Psoriasis - The Life Course Approach.

Over the last decades, Life Course Research (LCR), predominantly the domain of sociology, has been increasingly applied in health research, as Life Course Epidemiology (LCE). The latter is concerned with disease patterns over time, accumulation of exposures over time, critical time periods and patterns of risk. We argue that concepts from LCR and LCE could be widely applied in dermatology, in general, and, more precisely, in the study of chronic inflammatory skin diseases, e.g. atopic eczema and psoriasis. The life course approach can generally be applied in two different ways. It may be used in the more traditional manner, in which the disease and its patterns over time are examined as the outcome vari-able. Conversely, it can examine life course as the outcome variable, which is dependent on the disease course, the treatments administered, and other physical or psychosocial environmental exposures. In dermatology, this second application of the LCR concepts is both promising and relevant because of the notable impact of chronic skin diseases on the patients' quality of life. In particular, we argue how LCR may be conducive to a better understanding of the concept of 'Cumulative Life Course Impairment', which is increasingly gaining acceptance. This approach helps identifying not only individuals at risk and particularly vulnerable patients but also critical periods for optimising interventions in order to avoid life course impairment. It also may facilitate more appropriate treatment decisions in clinical practice.

The Handicap of Hidradenitis Suppurativa.

Hidradenitis suppurativa (HS) is a chronic skin disease, with painful, foul-smelling, recurring inflammation, leading to a diminished quality of life. Patients with HS also often suffer from depression, have an impaired sexual health, and may have difficulty performing their work duties.

Effect of Age at Diagnosis on Chronic Quality of Life and Long-Term Outcomes of Individuals with Psoriasis.

Psoriasis is a skin disorder that frequently begins in the pediatric and young adult population but imposes physical and psychosocial burdens over a lifetime. The objective of this retrospective cohort study was to evaluate the effect of age at diagnosis on the lifetime outcomes of psoriasis patients. Individuals with psoriasis (N = 114) completed a questionnaire regarding disabilities, relationships, education, finances, and medical outcomes. Responses were compared among quartiles of age at diagnosis and regression analyses were performed. Those diagnosed at a younger age were more likely to have a greater lifetime Dermatology Life Quality Index (LT DLQI) (p < 0.001), have felt depressed (p = 0.003), believe that psoriasis had caused their depression (p < 0.001), experience lifetime sleep problems (p = 0.004), use recreational drugs (p < 0.001), hide their psoriasis over their lifetime (p < 0.001), and experience more severe lifetime discrimination in social settings (p = 0.002). Early onset psoriasis is associated with depression, social discrimination, and greater LT DLQI.

Psoriasis and the life cycle of persistent life effects.

Psoriasis is associated with significant physical, social, and behavioral comorbidities that create a substantial burden. We outline herein that these comorbidities start early in life and persist for decades, ultimately impacting the entire life course of patients with psoriasis. By highlighting the ages that psoriasis patients are affected with physical, social, behavioral and emotional comorbidities, we demonstrate the age-appropriate considerations for psoriasis patients.

Patient-clinician concordance, face-time and access.

PURPOSE: People in socially disadvantageous positions may receive less time with their clinicians and consequently reduced access to healthcare resources, potentially magnifying health disparities. Socio-cultural characteristics of clinicians and patients may influence the time spent together. The purpose of this paper is to explore the relationship between clinician/patient time and clinician and patient characteristics using real-time location systems (RTLS). DESIGN/METHODOLOGY/APPROACH: In the MGH/MGPO Outpatient RFID (radio-frequency identification) project clinicians and patients wore RTLS tags during the workday to measure face-time (FT), the duration patients and clinicians are co-located, wait time (WT); i.e. from registration to clinical encounter and flow time (FLT) from registration to discharge. Demographic data were derived from the health system's electronic medical record (EMR). The RTLS and EMR data were synthesized and analyzed using standard structured-query language and statistical analytic methods. FINDINGS: From January 1, 2009 to January 1, 2011, 1,593 clinical encounters were associated with RTLS measured FTs, which differed with socioeconomic status and gender: women and lower income people received greater FT. WT was significantly longer for lower socioeconomic patients and for patients seeing trainee clinicians, women or majority ethnic group clinicians (Caucasian). FLT was shortest for men, higher socioeconomic status and for attending physician patients. Demographic concordance between patient and clinician did not significantly affect process times. RESEARCH LIMITATIONS/IMPLICATIONS: The study demonstrates the feasibility of using RTLS to capture clinically relevant process measures and suggests that the clinical delivery system surrounding a clinical encounter may more significantly influence access to clinician time than individual patient and clinician characteristics. ORIGINALITY/VALUE: Applying RTLS to healthcare is coming. We can now successfully install and run these systems in healthcare settings and extract useful information from them. Interactions with the clinical delivery system are at least as important as interactions with clinicians for providing access to care: measure FT, WT and FLT with RTLS; link clinical behavior, e.g. FT, with patient characteristics; explore how individual characteristics interact with system behavior.

Success of automated algorithmic scheduling in an outpatient setting.

OBJECTIVE: To determine if algorithmically generated double-booking recommendations could increase patient volume per clinical session without increasing the burden on physicians. STUDY DESIGN: A randomized controlled trial was conducted with 519 clinical sessions for 13 dermatologists from December 1, 2011, through March 31, 2012. METHODS: Sessions were randomly assigned to "Smart-Booking," an algorithm that generates double-booking recommendations using a missed appointment (no-shows + same-day cancella- tions) predictive model (c-statistic 0.71), or to a control arm where usual booking rules were applied. The primary outcomes were the average number and variance of arrived patients per session, after controlling by physician. In addition, physicians received a survey after each session to quantify how busy they felt during that session. RESULTS: 257 sessions were randomized to Smart-Booking and 262 sessions were randomized to control booking. Using a generalized multivariate linear model, the average number of arrived patients per session was higher in the Smart-Booking intervention arm than the control (15.7 vs 15.2, difference between groups 4.2; 95% CI, 0.08-0.75; P = .014).The variance was also higher in the intervention than control (3.72 vs 3.33, P = .38).The survey response rate was 92% and the physicians reported being similarly busy in each study arm. CONCLUSIONS: Algorithmically generated double-booking recommendations of dermatology clinical sessions using individual physician assumptions and predictive modeling can increase the number of arrived patients without overburdening physicians, and is likely scalable to other settings.

A survey assessment of the recognition and treatment of psychocutaneous disorders in the outpatient dermatology setting: how prepared are we?

BACKGROUND: Dermatologists provide the bulk of psychocutaneous care; however, recent studies suggest that dermatologists believe they are largely underprepared to treat most psychocutaneous conditions. OBJECTIVE: We sought to identify gaps in psychodermatologic knowledge among practicing dermatologists in two academic institutions. METHODS: An online survey was sent to 59 dermatologists at the Massachusetts General Hospital (Boston, MA) and Brigham and Women's Hospital (Boston, MA) from July 2010 through October 2011. RESULTS: The response rate was 40 of 59 (68%). More than 50% of dermatologists were comfortable making diagnoses for 8 of 10 psychocutaneous disorders. In all, 57% were comfortable making a diagnosis of depression. A total of 11% were comfortable starting antidepressants; 3%, antipsychotics; and 66%, medications for neuropathic pain. In all, 72%, 68%, and 21% of dermatologists never prescribe antidepressants, antipsychotics, or medications for neuropathic pain, respectively. Only 38% believed they were successful treating compulsive skin picking; 15%, body dysmorphic disorder; 27%, delusions of parasitosis; and 24%, depression. LIMITATIONS: Limitations include small sample size, data extraction from an academic setting, self-reporting of outcome measures, and response bias. CONCLUSION: Although the majority of the physicians surveyed believed they were capable of diagnosing psychocutaneous disease, very few were comfortable starting psychotropics or thought they were successful treating such conditions.

The effects of adalimumab treatment and psoriasis severity on self-reported work productivity and activity impairment for patients with moderate to severe psoriasis.

BACKGROUND: Psoriasis significantly impairs work productivity and daily activities. OBJECTIVES: We sought to examine the effects of adalimumab on psoriasis-related work productivity and activity impairment and associations between the impairment and psoriasis severity in patients with moderate to severe psoriasis. METHODS: Data were from the first 16 weeks of the Randomized controlled EValuation of adalimumab Every other week dosing in moderate to severe psoriasis TriAL (REVEAL). Outcomes as measured by the Work Productivity and Activity Impairment Questionnaire for Psoriasis (WPAI-Psoriasis) included employment status, total work productivity impairment, and total activity impairment. Logistic regression and analyses of covariance were used to assess the effects of adalimumab and treatment response (≥ 75% improvement in Psoriasis Area and Severity Index responders) on WPAI-Psoriasis outcomes. Longitudinal generalized estimating equations and Pearson correlation coefficients were used to assess associations between WPAI outcomes and psoriasis severity. RESULTS: Greater improvements in total work productivity impairment and total activity impairment were observed with adalimumab treatment versus placebo (15.5 and 11.1 percentage points, respectively; P < .001). Unemployment rate, total work productivity impairment, and total activity impairment were significantly associated with greater baseline psoriasis severity. Changes in WPAI outcomes were significantly correlated with greater psoriasis severity. The Dermatology Life Quality Index had stronger associations with changes in WPAI outcomes compared with clinical severity measures (Psoriasis Area and Severity Index and Physician Global Assessment). LIMITATIONS: REVEAL only included WPAI data for 16 weeks. Therefore, long-term impact of adalimumab treatment on productivity outcomes could not be assessed. In addition, information on occupational job title or industry was not collected and data were not adjusted for psoriatic arthritis. CONCLUSIONS: Adalimumab reduced psoriasis-related work productivity and activity impairment in patients with moderate to severe psoriasis.

Time for a change? Updated guidelines using interferon gamma release assays for detection of latent tuberculosis infection in the office setting.

Treatment with tumor necrosis factor-alfa inhibitors and other systemic medications increases the risk of reactivating a latent tuberculosis (TB) infection. Therefore, screening for latent TB infection is important in dermatology patients eligible for treatment with these medications. Although the tuberculin skin test (TST) has its limitations, it has been the standard choice for diagnosis of latent TB infection. Since the development of interferon gamma release assays (IGRAs), the role of the TST has been re-evaluated and IGRAs have increasingly been incorporated into national guidelines. Although there are situations when either test may be performed, in individuals who have received a BCG vaccination and in those who are unlikely to return for a TST reading, IGRAs may be particularly helpful in distinguishing patients at risk for TB. This article discusses the advantages and disadvantages of both the TST and the IGRA and presents a summary of the Centers for Disease Control and Prevention 2010 guidelines for using IGRAs.

Review of treatment options for psoriasis in pregnant or lactating women: from the Medical Board of the National Psoriasis Foundation.

BACKGROUND: Treating psoriasis in pregnant and lactating women presents a special challenge. For ethical reasons, prospective randomized control trials have not been conducted in this patient population although these patients do encounter new-onset psoriasis in addition to flares and may require treatment throughout their pregnancies. OBJECTIVE: Our aim was to arrive at consensus recommendations on treatment options for psoriasis in pregnant and lactating women. METHODS: The literature was reviewed regarding all psoriasis therapies in pregnant and lactating women. RESULTS: Topical therapies including emollients and low- to moderate-potency topical steroids are first-line therapy for patients with limited psoriasis who are pregnant or breast-feeding. The consensus was that second-line treatment for pregnant women is narrowband ultraviolet B phototherapy or broadband ultraviolet B, if narrowband ultraviolet B is not available. Lastly, tumor necrosis factor-α inhibitors including adalimumab, etanercept, and infliximab may be used with caution as may cyclosporine and systemic steroids (in second and third trimesters). Some specific strategies may be used to minimize risk and exposure. LIMITATIONS: There are few evidence-based studies on treating psoriasis in pregnant and lactating women. CONCLUSIONS: Because there will always be a question of ethical concerns placing pregnant and lactating women in prospective clinical trials, investigation of both conventional and biologic agents are unlikely to ever be performed. Some of these medications used to treat psoriasis are known abortifacients, mutagens, or teratogens and must be clearly avoided but others can be used with relative confidence in select patients with appropriate counseling of risks and benefits.

Career trajectory and job satisfaction trends in Mohs micrographic surgeons.

BACKGROUND: Although many residents and fellows in Mohs surgery express an interest in academics, departure from academics occurs for many trainees or junior faculty. OBJECTIVE: We designed a survey, issued to all American College of Mohs Surgeons (ACMS) members in 2009, to assess reasons for practice selection. RESULTS: A response rate of 65.0% (n=455) was obtained. Of all ACMS members, 33.9% started in academic positions, and 66.1% started in private practice. Retention rates in private practice (61.2%) were significantly higher than in academics (28.0%) (p<.001). The rationale for selection of an academic career included referral base and teaching and research opportunities. Reasons for selection of a private practice career were higher salary, autonomy over resources, and geographic flexibility. There were high rates of departure from academics early on; reasons for departure included lack of support from the academic chair and lack of autonomy over resources. Surgeons leaving academia were able to perform Mohs surgery and continue interests in research and teaching with benefits of greater autonomy over resources in private practice. CONCLUSIONS: Novel efforts to retain academic Mohs surgeons are needed to ensure continued success and evolution of the specialty.

Practice models and roles of physician extenders in dermatologic surgery.

BACKGROUND: The prevalence of physician extenders (PEs) has increased significantly in dermatologic surgery over the last decade. METHODS: An analysis was performed of the staff in dermatologic surgery practices, roles of PEs, and level of supervision. RESULTS: Mohs fellowship-trained (MMSFT) dermatologic surgeons were more likely to employ registered nurses (n=85, 73.9%) than non-fellowship-trained (NMMSFT) surgeons (n=65, 50.0%, p<.05) (dermatologists who reported performing Mohs without having completed a Mohs College fellowship). NMMSFT surgeons (n=46, 35.4%) were 33% more likely to employ physician assistants than MMSFT surgeons (n=30, 26.1%, p=.05). Both surgeon types reported that their physician assistants and nurse practitioners spent the majority of their time treating medical dermatology patients, but NMMSFT surgeons were twice as likely as MMSFT surgeons to have their PEs involved in performing or assisting with cosmetic procedures. MMSFT surgeons (38.5%) were twice as likely to have direct supervision of their PEs as NMMSFT surgeons (16.1%, p=.01). CONCLUSIONS: PEs are highly prevalent in dermatologic surgery practices and are playing direct roles in the delivery of dermatologic care. Promoting patient safety through appropriate extender supervision and reporting of patient outcomes are highly needed as this sector of the dermatologic surgery workforce continues to expand.