Clinical Review & Education
From The JAMA Network
Patient Satisfaction and Quality of Life in Psoriasis and Psoriatic Arthritis Katherine M. Mercy, MD; Kenneth B. Gordon, MD; Amy S. Paller, MD, MS
JAMA DERMATOLOGY Undertreatment, Treatment Trends, and Treatment Dissatisfaction Among Patients With Psoriasis and Psoriatic Arthritis in the United States: Findings From the National Psoriasis Foundation Surveys, 2003-2011
RESULTS A total of 5604 patients with psoriasis or psoriatic
undertreatment of psoriatic diseases, trends in treatment use, treatment satisfaction, and reasons for medication discontinuation among patients with psoriasis and psoriatic arthritis.
arthritis completed the survey. From 2003 through 2011, patients who were untreated ranged from 36.6% to 49.2% of patients with mild psoriasis, 23.6% to 35.5% of patients with moderate psoriasis, and 9.4% to 29.7% of patients with severe psoriasis. Among those receiving treatment, 29.5% of patients with moderate psoriasis and 21.5% of patients with severe psoriasis were treated with topical agents alone. The most frequently used phototherapy modality is UV-B, whereas methotrexate is the most commonly used oral agent. Although adverse effects and a lack of effectiveness were primary reasons for discontinuing biological agents, the inability to obtain adequate insurance coverage was among the top reasons for discontinuation. Overall, 52.3% of patients with psoriasis and 45.5% of patients with psoriatic arthritis were dissatisfied with their treatment.
DESIGN, SETTING, AND PARTICIPANTS We used the national survey data collected by the National Psoriasis Foundation via biannual surveys conducted from January 1, 2003, through December 31, 2011, in the United States. Survey data were collected from randomly sampled patients with psoriasis and psoriatic arthritis in the US population from a database of more than 76 000 patients with psoriatic diseases.
CONCLUSIONS AND RELEVANCE Nontreatment and undertreatment of patients with psoriasis and psoriatic arthritis remain a significant problem in the United States. While various treatment modalities are available for psoriasis and psoriatic arthritis, widespread treatment dissatisfaction exists. Efforts in advocacy and education are necessary to ensure that effective treatments are accessible to this patient population.
MAIN OUTCOMES AND MEASURES Nontreatment, undertreatment, and treatment trends determined by the use
JAMA Dermatol. 2013;149(10):1180-1185.
April W. Armstrong, MD, MPH; Andrew D. Robertson, PhD; Julie Wu, BS; Clayton Schupp, PhD; Mark G. Lebwohl, MD IMPORTANCE Psoriasis and psoriatic arthritis inflict significant
morbidity. Data on undertreatment, treatment use, and treatment satisfaction are paramount to identify priority areas for advocacy, education, and research to improve patient outcomes. OBJECTIVES To determine the extent of nontreatment and
Although available topical and systemic treatments for psoriasis and psoriatic arthritis continue to evolve, little is known about adequacy of treatment for patients with psoriasis. In addition, patient satisfaction has seldom been studied or incorporated into psoriasis practice guidelines. Instead, studies have classically used physician-centered objective measures as a means to determine adequacy of psoriasis treatment. Yet patient satisfaction remains an important consideration that has been correlated with patient adherence with psoriasis therapy and treatment outcomes.1 In addition, patient satisfaction contributes to responses in healthrelated quality-of-life indices (eg, Dermatology Life Quality Index).2 In an effort to further characterize satisfaction among patients with psoriasis, Armstrong et al 3 published results in 2676
of prescription medication (topical, phototherapeutic, oral systemic, and biologic), as well as treatment satisfaction and reasons for medication discontinuation.
doi:10.1001/jamadermatol.2013.5264.
JAMA Dermatology of National Psoriasis Foundation (NPF) surveys administered from 2003 to 2011, reporting responses from 5604 members with psoriasis and psoriatic arthritis. In this study, NPF-generated questionnaires compared psoriasis severity and the use of prescription medications. Survey results showed that 9.4% and 23.6% of respondents with severe and moderate psoriasis, respectively, received no treatment for psoriasis and psoriatic arthritis, suggesting marked undertreatment. Even more striking, however, was that 52.3% of respondents with psoriasis and 45.5% of respondents with psoriatic arthritis were dissatisfied their treatment. Dissatisfaction was highest among respondents with moderate (3%-10% body surface area) psoriasis. By surveying patient satisfaction in large patient populations, inves-
JAMA December 24/31, 2014 Volume 312, Number 24
Copyright 2014 American Medical Association. All rights reserved.
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From The JAMA Network Clinical Review & Education
tigators overcame potential selection bias seen in smaller clinical studies. However, the study was limited in its failure to explore specific contributors to dissatisfaction and its lack of stratification of satisfaction by treatment type or outcome. Using similar methodology, van Cranenburgh et al4 administered a study-specific web-based patient satisfaction survey to 1293 members of psoriasis patient associations in the Netherlands and overall found less patient dissatisfaction (10%-17%) than in the study by Armstrong et al.3 After controlling for demographics and clinical characteristics (eg, psoriasis type, location, and disease severity), patients receiving biologic therapy were most satisfied and patients receiving topical therapy were the least satisfied of all treatment groups. Similarly, a recent cross-sectional study of 1182 patients in the Dermatology Clinical Effectiveness Research Network in the United States found that patient satisfaction scores were highest for patients receiving biologic monotherapy, biologicmethotrexate combinations, or phototherapy and were lowest for patients receiving topical therapies only or acitretin.2 The high rate of treatment of patients in the study by Armstrong et al3 with severe and moderate psoriasis with topical medications alone (21.5% and 29.5%, respectively) could have further contributed to the increased patient dissatisfaction. According to the NPF survey, patients cited fewer adverse effects of treatment as the primary reason for limiting treatment to topical medications. Indeed, physician unwillingness to prescribe systemic treatments was the third most common reason in the NPF survey that patients with psoriasis received only topical medications, suggesting that counseling about the potential risks and benefits of available systemic treatments was insufficient. The difficulty in obtaining coverage of medication costs by insurance might also prohibit some physicians from prescribing biologic medications. A recent trial of brodalumab in moderate-to-severe psoriasis revealed improvement in the Dermatology Life Quality Index as early as 4 weeks into treatment. The degree of improvement in patient ARTICLE INFORMATION Author Affiliations: Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois. Corresponding Author: Amy S. Paller, MD, MS, Department of Dermatology, Northwestern University Feinberg School of Medicine, 676 N St Clair, Ste 1600, Chicago, IL 60611 (apaller @northwestern.edu). Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Gordon reported having received grants, personal fees, or both from Abbott, Amgen, Celgene, Eli Lilly, Janssen, Novartis, Pfizer, and Merck. Dr Paller reported having received an honorarium for consultating for Abbvie and having been an investigator without personal compensation for Amgen. No other disclosures were reported. REFERENCES
quality-of-life measures correlated with extent of clinical response.5 Given the potential efficacy of emerging biologic therapies, it will be important to further assess physician hesitation to prescribe these agents. Importantly, treatment of psoriasis is a key component in management of the overall health of the individual. In a randomized, double-blind, placebo-controlled study of ustekinumab in 1230 patients with moderate-to-severe psoriasis, 40.3% and 26.7% of patients reported baseline anxiety and depression, respectively,6 with scores comparable with those of patients given the diagnosis of breast cancer or chronic obstructive pulmonary disease. During 1 year of treatment with ustekinumab, levels of anxiety and depression improved significantly and correlated with psoriasis improvement, as measured by the Physician Assessment of Severity Index. Studies also highlight the relationship between psoriasis and obesity, metabolic disease, stroke, and cardiovascular events. Given that an underlying chronic inflammatory state links these disorders, effective treatment of psoriasis-associated inflammation might mitigate these comorbidities. Indeed, treatment of psoriasis with methotrexate7 or with tumor necrosis factor inhibitors8 is associated with decreased cardiovascular morbidity and mortality. Acknowledging these metabolic risks is important in dermatologists’ approach to patients with psoriasis and may lead to more effective management. Addressing patient satisfaction improves patient adherence and thus has a major effect on treatment outcomes for both psoriasis and its comorbidities. As such, the significant percentage of dissatisfied psoriasis patients in the study by Armstrong et al3 has serious implications for adherence and treatment outcomes. Future studies should be conducted to further evaluate components of patient satisfaction and the relationship to treatment outcomes. In addition, patient preference and satisfaction should be incorporated into future practice guidelines for psoriasis and psoriatic arthritis.
2. Callis Duffin K, Yeung H, Takeshita J, et al. Patient satisfaction with treatments for moderate-to-severe plaque psoriasis in clinical practice. Br J Dermatol. 2014;170(3):672-680. 3. Armstrong AW, Robertson AD, Wu J, Schupp C, Lebwohl MG. Undertreatment, treatment trends, and treatment dissatisfaction among patients with psoriasis and psoriatic arthritis in the United States: findings from the National Psoriasis Foundation surveys, 2003-2011. JAMA Dermatol. 2013;149(10): 1180-1185. 4. van Cranenburgh OD, de Korte J, Sprangers MA, de Rie MA, Smets EM. Satisfaction with treatment among patients with psoriasis: a web-based survey study. Br J Dermatol. 2013;169(2):398-405. 5. Gordon KB, Kimball AB, Chau D, et al. Impact of brodalumab treatment on psoriasis symptoms and health-related quality of life: use of a novel patient-reported outcome measure, the Psoriasis Symptom Inventory. Br J Dermatol. 2014;170(3): 705-715.
6. Langley RG, Feldman SR, Han C, et al. Ustekinumab significantly improves symptoms of anxiety, depression, and skin-related quality of life in patients with moderate-to-severe psoriasis: results from a randomized, double-blind, placebo-controlled phase III trial. J Am Acad Dermatol. 2010;63(3):457-465. 7. Prodanovich S, Ma F, Taylor JR, Pezon C, Fasihi T, Kirsner RS. Methotrexate reduces incidence of vascular diseases in veterans with psoriasis or rheumatoid arthritis. J Am Acad Dermatol. 2005;52 (2):262-267. 8. Wu JJ, Poon KY, Channual JC, Shen AY. Association between tumor necrosis factor inhibitor therapy and myocardial infarction risk in patients with psoriasis. Arch Dermatol. 2012;148(11): 1244-1250.
1. Finlay AY, Ortonne JP. Patient satisfaction with psoriasis therapies: an update and introduction to biologic therapy. J Cutan Med Surg. 2004;8(5):310320.
jama.com
JAMA December 24/31, 2014 Volume 312, Number 24
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of Iowa User on 06/01/2015
2677
From The JAMA Network
Patient Satisfaction and Quality of Life in Psoriasis and Psoriatic Arthritis Katherine M. Mercy, MD; Kenneth B. Gordon, MD; Amy S. Paller, MD, MS
JAMA DERMATOLOGY Undertreatment, Treatment Trends, and Treatment Dissatisfaction Among Patients With Psoriasis and Psoriatic Arthritis in the United States: Findings From the National Psoriasis Foundation Surveys, 2003-2011
RESULTS A total of 5604 patients with psoriasis or psoriatic
undertreatment of psoriatic diseases, trends in treatment use, treatment satisfaction, and reasons for medication discontinuation among patients with psoriasis and psoriatic arthritis.
arthritis completed the survey. From 2003 through 2011, patients who were untreated ranged from 36.6% to 49.2% of patients with mild psoriasis, 23.6% to 35.5% of patients with moderate psoriasis, and 9.4% to 29.7% of patients with severe psoriasis. Among those receiving treatment, 29.5% of patients with moderate psoriasis and 21.5% of patients with severe psoriasis were treated with topical agents alone. The most frequently used phototherapy modality is UV-B, whereas methotrexate is the most commonly used oral agent. Although adverse effects and a lack of effectiveness were primary reasons for discontinuing biological agents, the inability to obtain adequate insurance coverage was among the top reasons for discontinuation. Overall, 52.3% of patients with psoriasis and 45.5% of patients with psoriatic arthritis were dissatisfied with their treatment.
DESIGN, SETTING, AND PARTICIPANTS We used the national survey data collected by the National Psoriasis Foundation via biannual surveys conducted from January 1, 2003, through December 31, 2011, in the United States. Survey data were collected from randomly sampled patients with psoriasis and psoriatic arthritis in the US population from a database of more than 76 000 patients with psoriatic diseases.
CONCLUSIONS AND RELEVANCE Nontreatment and undertreatment of patients with psoriasis and psoriatic arthritis remain a significant problem in the United States. While various treatment modalities are available for psoriasis and psoriatic arthritis, widespread treatment dissatisfaction exists. Efforts in advocacy and education are necessary to ensure that effective treatments are accessible to this patient population.
MAIN OUTCOMES AND MEASURES Nontreatment, undertreatment, and treatment trends determined by the use
JAMA Dermatol. 2013;149(10):1180-1185.
April W. Armstrong, MD, MPH; Andrew D. Robertson, PhD; Julie Wu, BS; Clayton Schupp, PhD; Mark G. Lebwohl, MD IMPORTANCE Psoriasis and psoriatic arthritis inflict significant
morbidity. Data on undertreatment, treatment use, and treatment satisfaction are paramount to identify priority areas for advocacy, education, and research to improve patient outcomes. OBJECTIVES To determine the extent of nontreatment and
Although available topical and systemic treatments for psoriasis and psoriatic arthritis continue to evolve, little is known about adequacy of treatment for patients with psoriasis. In addition, patient satisfaction has seldom been studied or incorporated into psoriasis practice guidelines. Instead, studies have classically used physician-centered objective measures as a means to determine adequacy of psoriasis treatment. Yet patient satisfaction remains an important consideration that has been correlated with patient adherence with psoriasis therapy and treatment outcomes.1 In addition, patient satisfaction contributes to responses in healthrelated quality-of-life indices (eg, Dermatology Life Quality Index).2 In an effort to further characterize satisfaction among patients with psoriasis, Armstrong et al 3 published results in 2676
of prescription medication (topical, phototherapeutic, oral systemic, and biologic), as well as treatment satisfaction and reasons for medication discontinuation.
doi:10.1001/jamadermatol.2013.5264.
JAMA Dermatology of National Psoriasis Foundation (NPF) surveys administered from 2003 to 2011, reporting responses from 5604 members with psoriasis and psoriatic arthritis. In this study, NPF-generated questionnaires compared psoriasis severity and the use of prescription medications. Survey results showed that 9.4% and 23.6% of respondents with severe and moderate psoriasis, respectively, received no treatment for psoriasis and psoriatic arthritis, suggesting marked undertreatment. Even more striking, however, was that 52.3% of respondents with psoriasis and 45.5% of respondents with psoriatic arthritis were dissatisfied their treatment. Dissatisfaction was highest among respondents with moderate (3%-10% body surface area) psoriasis. By surveying patient satisfaction in large patient populations, inves-
JAMA December 24/31, 2014 Volume 312, Number 24
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of Iowa User on 06/01/2015
jama.com
From The JAMA Network Clinical Review & Education
tigators overcame potential selection bias seen in smaller clinical studies. However, the study was limited in its failure to explore specific contributors to dissatisfaction and its lack of stratification of satisfaction by treatment type or outcome. Using similar methodology, van Cranenburgh et al4 administered a study-specific web-based patient satisfaction survey to 1293 members of psoriasis patient associations in the Netherlands and overall found less patient dissatisfaction (10%-17%) than in the study by Armstrong et al.3 After controlling for demographics and clinical characteristics (eg, psoriasis type, location, and disease severity), patients receiving biologic therapy were most satisfied and patients receiving topical therapy were the least satisfied of all treatment groups. Similarly, a recent cross-sectional study of 1182 patients in the Dermatology Clinical Effectiveness Research Network in the United States found that patient satisfaction scores were highest for patients receiving biologic monotherapy, biologicmethotrexate combinations, or phototherapy and were lowest for patients receiving topical therapies only or acitretin.2 The high rate of treatment of patients in the study by Armstrong et al3 with severe and moderate psoriasis with topical medications alone (21.5% and 29.5%, respectively) could have further contributed to the increased patient dissatisfaction. According to the NPF survey, patients cited fewer adverse effects of treatment as the primary reason for limiting treatment to topical medications. Indeed, physician unwillingness to prescribe systemic treatments was the third most common reason in the NPF survey that patients with psoriasis received only topical medications, suggesting that counseling about the potential risks and benefits of available systemic treatments was insufficient. The difficulty in obtaining coverage of medication costs by insurance might also prohibit some physicians from prescribing biologic medications. A recent trial of brodalumab in moderate-to-severe psoriasis revealed improvement in the Dermatology Life Quality Index as early as 4 weeks into treatment. The degree of improvement in patient ARTICLE INFORMATION Author Affiliations: Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois. Corresponding Author: Amy S. Paller, MD, MS, Department of Dermatology, Northwestern University Feinberg School of Medicine, 676 N St Clair, Ste 1600, Chicago, IL 60611 (apaller @northwestern.edu). Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Gordon reported having received grants, personal fees, or both from Abbott, Amgen, Celgene, Eli Lilly, Janssen, Novartis, Pfizer, and Merck. Dr Paller reported having received an honorarium for consultating for Abbvie and having been an investigator without personal compensation for Amgen. No other disclosures were reported. REFERENCES
quality-of-life measures correlated with extent of clinical response.5 Given the potential efficacy of emerging biologic therapies, it will be important to further assess physician hesitation to prescribe these agents. Importantly, treatment of psoriasis is a key component in management of the overall health of the individual. In a randomized, double-blind, placebo-controlled study of ustekinumab in 1230 patients with moderate-to-severe psoriasis, 40.3% and 26.7% of patients reported baseline anxiety and depression, respectively,6 with scores comparable with those of patients given the diagnosis of breast cancer or chronic obstructive pulmonary disease. During 1 year of treatment with ustekinumab, levels of anxiety and depression improved significantly and correlated with psoriasis improvement, as measured by the Physician Assessment of Severity Index. Studies also highlight the relationship between psoriasis and obesity, metabolic disease, stroke, and cardiovascular events. Given that an underlying chronic inflammatory state links these disorders, effective treatment of psoriasis-associated inflammation might mitigate these comorbidities. Indeed, treatment of psoriasis with methotrexate7 or with tumor necrosis factor inhibitors8 is associated with decreased cardiovascular morbidity and mortality. Acknowledging these metabolic risks is important in dermatologists’ approach to patients with psoriasis and may lead to more effective management. Addressing patient satisfaction improves patient adherence and thus has a major effect on treatment outcomes for both psoriasis and its comorbidities. As such, the significant percentage of dissatisfied psoriasis patients in the study by Armstrong et al3 has serious implications for adherence and treatment outcomes. Future studies should be conducted to further evaluate components of patient satisfaction and the relationship to treatment outcomes. In addition, patient preference and satisfaction should be incorporated into future practice guidelines for psoriasis and psoriatic arthritis.
2. Callis Duffin K, Yeung H, Takeshita J, et al. Patient satisfaction with treatments for moderate-to-severe plaque psoriasis in clinical practice. Br J Dermatol. 2014;170(3):672-680. 3. Armstrong AW, Robertson AD, Wu J, Schupp C, Lebwohl MG. Undertreatment, treatment trends, and treatment dissatisfaction among patients with psoriasis and psoriatic arthritis in the United States: findings from the National Psoriasis Foundation surveys, 2003-2011. JAMA Dermatol. 2013;149(10): 1180-1185. 4. van Cranenburgh OD, de Korte J, Sprangers MA, de Rie MA, Smets EM. Satisfaction with treatment among patients with psoriasis: a web-based survey study. Br J Dermatol. 2013;169(2):398-405. 5. Gordon KB, Kimball AB, Chau D, et al. Impact of brodalumab treatment on psoriasis symptoms and health-related quality of life: use of a novel patient-reported outcome measure, the Psoriasis Symptom Inventory. Br J Dermatol. 2014;170(3): 705-715.
6. Langley RG, Feldman SR, Han C, et al. Ustekinumab significantly improves symptoms of anxiety, depression, and skin-related quality of life in patients with moderate-to-severe psoriasis: results from a randomized, double-blind, placebo-controlled phase III trial. J Am Acad Dermatol. 2010;63(3):457-465. 7. Prodanovich S, Ma F, Taylor JR, Pezon C, Fasihi T, Kirsner RS. Methotrexate reduces incidence of vascular diseases in veterans with psoriasis or rheumatoid arthritis. J Am Acad Dermatol. 2005;52 (2):262-267. 8. Wu JJ, Poon KY, Channual JC, Shen AY. Association between tumor necrosis factor inhibitor therapy and myocardial infarction risk in patients with psoriasis. Arch Dermatol. 2012;148(11): 1244-1250.
1. Finlay AY, Ortonne JP. Patient satisfaction with psoriasis therapies: an update and introduction to biologic therapy. J Cutan Med Surg. 2004;8(5):310320.
jama.com
JAMA December 24/31, 2014 Volume 312, Number 24
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of Iowa User on 06/01/2015
2677
