At lectures on psoriasis you can see eyes glaze over; BlackBerry addicts turn on their cell phones, and workaholics open their laptops when a speaker mentions quality of life or patient satisfaction. Quality-of-life and patient satisfaction surveys are met with groans by investigators for whom this just means more work. But the impact of patient satisfaction on patients' current and future quality of life is critical, and the impact on their family, friends, coworkers, employers and customers is tangible. Moreover, satisfaction with therapy affects adherence to that therapy, and poor adherence is known to be an enormous problem in dermatology. In a study performed at an outpatient clinic, one-third of prescriptions were never even filled.[1] In another small study, 95% of patients were found to underdose topical therapies,[2] and adherence to a 5-day treatment course of a topical steroid among patients with atopic dermatitis was only 40%.[3]
As shown in the study by Callis Duffin et al.,[4] in this issue of BJD, it is not surprising that patient satisfaction is lower for topical therapies than for all other therapies. Nor is it surprising that these scores are also lower for narrowband ultraviolet (UV)B, which requires office visits up to three times per week, and for infliximab, which requires in-office infusions at least every 8 weeks.
More than ever before, patient-reported outcomes are being used by the government and by insurers to justify treatments. And in an era when adherence is coming under closer scrutiny, treatments associated with greater patient satisfaction are likely to lead to greater adherence.
Clinical scores such as the Psoriasis Activity and Severity Index are helpful, even if imperfect. Those scores generally correlate well with quality-of-life scores and patient satisfaction scores. However, looking only at clinical scores, it is easy for physicians to overlook the side-effects of treatments that work – but these emerge much more clearly in patient satisfaction scores. Methotrexate, for example, requires more laboratory monitoring and is often associated with nausea, oral ulcers and a sense of malaise, not to mention the symptoms associated with megaloblastic anaemia. Yet, all of us have heard the methotrexate enthusiast who says: 'I've never had a patient with side-effects from methotrexate and it works for everyone.' It's amazing how many of our colleagues don't realize their patients are doing well only because they've gone to other dermatologists who prescribed more satisfying treatments. By now, we all should realize that the justifiable enthusiasm for methotrexate should be related to its price, as it has been shown to be less effective and have more side-effects than at least one of our biological therapies for which a head-to-head comparison has been performed.[5]
The challenge is to come up with an easy quality-of-life or patient satisfaction measure that takes little time on the part of investigators and clinicians. The Treatment Satisfaction Questionnaire for Medication version II (TSQM) consists of 11 items concerning key points: effectiveness, adverse effects, convenience of therapies and satisfaction with those therapies.[6] Using that simple questionnaire, Callis Duffin et al. have shown that patients receiving methotrexate monotherapy had significantly lower patient-reported effectiveness scores than those receiving subcutaneously administered biologics (adalimumab, etanercept, ustekinumab), narrowband UVB phototherapy or adalimumab with methotrexate. Conversely, methotrexate monotherapy was significantly more convenient than topical therapies, infliximab or narrowband UVB phototherapy.
Because we are all under pressure by insurers to see more patients in less time, and because clinical evaluations of psoriasis correlate with patient satisfaction and quality of life, it is unlikely that surveys like the TSQM will be performed in clinical practice. But in a study setting, the TSQM provides valuable information that can be used to influence regulatory agencies and insurers.
The British Journal of Dermatology. 2014;170(3):494-495. © 2014 Blackwell Publishing