, 2014 and December 31, 2017 were retrieved from the department’s electronic database. Patients admitted exclusively for day care were not included in the study. Variables analyzed for all admissions included patient age, gender, duration of admission stay, primary dermatological diagnosis, comorbidities, complications, and inter-specialty consults during the hospital stay. We also looked at the number of re-admissions, primary dermatological diagnosis for re-admissions, reason for re-admission and the interval from the date of discharge to the date of re-admission.

Statistical analysis

As some patients were admitted more than once, characteristics such as gender and co-morbidities were presented for patients (instead for all admissions) as recorded at the initial admission to avoid duplication of data, while results for complications and inter-specialty consults was presented for all admissions (including re-admissions) as these events would be unique for every admission. Continuous variables were presented as mean and standard deviation (median, interquartile range and absolute range), while categorical variables were presented as frequency (%). Continuous variables were compared using Student’s t-test, and categorical variables using Chi-square test or Fisher’s exact test. The patient profile and admission characteristics (patient age groups, gender, primary dermatological diagnosis, comorbidities, complications during admission and duration of hospital stay during first admission) associated with re-admissions were identified using logistic regression analysis. A P -value≤ 0.05 was considered statistically significant.

Results

During the four-year study period, a total of 3,20,741 patients (approximately 80,000 patients per year) visited our out-patient department. There were 2831 admissions during this period with 48 deaths (1.7%). The discharge records of 2032 (71.8%) admissions for 1664 patients could be retrieved from our database for analysis, of whom 842 (51%) were males accounting for 1036 (51%) admissions. There were 280 (17%) children (age <18 years) and 1384 adults (83%) accounting for 327 (16%) and 1705 (84%) admissions respectively. The mean age of the patients at admissions was 34.8 ± 17.2 years (range 0.1–91 years). The year-wise breakup of admission numbers and patient characteristicsis shown in Table 1.

Table 1:: Year-wise break-up of admission numbers and patient characteristics
Total 2014 2015 2016 2017
Total number of admissions 2831 674 677 716 764
Mortality 48 (1.7%) 12 (1.8%) 11 (1.6%) 17 (2.4%) 8 (1.1%)
Admissions analyzed 2032 (71.8%) 324 (48.1%) 563 (83.2%) 587 (81.9%) 558 (73%)
Number of patients 1664 294 465 473 432
Males
- Admissions 1036 172 284 314 266
- Patients 842 154 225 246 217
Females
- Admissions 996 152 279 273 292
- Patients 822 140 240 227 215
Mean age in years (range) 34.84±17.18 36.13±17.48 34.25±17.18 35.38±17.23 34.11±16.93
(0.1–91) (0.6–91) (0.1–79) (0.1–84) (0.1–78)
Mean duration of hospital stay in 13.95±11.67 15.61±13.15 13.26±11.71 14.22±10.95 13.40±11.38
days (median, range) (11, 1–118) (12, 1–95) (10, 1–118) (11, 1–81) (10, 1–109)

Primary dermatological diagnoses, comorbidities and complications

Immunobullous disorders (576, 28%) and connective tissue diseases (409, 20%) constituted for about half of the admissions. Infections (179, 8.8%; including leprosy and sexually transmitted infections), psoriasis (153, 7.5%) and reactive arthritis (92, 4.5%) were also frequently admitted. The complete list of dermatological diagnoses is shown in Table 2.

Table 2:: List of dermatology diagnosis for all admissions (n=2032)
Dermatologic diagnosis Frequency (%)
Immunobullous disorders 576 (28.2%)
Pemphigus vulgaris 455
Pemphigus foliaceus 58
Bullous pemphigoid 22
Cicatricial pemphigoid 12
Linear IgA disease 12
Epidermolysis bullosa acquisita 2
Others 15
Connective tissue diseases 409 (20.1%)
Systemic sclerosis 252
Lupus erythematosus 87
Dermatomyositis 31
SSc/RA overlap 6
SSc/DM overlap 9
SSc/SLE overlap 5
SLE/DM overlap 3
Morphea 7
Others 9
Infections (total) 179 (8.8%)
Cutaneous infections 93 (4.6%)
Mycetoma 25
Deep fungal infections 16
Cellulitis 14
Cutaneous tuberculosis 13
Suspected fungal or mycobacterial infections 8
Generalized verrucosis 4
Post-kala-azar dermal leishmaniasis 2
Others 11
Leprosy 64 (3.1%)
Sexually transmitted diseases 22 (1%)
Anogenital warts 5
Genital herpes 6
Vaginal discharge 4
Secondary syphilis 3
Others 4
Psoriasis 153(7.5%)
Reactive arthritis 92 (4.5%)
Cutaneous adverse drug reactions 86 (4.2%)
SJS/TEN 27
DRESS 24
Maculopapular rash 18
Fixed drug eruption 8
Erythroderma 3
Others 6
Erythrodermas 69 (3.4%)
Psoriasis 33
Dermatitis 22
Not specified 14
Genodermatoses 68 (3.4%)
Congenital ichthyosis 29
Inherited epidermolysis bullosa 10
Porphyria 8
Ectodermal dysplasia 5
Others 16
Dermatitis 59 (2.9%)
Atopic/endogenous dermatitis 28
Parthenium dermatitis 15
Others 16
Oral drug challenge 41 (2%)
Infantile hemangiomas and vascular malformations 41 (2%)
Vasculitis 32 (1.6%)
Chronic urticaria 30 (1.5%)
Cutaneous malignancies and lymphomas 28 (1.3%)
Basal cell carcinoma 2
Squamous cell carcinoma 6
Malignant melanoma 1
Kaposi sarcoma 1
Cutaneous T-cell lymphoma 17
Cutaneous B-cell lymphoma 1
Miscellaneous 129 (6.3%)
Including Neutrophilic dermatosis (18), histiocytosis (11) and PRP (11)
Uncertain diagnoses 40 (2%)

SSc: Systemic sclerosis, RA: Rheumatoid arthritis, DM: Dermatomyositis, SLE: Systemic lupus erythematosus, SJS: Stevens-Johnson syndrome, TEN: Toxic epidermal necrolysis, DRESS: Drug reaction with eosinophilia and systemic symptoms

The mean duration of admission was 14 ± 11.7 (median 11, IQR 7–17, range 1–118) days. Patients with cutaneous lymphomas had the longest mean hospital stays of 25 days. Patients with reactive arthritis and cutaneous infections averaged hospital stays of 20 days, while stays were shorter (≈ 12 days) for immunobullous disorders, leprosy and dermatitis [Table 3].

Table 3:: Hospital stay, complications, and interspecialty consultation rates for major diagnostic admission categories
Diagnosis Admissions, n Hospital stay, mean no. of days, (median, range) Complications, n (%) Interspecialty consults, n (%)
Immunobullous disorders 576 11.83±10.34, (8, 1–109) 69/486 (14.2) 276/477 (86.4)
Connective tissue diseases 409 13.04±8.57, (11, 1–81) 33/350 (9.4) 239/354 (67.5)
Psoriasis 153 13.45±13.71, (10, 1–95) 13/131 (9.9) 91/128 (71)
Cutaneous infections 93 20.16±17.78, (16, 2–118) 9/83 (10.8) 58/85 (68.2)
Reactive arthritis 92 20.50±17.65, (15, 2–80) 11/82 (13.4) 51/83 (61.4)
Drug reactions 86 15.37±10.07, (13, 2–50) 13/78 (16.7) 60/79 (75.9)
Erythrodermas 69 15.73±11.03, (12, 3–51) 8/59 (13.6) 35/60 (58.3)
Genodermatoses 68 10.52±6.07, (8.5, 2–27) 3/59 (5.1) 46/58 (79.3)
Leprosy 64 12.15±7.24, (10, 3–32) 3/54 (5.6) 28/54 (51.9)
Dermatitis 59 12.45±10.56, (10, 2–66) 4/52 (7.7) 34/53 (64.2)
Drug provocations 41 15.7±16.28, (12, 5–111) 0/38 15/38(39.5)
Infantile hemangiomas and vascular malformations 41 10.78±6.94, (10, 1–37) 3/36 (8.3) 15/36(41.7)
Vasculitis 32 20.81±13.37 (19, 4–51) 7/28 (24) 22/28 (78.6)
Chronic urticaria 30 11.66±8.39, (10.5, 1–37) 0/30 8/25 (32)
Sexually transmitted infections 22 15.04±7.97, (14.5, 2–40) 0/21 13/19 (68.4)
Cutaneous lymphomas 18 24.88±14.88, (21, 6–59) 2/17 (11.8) 14/16 (87.5)
Cutaneous malignancies 10 21.4±19.77, (15.5, 2–66) 0/7 9/10 (90)

Comorbidities were seen in 594 (40%, out of 1490 patients for whom co-morbidity data was available) patients. Up to four comorbidities were seen in these patients, including 435 (73%) patients with a single comorbidity, 130 (22%) with 2, 28 (5%) with three, and one patient with four comorbidities. The coexisting conditions in order of decreasing frequency were diabetes mellitus (149, 25%), hypertension (122, 21%), anemia (92, 16%), psoriatic arthritis (40, 6.7%), hypothyroidism (37, 6.2%), tuberculosis (34, 5.7%) and psychiatric disorders (33, 5.6%).

A total of 205 complications developed in 183 (10.5%, out of 1742 admissions for whom this data was available) admissions during their stay in the hospital. A single complication occurred in 161 of these admissions and two complications were noted in 22 admissions. The most common complications were treatment-related adverse events (110, 53.7%) and hospital acquired infections (89, 43.4%). Deep venous thrombosis and decubitus ulcers were rare and were seen in five and one admissions respectively, Treatment associated complications comprised 77 cases of transaminitis, 17 of leukopenia, seven with acute kidney injury, five of thrombocytopenia, three infusion reactions and a single case of hemorrhagic cystitis.

Of the 89 hospital-acquired infections in 83 admissions, urinary tract infections were seen in 22, pneumonia in 21, cellulitis in 18, eczema herpeticum in 15, and sepsis in 13 admissions. The majority of hospital infections occurred in patients with immunobullous disorders (39/89, 43.8%). Hospital infections also occurred in connective tissue diseases (11, 12.3%), DRESS, psoriasis and erythroderma (5, 5.6% each), reactive arthritis (4, 4.5%) and leprosy (2, 2.2%).

Inter-specialty consultations were necessary in 1100 (63%, out of 1746 admissions for whom this data was available) admissions, with the maximum number of such consultations being nine in one case. A total of 1736 interspeciality consultations were conducted in these 1100 admissions, with 675 admissions needing a single consult, 290 needing two consults, 88 requiring three consults, and 47 (4.3%) needed four or more consults. The most frequently consulted specialties were endocrinology (289, 16.6%), internal medicine (219, 12.6%), pulmonary medicine (192, 11.1%), gastroenterology (110, 6.3%), ophthalmology (120, 6.9%), rheumatology (87, 5%) and psychiatry (68, 3.9%).

The duration of hospital stay, complications and interspecialty consultation rates per admission for the major categories of diagnoses are shown in Table 3.

Profile of hospital re-admissions

Two hundred and fifty six patients (15.4%) were re-admitted one or more times (range 1-10) for a total of 368 (18.1%) re-admissions. These 256 patients accounted for 624 (30.7%) of the 2032 admissions, and included 181 (70.7%) who were re-admitted once, 56 (21.9%) who were re-admitted twice, 13 (5.1%) who were re-admitted thrice and 6 (2.3%) patients who were re-admitted four times or more (range 4–10). The mean interval between the date of discharge and re-admissions (n = 368) was 154.16 ± 193.97 days (median 70, IQR 24–211.5, range 2–1015 days). The 30-day and 1-year re-admission rates were 5.3% (108/2032) and 15.8% (322/2032), respectively. The time interval between discharge and re-admission is shown in Figure 1.

Figure 1:: Break-up of time intervals between discharge and re-admission

Among the re-admissions, immunobullous disorders (n=134/368, 36.4%) were the most common diagnosis, followed by connective tissue diseases (n=68, 18.5%), reactive arthritis (n=40, 10.9%), psoriasis (n=34, 9.2%) and erythrodermas (n=16, 4.3%). A detailed list of the reason for re-admissions is given in Table 4.

Table 4:: Reasons for re-admission (n=338)*
Reason Number (%)
Administering subsequent doses of pulsed steroids or biologics 137 (37.5%)
Exacerbation of the primary dermatological disease 121 (32.8%
Re-evaluation of the disease 17 (4.6%)
Treatment-related complications 16 (4.3%)
Oral drug challenge 7 (1.9%)
Unrelated to the primary diagnosis 40 (10.9%)
Infections 22
Comorbidities 9
Miscellaneous causes 9
*Reason for re-admission not available 30 (8.1%)

Table 5 shows patient and admission variables associated with re-admissions. Adults (OR 1.54), patients with long (> 4 weeks) hospital stays (OR 1.73), patients with immunobullous disorders (OR 1.72) or psoriasis (OR 1.62), and those with comorbidities (OR 1.46-1.59) or complications (OR 1.93) were more likely to be re-admitted. However, patients with drug reactions were significantly less likely to be re-admitted (OR 0.34).

Table 5:: Comparison of baseline admission profiles between patients with and without re-admissions
Baseline parameters Patients with re-admission (n=256) Patients without re-admissions (n=1408) P-value OR (95% CI) P-value
Mean age (range) in years 35.24±15.5 (0.6–76) 34.88±18.03 (0.1–91) 0.802 -
Age group (years) 0.005*
Children (<18) 33 (12.9%) 247 (17.5%) 1.00
Adults (18–59) 207 (80.9%) 1004 (71.3%) 1.54 (1.04–2.29) 0.030*
Elderly (≥60) 16 (6.3%) 157 (11.2%) 0.76 (0.41–1.43) 0.399
Gender 0.730
Male 127 (49.6%) 715 (50.8%) 1.00
Female 129 (50.4%) 693 (49.2%) 1.05 (0.80–1.37) 0.730
Mean duration of admission (median, range) in days 14.89±11.26 (12, 1–75) 13.89±11.31 (11, 1–111) 0.193 -
Duration of admission (weeks) 0.047*
<2 162 (63.2%) 955 (67.8%) 1.00
2–4 64 (25%) 351(24.9%) 1.07 (0.79–1.47) 0.652
>4 30 (11.7%) 102 (7.2%) 1.73 (1.12–2.69) 0.014*
Number of patients with comorbidities 110/228 (48.2%) 484/1262 (38.4%) 0.005*
0 118 (51.7%) 778 (61.6%) 1.00
1 79 (34.6%) 356 (28.2%) 0.017* 1.46 (1.07–1.99) 0.017*
>1 31 (113.6%) 128 (10.1%) 1.59 (1.03–2.47) 0.036*
Number of patients with complications 32/210 (15.2%) 103/1206 (8.5%) <0.002*
0 178 (84.8%) 1103 (91.5%) <0.002* 1.00
≥1 32 (15.2%) 103 (8.6%) 1.93 (1.26–2.95) 0.003*
Number of patients with interspecialty consults 140/210 (66.6%) 750/1214 (61.8%) 0.176
0 70 (33.3%) 464 (38.2%) 1.00
1 89 (42.4%) 468 (38.6%) 0.387 1.26 (0.89–1.77) 0.179
>1 51 (24.3%) 282 (23.2%) 1.19 (0.81–1.77) 0.362
Diagnosis
Immunobullous disorders 92 (35.9%) 346 (24.6%) <0.001* 1.72 (1.29–2.28) <0.001*
Connective tissue diseases 53 (20.7%) 288 (20.5%) 0.933 1.02 (0.73–1.41) 0.928
Psoriasis 26 (10.2%) 92 (6.5%) 0.046* 1.62 (1.02–2.55) 0.039*
Reactive arthritis 13 (5.1%) 39 (2.8%) 0.075 1.88 (0.98–3.56) 0.054
Cutaneous infections 06 (2.3%) 74 (5.3%) 0.055 0.43 (0.18–1.01) 0.051
Cutaneous adverse drug reactions 05 (1.9%) 77 (5.5%) 0.017* 0.34 (0.14–0.86) 0.022*
Erythroderma 13 (5.1%) 45 (3.2%) 0.138 1.62 (0.86–3.05) 0.134
Genodermatoses 05 (1.9%) 58 (4.1%) 0.109 0.46 (0.18–1.16) 0.103
Leprosy 07 (2.7%) 49 (3.5%) 0.706 0.78 (0.35–1.74) 0.544
Dermatitis 06 (2.3%) 48 (3.4%) 0.448 0.68 (0.28–1.61) 0.379
Drug provocation 02 (0.8%) 35 (2.5%) 0.106 0.31 (0.07–1.29) 0.108
Infantile hemangioma and vascular malformations 02 (0.8%) 37 (2.6%) 0.074 0.29 (0.07–1.22) 0.091
Vasculitis 03 (1.2%) 21 (1.5%) 1.000 0.78 (0.23–2.64) 0.694
Chronic urticaria 02 (0.8%) 25 (1.8%) 0.416 0.44 (0.10–1.86) 0.260
Sexually transmitted infections 02 (0.8%) 19 (1.3%) 0.759 0.58 (0.13–2.48) 0.459
Cutaneous lymphomas 01 (0.4%) 16 (1.1%) 0.496 0.34 (0.04–2.58) 0.298
Cutaneous malignancies 00 (0%) 10 (0.7%) 0.376 0.26 (0.02–4.44) 0.352

CI: Confidence interval, OR: Odds ratio

Discussion

This study provides detailed information regarding the profile of admissions in the dermatology ward of a tertiary center in North India. Immunobullous disorders and connective tissue diseases were the most common diagnoses, accounting for almost half (48.5%) of the admissions. Other common diagnoses included psoriasis, infections, reactive arthritis and drug reactions. Of the immunobullous disorders, pemphigus vulgaris was the most common (455/576, 78.9%), while in the connective tissue disease group, systemic sclerosis (including overlap syndromes) was most frequently seen (272/409, 66.5%).

The pattern of diagnoses in our inpatients was quite different from that seen in the West where dermatitis, psoriasis, chronic wounds and skin neoplasms figure prominently.2-6 Data regarding the profile of admitted dermatology patients from India and Asia are sparse, but as in the present study, immunobullous disorders were the most common in reports from East India7 and Iran8. The higher proportion of connective tissue diseases and reactive arthritis in our study may, at least in part, be due to the lack of in-patient rheumatology services at our hospital.

Infections, including leprosy and sexually transmitted infections, constituted 8.8% of admissions in our study whereas in the other Indian study by Sen et al7, they comprised 19.5% of all admissions. Dermatitis, reported to be the most common admission diagnoses (16–44%) in studies from the West,2,4-6 made up only 2.9% of our admissions, and about 5% in the study by Sen et al.7 Similarly, cutaneous lymphomas and malignancies comprised only 1.3% of our admissions in comparison to 6–36% of admissions in the West.2,3,6 Notably, about 2% of our admissions had an uncertain diagnosis even at discharge, reflecting the complex patient profile and diagnostic dilemmas that present to us.

The mean hospital stay of 14 days in our study was similar to the average 13 days hospital stay reported from Brazil.4 Shorter hospital stays of 11, 10, 7 and 4 days respectively were noted in studies from UK6, Australia9, Spain3, and the USA2 but longer hospital stays of over 20 days were reported in the study by Sen et al7 and from South Africa.5 Our patients with cutaneous lymphomas and cutaneous malignancies had long hospital stays of over 21 days owing to multiple diagnostic and staging investigations. Patients with reactive arthritis also recorded long hospital stays (> 20 days) for administration of biologics and multiple inter-speciality consultations with rheumatology and pain management specialties. However, our patients with immunobullous disorders had relatively short hospital stays averaging 11.8 days, in contrast to the long stays of 22 days in other reports.4,5,7

About 40% of our patients had one or more comorbidities. Diabetes mellitus and hypertension were the most frequent comorbidities.4 The complication rate of 10% was much lower than that (25%) reported in the study by Sen et al.7 Hospital-acquired infection were seen in 5% (89/1742) of our admissions which is similar to that (6%) reported in the Brazilian study, 4 and were most frequent among patients with immunobullous disorders. Sepsis was documented in 0.75% our admissions. This is much lower than that (4.6%) reported in an earlier study from our ward in 2004–2006.10 Although this difference could be due to better hospital infection control practices currently followed, it is more likely that since the focus of the previous study was sepsis in the dermatology ward, it resulted in a more sensitive recording of sepsis-related data. Blood stream infections accounted for a third of all hospital acquired infections (translating into about 2% of all admissions) in the Brazilian study.4

About 15% (256/1664) of our patients were re-admitted, making up 30% (624/2032) of our total admissions. The re-admissions alone accounted for about 18% (368/2032) of our total admissions. The majority of these re-admissions (88%) were related to the primary dermatology diagnosis, while the remaining (12%) were re-admitted for unrelated reasons. In our study, 30-day re-admission rates were 5%, while they were 1.8% in a study from Spain,3 and 9.8% and 12.3% in two US studies.11,12 The one-year re-admission rate was 12.5% in the Spanish study in comparison to 16% in our study. Many patients with chronic skin illnesses discontinue treatment after initial recovery without further consultation, leading to disease flare-ups requiring re-admissions. One way to reduce the re-admissions is to ensure proper counseling at the time of discharge. Telephonic contacts with discharged patients a few weeks after discharge may help prevent such outcomes.

Patients with immunobullous disorders and psoriasis were more likely to be re-admitted than other conditions. The course of these diseases is marked with exacerbations or relapses, necessitating frequent hospitalizations. Psoriasis was reported as a frequent cause of re-admission in the study from Spain,3 while high re-admission rates were noted in patients with cutaneous lymphomas, connective tissue diseases and graft-versus-host disease in reports from the USA.11,12 A longer stay during the first hospitalization and occurrence of complications were also associated with a higher re-admission rate in our study. The presence of comorbidities was another risk factor for re-admission.11,12 Children were less likely to require re-admissions, and this may be related to the less frequent occurrence of immunobullous disorders and psoriasis (associated with higher rates of re-admission) in this age group. There were no gender differences for re-admission in our study but Arnold et al.11 noted that females were more likely to be re-admitted. Arnold et al.11 also noted that other factors such as having public medical insurance, belonging to a low-income community or admission in a large hospital were associated with higher rates of re-admission,11 but we did not examine these variables.

In-patient dermatology services have been on the decline in the West.1,13 The need for dermatology wards has recently become the subject of debate, particularly with the development of newer, more efficacious treatments including biologics for severe skin diseases. It has been suggested that patients with skin diseases requiring in-patient care may be admitted under other specialist units with dermatologists providing consultative services.13,14 Although patients with skin disease as part of multisystem disease (e.g., an autoimmune connective tissue disease) or having significant comorbidities (e.g., uncontrolled diabetes or end-stage renal disease) may be better managed in a general medical ward with a visiting consultant dermatologist, there is no disputing the fact that patients with severe primary cutaneous disease such as psoriasis, dermatitis or pemphigus would be better managed in a dermatology ward with the dermatologist in direct control. Patients requiring oral drug provocation or those with a complex skin disease that is a diagnostic challenge would be best managed in specialist dermatology wards. The quality-of-life of patients with severe dermatological illnesses has been shown to significantly improve after hospital admission.15,16

Being a tertiary care teaching institute, patients with severe and complex diseases are often referred to us who get admitted, while some patients are admitted for academic reasons also. Apart from the disease profile and severity, there may be administrative and other factors influencing dermatology admissions. Our institute being a government hospital with minimal healthcare charges may also influence admissions; hospitalizations are often needed for arranging or indenting medications and biologicals for poor patients. Our institute caters to the population from the entire North India and patients coming from far off places requiring multiple dermatosurgery or ablative sessions are also often admitted. Other reasons for admission may include facilitating cross-consultations with other departments and admissions owing to lack of inpatient facilites in allied specialties (such as rheumatology).

Limitations

Limitations of our study include its retrospective design and some missing entries in the discharge summaries. As the data was searched from discharge summaries, information regarding transfers to other specialties or intensive care units, and mortalities was not available. Also, details not routinely recorded in the discharge sheets such as patient residence and socioeconomic status, as well as source of admission such as from outpatient service, emergency ward or if transferred from other specialty could not be analyzed.

Conclusion

Our study provides a glimpse of profile of patients admitted in a dermatology ward of a tertiary care center in North India. The pattern of admission diagnoses differed from that reported in western studies. A significant proportion of patients get re-admitted. Certain diagnoses, patient demographic characteristics and background medical profile and those requiring a longer hospital stay or developing complications are more likely to be re-admitted.

Declaration of patient consent

The patient's consent is not required as the patient's identity is not disclosed or compromised.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

  1. , , . The changing status of inpatient dermatology at American academic dermatology programs. J Am Acad Dermatol. 1999;40:755-7.
    [CrossRef] [Google Scholar]
  2. , , , , , , et al. Experience with the dermatology inpatient hospital service for adults: Mayo Clinic, 2000-2010. J Eur Acad Dermatol Venereol. 2013;27:1360-5.
    [CrossRef] [PubMed] [Google Scholar]
  3. , , , , , . Inpatient dermatology: Characteristics of patients and admissions in a Spanish hospital. J Eur Acad Dermatol Venereol. 2002;16:334-8.
    [CrossRef] [PubMed] [Google Scholar]
  4. , , , . Inpatient dermatology: Profile of patients and characteristics of admissions to a tertiary dermatology inpatient unit in São Paulo, Brazil. Int J Dermatol. 2014;53:685-91.
    [CrossRef] [PubMed] [Google Scholar]
  5. , , , , . Pattern of admissions to a tertiary dermatology unit in South Africa. Int J Dermatol. 2002;41:568-70.
    [CrossRef] [PubMed] [Google Scholar]
  6. , , , , . The value of in-patient dermatology: A survey of in-patients in Scotland and Northern England. Br J Dermatol. 1999;140:474-9.
    [CrossRef] [PubMed] [Google Scholar]
  7. , , , . Inpatient dermatology: Characteristics of patients and admissions in a tertiary level hospital in Eastern India. Indian J Dermatol. 2016;61:561-4.
    [CrossRef] [PubMed] [Google Scholar]
  8. , , , , . Patterns of admissions to a Referral Skin Hospital in Iran. Iran J Dermatol. 2008;11:156-8.
    [Google Scholar]
  9. , . Inpatient dermatology: Pattern of admissions and patients' characteristics in an Australian hospital. Australas J Dermatol. 2014;55:191-5.
    [CrossRef] [PubMed] [Google Scholar]
  10. , , , , . Clinical and bacteriological profile and outcome of sepsis in dermatology ward in tertiary care center in New Delhi. Indian J Dermatol Venereol Leprol. 2011;77:141-7.
    [CrossRef] [PubMed] [Google Scholar]
  11. , , . Hospital readmissions among patients with skin disease: A retrospective cohort study. J Am Acad Dermatol. 2018;79:696-701.
    [CrossRef] [PubMed] [Google Scholar]
  12. , , , , , . Dermatology-specific and all-cause 30-day and calendar-year readmissions and costs for dermatologic diseases from 2010 to 2014. J Am Acad Dermatol. 2019;81:740-8.
    [CrossRef] [PubMed] [Google Scholar]
  13. , . Dermatology inpatient care in the UK: Rarely possible, hard to defend but occasionally essential. Br J Dermatol. 2019;180:440-2.
    [CrossRef] [PubMed] [Google Scholar]
  14. . Society of Dermatology Hospitalists. Inpatient dermatology: A paradigm shift in the management of skin disease in the hospital. Br J Dermatol. 2019;180:966-7.
    [CrossRef] [PubMed] [Google Scholar]
  15. , , . The need for dedicated dermatology beds. Clin Med Lond Engl. 2011;11:300-1.
    [CrossRef] [PubMed] [Google Scholar]
  16. , , , , , . Hospitalization for severe skin disease improves quality of life in the United Kingdom and the United States: A comparative study. J Am Acad Dermatol. 2003;49:249-54.
    [CrossRef] [Google Scholar]
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