Identifying Unmet Care Needs and Important Treatment Attributes in the Management of Hidradenitis Suppurativa: A Qualitative Interview Study

Expert consensus on unmet needs, referral criteria and treatment goals for hidradenitis suppurativa in Saudi Arabia

Purpose: There is limited information about the diagnosis and treatment of hidradenitis suppurativa (HS) in the Kingdom of Saudi Arabia (KSA). This Delphi consensus study was conducted to develop recommendations for the management of HS in the KSA.Methods: The expert panel including 12 dermatologists with extensive experience treating HS patients provided nine consensus statements and recommendations on diagnosis and assessment, management, comorbidities and multidisciplinary approach, and education. The experts also developed clinical questions pertaining to the management of HS and rolled out as a survey to 119 dermatologists practising in the KSA.Results: The topics covered included: referring physicians' awareness of HS; referral criteria for HS; definition of moderate-to-severe HS; treatment goals; definition of treatment success; treatment and biologic initiation; comorbidities and multidisciplinary approach; patient education and awareness of HS. Full consensus (100%) from the expert dermatologists was received on all the topics except referring physicians' awareness of HS, definition of treatment success, and treatment and biologic initiation. The survey results resonated with the expert opinion.Conclusion: As HS is a chronic disease with negative impact on quality-of-life, timely diagnosis and treatment, early identification of comorbid conditions and a multidisciplinary care approach are crucial for effective management of HS.

Exploring racial and ethnic disparities in the hidradenitis suppurativa patient disease journey: Results from a real-world study in Europe and the USA

Hidradenitis suppurativa (HS) is an inflammatory skin disease associated with high morbidity and disability that has limited treatment options. People from racial and ethnic minority groups may experience greater disease severity and delay to diagnosis. This study assessed the impact of race/ethnicity on HS diagnosis and management in real-world clinical settings. Data were derived from the Adelphi Real World Hidradenitis Suppurativa Disease Specific Programme, a survey of dermatologists and their consulting HS patients in five European countries and the USA in 2020/2021. Dermatologists returned demographic and clinical data, and treatment goals and satisfaction for their next five to seven consulting patients. Patients completed a questionnaire on disease history and diagnosis, disease burden, and treatment satisfaction. Groups were compared with bivariate tests. In total, 312 physicians returned data on 1787 patients; 57.6% were female and 77.7% White. People from racial and ethnic minority groups were younger than White patients (32.9 ± 11.6 vs. 34.9 ± 12.4, mean ± standard deviation) and reported symptoms at a younger age (23.3 ± 10.8 vs. 26.2 ± 11.1), but their time to first consultation was longer than for White patients (2.6 ± 5.7 vs. 1.2 ± 2.5 years). People from racial and ethnic minority groups took longer to receive a correct diagnosis following first consultation (2.7 ± 5.3 vs. 1.5 ± 4.1 years) and were more likely to be misdiagnosed with boils (73.5% vs. 40.4%). People from racial and ethnic minority groups had a greater disease awareness at diagnosis and reported wanting greater support. People from racial and ethnic minority groups reported a greater impact on life, more severe pain, and a greater level of activity impairment in the Work Productivity and Activity Impairment: General Health (27.0 ± 25.2 vs. 20.0 ± 20.6). All P values were ≤0.05. These data show evidence of delayed diagnosis and higher HS symptom burden amongst people from racial and ethnic minority groups, highlighting health disparities in HS.

Patient-reported assessment of medical care for chronic inflammatory skin diseases: an enterprise-based survey

Background

Chronic inflammatory skin diseases (CISDs) are among the most common diseases in the Western world. Current estimates of medical care for CISDs are primarily based on surveys among patients in medical care facilities and on health insurance data.

Aim

Survey-based examination to what extent CISD patients in health-aware environment consider their skin disease to be controlled.

Methods

The survey of CISD patients was carried out in 2022 among the employees of a pharmaceutical company located in Germany and Switzerland. Software-based, anonymous, self-reported questionnaires were used.

Results

The number of employees, who answered the questionnaire, was 905. Of these, 222 participants (24.5%) reported having at least one CISD. 28.7% of participants with CISD described their disease as being hardly or not controlled. Regarding the nature of disease, more than one third of participants suffering from hidradenitis suppurativa (HS) or psoriasis fell into the hardly/not controlled category. In contrast, the largest proportion of participants with chronic spontaneous urticaria (43%) or atopic dermatitis (42%) considered their CISD to be completely or well controlled. Only 35.5% of CISD sufferers stated that they were currently under medical care for their skin condition. Being under medical care, however, had no influence on the extent CISD sufferers considered their skin disease to be controlled. The number of active CISD episodes but not the total number of symptomatic days per year was negatively associated with poor disease control (p = 0.042 and p = 0.856, respectively). Poor disease control had a negative effect on the personal and professional lives of those affected, as deduced from its positive association with the extent of daily activity impairment and presenteeism (p = 0.005 and p = 0.005, respectively). Moreover, 41.4 and 20.7% of participants with hardly/not controlled disease stated that their CISD had a moderate and severe or very severe impact on their overall lives (p < 0.001), respectively. A severe or very severe impact of their CISD on their overall life was most commonly reported by participants with HS.

Conclusion

Medical care for CISDs, even in an environment with high socio-economic standard and high health-awareness, still appears to be limited and has a negative impact on individuals and society.

Burden of Hidradenitis Suppurativa: A Systematic Literature Review of Patient Reported Outcomes

INTRODUCTION

Hidradenitis suppurativa (HS) has a profound negative impact on patients' health-related quality of life (HRQoL). Here we summarize the evidence on HRQoL and Patient Reported Outcomes (PROs) in patients with HS in real-world settings by conducting a systematic literature review (SLR) of observational studies.

METHODS

Data sources included MEDLINE, Embase & PsycINFO between January 1, 2010 and August 29, 2021, and conference proceedings between 2019 and 2021. Identified abstracts were reviewed and screened independently by two reviewers. Eligibility criteria included patients with HS of any severity, sample size ≥ 100, reporting PROs including HRQoL measures. Included studies were critically appraised.

RESULTS

Fifty-eight observational studies matched inclusion criteria. Dermatology Life Quality Index (DLQI) was the most commonly utilized instrument: 57% of included studies reported mean baseline DLQI scores, ranging between 8.4 and 16.9, indicating a very large impact on the patients' HRQoL. Higher scores were reported with increasing disease severity and among female patients. Pain was assessed mostly by an 11-point (0-10) numeric rating scale (NRS) with a mean baseline score ranging from 3.6 to 7.7 indicating moderate to high pain levels. There was a negative impact of HS on patients' psychological well-being, based on PRO scores related to depression and anxiety. A high proportion of sexual dysfunction was reported, with a larger impact on women than men. Work productivity and leisure activity were consistently found to be impaired in patients with HS.

CONCLUSIONS

All included studies reported a negative impact of HS on patients' lives. A diverse set of disease- and non-disease-specific PRO instruments were utilized highlighting the need for more consistent use of HS-specific validated PRO instruments to assess the impact of HS on the different aspects of patients' HRQoL to allow for data to be more meaningfully interpreted and compared in real-world settings. Patients with HS need better disease management approaches that address the observed low quality of life.

Outcome Measures for the Evaluation of Treatment Response in Hidradenitis Suppurativa for Clinical Practice: A HiSTORIC Consensus Statement

Importance

Although several clinician- and patient-reported outcome measures have been developed for trials in hidradenitis suppurativa (HS), there is currently no consensus on which measures are best suited for use in clinical practice. Identifying validated and feasible measures applicable to the practice setting has the potential to optimize treatment strategies and generate generalizable evidence that may inform treatment guidelines.

Objective

To establish consensus on a core set of clinician- and patient-reported outcome measures recommended for use in clinical practice and to establish the appropriate interval within which these measures should be applied.

Evidence Review

Clinician- and patient-reported HS measures and studies describing their psychometric properties were identified through literature reviews. Identified measures comprised an item reduction survey and subsequent electronic Delphi (e-Delphi) consensus rounds. In each consensus round, a summary of outcome measure components and scoring methods was provided to participants. Experts were provided with feasibility characteristics of clinician measures to aid selection. Consensus was achieved if at least 67% of respondents agreed with use of a measure in clinical practice.

Findings

Among HS experts, response rates for item reduction, e-Delphi round 1, and e-Delphi round 2 surveys were 76.4% (42 of 55), 90.5% (38 of 42), and 92.9% (39 of 42), respectively; among patient research partners (PRPs), response rates were 70.8% (17 of 24), 100% (17 of 17), and 82.4% (14 of 17), respectively. The majority of experts across rounds were practicing dermatologists with 18 to 19 years of clinical experience. In the final e-Delphi round, most PRPs were female (12 [85.7%] vs 2 males [11.8%]) and aged 30 to 49 years. In the final e-Delphi round, HS experts and PRPs agreed with the use of the HS Investigator Global Assessment (28 [71.8%]) and HS Quality of Life score (13 [92.9%]), respectively. The most expert-preferred assessment interval in which to apply these measures was 3 months (27 [69.2%]).

Conclusions and Relevance

An international group of HS experts and PRPs achieved consensus on a core set of HS measures suitable for use in clinical practice. Consistent use of these measures may lead to more accurate assessments of HS disease activity and life outcomes, facilitating shared treatment decision-making in the practice setting.

Understanding Hurley Stage III Hidradenitis Suppurativa Patients' Experiences With Pain: A Cross-Sectional Analysis

BACKGROUND

More than 90% of patients with hidradenitis suppurativa (HS) report that pain interferes with their quality of life (QoL) and pain may have a larger impact on QoL than disease severity alone.

OBJECTIVES

The purpose of this study was to understand the impact of pain on the daily lives of patients with Hurley stage III HS.

METHODS

This was a single-center, prospective cross-sectional study that was conducted at Beacon Dermatology in Calgary, AB. Patients ≥ 18 years old with Hurley stage III HS in at least one area of the body were prospectively invited to participate in this study. The study consisted of survey questions on patients' demographic information, past medical histories, HS-related pain histories, and previous therapies for pain management. Additionally, patients completed a series of standardized rating scales on their pain and overall QoL.

RESULTS

Of the 10 patients that participated in the study, 90% (9/10) expressed a desire for more counselling on pain management options. Many patients (8/10, 80%) reported routine use of over-the-counter pain medications and 70% (7/10) used complementary and alternative medicines (CAMs) to manage their pain. Patients' efficacy ratings of HS treatments in controlling their pain revealed that topical treatments provided minimal or no relief, while surgical interventions had the highest efficacy for reducing pain. Patients' average worst pain over the preceding 24 hrs was 6.3 +/- 2.5 (2-9) on the Numerical Rating Scale for pain and the mean Dermatology Life Quality Index score was 19.5 +/- 8.2 (5-29).

CONCLUSIONS

Patients with Hurley stage III HS report high levels of daily pain and QoL impairment and many individuals use over-the-counter treatments and CAMs to manage their pain. Physicians involved in the care of HS patients should consider implementing routine counselling on pain management into their clinical practices, especially for patients with severe HS.

Patient perspectives of wound care management in hidradenitis suppurativa

Wound care management and costs in hidradenitis suppurativa (HS) are unmet needs. This study explored patient perspectives of at-home management of acute flares of HS and chronic daily wounds, their satisfaction with current wound care methods, and the financial burden of wound care supplies. An anonymous, multiple choice, cross-sectional questionnaire was distributed among online HS-related forums between August and October 2022. Participants 18 years or older with a diagnosis of HS who live in the United States were included. In total, 302 participants completed the questionnaire: 168 White (55.6%), 76 Black (25.2%), 33 Hispanic (10.9%), 7 Asian (2.3%), 12 multiracial (4.0%), and 6 other (2.0%). Dressings commonly reported included gauze, panty liners or menstrual pads, tissues or toilet paper, antiseptic dressing, abdominal pads, and adhesive bandages. Commonly reported topical remedies for acute flares of HS included warm compresses, Epsom salt baths, Vicks VapoRub, tea tree oil, witch hazel, and bleach baths. One-third of participants (n = 102) reported dissatisfaction with current wound care methods, and 48.8% (n = 103) believed that their dermatologist does not meet their wound care needs. Nearly half (n = 135) reported being unable to afford the type and quantity of dressings and wound care supplies they would ideally want. Black participants were more likely than White participants to report being unable to afford their dressings and find the cost as very burdensome. Overall, dermatologists must improve patient education of wound care methods in HS and address the financial burden of wound care supplies by exploring insurance-funded options.

Patient Perspectives of Health System Barriers to Accessing Care for Hidradenitis Suppurativa: A Qualitative Study

Importance

Patient-perceived barriers to hidradenitis suppurativa (HS) care are poorly understood. Understanding health care barriers is a critical first step toward improving care for this population.

Objective

To characterize the health care experiences of people living with HS, including perceived barriers and facilitators to health care access, and to elucidate potential associations among these barriers and facilitators, health care access, and disease activity.

Design, Setting, and Participants

In this qualitative study, an inductive thematic analysis was conducted on 45 in-depth, 60- to 90-minute semistructured interviews of 45 people with HS from diverse sociodemographic backgrounds that took place between March and April 2020. Individuals were eligible if they could speak English, were 18 years or older, and were diagnosed with HS. A diagnosis of HS was confirmed through physician diagnosis or through self-reported, affirmative response to the validated screening question, "Do you experience boils in your armpits or groin that recur at least every six months?"

Main Outcomes and Measures

Interviews were audio recorded and transcribed verbatim. A modified grounded theory approach was used to develop the codebook, which investigators used for inductive thematic analysis.

Results

Among the 45 participants included, the median (IQR) age was 37 (16) years, 33 (73%) were female, and 22 (49%) were White. There were 6 interrelated themes associated with participant-perceived barriers to accessing HS care: (1) bidirectional associations of disease activity and employment, (2) association of employment with health care coverage, (3) association of health care coverage with costs and perceived access to care, (4) association of costs with access to patient-centered care, (5) health care professional attitudes and knowledge influence patient-centered care and perceived access to care and disease activity, and (6) health system characteristics influence patient-centered care and associated costs, perceived access to care, and disease activity.

Conclusions and Relevance

This qualitative study highlights themes that generate a conceptual model for understanding barriers that may act synergistically to limit health care access and influence disease activity. The disease activity of HS may be reduced when cycle elements are optimized. This study also highlights areas for future investigations and potential systems-level changes to improve access to patient-centered HS care.

Patient Preferences in the Management of Hidradenitis Suppurativa: Results of a Multinational Discrete Choice Experiment in Europe

BACKGROUND AND OBJECTIVE

Hidradenitis suppurativa is a chronic inflammatory skin disease that can lead to a substantial reduction in quality of life. Recent studies revealed high levels of unmet care needs of patients with hidradenitis suppurativa, but their preferences in treatment decision making have scarcely been investigated. This study aimed to reveal which treatment attributes adult patients with HS in Europe consider most important in treatment decision-making.

METHODS

A discrete choice experiment was conducted with adult patients with hidradenitis suppurativa in Europe to reveal which treatment attributes are most important when making treatment decisions. Participants were presented with 15 sets of two treatment options and asked for each to choose the treatment they preferred. The treatments were characterized by six attributes informed by a prior literature review and qualitative research: effectiveness, pain reduction, duration of treatment benefit, risk of mild adverse event, risk of serious infection, and mode of administration. A random parameter logit model was used to estimate patients' preferences with additional subgroup and latent class models used to explore any differences in preferences across patient groups.

RESULTS

Two hundred and nineteen adult patients with hidradenitis suppurativa were included in the analysis (90% women, mean age 38 years). For all six treatment attributes, significant differences were observed between levels. Given the range of levels of each attribute, the most important treatment attributes were effectiveness (47.9%), followed by pain reduction (17.3%), annual risk of a mild adverse event (14.4%), annual risk of a serious infection (10.3%), mode of administration (5.3%), and duration of treatment benefit (4.8%). Higher levels of effectiveness, namely a 75% or 100% reduction in the abscess and inflammatory nodule count, were preferred over levels of effectiveness primarily investigated in randomized clinical trials of hidradenitis suppurativa (a 50% reduction). Results were largely consistent across subgroups and three latent class groups were identified.

CONCLUSIONS

This study revealed the most important treatment characteristics for patients with hidradenitis suppurativa that can help inform joint patient-physician decision making in the management of hidradenitis suppurativa. Designing future hidradenitis suppurativa treatments according to stated preferences, namely, to offer higher levels of effectiveness and pain improvement without higher risks of adverse events, may increase patients' treatment concordance and lead to improved disease management outcomes.

Hidradenitis Suppurativa’s Impact on Social Activities: An Observational Study

Hidradenitis suppurativa (HS) can severely impact patients’ quality of life. However, its specific impact on participation in everyday social activities is not well characterized. We recruited a cohort of patients with HS to complete a survey assessing the degree of interference HS has on participation in social activities. Patients also completed the Brief Fear of Negative Evaluation (BFNE) to assess levels of social anxiety. The majority of patients in our cohort, regardless of Hurley Stage, reported interference with social activities, and patients with more painful nodules and greater body region involvement reported greater interference with social activities. BFNE scores were high in our cohort, and patients with higher BFNE scores reported greater interference in all social activities assessed. Both the physical and psychological effects of HS may interfere with patients’ participation in social activities, and efforts to treat both aspects may improve quality of life.

What Matters for Evaluating the Quality of Mental Healthcare? Identifying Important Aspects in Qualitative Focus Groups with Service Users and Frontline Mental Health Professionals

Background

Evaluating quality in mental healthcare is essential for ensuring a high-quality experience for service users (SUs). Policy-defined quality indicators, however, risk misalignment with the perspectives of SUs and mental healthcare professionals (MHPs). There is value in exploring how SUs and frontline MHPs think quality should be measured.

Objectives

Our study objectives were to: (1) identify aspects that SUs and MHPs deem important for assessing quality in mental healthcare to help support attribute selection in a subsequent discrete choice experiment and (2) explore similarities and differences between SU and MHPs’ views.

Methods

Semi-structured qualitative focus groups (n = 6) were conducted with SUs (n = 14) and MHPs (n = 8) recruited from a UK National Health Service Trust. A topic guide was generated from a review of UK policy documents and existing data used to measure quality in mental healthcare in England. Transcripts were analysed using a framework analysis.

Results

Twenty-one subthemes were identified, grouped within six themes: accessing mental healthcare; assessing the benefits of care; co-ordinated approach; delivering mental healthcare; individualised care; and role of the person providing care. Themes such as person-centred care, capacity and resources, and receiving the right type of care received more coverage than others. Service users and MHPs displayed high concordance in their views, with minor areas of divergence.

Conclusions

We developed a comprehensive six-theme framework for understanding quality in mental healthcare from the viewpoint of the SU and frontline MHP, which can be used to help inform the selection of a meaningful set of quality indicators in mental health for research and practice.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40271-022-00580-0.

Trends in Hidradenitis Suppurativa Disease Severity and Quality of Life Outcome Measures: Scoping Review

BACKGROUND

Although there has been an increase in the number of randomized controlled trials evaluating treatment efficacy for hidradenitis suppurativa (HS), instrument measurements of disease severity and quality of life (QoL) are varied, making the compilation of data and comparisons between studies a challenge for clinicians.

OBJECTIVE

We aimed to perform a systematic literature search to examine the recent trends in the use of disease severity and QoL outcome instruments in randomized controlled trials that have been conducted on patients with HS.

METHODS

A scoping review was conducted in February 2021. The PubMed, Embase, Web of Science, and Cochrane databases were used to identify all articles published from January 1964 to February 2021. In total, 41 articles were included in this systematic review.

RESULTS

The HS Clinical Response (HiSCR) score (18/41, 44%) was the most commonly used instrument for disease severity, followed by the Sartorius and Modified Sartorius scales (combined: 16/41, 39%). The Dermatology Life Quality Index (18/41, 44%) and visual analogue pain scales (12/41, 29%) were the most commonly used QoL outcome instruments in HS research.

CONCLUSIONS

Randomized controlled trials conducted from 2013 onward commonly used the validated HiSCR score, while older studies were more heterogeneous and less likely to use a validated scale. A few (6/18, 33%) QoL measures were validated instruments but were not specific to HS; therefore, they may not be representative of all factors that impact patients with HS.

TRIAL REGISTRATION

National Institute of Health Research PROSPERO CRD42020209582; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020209582.