Treatment and Referral for Psoriasis in UK Primary Care
Treatment and Referral for Psoriasis in UK Primary Care
A total of 10,832 patients who were newly diagnosed with psoriasis between 1 July 2007 and 31 October 2009 and met the study inclusion and exclusion criteria were identified. Psoriasis was diagnosed around the age of 49 years for men and women (Table 1). BMI was not significantly different between males and females and its distribution was similar to the general UK population (28 kg/m). Eczema, present in 31% of newly diagnosed psoriasis patients, was the most commonly reported comorbid condition followed by hypertension (24%). Approximately 40% of patients did not have any of the selected comorbid conditions. The distribution of social class (Townsend deprivation quintiles) was similar to the social class distribution of the general population in THIN. At index date, approximately 80% of newly diagnosed psoriasis patients received topical pharmacological therapy for the treatment of psoriasis. Approximately, 24% of patients started therapy with a combination of vitamin D3 analogues, corticosteroids, and tar or tar combination products, with a total of 40% using vitamin D3 analogues, 39% using corticosteroids, and 14% using tar or tar combination products at index. All other therapies for psoriasis were used by < 1% of patients at index.
The standardized incidence rate of diagnosed adult psoriasis in 2008 was 28 (95% CI: 28–29) per 10,000 person-years. The incidence rate was highest for 60–69 year olds at 34 (95% CI: 31–36) per 10,000 person-years. Incidence did not vary by sex (Table 2).
A total of 1,950 (18%) patients within the incident cohort had a referral to a dermatologist. The referral rate was 18.1 (95% CI: 17.3–18.9) per 100 person-years. Amongst those that were referred, 49% were male and median age at diagnosis was 49 (interquartile range: 35–62) years. The distribution of time to referral showed a clustering of patients who were referred very shortly after diagnosis (within 30 days of diagnosis). For patients referred after 30 days of diagnosis, the distribution of time to referral ranged from 31 days to 2.3 years with no clear clustering so these patients were grouped together as referral >30 days after diagnosis. Approximately 61% of referred patients (n = 1,183) were referred to a dermatologist within 30 days of diagnosis (immediately referred) and 39% were referred after 30 days post-diagnosis and were managed in primary care up to their referral date (Figure 1).
(Enlarge Image)
Figure 1.
Distribution of time to referral to secondary care dermatology specialist (n = 1,950).
The median time to referral for patients referred within the first month was the day of diagnosis (day 0, interquartile range: 0–6 days). Demographic characteristics, including age (mean [SD]: 49.2 years [17.5] vs. 48.8 [17.9]), gender (46.8% vs. 48.8% men), BMI (28.1 kg/m [6.4] vs. 27.6 [6.0]), and number of psoriasis-related prescriptions at index (0.6 [0.9] vs. 0.4 [0.7]) were similar between cases that were immediately referred and their matched controls that were not referred to a dermatologist. Mean number of GP visits in the year prior to referral was 2.0 [1.5] for immediately referred patients compared to 1.8 [1.4] for patients not referred to a dermatologist (p<0.05). Mean number of comorbid conditions was 1.2 [1.3] for immediately referred patients compared to 1.1 [1.2] for patients not referred (p<0.05). For those who were referred immediately, a greater number of GP visits prior to a dermatologist referral significantly increased the likelihood of referral (OR = 1.14, 95% CI: 1.08–1.20) compared to controls, after adjusting for age, gender, number of comorbid conditions, psoriatic arthritis diagnosis, and psoriasis-related prescription at index (Table 3). A prescription at index of tar products also increased the likelihood of being referred immediately (OR = 2.00, 95% CI: 1.45–2.76), as did vitamin D3 analogue (OR = 1.84, 95% CI: 1.50–2.25) and corticosteroid (OR = 1.56, 95% CI: 1.26–1.92) prescriptions compared to controls (Table 3).
For patients who were referred to a dermatologist > 30 days after diagnosis (later referred patients), demographic characteristics, including age (48.5 years [19.0] vs. 49.2 [17.8]), gender (51.1% vs. 50.3% men), BMI (28.1 kg/m [6.2] vs. 27.6 [6.0]), and the number of comorbid conditions (1.3 [1.3] vs. 1.2 [1.3]) in the year period were similar between cases (later referred patients) and controls. The median time to referral to a dermatologist was 5.6 (interquartile range: 2.8–11.5) months after the psoriasis diagnosis. The mean number of GP visits in the year prior to referral was 3.0 [2.0] for later referred patients compared to 1.4 [1.3] for patients not referred to a dermatologist (p<0.05); the mean number of psoriasis-related prescriptions at index was 0.6 [1.0] for later referred patients and 0.1 [0.5] for controls (p>0.05). Overall, later-referred patients made 5.34 visits to the GP before they were referred to a dermatologist. Of those GP visits, 2.73 visits were psoriasis-related.
After adjusting for age, gender, number of comorbid conditions, psoriatic arthritis diagnosis, and psoriasis-related prescription, a greater number of GP visits prior to referral increased the likelihood of later referral (OR = 1.87, 95% CI: 1.73–2.01) compared to controls (Table 3). A prescription for vitamin D3 analogues within 30 days before referral also increased the likelihood of being later referred (OR = 4.67, 95% CI: 2.78–7.84), as did corticosteroids (OR = 2.43) and tar products (OR = 1.95) compared to controls.
Results
A total of 10,832 patients who were newly diagnosed with psoriasis between 1 July 2007 and 31 October 2009 and met the study inclusion and exclusion criteria were identified. Psoriasis was diagnosed around the age of 49 years for men and women (Table 1). BMI was not significantly different between males and females and its distribution was similar to the general UK population (28 kg/m). Eczema, present in 31% of newly diagnosed psoriasis patients, was the most commonly reported comorbid condition followed by hypertension (24%). Approximately 40% of patients did not have any of the selected comorbid conditions. The distribution of social class (Townsend deprivation quintiles) was similar to the social class distribution of the general population in THIN. At index date, approximately 80% of newly diagnosed psoriasis patients received topical pharmacological therapy for the treatment of psoriasis. Approximately, 24% of patients started therapy with a combination of vitamin D3 analogues, corticosteroids, and tar or tar combination products, with a total of 40% using vitamin D3 analogues, 39% using corticosteroids, and 14% using tar or tar combination products at index. All other therapies for psoriasis were used by < 1% of patients at index.
Incidence of Diagnosed Psoriasis
The standardized incidence rate of diagnosed adult psoriasis in 2008 was 28 (95% CI: 28–29) per 10,000 person-years. The incidence rate was highest for 60–69 year olds at 34 (95% CI: 31–36) per 10,000 person-years. Incidence did not vary by sex (Table 2).
Referrals to Dermatologists
A total of 1,950 (18%) patients within the incident cohort had a referral to a dermatologist. The referral rate was 18.1 (95% CI: 17.3–18.9) per 100 person-years. Amongst those that were referred, 49% were male and median age at diagnosis was 49 (interquartile range: 35–62) years. The distribution of time to referral showed a clustering of patients who were referred very shortly after diagnosis (within 30 days of diagnosis). For patients referred after 30 days of diagnosis, the distribution of time to referral ranged from 31 days to 2.3 years with no clear clustering so these patients were grouped together as referral >30 days after diagnosis. Approximately 61% of referred patients (n = 1,183) were referred to a dermatologist within 30 days of diagnosis (immediately referred) and 39% were referred after 30 days post-diagnosis and were managed in primary care up to their referral date (Figure 1).
(Enlarge Image)
Figure 1.
Distribution of time to referral to secondary care dermatology specialist (n = 1,950).
The median time to referral for patients referred within the first month was the day of diagnosis (day 0, interquartile range: 0–6 days). Demographic characteristics, including age (mean [SD]: 49.2 years [17.5] vs. 48.8 [17.9]), gender (46.8% vs. 48.8% men), BMI (28.1 kg/m [6.4] vs. 27.6 [6.0]), and number of psoriasis-related prescriptions at index (0.6 [0.9] vs. 0.4 [0.7]) were similar between cases that were immediately referred and their matched controls that were not referred to a dermatologist. Mean number of GP visits in the year prior to referral was 2.0 [1.5] for immediately referred patients compared to 1.8 [1.4] for patients not referred to a dermatologist (p<0.05). Mean number of comorbid conditions was 1.2 [1.3] for immediately referred patients compared to 1.1 [1.2] for patients not referred (p<0.05). For those who were referred immediately, a greater number of GP visits prior to a dermatologist referral significantly increased the likelihood of referral (OR = 1.14, 95% CI: 1.08–1.20) compared to controls, after adjusting for age, gender, number of comorbid conditions, psoriatic arthritis diagnosis, and psoriasis-related prescription at index (Table 3). A prescription at index of tar products also increased the likelihood of being referred immediately (OR = 2.00, 95% CI: 1.45–2.76), as did vitamin D3 analogue (OR = 1.84, 95% CI: 1.50–2.25) and corticosteroid (OR = 1.56, 95% CI: 1.26–1.92) prescriptions compared to controls (Table 3).
For patients who were referred to a dermatologist > 30 days after diagnosis (later referred patients), demographic characteristics, including age (48.5 years [19.0] vs. 49.2 [17.8]), gender (51.1% vs. 50.3% men), BMI (28.1 kg/m [6.2] vs. 27.6 [6.0]), and the number of comorbid conditions (1.3 [1.3] vs. 1.2 [1.3]) in the year period were similar between cases (later referred patients) and controls. The median time to referral to a dermatologist was 5.6 (interquartile range: 2.8–11.5) months after the psoriasis diagnosis. The mean number of GP visits in the year prior to referral was 3.0 [2.0] for later referred patients compared to 1.4 [1.3] for patients not referred to a dermatologist (p<0.05); the mean number of psoriasis-related prescriptions at index was 0.6 [1.0] for later referred patients and 0.1 [0.5] for controls (p>0.05). Overall, later-referred patients made 5.34 visits to the GP before they were referred to a dermatologist. Of those GP visits, 2.73 visits were psoriasis-related.
After adjusting for age, gender, number of comorbid conditions, psoriatic arthritis diagnosis, and psoriasis-related prescription, a greater number of GP visits prior to referral increased the likelihood of later referral (OR = 1.87, 95% CI: 1.73–2.01) compared to controls (Table 3). A prescription for vitamin D3 analogues within 30 days before referral also increased the likelihood of being later referred (OR = 4.67, 95% CI: 2.78–7.84), as did corticosteroids (OR = 2.43) and tar products (OR = 1.95) compared to controls.
