Does enough quality of life-related discussion occur during dermatology outpatient consultations?

Quality of life of dermatology outpatients and its associated factors in Halibet National Referral Hospital in Asmara, Eritrea

Skin diseases are prevalent globally and can have detrimental effects on the individual's health-related quality of life (HRQoL). The treatment of dermatological patients typically focuses on clinical signs and symptoms and a subjective view of the impact of the disease on the patient's life. Assessing quality of life can help provide patients with better service, by acknowledging their real needs and interfering with treatment decisions. The aim of the study was therefore to assess quality of life of dermatology outpatients and its associated factors. An analytical cross-sectional study was conducted in the dermatology clinic of Halibet National Referral Hospital in Asmara, Eritrea. HRQoL data were collected between May 6 and August 18, 2022 using a validated standard tool (Skindex-29). Descriptive statistics, logistic regression and paired t-test were employed using Statistical Package for Social Sciences (Version-26.0). A total of 375 dermatology clinic out-patients with a median age of 29 (Interquartile range: 25) were included in the study. The most commonly seen skin diseases were eczema, seborrhoeic dermatitis and tinea pedis. Emotion, symptom, and functioning domains of HRQoL were severely impaired in 75.7%, 50.4% and 57.6% of all dermatology outpatients, respectively. More than half of the respondents (57.9%) had a severely impaired overall HRQoL. In the overall HRQoL, being a rural resident [Adjusted Odds Ratio (AOR) 1.98, 95% CI 1.18, 3.33] and presence of chronic illness (AOR 2.16, 95% CI 1.22, 3.82) were significantly associated with severely impaired overall quality of life. A significantly higher mean score (p < 0.001) was observed in emotion [Mean (M) = 55.60, Standard Deviation (SD) = 21.0] as compared to functioning (M = 46.89, SD = 21.2). On the other hand, significantly higher mean score (p < 0.001) was observed on symptom (M = 54.08, SD = 20.5) as compared to functioning (M = 46.89, SD = 21.2). Skin diseases severely affected the emotion, functioning, and symptom domains of health-related quality of life. This highlights the importance of providing physical and psychosocial support to patients with dermatologic problems.

The Impact of Acne, Atopic Dermatitis, Skin Toxicities and Scars on Quality of Life and the Importance of a Holistic Treatment Approach

Skin conditions such as acne, atopic dermatitis, skin toxicity from oncology treatment, and scars are among the most common health conditions and negatively impact quality of life (QoL). Yet the physician perception of this impact often varies greatly from the patient perception. This is important because patient illness perception is closely linked with seeking help and treatment adherence behaviors. The objective of this review is to better understand the impact of these four highly prevalent skin conditions on QoL including their health-related economic factors to improve treatment outcomes. The literature search included literature published on QoL with acne, atopic dermatitis, scars (from any cause) and skin toxicities on PubMed between 2015 and 2020. We found that patients with skin conditions have a much higher frequency of altered QoL and psychological distress than those without. Also, skin conditions negatively impact self-image and can cause feelings of isolation, loneliness, lower self-esteem, and lower body satisfaction. Additionally, physical discomfort adds to the psychological distress. These physical and psychological impacts are an enormous financial burden on patients, their families and society. We found evidence that holistic treatment including treating the skin condition itself, providing wider peer and psychological support as well as shared decision-making, therapeutic patient education and dermatologist involvement improves outcomes. Holistic history-taking, checklists, or the use of more formal QoL scoring tools can be incorporated into routine consultations to better assess patient well-being and provide clinicians with important information for adapting treatment to individual patient requirements. In conclusion, this review highlights the overall impact of skin conditions (including psychological and QoL impacts) and the importance of providing holistic care to optimize treatment outcomes. A comprehensive QoL screening tool would be useful to help provide patient-centered treatment.

Glaucoma patient-provider communication about vision quality-of-life

OBJECTIVE

The purpose of this study was to: (a) describe the extent to which ophthalmologists and glaucoma patients discuss vision quality-of-life during office visits, and (b) examine the association between patient and ophthalmologist characteristics and provider-patient communication about vision quality-of-life.

METHODS

Patients with glaucoma who were newly prescribed or on glaucoma medications were recruited at six ophthalmology clinics. Patients' visits were video-tape recorded and quality-of-life communication variables were coded. Generalized estimating equations were used to analyze the data.

RESULTS

Two hundred and seventy-nine patients participated. Specific glaucoma quality-of-life domains were discussed during only 13% of visits. Older patients were significantly more likely to discuss one or more vision quality-of-life domains than younger patients. African American patients were significantly less likely to make statements about their vision quality-of-life and providers were less likely to ask them one or more vision quality-of-life questions than non-African American patients.

CONCLUSION

Eye care providers and patients infrequently discussed the patient's vision quality-of-life during glaucoma visits. African American patients were less likely to communicate about vision quality-of-life than non-African American patients.

PRACTICE IMPLICATIONS

Eye care providers should make sure to discuss vision quality-of-life with glaucoma patients.

Patient-Reported Outcome Measurement in Clinical Dermatological Practice: Relevance and Feasibility of a Web-Based Portal

BACKGROUND/AIMS

Patient-reported outcomes (PROs) are increasingly considered important. We developed a web-based application to electronically assess PROs in routine dermatological practice. We assessed (1) the relevance of PRO measurement according to health care providers and patients, (2) the feasibility of our application in routine practice according to health care providers, supporting staff and patients, and (3) barriers/facilitators for implementation according to health care providers and supporting staff.

METHODS

Health care providers, supporting staff and patients completed study-specific questionnaires. Also, website statistics were analysed.

RESULTS

3/6 clinics participated, including 9 professionals and 80 patients. Both health care providers and patients rated PRO measurement as relevant. However, implementation was only moderately feasible. Time constraints and logistical problems were mentioned as barriers, and motivated patients and supportive staff as facilitators.

CONCLUSION

Electronic PRO assessment in routine practice is not self-evident. Adjustments in logistics are recommended to optimize implementation, using a plan-do-study-act approach.

The dermatology outpatient discharge decision: understanding a critical but neglected process

Discharge from dermatology outpatients is a critical endpoint of patient care. Despite this, there has been very little research concerning the discharge process and factors influencing the discharge decision. To identify the factors influencing discharge decisions, articles from 1970 to April 2013 were searched in MEDLINE via Ovid, CINAHL, PROQUEST and Google Scholar using the keywords 'patient discharge', 'discharge decision', 'factors influencing discharge', 'clinical decision making', 'discharge decision making', 'process of discharge decision', 'outpatient', 'follow up', 'skin disease' and 'dermatology'. Only articles describing outpatient discharge decisions were included. Seventeen outpatient discharge articles were identified, 12 from the U.K. (seven dermatology) and five from the U.S.A., Canada, Australia and Taiwan (all nondermatology). The main influences on outpatient discharge identified were diagnosis and disease severity, clinician's level of experience and perception, patient's preferences, patient's behaviour and quality of life. These influences affected the clinician's judgement on discharge decisions both in appropriate and in inappropriate ways. Little is known concerning discharge decision making in dermatology. Given the central importance of such decisions in the appropriate care of patients and the efficient running of any dermatology service, greater understanding of the influences on discharge decision making is needed. It is therefore critical for dermatologists to be aware of these influences and to ensure that decisions are taken only in the best interests of patients. Further research is required to inform the training of dermatologists on how to take the most appropriate discharge decisions.

Quality of life profile and correlated factors in chronic leg ulcer patients in the mid-west of São Paulo State, Brazil

BACKGROUND

Chronic leg ulcer may have an impact on patients' quality of life.

OBJECTIVES

This study aimed to identify the impact of leg ulcers on patient's quality of life using the Dermatology Life Quality Index and to define the main factors correlated with this perception.

METHOD

Cross-sectional, non-probabilistic sampling study. We included patients with chronic leg ulcers being treated for at least 3 months. A sociodemographic and clinical survey was conducted to assess the profile of the ulcers. We administered a screening for depressive symptoms and the Dermatology Life Quality Index. We performed a descriptive statistical analysis, chi-square test and Mann-Whitney test for categorical data, Pearson for numeric variables, and multiple regression for categorical data.

RESULTS

Forty-one patients were assessed. Their mean age was 61.78 years. Venous ulcers (48.8%) were the most prevalent. Seventy-three percent of the sample perceived no impact/low impact on quality of life in the past week, and 26.8% perceived moderate/high impact. A multiple regression analysis identified the causes of lesion, pain related to the ulcers, time of onset, and severity of the depressive symptoms as the variables that had an influence on quality of life.

CONCLUSIONS

The majority of the sample perceived low or no impact of the condition on the quality of the life. The variables etiology of the lesion (p<0.001), pain related to the ulcers (p=0.001), time of onset (p=0.006), and severity of the depressive symptoms (p<0.001) had an influence on the quality of life, suggesting the need for further studies with more robust designs to confirm the causal relationship between these characteristics and quality of life.

Impact on the quality of life of dermatological patients in southern Brazil

BACKGROUNDS

Skin diseases are extremely frequent and may affect quality of life; therefore, it is important to assess it and identify which factors are associated with it.

OBJECTIVES

To assess quality of life and its associated factors in dermatological patients.

METHODS

A cross-sectional study involving a sample of 548 patients seen at the Dermatology Outpatient Clinic of Sistema Único de Saúde (the Brazilian National Public Health System), University Hospital, Federal University of Rio Grande do Sul (RS). Information related to socio-demographic data, medical consultation and quality of life was collected by means of the Dermatology Life Quality Index.

RESULTS

A median of 7 and a mean of 7.7 (SD = 5.0) were obtained with the Dermatology Life Quality Index. The skin diseases with higher scores on the Dermatology Life Quality Index were psoriasis (median = 15.5), vitiligo (median = 13), atopic dermatitis (median = 12) and acne (median = 10). With respect to factors associated with quality of life, it was found that younger, single patients with a low income, one skin disease and longer disease duration presented poorer quality of life.

CONCLUSION

The assessment of the impact of dermatoses on patients' quality of life is important for clinical management. It is essential to detect patients at higher risk of experiencing worse quality of life in order to treat them in a more integrated way.

Psodisk, a new visual method for assessing the burden of psoriasis on patients

BACKGROUND

The last decades have witnessed an increasing interest for the psychosocial aspects of chronic skin diseases, such as psoriasis. Nonetheless, systematic assessments of the impact of psoriasis on patients' lives are rarely done in daily clinical practice. The existing instruments are mostly meant to be completed by patients alone, and rarely comprise a graphical representation of the results.

OBJECTIVE

To develop a questionnaire allowing both a quick assessment of the impact of psoriasis on patients and, at the same time, an intuitive graphic visualization of the outcome of the test.

METHODS

A preliminary version of an Italian questionnaire aimed to assess the global impact of psoriasis on patients, meant to be filled in together by the patient and the dermatologist and to produce visual, intuitive results, was developed through focus groups. The instrument was then the object of a Delphi survey addressed to a panel of experts, to assess both the need of possible improvements of the questionnaire (in terms of the formulations of the questions and of the domains to be explored) and the usefulness of the questionnaire.

RESULTS

A 10-item questionnaire in Italian, taking into account different aspects of the burden of psoriasis on the patient, was developed. The answers are given on a 10-point visual analogue scale and graphically represented on a disc as a polygon.

CONCLUSIONS

A formal validation of the questionnaire and a study to assess potential clinical and psychological benefits of a systematic implementation of the instrument in daily practice are planned.

CIS-based registration of quality of life in a single source approach

Background

Documenting quality of life (QoL) in routine medical care and using it both for treatment and for clinical research is not common, although such information is absolutely valuable for physicians and patients alike. We therefore aimed at developing an efficient method to integrate quality of life information into the clinical information system (CIS) and thus make it available for clinical care and secondary use.

Methods

We piloted our method in three different medical departments, using five different QoL questionnaires. In this setting we used structured interviews and onsite observations to perform workflow and form analyses. The forms and pertinent data reports were implemented using the integrated tools of the local CIS. A web-based application for mobile devices was developed based on XML schemata to facilitate data import into the CIS. Data exports of the CIS were analysed with statistical software to perform an analysis of data quality.

Results

The quality of life questionnaires are now regularly documented by patients and physicians. The resulting data is available in the Electronic Health Record (EHR) and can be used for treatment purposes and communication as well as research functionalities. The completion of questionnaires by the patients themselves using a mobile device (iPad) and the import of the respective data into the CIS forms were successfully tested in a pilot installation. The quality of data is rendered high by the use of automatic score calculations as well as the automatic creation of forms for follow-up documentation. The QoL data was exported to research databases for use in scientific analysis.

Conclusion

The CIS-based QoL is technically feasible, clinically accepted and provides an excellent quality of data for medical treatment and clinical research. Our approach with a commercial CIS and the web-based application is transferable to other sites.

Nonclinical influences, beyond diagnosis and severity, on clinical decision making in dermatology: understanding the gap between guidelines and practice

BACKGROUND

Clinical decision making in dermatology is a complex process and might be influenced by a wide range of nonclinical factors.

OBJECTIVES

The aim of this study was to explore the role of nonclinical influences, beyond diagnosis and severity, on clinical decision making in dermatology.

METHODS

Semi-structured qualitative interviews were conducted with 46 clinicians working in departments of dermatology of nine different hospitals in Wales. Interviews were audio-recorded and later transcribed and their contents analysed.

RESULTS

Nonclinical factors influencing patient management decisions in dermatology that were identified related to patients, clinicians and practice characteristics. Patient-related factors included place of residence, socioeconomic circumstances, education and intelligence, ethnicity, age, treatment adherence, expectations from treatment, quality of life, concerns and worries, difficult patients, and family members or friends. Clinician-related factors included time constraints in clinic, clinicians' personal circumstances, relationship with colleagues, and relationship with pharmaceutical companies. Practice-related factors included working in private practice, cost of treatment to the National Health Service (NHS), prescribing bureaucracy, and availability of treatment service in the work place. There was a difference between the consultants' views and those of the other clinicians over the impact of pharmaceutical companies on clinicians' prescribing and the awareness of treatment costs to the NHS. Most of the factors identified could potentially influence the clinicians' decision-making process subconsciously. Some clinicians highlighted that these factors are untaught in the medical curriculum, and are usually ignored in clinical guidelines, and therefore represent a challenge to the practice of evidence-based medicine.

CONCLUSIONS

This study has described one aspect of the reality of medical decision making beyond the conventional evidence-based guidelines approach. Proper understanding of nonclinical influences on decision making is of paramount importance for the best patient-centred treatment outcomes.

Non-clinical influences on clinical decision-making: a major challenge to evidence-based practice

This article reviews an aspect of daily clinical practice which is of critical importance in virtually every clinical consultation, but which is seldom formally considered. Non-clinical influences on clinical decision-making profoundly affect medical decisions. These influences include patient-related factors such as socioeconomic status, quality of life and patient's expectations and wishes, physician-related factors such as personal characteristics and interaction with their professional community, and features of clinical practice such as private versus public practice as well as local management policies. This review brings together the different strands of knowledge concerning non-clinical influences on clinical decision-making. This aspect of decision-making may be the biggest obstacle to the reality of practising evidence-based medicine. It needs to be understood in order to develop clinical strategies that will facilitate the practice of evidence-based medicine.

The Dermatology Life Quality Index 1994-2007: a comprehensive review of validation data and clinical results

BACKGROUND

The Dermatology Life Quality Index (DLQI) is one of the most widely used dermatology-specific quality of life instruments. Over the last 5 years there has been great interest in its use.

OBJECTIVES

To collect and present all information regarding the technical properties and the clinical use of the DLQI from the date it was published to the end of 2007 for use as a single source of reference.

METHODS

A detailed literature search was conducted using electronic reference databases and the DLQI library in the Department of Dermatology, Cardiff University. All publications mentioning any aspect of the DLQI, from the time of its development to the end of 2007, were identified and the data concerning the DLQI in terms of its psychometric analysis, and use in clinical trials, epidemiological studies and health services research, were extracted and tabulated with all the relevant references.

RESULTS

In total, 272 full articles which have included the DLQI were reviewed. Studies described in these articles were divided into five main categories: psychometric studies, descriptive/epidemiological studies, drug (topical and systemic) trials, clinical practice research, and therapeutic interventions. The DLQI has been used in 33 different skin conditions in 32 countries and is available in 55 languages. Psychometric aspects of the DLQI such as validity, reliability, responsiveness to change, factor structure, and minimal important difference were described in 115 studies. The DLQI has been used in 33 studies assessing the effectiveness of 14 different types of therapeutic interventions and in 37 studies evaluating nine types of clinical practice research. Sixty studies have used it alone or in parallel with other instruments as an outcome measure in clinical trials of 18 systemic drugs while 22 studies have used it in 14 different topical drug trials. The DLQI has also been used in 27 multinational studies.

CONCLUSIONS

During the last 14 years there has been a gradual increase in the international use of the DLQI. The brevity and simplicity of use of the DLQI has resulted in its popularity both in clinical practice and in research. However, there are various issues in particular regarding its unidimensionality, differential item functioning, and minimal clinically important difference, which require further research. This article should facilitate the work of potential users of the DLQI by providing a readily available source of references for different aspects of the DLQI.

The Practical Reality of Using a Patient-Reported Outcome Measure in a Routine Dermatology Clinic

OBJECTIVE

To explore whether clinicians used formal quality of life (QoL) information if provided by patients completing the Dermatology Life Quality Index (DLQI) questionnaire and whether the information influenced treatment decision-taking.

METHODS

The DLQI was completed by adult patients attending a dermatology secondary-care clinic as they arrived at their appointment and given to the clinician. Clinicians recorded whether the DLQI information was used and whether it influenced treatment decision-making.

RESULTS

A total of 417 patients attended and 268 questionnaires (64.3%) were completed. The mean DLQI score was 7 (median = 5, range = 0-30). In 64 consultations (28.8%), clinicians used the DLQI information; in 37 of these consultations (57.8%) the DLQI information influenced the clinicians' treatment decision-making. The mean DLQI score for these 37 consultations was 11.3 (median = 10.0, range = 0-29), indicating a large effect on patients' QoL. QoL discussion occurred in 85 of 98 consultations observed. The domains of QoL most frequently discussed concerned symptoms (74 consultations) and problems caused by the treatment (24 consultations).

CONCLUSIONS

Clinicians may use formal QoL information if available in routine clinics. Treatment decisions may be influenced for those with high QoL impairment. Routine systematic assessment of QoL may therefore be of benefit.

Changes in mood predict disease activity and quality of life in patients with psoriasis following emotional disclosure

OBJECTIVE

The present study examined the effects of emotional disclosure (ED) intervention on both disease severity and quality of life in patients with psoriasis.

METHODS

Fifty-nine patients were recruited (mean age, 50 years; 32 men and 27 women; mean length of diagnosis, 22 years). Individuals were randomly assigned to receive ED intervention or standard control writing intervention. Disease severity, quality of life, and mood were assessed at baseline and at 2, 8, and 12 weeks postintervention.

RESULTS

Disease severity and quality of life improved in both groups over the follow-up period. Preliminary analysis suggested no differences in the magnitude of improvement between the groups. However, predictors of improvement were found to differ. Disease severity on Week 12 was predicted by changes in mood in intervention patients and seasonal variation in control patients. In contrast, quality of life on Week 12 was predicted by baseline quality of life in intervention patients, while seasonal variation approached significance for control patients.

CONCLUSIONS

Changes in mood following ED predicted improvements in disease severity in patients with psoriasis. However, the degree of improvement did not differ between intervention and control patients.

Update on the use of ciclosporin in immune-mediated dermatoses

Immune-mediated dermatoses, such as psoriasis and atopic dermatitis, affect a significant proportion of the population. Although most cases are not life threatening, these diseases can have a profound effect on the sufferer's quality of life and that of their family. Systemic therapy, such as ciclosporin, is often indicated for severe or recalcitrant disease. The efficacy of ciclosporin in the treatment of psoriasis and atopic dermatitis has been established and clinical data also demonstrate its efficacy in treating less common but equally challenging conditions such as pyoderma gangrenosum, lichen planus, autoimmune bullous disease, recalcitrant chronic idiopathic urticaria and chronic dermatitis of the hands and feet. The risk of potential adverse events associated with ciclosporin is greatly reduced if current treatment and monitoring guidelines are followed.