The intersection of dermatology and rheumatology is most evident in instances of psoriasis and psoriatic arthritis (PsA), which often occur in a single patient simultaneously. The inflammatory conditions are interconnected, with PsA primarily developing among individuals with an established psoriasis diagnosis.^1,2

The identification of individuals at risk of PsA development is widely accepted as necessary for clinicians treating those with psoriasis. Scalp and nail psoriasis involvement, as well as inverse psoriasis and one’s cutaneous disease severity, are all known clinical features indicating higher risk among patients of developing PsA.^3,4

Around 30% of patients with psoriasis develop PsA at some point in their lives, so the treatment and management of both conditions can quickly become a reality for many patients with 1 condition or the other.⁵ Treatments approved for these conditions can overlap as well, as is the case of the drugs apremilast (Otezla) and deucravacitinib (Sotyktu).

There may be a wide variety of management strategies implemented by clinicians when working with patients that suffer from psoriatic disease, but it is becoming more widely accepted that patient-reported outcomes (PROs) are essential as an assessment of the usefulness of such strategies and as endpoints for clinical research.

In this feature, 3 experts are featured to discuss the necessity of implementation of PROs in managing both psoriatic diseases.

The HCPLive editorial team spoke with Raj Chovatiya, MD, PhD, clinical associate professor of medicine for the Rosalind Franklin University of Medicine and Science and founder and director of the Center for Medical Dermatology and Immunology Research in Chicago.

The team also interviewed Amanda Mixon, PA-C, a physician assistant at UCHealth Rheumatology Clinic who specializes in helping patients to manage rheumatologic conditions such as PsA. Lastly, the team spoke with David Chandler, the Chief Executive of the nonprofit organization known as the Psoriasis and Psoriatic Arthritis Alliance (PAPAA).

Chovatiya and Mixon are featured in interviews posted in a video series above. Chandler’s discussion with the editorial team was submitted in writing and posted below. The 3 experts, each with their own approaches to the questions posed, express views which highlight important points about the value of PROs in the management of psoriasis and psoriatic arthritis.

HCPLive: What are the main benefits of incorporating PROs into the treatment and management of psoriatic disease?

Chandler: The main advantage is that the psoriatic arthritis patient is playing an active role in their care, this real-world direct patient data that is outside of clinical trials, can provide a physician with important information that perhaps was not recorded or seen as important in a trial.

Some important issues that influence how someone feels, often cannot be seen within the standard validated test, this type of feedback will help to consider ongoing therapy. The notion of patient-centered care and patient-perspective, also plays in here, where what is important, is now recorded and used to influence future care, that has to be seen as an advantage. Communication is also improved, as a patient feels they are part of the process.

HCPLive: What are some of the challenges and limitations associated with collecting and using PROs in clinical practice?

Chandler: I suspect that the accuracy and memory recall could provide an issue. Therefore, a baseline needs to be established. Between patient and physician, there could be different reference points that do not correlate with validated tests.

So, over time although pain may be at a similar point as at baseline, the patient may become ‘used to it’ and accept it, therefore not report any worsening, which could be interpreted as improvement. Tracking those could provide useful insight across other patients too.

HCPLive: How can healthcare providers effectively integrate PROs into their routine clinical practice?

Chandler: In the UK it will depend on where the patient is being treated, we have a primary care general doctor and secondary care specialist, the latter may be a generalist too. So, for psoriatic arthritis if it is being managed at primary care, the pressure and time may limit the ability to record and enter into such detail, this is not a criticism, but a general recognition of the work load and need to see as many people as possible.

For secondary care, where the likelihood of more severe disease is being managed, the need to monitor benefit is perhaps more important not least due to the potential recommendations made by HTA assessments for cost-effectiveness of drugs. Including PROs in that patient consult, will add to the likely benefit, so using again a baseline and then asking the patient to report back. The important issue is to make sure that this is to aid care and improve outcomes, not limit access due to cost.

HCPLive: What do you see as the future of PROs in the treatment and management of psoriatic disease?

Chandler: We need real-world data, the lived experience, so making the assessment and follow-up a standard part of care, by demonstrating the benefits could see them as vital. If they become difficult to record and do not help reduce disease symptoms then both patient and physician will be reluctant to use them, unless they become a mandatory part of prescribing, which perhaps would not be a bad thing.

HCPLive: How can policy makers and healthcare organizations encourage the broader adoption of PROs?

Chandler: If it can be shown that the use of PROs can improve patient care and reduce the need for constant monitoring and perhaps reduce costs, then policy makers are likely to support the introduction, if not I’m not sure much else will increase enthusiasm.

HCPLive: In your opinion, what is the overall impact of using PROs on the quality of life and health outcomes for patients with psoriatic disease?

Chandler: I think the main impact is that the care process becomes a partnership and the patient feels more in control, by actively monitoring their own outcomes and knowing that could improve their progression is very empowering, the shift from ‘doctor tells, patient does’ to ‘doctor asks patient considers and actively manages’ and reports, particularly how their quality of life has improved, changed or otherwise, can only be a good idea in the management of psoriatic arthritis.

HCPLive: How can the broader healthcare system benefit from incorporating PROs into chronic disease management?

Chandler: That’s an interesting question. We have limited capacity in the UK, with longer waiting lists and issues with increasing health care cost. Chronic disease probably takes up a huge amount of the capacity.

For psoriatic arthritis and other inflammatory conditions, we know if left untreated there is a potential for joint damage, which could lead to disability and extra care and of course cost. The benefit of managing people early, and reducing the need for constant recalls, could free up capacity and improve the overall benefit to other people. Therefore, those that can be monitored effectively, are.

References

1. ^{Gladman DD, Antoni C, Mease P, Clegg DO, Nash P. Psoriatic arthritis: epidemiology, clinical features, course, and outcome. Ann Rheum Dis. 2005;64 Suppl 2:ii14–ii17.}
2. ^{Zabotti A, Tinazzi I, Aydin SZ, McGonagle D. From Psoriasis to Psoriatic Arthritis: Insights from Imaging on the Transition to Psoriatic Arthritis and Implications for Arthritis Prevention. Curr Rheumatol Rep. 2020 May 16;22(6):24. doi: 10.1007/s11926-020-00891-x. PMID: 32418006; PMCID: PMC7230038.}
3. ^{Wilson FC, Icen M, Crowson CS, McEvoy MT, Gabriel SE, Kremers HM. Incidence and clinical predictors of psoriatic arthritis in patients with psoriasis: a population-based study. Arthritis Rheum. 2009;61(2):233–239.}
4. ^{Gladman DD, Antoni C, Mease P, Clegg DO, Nash P. Psoriatic arthritis: epidemiology, clinical features, course, and outcome. Ann Rheum Dis. 2005;64 Suppl 2:ii14–ii17.}
5. ^{Gisondi P, Bellinato F, Maurelli M, Geat D, Zabotti A, McGonagle D, Girolomoni G. Reducing the Risk of Developing Psoriatic Arthritis in Patients with Psoriasis. Psoriasis (Auckl). 2022 Aug 10;12:213-220. doi: 10.2147/PTT.S323300. PMID: 35975124; PMCID: PMC9375973.}