Cost of Moderate to Severe Plaque Psoriasis in Germany: A Multicenter Cost-of-Illness Study

Psoriasis: is the impairment to a patient's life cumulative?

Psoriasis is associated with significant physical and psychological burden affecting all facets of a patient's life--relationships, social activities, work and emotional wellbeing. The cumulative effect of this disability may be self-perpetuating social disconnection and failure to achieve a 'full life potential' in some patients. Health-related quality of life studies have quantified the burden of psoriasis providing predominantly cross-sectional data and point-in-time images of patients' lives rather than assessing the possible cumulative disability over a patient's lifetime. However, social and economic outcomes indicate there are likely negative impacts that accumulate over time. To capture the cumulative effect of psoriasis and its associated co-morbidities and stigma over a patient's life course, we propose the concept of 'Cumulative Life Course Impairment' (CLCI). CLCI results from an interaction between (A) the burden of stigmatization, and physical and psychological co-morbidities and (B) coping strategies and external factors. Several key aspects of the CLCI concept are supported by data similar to that used in health-related quality of life assessments. Future research should focus on (i) establishing key components of CLCI and determining the mechanisms of impairment through longitudinal or retrospective case-control studies, and (ii) assessing factors that put patients at increased risk of developing CLCI. In the future, this concept may lead to a better understanding of the overall impact of psoriasis, help identify more vulnerable patients, and facilitate more appropriate treatment decisions or earlier referrals. To our knowledge, this is a first attempt to apply and develop concepts from 'Life Course Epidemiology' to psoriasis research.

Nail psoriasis in Germany: epidemiology and burden of disease

BACKGROUND

Although nail psoriasis affects a marked proportion of patients with psoriasis and causes significant psychological stress, only few epidemiological data characterizing patients with nail involvement are available.

OBJECTIVES

To gain robust data on the epidemiology and disease burden of nail psoriasis in Germany.

METHODS

Two nationwide, noninterventional, cross-sectional studies on psoriasis health care were conducted in 2005 and 2007, involving 48 (2005) and 130 (2007) German office-based and clinic-based dermatological centres. Data of n=3531 patients with psoriasis were collected using standardized questionnaires and physical examinations by trained dermatologists. Patients with nail psoriasis were compared with patients without any nail involvement concerning sex, age, disease duration, family history, disease severity, presence of psoriatic arthritis (PsA), health-related quality of life (HRQoL), number of inpatient therapies, and days off work.

RESULTS

Nail psoriasis was diagnosed in 40·9% of the patients; prevalence was 11·2 percentage points higher in men than in women. Patients with nail involvement had a longer disease duration (21·9 vs. 18·1 years), higher disease severity (mean Psoriasis Area and Severity Index 12·7 vs. 9·3), higher frequency of PsA (26·0% vs. 12·7%), stronger impairment of HRQoL (mean Dermatology Life Quality Index 8·9 vs. 7·3), and a 2·5-fold higher rate of inpatient treatments.

CONCLUSIONS

Nail involvement is a relevant manifestation of psoriasis and is associated with a higher disease severity and quality of life impairment. Accordingly, management of psoriasis should include a special focus on nail involvement.

How do regional factors influence psoriasis patient care in Germany?

BACKGROUND

Two national surveys conducted in 2005 and 2007 indicated deficits in psoriasis care in Germany, although there has been a notable nationwide improvement within this period. It remained unclear whether regional differences in psoriasis health care have an influence on patient outcomes in Germany.

AIM

Assessment of regional differences in the health care situation of patient with psoriasis in Germany.

PATIENTS AND METHODS

Nation-wide cross-sectional study in 130 dermatological practices and clinics. Regional classification was based on the affiliation to the Associations of Statutory Health Insurance Physicians. A panel of experts developed eight criteria as indicators of quality of care, among them clinical characteristics and severity of psoriasis (PASI), previous treatments, quality of life and patient-relevant therapeutic benefits.

RESULTS

Care indicators showed marked regional differences. The proportion of patients with preceding systemic or biologic treatment varied between regions. Those regions with high proportions had better results in patient-reported outcomes.

CONCLUSIONS

Differences in economic and regulatory conditions of health care might account for the observed regional variations. Thus, further analyses of these factors are of great importance to assure consistent psoriasis health care in Germany.

Long-term efalizumab therapy for patients with moderate-to-severe, chronic plaque psoriasis: results from an Australian expanded access program

BACKGROUND

Psoriasis is a chronic skin disease that can impact heavily on a patient's well-being. Efalizumab, a unique, targeted, biological therapy, has demonstrated efficacy in treating moderate-to-severe, chronic plaque psoriasis with <or=36 months of continuous therapy. The objective of this Extended Access Program (EAP) was to evaluate further the benefit of efalizumab as long-term therapy in a real-world clinical setting.

METHODS

After an initial conditioning dose of efalizumab (0.7 mg/kg subcutaneously), a weekly dose of efalizumab (1.0 mg/kg) was administered for <or=21 months. Patients with reduced Psoriasis Area and Severity Index (PASI) scores (>or=50%, or a score <or=8) at month 3 entered the long-term maintenance treatment period.

RESULTS

In total, 101 patients (>18 years) with severe plaque psoriasis enrolled on the EAP, of these 93 (92.1%) met all the inclusion criteria. After 3 months of treatment, 84/101 (83.2%) patients had evaluable data and entered the maintenance period. After 3 months, 57/84 (67.9%) patients had achieved PASI-50. Using an intent-to-treat analysis, after 21 months of treatment, PASI-75 and PASI-50 were achieved by 43/101 (42.6%) and 69/101 (68.3%) of patients, respectively. Efalizumab was generally well tolerated during the 21 months of continuous therapy.

CONCLUSION

Efalizumab, 1.0 mg/kg/week, is effective and well tolerated in a 'real world' clinical setting, providing enduring reduction of psoriasis symptoms for up to 21 months.

Ten years of infliximab: its role in dermatology

Psoriasis is a common chronic inflammatory disease of the skin. Psoriatic arthritis may develop in about 20% of psoriasis patients while metabolic syndrome is a frequent comorbidity, and risk of cardiovascular disease is increased in psoriasis patients. Classical systemic treatments have not evolved much during the last decades; biological therapies on the contrary have added most significant progress in systemic treatment during the last 10 years. In particular tumor necrosis factor (TNF) blockade has changed the treatment outcomes in moderate to severe psoriasis patients. With drugs such as infliximab treatment goals of 75% improvement of psoriasis lesions together with significant improvement of quality of life can be achieved. Furthermore, skin clearance is possible in many patients with continued maintenance treatment with infliximab. More recent pivotal studies have shown that associated nail psoriasis responds well to infliximab, an outcome that was difficult to reach with classical therapies. There is good evidence that infliximab may be useful in other dermatological conditions such as pyoderma gangrenosum and hidradenitis suppurativa. Infliximab is an intravenous administration over a 2-hour period. Some patients may develop infusion reactions, and dermatologists need to be well aware of any possible adverse events that may be associated with anti-TNF treatment. Today, dermatologists have collected a broad experience with infliximab treatment of psoriasis and they have thus advanced their clinical practice accordingly.

Moderate and severe plaque psoriasis: cost-of-illness study in Italy

Psoriasis is a chronic inflammatory, immune-mediated skin disorder that affects 1.5-1.8 million people in Italy. The most common form of the disease is chronic plaque psoriasis, affecting about 90% of psoriasis patients, with about 20%-30% of them suffering from a moderate or severe condition. Little information is available about the economic impact of psoriasis in European countries. The primary objective of this study was to perform a cost-of-illness analysis of patients with moderate and severe plaque psoriasis in Italy. Therefore, direct, indirect costs, and intangible costs (quality of life - QoL) were assessed. In this national, multicenter, prospective, 3-month cost-of-illness study of moderate and severe plaque psoriasis, direct and indirect costs were assessed from the patient, third-party payer (National Health Service, NHS), and societal perspectives. From November 2003 to October 2004 consecutive patients were enrolled over a 1-year period, in order to minimize seasonal fluctuations in disease severity. 150 patients enrolled in 6 investigational sites in Italy, completed the study, and were eligible to be analyzed according to the study protocol. Intangible costs (QoL) were measured using SF36 and DLQI questionnaires. The mean total cost for psoriasis (average Psoriasis Area Severity Index [PASI] score 21.4), including direct and indirect items, was euro8,371.61 per patient per year. The mean cost for patients with moderate disease (PASI 20) was euro11,434.40 per year. Disease heavily affected QoL measured using SF36, and the impairment was greater in patients affected by a more severe form of disease. Moderate and severe plaque psoriasis is associated with extremely high costs, which are related to disease severity. Data from this study show that the more severe plaque psoriasis, the higher the direct and indirect costs for its management. Direct costs are higher than indirect costs; hospitalization represents the most significant item, accounting for 30% of the total expenses. QoL in moderate and severe plaque psoriasis is low compared with the population at large, confirming the high impact of plaque psoriasis on QoL. The relatively high average annual costs per patient point to the need for a more efficient and long-term control of psoriasis.

Disease severity, quality of life and health care in plaque-type psoriasis: a multicenter cross-sectional study in Germany

BACKGROUND

Plaque-type psoriasis produces significant morbidity, has negative effects on patients' health-related quality of life (HRQoL), and represents an economic burden.

OBJECTIVES

The assessment of disease severity, HRQoL and health care in plaque-type psoriasis in everyday German medical practice.

METHODS

Details of patients with plaque-type psoriasis were recorded by 48 dermatologists in Germany. During the visit, demographic data, medical history, previous and current treatments, occupational impairment, the current state of the disease (measured by the Psoriasis Area and Severity Index; PASI), overall lesion severity, and HRQoL were evaluated.

RESULTS

In total, 1,511 plaque-type psoriasis patients were included. The average PASI score was 12.0. The average Dermatology Life Quality Index score was 8.6. Among the patients with the severest psoriasis (PASI >20), only 45.4% had ever been prescribed systemic treatments.

CONCLUSIONS

Psoriasis patients have a reduced HRQoL and are not sufficiently treated in practice. A more widespread use of systemic treatment and the definition of treatment goals are essential to improve the standard of care for psoriasis patients.

Economic burden of psoriatic arthritis

Psoriatic arthritis (PsA) is a chronic autoimmune disease characterized by inflammatory arthritis in association with skin psoriasis (Ps). PsA may show a heterogeneous and variable clinical course, with involvement of peripheral and axial diarthrodial joints, periarticular structures such as entheses, as well as the skin and nails. Evidence is increasing that affected patients can have significant radiographic joint damage, functional impairment, reduced quality of life (QOL) and long-term work disability. The economic burden of PsA can be considerable. There is an increasing interest in pharmacoeconomic evaluations in PsA, driven mostly by the introduction of highly effective but expensive biologic agents, particularly inhibitors of the proinflammatory cytokine tumour necrosis factor (TNF)-alpha. Treatment with TNFalpha inhibitors results in not only substantial improvements in signs and symptoms of arthritis, but also improvements in all distinct sites of the disease, such as axial arthritis, dactylitis, enthesitis and skin disease. There is a dearth of published pharmacoeconomic evaluations in the field of PsA. The notable clinical efficacy of the TNFalpha inhibitors needs to be factored into a comprehensive assessment of their value. Further analyses are needed to optimize the use of the new biologic agents in PsA.

Cost-Effectiveness Model of Topical Treatment of Mild to Moderate Psoriasis Vulgaris in Germany

BACKGROUND

Psoriasis vulgaris requires lifelong treatment associated with considerable health cost. Studies showed that a combination of a steroid and a vitamin D(3) analogue is more effective than both compounds in monotherapy.

OBJECTIVE

To determine the cost-effectiveness of a fix calcipotriol/betamethasone combination (Daivobet/Dovobet/Taclonex) compared to a morning/evening non-fix calcipotriol/betamethasone combination in psoriasis treatment.

METHODS

A Markov model (discrete-time stochastic process based on transitions between health states) with 2 treatment arms (Daivobet/Dovobet/Taclonex vs. non-fix calcipotriol/betamethasone) over a 48-week time period was developed. The effectiveness criterion was the number of days with clearance or marked improvement. Clinical and health resource utilisation data were derived from randomised studies.

RESULTS

Treatment with Daivobet/Dovobet/Taclonex showed a higher cost-effectiveness compared to the non-fix combination, even when assuming a maximum compliance for the twice daily non-fix combination and varying the effectiveness of Daivobet/Dovobet/Taclonex by 10%.

CONCLUSION

Psoriasis treatment with a fix calcipotriol/betamethasone combination is more cost-effective than a non-fix morning/evening combination.

Cost-effectiveness of psoriasis therapy with etanercept in Germany

BACKGROUND

We estimated the cost-effectiveness of intermittent therapy with etanercept in patients with moderate-to-severe plaque-type psoriasis in comparison to non-systemic therapy in Germany.

PATIENTS AND METHODS

We performed a cost-utility analysis using the endpoint costs per quality-adjusted life year gained (costs/QALY). For this purpose, we adapted a UK-based Markov model by means of resource use data that we derived from a German cost study. Efficacy data, information on frequency of adverse events and changes in quality of life were derived from three pooled clinical trials. We extrapolated the further course of the disease and its treatment over a 10 year course.

RESULTS

For patients with an initial Psoriasis Area and Severity Index (PASI) > 10 and a Dermatology Life Quality Index (DLQI) > 10 the incremental cost-effectiveness ratio (ICER) for etanercept compared to non-systemic therapy was 45,491 euro/QALY. For patients with PASI and DLQI > 15 costs/QALY were 32,058 euro and among patients with severe plaque psoriasis (DLQI and PASI > 20) 18,154 euro.

CONCLUSIONS

According to internationally accepted levels of cost-effectiveness thresholds, the intermittent treatment of (moderate to) severe plaque-type psoriasis with etanercept is a cost-effective measure within the German healthcare system.

Treatment goals in psoriasis

The introduction of biologics has not only broadened the therapeutic armamentarium for psoriasis but also stimulated discussion about the treatment of this common skin condition. The recently presented German S3 psoriasis guideline contains detailed information on the efficacy of the different products and describes important safety and practical aspects of psoriasis treatments. Patient surveys and recent studies in Germany indicate a relatively high mean severity of skin symptoms and low quality of life among affected patients. One possible explanation is that the conventional traditional and new treatment options are not being used consistently. In this paper, minimum treatment goals for psoriasis that should be achieved by an individually selected treatment regimen are presented. If, after a defined period of time, an at least 50 % reduction of the baseline Psoriasis Area and Severity Index (PASI) and a Dermatology Life Quality Index of ( not less-than 5 is not reached, patients should be switched to another therapy, after a balanced discussion. Whenever necessary, a continuous maintenance therapy should be instituted with special attention to these goals. Patients should carefully be monitored for the presence of psoriatic arthritis and comorbidities because these may need to be integrated in the planning of treatment goals on an interdisciplinary basis.

Costs and quality of life in patients with moderate to severe plaque-type psoriasis in Germany: A multi-center study

BACKGROUND

This study evaluated costs, disease severity and health-related quality of life (QoL) in patients with moderate to severe plaque-type psoriasis.

PATIENTS AND METHODS

Patients with a 'psoriasis area and severity index' (PASI) > 12 and/or a body surface area (BSA) > 10 were enrolled in dermatological practices and hospital outpatient departments (n = 184) and the total costs of illness generated during the last 12 months were retrospectively calculated. QoL was assessed using the SF-36 and the DLQI. Participants were stratified into three subgroups according to the treatment received during the 1 year documentation period; a) patients without and b) patients with phototherapy or standard systemic therapy, and c) patients who had failed, were intolerant or had contraindications to at least two standard systemic therapies. The study was performed before biologics became available for the treatment of psoriasis in Germany.

RESULTS

Included patients had severe skin symptoms (mean PASI 18.2) and a highly impaired QoL (mean DLQI 10.6). Total annual costs amounted to euro 6,709. Patients belonging to subgroup C had the most severe skin symptoms (mean PASI 22.2), the lowest QoL (mean DLQI 12.6), the highest hospitalization rate and largest loss of productivity. These patients produced the highest total costs of 8.831 euro/y.

CONCLUSIONS

Patients who cannot (or can no longer) be adequately managed with standard treatments are characterized by high disease activity, high costs and reduced QoL. Improved treatment options particularly for these patients are medically necessary and appear economically sensible.

Emerging drugs for psoriasis

Psoriasis is a chronic immune-mediated inflammatory skin disease characterised by abnormal keratinocyte differentiation and proliferation. The immunopathogenesis is complex and novel evidence shows the involvement of both innate and adaptive immune response. Type 1 T cells and their effector cytokines play a pivotal role. Several drugs under preclinical and clinical development for psoriasis are directed against the immune response, targeting activation or proliferation of T cells, their trafficking and skin-homing, or effector cytokines. Among these, great attention has been given to TNF-alpha, following the demonstration of effectiveness of anti-TNF-alpha biologicals, and to IFN-gamma inducers. Another appealing approach concerns drugs capable of inducing immunological tolerance. Progress made in the recognition of intracellular events has prompted the development of small molecules and oligonucleotides that can inhibit specific molecular targets. There is, however, a plethora of other emerging drugs, clearly suggestive of the current interest for psoriasis, which are briefly described in this paper.