Research ArticleResearch

Evaluating practice patterns for managing moderate to severe plaque psoriasis

Role of the family physician

Yves Poulin, Norman Wasel, Daphne Chan, Geula Bernstein, Robin Andrew, Elisa Fraquelli and Kim Papp
Canadian Family Physician July 2012; 58 (7) e390-e400;

Abstract

Objective To describe practice patterns for care of Canadian patients with moderate to severe plaque psoriasis.

Design Online survey of a consumer panel.

Setting Participants were drawn from a population-wide Canadian consumer database.

Participants To be eligible to participate, respondents had to have been diagnosed with plaque psoriasis within the past 5 years, and to have had body surface area involvement of 3% or greater in the past 5 years, or to have psoriasis on a sensitive area of the body (hands, feet, scalp, face, or genitals), or to be currently receiving treatment with systemic agents or phototherapy for psoriasis.

Main outcome measures Proportion of respondents with psoriasis managed by FPs and other specialists, psoriasis therapies, comorbidities, and patient satisfaction.

Results Invitations were sent to 3845 panelists with self-reported psoriasis, of which 514 qualified to complete the survey. Family physicians were reported to be the primary providers for diagnosis and ongoing care of psoriasis in all provinces except Quebec. Overall physician care was reported to be satisfactory by 62% of respondents. Most respondents receiving over-the-counter therapies (55%) or prescribed topical therapies (61%) reported that their psoriasis was managed by FPs. Respondents receiving prescription oral or injectable medications or phototherapy were mainly managed by dermatologists (42%, 74%, and 71% of respondents, respectively). Ongoing management of respondents with body surface area involvement of 10% or greater was mainly split between dermatologists (47%) and FPs (45%), compared with rheumatologists (4%) or other health care professionals (4%). Of those respondents receiving medications for concomitant health conditions, treatment for high blood pressure was most common (92%), followed by treatment for heart disease (75%) and elevated cholesterol and lipid levels (68%).

Conclusion Patient-reported practice patterns for the diagnosis and management of moderate to severe psoriasis vary among provinces and in primary and secondary care settings.

Psoriasis affects approximately 1% to 3% of the Canadian population.1–3 It is associated with impaired physical and psychosocial functioning.4 In Canada, management of psoriasis is generally initiated through contact with patients’ FPs—the “gate-keepers” of the health care system5—with subsequent referral to other specialists.5–8 An integrated service model of care requires efficient and appropriate referral to provide continuity and optimize disease management.9,10 Canadian guidelines recommend that FPs consider referral to other specialists when plaque psoriasis is generalized, complex, distressing to the individual, or unresponsive to current therapy (Box 1).11 The guidelines also recommend involving other specialists when confirming the diagnosis, assessing therapeutic options, managing comorbidities, or providing in-depth counseling or patient education.11 Recent reports suggest psoriasis is associated with a number of serious comorbidities, some of which might share common immune-inflammatory mechanisms.12 Associated conditions include psoriatic arthritis,13–15 cardiovascular disease,16,17 diabetes,17 gastrointestinal diseases,11 being overweight or obese,18,19 metabolic dysfunction,13,17,18,20 and mental health disorders.13 An increased risk of mortality in individuals with psoriasis might be attributable at least in part to associated comorbidities.16,21

Recently published Canadian guidelines highlighted the need for assessing patterns of care in the management of plaque psoriasis and evaluating patient satisfaction.11 This study investigated the practice patterns for diagnosis and treatment by surveying a sample of Canadians with moderate to severe plaque psoriasis.

Box 1.

Criteria for referrals to specialists according to Canadian guidelines for the management of plaque psoriasis

Referrals to a specialist should be considered

  • when disease is extensive, distressing, or unresponsive, or when the patient requires in-depth counseling or education outside the scope of primary care practice;

  • to confirm a diagnosis, to assess or help establish an appropriate therapeutic regimen, or to help manage more complex cases;

  • in patients who become unresponsive to previously successful treatments or who experience other adverse reactions to topical medications; and

  • in response to a patient’s request for a referral to a dermatologist.

  • Data from Canadian Psoriasis Guidelines Committee.11

    • METHODS

    Design and measures

    A population-wide, cross-sectional sample representative of the adult Canadian population and balanced by region and sex was identified using proprietary consumer databases.22 These databases consisted of information on members of the general public who had consented to be contacted to complete surveys voluntarily. E-mail invitations were sent to a national sample of 3845 Canadian adults (≥ 18 years) with self-reported psoriasis (Figure 1).

    Figure 1.
    Figure 1.

    Selection process for survey respondents: Exclusion criteria included patient not diagnosed with psoriasis (N = 449), disease not identified as plaque-type psoriasis (N = 261), disease self-reported as very mild or mild psoriasis currently and at its worst in the past 5 years (N = 67), and body surface area involvement of less than 3% AND not affecting at least 1 sensitive area AND patient not currently taking prescribed oral or injectable medication or undergoing phototherapy (N = 80).

    * Respondents from the Ipsos database were provided with the opportunity to be randomly awarded cash and prizes, and those from the ICOM TargetSource database were not offered an incentive but understood that ICOM could contact them by e-mail.

    †Of a total sample of 3100, 1845 subjects who reported having psoriasis were available to receive e-mail invitations.

    Responses to a prescreening questionnaire determined eligibility. Respondents were included in the study if they reported being diagnosed by a physician with psoriasis of at least moderate severity (currently or at some time in the past 5 years) and having plaque-type psoriasis (through recognition of visual images and description). In addition, eligible subjects met at least 1 of the following criteria: a self-estimated body surface area (BSA) involvement of at least 3% at some time in the past 5 years using the palm method (ie, palm of the hand is approximately 1% of the BSA)23; psoriasis on a sensitive area of the body (hands, feet, scalp, face, or genitals); or current treatment with prescription systemic medication (oral or injectable) or phototherapy.

    The 30-minute online study completed by eligible respondents was conducted in December 2007 by Ipsos Interactive Services. Ethics approval for conducting the study and for the survey methodology and questionnaire (English and French) was provided by Research Review Board Inc. A range of health-related questions and 2 previously validated health-related quality of life patient-reported outcome instruments (the generic 8-Item Short Form Health Survey and the skin-specific Dermatology Life Quality Index) were included in the survey.24,25

    Data collection and analysis

    Data were entered into an SPSS database (version 12.0). Coding and data analyses were provided by Ipsos Health and were weighted by sex and region according to 2005 Canadian census statistics. Descriptive statistics were used to report the responses to each question. Proportions were used to present the weighted responses, with N representing the number of people who responded to the question. Correlations between associated variables were calculated using Pearson correlation coefficients. Statistical significance was set at P < .05. When conducting a general population survey, the usual target sample size is 1000 survey respondents to achieve a margin of error of 3%. For a study specifically targeting individuals affected by psoriasis, this sample size is difficult to achieve, and therefore a target sample size of 400 was set, which offered an acceptable margin of error.

    RESULTS

    Participants

    In summary, 1671 of 3845 invited subjects attempted the survey, with 1371 respondents reaching the prescreening phase (36% overall response rate). A total of 514 qualified respondents completed the survey (Figure 1); the survey has been previously described.3,22,26 This sample size of 514 has an estimated margin of error of 4.3%, at a 95% level of confidence, assuming that the sample proportion is at least 50% homogeneous. Tables 1 and 2 summarize the qualified respondents’ sociodemographic and psoriasis disease characteristics.

    View this table:
    Table 1.

    Sociodemographic characteristics of survey respondents who satisfied entrance criteria: N = 514.

    View this table:
    Table 2.

    Disease characteristics of survey respondents who satisfied entry criteria for study: N = 514.

    Diagnosis and management

    In all provinces except Quebec, psoriasis was most commonly diagnosed and managed by FPs compared with other physician types (Figures 2 and 3), including when care was needed after sudden worsening (Figure 4). In Quebec, diagnosis and management were predominantly carried out by dermatologists. The trend toward management predominantly by FPs was generally observed irrespective of reported BSA involvement (< 3% or ≥ 3%). However, respondents reporting BSA involvement of 10% or greater received care from dermatologists (47%) or FPs (45%), and few such respondents reported management by rheumatologists (4%) or other health care professionals (4%). Respondents reported an average of 3 physician visits per year for ongoing management of psoriasis (2.1, 3.5, and 4.9 visits per year for individuals reporting BSA involvement of < 3%, ≥ 3%, and ≥ 10%, respectively). The proportion of patients satisfied with physician management ranged from 55% to 70% (mean 62%) by region (Figure 5). Satisfaction was measured on a 4-point scale; the points were very satisfied, somewhat satisfied, not very satisfied, and not at all satisfied. Reports of very satisfied or somewhat satisfied were grouped together as satisfaction.

    Figure 2.
    Figure 2.

    Type of physician making first diagnosis of psoriasis by region as reported by survey respondents: N = 514.

    ATL—Atlantic Provinces (Nova Scotia, New Brunswick, Prince Edward Island, and Newfoundland and Labrador), PRA—Prairie Provinces (Manitoba, Saskatchewan, and Alberta).

    *Totals add to more than 100% owing to rounding.

    Figure 3.
    Figure 3.

    Type of physician seen most often for psoriasis by region as reported by survey respondents: N = 514.

    ATL—Atlantic Provinces (Nova Scotia, New Brunswick, Prince Edward Island, and Newfoundland and Labrador), PRA—Prairie Provinces (Manitoba, Saskatchewan, and Alberta).

    *Totals add to more than 100% owing to rounding.

    Figure 4.
    Figure 4.

    Action taken by respondents upon sudden worsening of symptoms of psoriasis, by region: N = 514.

    ATL—Atlantic Provinces (Nova Scotia, New Brunswick, Prince Edward Island, and Newfoundland and Labrador), PRA—Prairie Provinces (Manitoba, Saskatchewan, and Alberta).

    *Totals add to more than 100% owing to rounding.

    Figure 5.
    Figure 5.

    Proportion of patients who were satisfied with physician management, by region, as reported by survey respondents: N = 514.

    ATL—Atlantic Provinces (Nova Scotia, New Brunswick, Prince Edward Island, and Newfoundland and Labrador), PRA—Prairie Provinces (Manitoba, Saskatchewan, and Alberta).

    Practice patterns for treatment of psoriasis and comorbidities

    Most respondents reporting current use of over-the-counter (OTC) or prescribed topical therapies indicated their disease was managed mainly by FPs (Table 3). Respondents receiving prescription oral or injectable medications or phototherapy for psoriasis were most often managed by dermatologists.

    View this table:
    Table 3.

    Health care professionals visited most often for psoriasis treatment according to treatment received at the time of the survey: N = 514.

    Prescribed topical and OTC therapies were more common in all regions, while substantially fewer respondents reported receiving phototherapy or prescribed systemic (oral or injectable) medications (Table 4). Most patients (63%) receiving prescription injectable agents indicated they were very satisfied (score of ≥ 8 on the 10-point Likert scale), compared with only 38% of those treated with prescription oral therapies, and less than one-quarter of patients using OTC or prescription topical agents or phototherapy. Approximately 15% of respondents were not receiving any treatment at the time of the survey.

    View this table:
    Table 4.

    Current psoriasis treatments reported by respondents, by region, and proportion of respondents very satisfied with current treatments: Respondents could select multiple treatments.

    High blood pressure, elevated cholesterol or lipid levels, and being obese or overweight were the most common comorbidities reported (Table 5). No significant correlation was found between the prevalence of any single comorbidity and BSA involvement (r = −0.036). Of those respondents with reported comorbidities, treatment for high blood pressure was most common (92%), followed by treatment for heart disease (75%) and elevated cholesterol or lipid levels (68%). A substantial proportion of respondents were affected psychologically and reported taking prescription medications for anxiety (54%), insomnia (47%), or depression (61%).

    View this table:
    Table 5.

    Respondents with comorbidities who reported receiving treatment for the comorbid condition, according to BSA involvement: N = 514.

    Across Canada, about one-third of the total prescription costs were paid out of pocket (after reimbursements). Total monthly expenses incurred for prescription and OTC treatments for psoriasis were reported to range from $32 to $80 depending on the region.

    DISCUSSION

    Our survey results support the role of FPs in providing ongoing care for patients with moderate to severe plaque psoriasis. Current partitioning of care between FPs and other specialists, including treatment patterns for psoriasis and prevalent comorbidities, emphasizes the importance of efficiency and continuity in the referral and comanagement of this patient population.

    More than half of respondents (62%) reported they were satisfied with their physician care, which is a rate greater than that observed in a US study.27 Family physicians were reported to be the main providers for diagnosis and ongoing care across Canada. A unique trend was observed for Quebec; dermatologists were the main providers for diagnosis and ongoing care, similar to the practice patterns reported in the United States.28,29 This might be attributable to increased access to specialists, as suggested by the shorter wait times for specialist consult and alternate referral channels (eg, self-referral, referral through health care providers other than FPs) and possibly a greater number of dermatologists per resident in Quebec (Royal College of Physicians and Surgeons of Canada, personal communication, August 2010).30,31 Whether differences in practice patterns in Quebec compared with the rest of the Canadian provinces translate to differences in patient satisfaction would be important to explore in future studies. The overall number of clinic visits (3 times per year) for ongoing management of psoriasis was similar to that found in a UK study32 and was consistent with other findings in the United States and United Kingdom, which showed that while individuals with psoriasis do not frequently attend clinics, their use of medical resources remains substantial.32–34

    Current psoriasis guidelines recommend prescription oral or injectable medications or phototherapy as primary treatment for moderate to severe psoriasis or extensive lesions, while topical agents generally serve an adjunctive role.11,35 Most of our survey respondents reported current treatment with topical agents, consistent with previous findings that the use of such therapies might be disproportionately and inappropriately high for the optimal treatment of moderate to severe psoriasis.27,36 Respondents indicated relatively low satisfaction with topical agents and phototherapy compared with systemic therapies (oral and injectable), similar to findings from a recent Canadian survey reporting increased patient satisfaction with biologic therapy use compared with other therapies.37 Although the physicians who prescribed these topical treatments were not identified in the present survey, respondents visiting FPs for ongoing care of psoriasis were more likely to be using topical agents, consistent with findings from a UK study.32 Use of systemic (oral or injectable) medications or phototherapy was more prevalent among respondents who reported visiting dermatologists or rheumatologists for ongoing psoriatic disease management. The decision by FPs to prescribe primarily topical agents might depend on such factors as limited access to specialized treatments (eg, phototherapy or light therapy),38 familiarity and comfort with prescribing systemic therapies,28 perceived risk of interactions with concomitant medications,12 or costs to the patient.39,40

    Our finding that FPs served as the primary source of ongoing management for respondents reporting moderate to severe psoriasis (BSA involvement of ≥ 3%), and that they shared in the care of those with severe psoriasis (BSA involvement of ≥ 10%), has important implications for the care and referral of Canadians with psoriasis. First, with partitioning of services between primary and specialist care settings, the efficiency of inter-physician communication is critical to the coordination and continuity of management of psoriasis9 and other associated psychosocial and systemic comorbidities.41,42 Second, referrals guided by criteria recommended in the recent Canadian plaque psoriasis guidelines might help optimize the sharing of care between primary and secondary practices (Box 1).11 Third, the high prevalence of comorbidities and their associated treatments supports recommendations for monitoring, intervention, and consideration of possible multidrug interactions during patient management.11,12,43,44 Fourth, with skin manifestations of psoriasis generally appearing years before the onset of psoriatic arthritis,45,46 early detection of joint complaints and prompt diagnosis and intervention might be critical for detection of eventual progressive joint destruction.43,47,48 Finally, the prevalence of mental health disorders that respondents attributed to psoriasis supports the importance of monitoring for psychological issues and providing appropriate counseling and treatment or referral to a specialist.11

    Limitations

    Limitations of this study included a sample population derived from a pre-existing consumer panel rather than by random sampling. The consumer panel was constructed to represent the general Canadian population, but no eligible panelists lived in the territories. As a result, the territorial population was not represented, although it is known that most Canadians (99.68%) reside within the provinces.49 Of note, population samples were low in certain provinces, and caution must be exercised when drawing conclusions based on the provincial trends observed. The use of a consumer panel, as well as Internet-based methods of survey delivery, introduces a number of potential biases including selecting for individuals who are computer literate, have access to the Internet, are able and willing to devote time to online surveys, and might be more frustrated about their condition.50,51 The survey relied on the accuracy of self-report, and responses were not confirmed by medical records, although a previous study suggested that self-reporting in population surveys is reasonably accurate for chronic conditions,52 and patient-reported BSA involvement correlates closely with physician estimates.53

    Conclusion

    In this Canadian population with moderate to severe plaque psoriasis, FPs were reported to play an important role in diagnosis and ongoing management of the condition. Treatments received depended largely on whether management was in the primary or secondary care setting. Findings highlight the need to consider comorbidities and associated medications when treating patients with psoriasis, and the importance of an integrated “shared care” approach to management that includes the coordination of care with specialists and other health care professionals, as well as consideration of patients’ needs and preferences.

    Acknowledgments

    We thank John Howell for support in the development and editing of this manuscript, and Fernando Camacho for additional statistical analysis. The material was presented in part as a poster at the Canadian Dermatology Association 84th Annual Conference, July 2 to 3, 2009, in Vancouver, BC.

    Notes

    EDITOR’S KEY POINTS

    • The proportion of patients who were satisfied with their current care ranged from 55% to 70% (mean 62%) across Canada.

    • Family physicians were reported to be the primary providers for diagnosis and ongoing care of individuals with psoriasis in all provinces except Quebec, where this was done predominantly by dermatologists. Ongoing care of individuals reporting body surface area involvement of 10% or greater was mainly split between dermatologists (47%) and FPs (45%), compared with rheumatologists (4%) or other health care professionals (4%), which has implications for Canadian referral patterns and patient management.

    • Current psoriasis guidelines recommend prescription oral or injectable medications or phototherapy as primary treatment for moderate to severe psoriasis or extensive lesions; topical agents generally serve an adjunctive role. Most of the survey respondents reported current treatment with topical agents, consistent with previous findings that the use of such therapies might be disproportionately and inappropriately high for the optimal treatment of moderate to severe psoriasis.

    POINTS DE REPÈRE DU RÉDACTEUR

    • La proportion des patients qui étaient satisfaits de leur traitement actuel variait entre 55 % et 70 % (moyenne : 62 %) pour l’ensemble du Canada.

    • Les répondants rapportaient que les médecins de famille étaient les principaux responsables du diagnostic et du suivi du psoriasis dans toutes les provinces, sauf au Québec, où les dermatologues étaient plus nombreux à s’en occuper. Le suivi des personnes qui disaient avoir une atteinte d’au moins 10 % de la surface corporelle était partagé entre les dermatologues (47 %) et les MF (45 %), par rapport à 4 % pour les rhumatologues et 4% pour les autres professionnels de la santé, ce qui a des répercussions sur les façons de traiter les patients et de les diriger en spécialité au Canada.

    • Les directives actuelles sur le psoriasis recommandent l’utilisation de médicaments oraux ou injectables ou de photothérapie pour le traitement primaire du psoriasis modéré à sévère ou en cas de lésions étendues; les agents topiques ont généralement un rôle accessoire. La plupart des répondants à l’enquête disaient être actuellement traités avec des agents topiques, confirmant ainsi les observations antérieures voulant que la trop forte utilisation de ce type de traitement pourrait être disproportionnée et inappropriée par rapport à un traitement optimal du psoriasis modéré à sévère.

    Footnotes

    • This article has been peer reviewed.

    • Cet article a fait l’objet d’une révision par des pairs.

    • Contributors

      All authors contributed to the design of the study, the analysis and interpretation of data, and review of the manuscript, with Dr Bernstein contributing to analysis and interpretation of data and drafting of the manuscript.

    • Competing interests

      Dr Poulin has been a speakers’ bureau member and trialist for Amgen-Wyeth, Abbott, Astellas-Biogen, Centocor, Schering, Janssen-Ortho, Bristol-Myers Squibb, Celgene, Isotechnika, LeoPharma, Pfizer, Serono, and Pharmascience. Drs Papp and Bernstein are consultants for Janssen Inc. Dr Wasel has been a consultant and speaker for or received honoraria from Abbott, Amgen, Astellas, Biogen, EMD Serono, Isotechnika, Janssen-Ortho, LEO Pharma, Schering, and Wyeth. Dr Chan, Ms Andrew, and Ms Fraquelli are employees of Janssen Inc. The survey was supported by Janssen-Ortho Inc. Other than Dr Bernstein, who received consulting fees, the authors did not receive any honoraria from Janssen-Ortho Inc for their work on this paper.

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    Yves Poulin, Norman Wasel, Daphne Chan, Geula Bernstein, Robin Andrew, Elisa Fraquelli, Kim Papp
    Canadian Family Physician Jul 2012, 58 (7) e390-e400;
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