Trends in home phototherapy adoption in the US: Monetary disincentives are only the tip of the iceberg

Home UV Phototherapy

Phototherapy is an effective treatment for multiple dermatoses. However, patient inconvenience and poor access to office-based phototherapy may jeopardize adherence and treatment outcome. Home phototherapy offers a convenient, accessible, and effective therapy. We describe the history of home phototherapy, the devices available, and associated costs. A literature review used PubMed. Keywords included: "home phototherapy," "tanning beds," "narrowband ultraviolet B." In a randomized control trial, home phototherapy had similar efficacy to office-based phototherapy. Home phototherapy is associated with significant cost savings treatment and increased adherence. Home phototherapy should be considered for its economic value, good tolerability, adherence, and efficacy.

Home phototherapy for patients with vitiligo: challenges and solutions

Vitiligo is a chronic autoimmune condition involving selective dysfunction and destruction of melanocytes in the skin, hair, or both. The typical presentation is well-demarcated depigmented skin patches. Given vitiligo is the most common cause of depigmentation worldwide and early disease responds best to treatment, prompt diagnosis and proactive management of vitiligo are critical. While a wide variety of treatments has demonstrated variable effectiveness in treating vitiligo, phototherapy remains standard of care because of its proven efficacy and favorable side effect profile. However, many patients with vitiligo are unable to access affordable, consistent, or convenient phototherapy. To address these issues, home-based phototherapy has emerged as a patient-centered alternative. The purpose of this review is to discuss management of vitiligo with a specific focus on access to home-based phototherapy (HBPT) for patients with this condition. Key challenges to HBPT include misperceptions around safety and efficacy, inadequate physician education and training, insurance and financial barriers, and appropriate patient selection. Solutions to these challenges are presented, such as approaches to improve physician education and increasing the evidence surrounding the effectiveness and safety of this treatment for vitiligo. In addition, various practical considerations are discussed to guide dermatologists on how to approach HBPT as a treatment option for patients with vitiligo.

Prescribing Home Narrowband UVB Phototherapy: A Review of Current Approaches

Conventional, full-body phototherapy equipment is costly and therefore patients are usually treated in dermatology centres. Such office-based therapy is often not feasible for those patients who live far away from a phototherapy centre due to lost time and wages, inability to travel because of extensive skin disease, or prohibitive travel costs. Home phototherapy has emerged as a modality that meets the needs of those patients. Our aim was to review available studies on UV sources, treatment protocols, efficacy, and safety of home phototherapy. A literature review was conducted on PubMed using the terms "home" AND "phototherapy" AND ("guide" OR "approach" OR "review" OR "protocol"). From the data extracted, narrowband UVB (311 nm) offers the best balance between safety and efficacy and is recommended for home phototherapy by most authors. Treatment is safe and possible adverse effects are related to overexposure (erythema, blistering). The usual treatment protocol was administering treatments on alternating days, including weekends, with dosing based on the patient's Fitzpatrick skin type. We also provide information on the available home phototherapy systems in Canada and their reimbursement. Home phototherapy is underused in Canada. Narrowband UVB phototherapy sources equipped with a 3-dimensional panel provides a practical and safe option.

Perceptions of U.S. dermatology residency program directors regarding the adequacy of phototherapy training during residency

BACKGROUND/PURPOSE

Phototherapy utilization has declined over the last 20 years despite its efficacy and cost-effectiveness. Adequacy of phototherapy training in residency may be a contributing factor. The purpose of this study was to evaluate perceptions of U.S. dermatology residency program directors (PDs) regarding the effectiveness of their programs' phototherapy training and what constitutes adequate phototherapy education.

METHODS

A questionnaire was sent to PDs to assess phototherapy training within their program; aspects such as dedicated time, exposure to different modalities, and barriers to resident education were surveyed. We assessed the statistical association between these aspects and the perception by PDs that a program's training was adequate. Statistical testing was reported using Fisher's exact tests.

RESULTS

A total of 42 PDs responded. Residency training in oral psoralen and ultraviolet A therapy (PUVA), home phototherapy, and excimer laser, respectively, is not provided in 19.0%, 31.0%, and 47.6% of programs. 38.1% of programs provide ≤5 hours of phototherapy training over 3 years of training. 59.5% of PDs cited lack of curriculum time as the most common barrier to phototherapy education. 19.0% of PDs reported completely adequate phototherapy training, which was significantly associated with inclusion of faculty-led didactics, assigned reading, or hands-on clinical training in the curriculum.

CONCLUSIONS

There is a mismatch between the resources devoted to phototherapy education and the need for dedicated training reported by PDs. Limited time is allocated to phototherapy training during dermatology residency, and a large majority of PDs do not feel that the phototherapy training offered is completely adequate.

Improving access to home phototherapy for patients with psoriasis: current challenges and future prospects

Introduction

Although the treatment burden for phototherapy in the outpatient setting is considerable, prescription of home-based phototherapy has not been instigated. Home-based phototherapy seems more patient friendly in terms of avoiding the thrice-weekly hospital visits. So why are most treatments still given in a hospital setting? Is home-based treatment less effective? Are there financial barriers? Is the treatment not available? To answer these questions, a literature search was done.

Methods

A literature search of PubMed, Embase, and Cochrane Library databases was performed, using the search terms “psoriasis” and “phototherapy”. Selection was based on two rounds; the first round involved screening the title and abstract of all records and second involved evaluating the full text of the remaining articles for eligibility according to inclusion and exclusion criteria.

Results

In total, 23 publications were included with consensus of both researchers. Overall, the patients reported being very satisfied with home-based phototherapy. Results regarding effectivity in terms of improvement from disease severity and in quality of life were variable but generally positive. Reasons for reluctance varied from medicolegal and social aspects to lack of reimbursement and unfamiliarity on the side of the prescriber.

Conclusion

In the treatment for psoriasis, home-based phototherapy is as effective and safe as phototherapy in an outpatient setting. Patients were more satisfied with home-based phototherapy. Factors that negatively influence the prescription of or choice for home-based phototherapy can be summarized in terms of lack of control, lack of knowledge, and lack of a good reimbursement system.

Psoriasis causes significant economic burden to patients

INTRODUCTION

Psoriasis results in expenses to patients from many cost sources. Psoriasis treatments may result in considerable time and traveling costs, yet many studies fail to account for these costs. The objective of this study was to evaluate the multidimensional economic burden of psoriasis to patients.

METHODS

The study was based on 232 Finnish patients with psoriasis or psoriatic arthritis visiting a tertiary level dermatological clinic during a 1-year study period between October 1, 2009 and September 30, 2010. The data were based on a patient questionnaire, clinical data from the medical records and reimbursement data from the Finnish Social Insurance Institution. Item costs were based on true costs charged from the patients and all time cost estimates were based on the Human Capital Approach method.

RESULTS

199 patients with psoriasis and 33 with psoriatic arthritis were included in the study. Total costs were higher for patients receiving traditional systemic medications or phototherapy than those not receiving such treatment. Travel costs and travel time costs accounted for more than 60% of the costs of phototherapy. Skin care at home was time consuming and thus caused significant burden to patients. The majority of the visit costs arose from hospital visits and only a small proportion were attributed to visiting primary health care providers.

CONCLUSION

Visit charges and other patient co-payments were estimated to play a minor role in the total cost of psoriasis incurred by patients, while travel costs and lost time comprised the majority of the costs, which should not be omitted in future studies regarding costs of treatments.

Review of an established UK home phototherapy service 1998-2011: improving access to a cost-effective treatment for chronic skin disease

OBJECTIVES

To review the Tayside home phototherapy service, including numbers of patients treated, diagnoses and outcomes, side-effects and safety, cost-effectiveness and absolute costs. To consider why home or outpatient phototherapy is not available to all patients who might benefit and how this could be addressed.

STUDY DESIGN

Observational and cost analysis.

METHODS

Analysis of the Tayside home phototherapy database 1998 and 2011, home phototherapy patient questionnaires, outcome data, costs and a comparison with outpatient phototherapy. Review of literature and current national guidelines for phototherapy, traditional systemic and biologic therapies for psoriasis.

RESULTS

298 courses of home narrowband UVB (NB-UVB) phototherapy were undertaken by 212 patients between 1998 and 2011, five courses in 1998 increasing to 36 in 2011. The main diagnoses treated were psoriasis (72%), atopic dermatitis (8%), and desensitization of photodermatosis (7%). For psoriasis, 74.5% achieved clearance or minimal residual activity in a median of 30 exposures (range 10-60). The estimated costs to the hospital ranged from £229 to £314 per course (£307 to £422 per effective course for psoriasis), compared with £114 for out-patient therapy (£149 per effective course for psoriasis). The total cost to society (hospital and patient costs) is around £410 per course, compared to an estimated £550 for outpatient therapy for this group of patients. Treatment was well tolerated, erythema rates were similar to outpatient therapy, there were no complaints and the vast majority would choose home over outpatient phototherapy if required in the future.

CONCLUSIONS

Hospital supervised home phototherapy appears as safe and effective as outpatient therapy and provides equality of access for patients who cannot attend for outpatient therapy. These patients may otherwise be inadequately treated or given more costly and higher risk systemic therapies, particularly for psoriasis. Commissioners and clinicians involved in dermatology services should provide accessible phototherapy for all patients who might benefit, utilizing home phototherapy where outpatient access is not possible.

[Analysis of the cost effectiveness of home-based phototherapy with narrow-band UV-B radiation compared with biological drugs for the treatment of moderate to severe psoriasis]

BACKGROUND

Psoriasis is associated with high treatment costs due to the increasing use of biologic drugs. Phototherapy has been demonstrated to be safe and cost effective for the treatment of psoriasis, although it is limited by the requirement for patients to visit a hospital various times a week.

OBJECTIVES

To evaluate the efficiency of home-based phototherapy with narrow-band UV-B radiation compared with biologic drugs for the treatment of moderate to severe psoriasis under normal practice conditions in our setting.

METHODS

A retrospective cost-effectiveness study was undertaken in 12 patients with moderate to severe psoriasis. Half of the patients were treated with biologic drugs (2 with etanercept, 2 with adalimumab, and 2 with infliximab) and the other half with home-based phototherapy using a Waldmann UV100L-TL01 lamp. Clinical effectiveness was determined on the basis of achieving a 75% improvement in Psoriasis Area and Severity Index (PASI 75) within 16 weeks of treatment.

RESULTS

Treatment was considered to be effective in 5 out of 6 patients (83%) treated with biologics and 4 out of 6 patients (66%) treated with home-based phototherapy. The direct costs required to achieve PASI 75 were 8256€ per patient for biologics and 903€ per patient for home-based phototherapy. The costs associated with effective treatment using biologic drugs in a single patient would provide effective home-based phototherapy for 9.1 patients.

LIMITATIONS

The study included a limited number of patients analyzed over a short time period (16 weeks) and the comparison group included multiple treatments with different predicted responses.

CONCLUSIONS

Although biologic drugs exhibited greater efficacy, home-based phototherapy was more efficient for the treatment of moderate to severe psoriasis. Home-based phototherapy represents a cost-effective treatment option for patients with psoriasis and may be appropriate for use in the Spanish health care system.

A pharmacoeconomic analysis of severe psoriasis therapy: a review of treatment choices and cost efficiency

INTRODUCTION

Psoriasis is a chronic, inflammatory disease afflicting 2% of the US population; it results in significant morbidity. The annual healthcare costs related to psoriasis are an estimated $11.3 billion and, with an expanding biologic market, an updated costs analysis is needed.

AREAS COVERED

Current treatments, including systemic agents (acitretin, cyclosporine, methotrexate), phototherapies and all available biologics (adalimumab, etanercept, infliximab, alefacept, ustekinumab) appropriate for severe psoriasis are described mechanistically and with regard to their efficacy, quality-of-life improvements and side effects. A cost-efficacy model considering US health-system-based annual costs, clinical and quality-of-life improvements was created. Reported Psoriasis Area and Severity Index improvement of 75% from baseline (PASI-75) scores, Dermatology Life Quality Index (DLQI) improvements and estimated costs of medications are described. Annual costs ranged from $1330 for methotrexate to $48,731 for high-dose etanercept. The lowest cost per achieving DLQI minimally important difference was from phototherapy; the highest was from alefacept. The lowest costs per patient achieving PASI-75 was from methotrexate and the highest was from alefacept.

EXPERT OPINION

Phototherapies and methotrexate offer high efficacy for their costs. Therapeutic approaches must be individualized for each patient given all considerations described.