Julie Wu

Undertreatment, treatment trends, and treatment dissatisfaction among patients with psoriasis and psoriatic arthritis in the United States: findings from the National Psoriasis Foundation surveys, 2003-2011.

IMPORTANCE Psoriasis and psoriatic arthritis inflict significant morbidity. Data on undertreatment, treatment use, and treatment satisfaction are paramount to identify priority areas for advocacy, education, and research to improve patient outcomes. OBJECTIVES To determine the extent of nontreatment and undertreatment of psoriatic diseases, trends in treatment use, treatment satisfaction, and reasons for medication discontinuation among patients with psoriasis and psoriatic arthritis. DESIGN, SETTING, AND PARTICIPANTS We used the national survey data collected by the National Psoriasis Foundation via biannual surveys conducted from January 1, 2003, through December 31, 2011, in the United States. Survey data were collected from randomly sampled patients with psoriasis and psoriatic arthritis in the US population from a database of more than 76,000 patients with psoriatic diseases. MAIN OUTCOMES AND MEASURES Nontreatment, undertreatment, and treatment trends determined by the use of prescription medication (topical, phototherapeutic, oral systemic, and biologic), as well as treatment satisfaction and reasons for medication discontinuation. RESULTS A total of 5604 patients with psoriasis or psoriatic arthritis completed the survey. From 2003 through 2011, patients who were untreated ranged from 36.6% to 49.2% of patients with mild psoriasis, 23.6% to 35.5% of patients with moderate psoriasis, and 9.4% to 29.7% of patients with severe psoriasis. Among those receiving treatment, 29.5% of patients with moderate psoriasis and 21.5% of patients with severe psoriasis were treated with topical agents alone. The most frequently used phototherapy modality is UV-B, whereas methotrexate is the most commonly used oral agent. Although adverse effects and a lack of effectiveness were primary reasons for discontinuing biological agents, the inability to obtain adequate insurance coverage was among the top reasons for discontinuation. Overall, 52.3% of patients with psoriasis and 45.5% of patients with psoriatic arthritis were dissatisfied with their treatment. CONCLUSIONS AND RELEVANCE Nontreatment and undertreatment of patients with psoriasis and psoriatic arthritis remain a significant problem in the United States. While various treatment modalities are available for psoriasis and psoriatic arthritis, widespread treatment dissatisfaction exists. Efforts in advocacy and education are necessary to ensure that effective treatments are accessible to this patient population.

State of teledermatology programs in the United States

BACKGROUND Teledermatology programs in the United States have evolved over the past several decades. No systematic survey of teledermatology programs in the United States is available in peer-reviewed literature. OBJECTIVE To provide up-to-date information regarding the state of teledermatology programs in the United States. METHODS Active U.S. teledermatology programs were surveyed in 2011 with regards to practice models, clinical volume, and payment methods. These findings were compared with those from 2003. RESULTS By January 2012, 37 teledermatology programs were active in the United States. Store-and-forward teledermatology was the most frequent delivery modality offered by 30 (81%) of the programs. The majority of the programs were based at academic institutions (49%), followed by Veterans Administration hospitals (27%), private practice (16%), and health maintenance organizations (HMOs) (8%). The majority of programs (67%) provided services to their home state only, whereas the rest also served additional U.S. states or abroad. The median number of consultations per program was 309 (range, 5-6500) in 2011. The most frequent payer sources were private payers, followed by self-pay, Medicaid, Medicare, and HMOs. Since 2003, with the confirmed discontinuation of 24 previously active programs, the total number of active teledermatology programs in 2011 was 60% of that in 2003. However, the annual consult volume per program nearly doubled for the sustainable programs in 2011. LIMITATIONS Itemized billing information was not uniformly available from all programs. CONCLUSION The turnover in teledermatology programs is relatively constant, with an increase in consult volume for sustainable programs. Store-and-forward is the dominant modality of delivery, while hybrid technology model is emerging.

Smoking cessation is associated with decreased mortality and improved amputation-free survival among patients with symptomatic peripheral artery disease

OBJECTIVE Although smoking cessation is recommended for all patients with peripheral artery disease, there are little data regarding the prevalence of smoking among patients at the time of angiography or the effect of smoking cessation on clinical outcomes. METHODS Consecutive patients with claudication or critical limb ischemia who underwent peripheral angiography from 2006 to 2013 were included in an observational cohort analysis. Smoking status was assessed at the time of angiography and during follow-up clinic visits. Kaplan-Meier analysis was used to assess the relationship between smoking cessation, mortality, and amputation-free survival. RESULTS Among 739 patients (423 men and 316 women; mean age, 60 ± 12 years), 204 (28%) remained active smokers at the time of lower extremity angiography. At the time of angiography, the mean number of cigarettes smoked per day was 16 ± 10, and the mean pack-years was 40 ± 25. During the course of the subsequent year, 61 patients (30%) successfully quit smoking and maintained continued abstinence. Baseline medication use between groups did not differ significantly. The mean ankle-brachial index was also similar for quitters vs nonquitters (0.53 ± 24 vs 0.49 ± 0.22; P = .3). During follow-up to 5 years, patients who quit smoking had significantly lower all-cause mortality (14% vs 31%; hazard ratio, 0.40; 95% confidence interval, 0.18-0.90) and improved amputation-free survival (81% vs 60%; hazard ratio, 0.43, 95% confidence interval, 0.22-0.86) compared with patients who continued smoking, with most of the difference driven by reduced mortality among patients who quit smoking. The findings remained significant on multivariable analysis. CONCLUSIONS Approximately one-third of active smokers with peripheral artery disease successfully quit smoking ≤ 1 year after lower extremity angiography. Patients who quit smoking have lower mortality and improved amputation-free survival compared with patients who continue smoking.

Harnessing the power of crowds: crowdsourcing as a novel research method for evaluation of acne treatments.

AbstractBackground: Crowdsourcing is a novel process of data collection that can provide insight into the effectiveness of acne treatments in real-world settings. Little is known regarding the feasibility of crowdsourcing as a means of collecting dermatology research data, the quality of collected data, and how the data compare to the published literature. Objective: The objective of this analysis is to compare acne data collected from a medical crowdsourcing site with high-quality controlled studies from peer-reviewed medical literature. Methods: Crowdsourced data was collected from 662 online acne patients. Online patients reported data in a Likert-type format to characterize their symptom severity (740 total responses) and their treatment outcomes (958 total responses). The crowdsourced data were compared with meta-analyses and reviews on acne treatment from August 20, 2010 to August 20, 2011. Results: We compared topical, oral systemic, alternative, phototherapy, and physical acne treatments of crowdsourced data to published literature. We focused on topical tretinoin due to the large number of online patient responses. While approximately 80% of tretinoin users observed clinical improvement after a 12-week treatment period in clinical trials, 46% of online users reported improvement in an unspecified time period. For most topical treatments, medication with high efficacy in clinical trials did not produce high effectiveness ratings based on the crowdsourced online data. Conclusion: While limitations exist with the current methods of crowdsourced data collection, with standardization of data collection and use of validated instruments, crowdsourcing will provide an important and valuable platform for collecting high-volume patient data in real-world settings.

Metabolomics in psoriatic disease: pilot study reveals metabolite differences in psoriasis and psoriatic arthritis

Importance: While “omics” studies have advanced our understanding of inflammatory skin diseases, metabolomics is mostly an unexplored field in dermatology. Objective: We sought to elucidate the pathogenesis of psoriatic diseases by determining the differences in metabolomic profiles among psoriasis patients with or without psoriatic arthritis and healthy controls. Design: We employed a global metabolomics approach to compare circulating metabolites from patients with psoriasis, psoriasis and psoriatic arthritis, and healthy controls. Setting: Study participants were recruited from the general community and from the Psoriasis Clinic at the University of California Davis in United States. Participants: We examined metabolomic profiles using blood serum samples from 30 patients age and gender matched into three groups: 10 patients with psoriasis, 10 patients with psoriasis and psoriatic arthritis and 10 control participants. Main outcome(s) and measures(s): Metabolite levels were measured calculating the mean peak intensities from gas chromatography time-of-flight mass spectrometry. Results: Multivariate analyses of metabolomics profiles revealed altered serum metabolites among the study population. Compared to control patients, psoriasis patients had a higher level of alpha ketoglutaric acid (Pso: 288 ± 88; Control: 209 ± 69; p=0.03), a lower level of asparagine (Pso: 5460 ± 980; Control: 7260 ± 2100; p=0.02), and a lower level of glutamine (Pso: 86000 ± 20000; Control: 111000 ± 27000; p=0.02). Compared to control patients, patients with psoriasis and psoriatic arthritis had increased levels of glucuronic acid (Pso + PsA: 638 ± 250; Control: 347 ± 61; p=0.001). Compared to patients with psoriasis alone, patients with both psoriasis and psoriatic arthritis had a decreased level of alpha ketoglutaric acid (Pso + PsA: 186 ± 80; Pso: 288 ± 88; p=0.02) and an increased level of lignoceric acid (Pso + PsA: 442 ± 280; Pso: 214 ± 64; p=0.02). Conclusions and relevance: The metabolite differences help elucidate the pathogenesis of psoriasis and psoriatic arthritis and they may provide insights for therapeutic development.

Crowdsourcing for data collection: a pilot study comparing patient-reported experiences and clinical trial data for the treatment of seborrheic dermatitis.

CROWDSOURCING is a novel method of research data collection. One type of crowdsourcing in healthcare research invites patients to report their symptoms and responses to treatments online (1, 2). These websites have the potential to generate large volumes of real-world patient data on treatment outcomes. However, few studies exist that compare crowdsourced data to peer-reviewed literature. In this pilot study, we examined how data from patients with seborrheic dermatitis from a crowdsourcing site compared with results from randomized controlled studies. We obtained anonymized data from a popular crowdsourcing site, CureTogether (curetogether.com), on patients with seborrheic dermatitis from 2008 to 2011. To compare the crowdsourced data to published literature, we searched Medline for systematic reviews and meta-analyses examining treatments for seborrheic dermatitis from 5 August 2008 to 5 August 2011. A total of 65 online patients with seborrheic dermatitis provided 167 symptom responses and 120 treatment responses (Tables 1 and 2). Thirty-five percent (7/20) of online patients reported improvement using an unspecified shampoo. Seventeen percent (1/6) of online patients reported improvement with selenium sulfide shampoo, and 25% (1/4) reported improvement with ketoconazole shampoo. Although the majority of online patients were not able to achieve adequate control with topical antifungal preparations, the literature suggests otherwise. In a randomized controlled trial by Danby et al., patients with moderateto-severe seborrheic dermatitis were treated with selenium sulfide 2.5% shampoo, ketoconazole 2% shampoo, or placebo shampoo twice weekly. Both ketoconazole and selenium sulfide shampoo were effective treatments for seborrheic dermatitis (3). In addition to topical antifungal treatments, topical corticosteroids are used to manage seborrheic dermatitis-associated erythema and pruritus on the facial and ear regions (4). From the crowdsourcing site, 27% (7/26) of online patients reported improvement with topical corticosteroid preparations. Of these patients, 33% (5/15) reported improvement with hydrocortisone and 18.2% (2/11) reported improvement with an unspecified topical steroid. Although most patients were not able to achieve adequate control with topical corticosteroid preparations, controlled studies have shown that low-potency corticosteroids are highly effective. For example, 94.4% of patients achieved adequate responses after 4-week treatment with 1% hydrocortisone cream (5). Alternative treatments, such as tea tree oil, were found to be ineffective among online patients. On the crowdsourcing site, 0% (0/6) of online patients reported improvement with tea tree oil. The antifungal property of tea tree oil

Effectiveness of a novel interactive health care education tool on clinical outcomes and quality of life in acne patients: A randomized controlled pilot study

Abstract Background: We developed an Internet-based education tool (My Personalized Application for health Care Education, MyPACE) to promote patient comprehension about acne. Objective: To determine if MyPACE improves clinical outcomes and quality of life in acne patients. Methods: Modeling the spaced education approach, 50 participants received weekly multiple-choice questions for 12 weeks. Those randomized to the intervention group received acne-related questions, while those in the control group received non-dermatologic health-related questions. Acne lesion counts and Dermatology Life Quality Index (DLQI) scores were recorded at initial enrollment and at 12 weeks. Results: Within-group analysis for the intervention group showed a significant mean change in inflammatory and non-inflammatory acne lesions per person (−3.2 ± 1.3, p = 0.0219; −4.4 ± 1.8, p = 0.0267, respectively). The control group only demonstrated a significant mean change in inflammatory lesions (−2.8 ± 0.80, p = 0.0040). Both groups had statistically significant improvement in DLQI score. Compared with participants in the control group, those receiving acne-related questions experienced greater improvement in clinical outcomes and quality of life. Limitations: The small sample size limited our ability to detect statistically significant differences. Conclusion: Internet-based, disease-specific, spaced education tools may be more effective than non-targeted tools for improving clinical outcomes and quality of life.