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Chronic hand eczema in the Clinical Practice Research Datalink (CPRD): Prevalence, incidence, comorbidities, and initial treatment
EPIDEMIOLOGY AND HEALTH SERVICES ADMINISTRATION 1846 An audit of the management of basal cell carcinoma in Wales, the United Kingdom Mei Fong Chin, MBChB, Welsh Institute of Dermatology, Cardiff, United Kingdom; Ruwani P. Katugampola, Welsh Institute of Dermatology, Cardiff, United Kingdom Basal cell carcinoma (BCC) is the most common skin cancer in Europe and is increasing in incidence. An audit on the management of BCC in Dermatology secondary care in Wales, United Kingdom, was carried out in 2013. This was compared with data from a similar audit in 2006, thus closing the audit loop. Both audits were based on the guidelines for management of BCC published by the British Association of Dermatologists (BAD) in 2008 (Telfer et al). All consultant dermatologists in the six health boards across Wales were emailed the audit pro forma in November 2013. Each consultant was asked to retrospectively record details of the first 20 cases of BCC seen since January 2013. Data were collected on the documentation of pre- and postoperative risk factors, treatment of the BCCs, and subsequent follow up. Data for 332 cases were obtained. The size, site, and definition of clinical margins (ie, well defined, morpheic) of BCCs were documented in 77.4%, 99.7%, and 57.8% of cases, respectively. Treatment of BCCs [2 cm on high risk sites and those with ill-defined margins were found to be appropriate. Documentation rates of certain risk factors, such as site, size, and clinical margins were similar to or slightly improved compared to 2006. Whether previous treatment had failed was documented in 93.4% of cases and whether the patient was immunosuppressed was recorded in 82.2%. The histologic subtype was recorded in 91.5% of cases, but perineural invasion and perivascular invasion was only recorded in 25.2% and 20.6% of cases, respectively. Margins of excision were recorded in 81.6% of cases. Over 50% of BCCs with documented margins were excised with margins of #3 mm. The all Wales complete excision rate in 2013 was 93.1%, compared to 92.5% in 2006. Follow-up was arranged for all incompletely excised BCCs. A biopsy was taken in only half of BCCs that were treated nonsurgically. Several areas for improvement were identified from this reaudit. All risk factors for BCCs that increase the likelihood of recurrence should be documented. Histology reporting should routinely include the documentation of perineural and perivascular invasion. Patients with completely excised BCCs with no other risk factors and/or ongoing dermatologic issues should not be followed up to reduce the burden on already stretched dermatology services. This audit should be repeated in 2-3 years’ time to ensure ongoing compliance with the BAD guidelines. Commercial support: None identified.
1702 Assessment of burden of disease in patients with psoriasis, atopic dermatitis and basal cell carcinoma using Pictorial Representation of Illness and Self-Measure (PRISM) Matthias Hofmann, PhD, Department of Dermatology, Venereology and Allergology, Frankfurt, Germany; Nina Pliquet, MD, Department of Cardiology, Angiology, Pneumology, Nephrology and Internistic Intensive Care, Hanau, Germany; Konstantinos Fotiou, PhD, Department of Dermatology, Venereology and Allergology, Frankfurt, Germany; Roland Kaufmann, MD, Department of Dermatology, Venereology and Allergology, Frankfurt, Germany; Diamant Thaci, MD, Comprehensive Center for Inflammation Medicine, L€ ubeck, Germany Introduction and
432 Biologic use and associated factors in a nationally representative sample of Medicare patients with psoriasis Junko Takeshita, MD, PhD, University of Pennsylvania, Philadelphia, PA, United States; Joel Gelfand, MD, MS, University of Pennsylvania, Philadelphia, PA, United States; Penxiang Li, PhD, University of Pennsylvania, Philadelphia, PA, United States; Lionel Pinto, MS, Amgen Inc, Thousand Oaks, CA, United States; Xinyan Yu, MD, MS, University of Pennsylvania, Philadelphia, PA, United States; Preethi Rao, MS, University of Pennsylvania, Philadelphia, PA, United States; Hema Viswanathan, PhD, Amgen Inc, Thousand Oaks, CA, United States; Jalpa Doshi, PhD, University of Pennsylvania, Philadelphia, PA, United States Purpose: Treatment of psoriasis in the elderly is poorly understood and represents an important research gap. This study was aimed at examining biologic treatment utilization and associated factors in a nationally representative sample of Medicare patients with psoriasis. Methods: This retrospective cross-sectional study used the 5% random sample Medicare claims files to examine beneficiaries with continuous fee-for-service Medicare Part A and B coverage and stand-alone Part D plan enrollment in 2010. Patients who had at least 2 claims for psoriasis (ICD-9 code 696.1) were included in the analysis. The receipt of phototherapy, oral systemic and/or biologic therapy was used as a proxy to define moderate to severe psoriasis. Logistic regression was used to identify factors associated with biologic use. Results: A total of 4107 patients had at least 2 psoriasis claims, representing a prevalence of 0.5%. About 28% (n ¼ 1145) of all psoriasis patients received treatments indicative of moderate to severe psoriasis. Biologics were used by 433 patients (11% of all psoriasis patients; 38% of patients with moderate to severe psoriasis) and were distributed as follows: adalimumab 35%, alefacept 1%, etanercept 47%, infliximab 21%, and ustekinumab 6% (patients could have claims for more than one specific biologic). Among biologic users, 28% used a physicianadministered biologic covered under the Part B medical benefit and 82% used a selfadministered biologic covered under the Part D drug benefit. Similar patterns of biologic use were found when psoriasis was identified based on at least one dermatologist claim of 696.1. In multivariate analyses among patients with moderate to severe psoriasis, older age and malignancy were associated with lower odds of biologic use. As compared to patients with minimal out-of-pocket costs given lowincome subsidies (LIS) under Part D, patients without LIS had 70% lower odds of biologic use (OR 0.32, 95% CI 0.12-0.87). Patients with concomitant psoriatic arthritis had 4-fold higher odds of using biologics (OR 4.15, 95% CI 2.93-5.87). Conclusions: Only a third of Medicare patients with moderate to severe psoriasis used a biologic in 2010. Results suggest that younger age, having LIS under Part D, and presence of psoriatic arthritis were positively associated with biologic use. Higher out-of-pocket costs among patients without LIS may limit access to biologics among Medicare Part D patients with moderate to severe psoriasis. 100% is Sponsored by Amgen Inc
1196
Objectives: Patient reported outcome (PRO) measurements are the main tool to obtain data of life quality. In the current study, the nonverbal visualization tool PRISM was utilized to assess the burden of disease in patients with psoriasis, atopic dermatitis or basal cell carcinoma. PRISM features higher expressiveness in regard to burden of disease measurements compared to standard patient-reported outcome measurements as DLQI, EQ-5D and SF-36. Patients and methods: In total 90 patients with psoriasis (n ¼ 30), atopic dermatitis (n ¼ 30) or basal cell carcinoma (n ¼ 30) were included in a prospective study at the Department of Dermatology, Venereology and Allergology in Frankfurt. PRO assessments were performed in all patients utilizing DLQI, EQ-5D and SF-36 as well as the visualizing instrument PRISM in regard to their quality of life and burden of disease. For assessment of PRISM, all patients received a white, A4-sized square plate and were asked to place a disk representing their disease in relation to a disk representing their ‘‘self’’ on it. Results: Data obtained with DLQI and PRISM feature a significant high correlation (rs ¼ -0.56) corroborating earlier data of our group. Furthermore, we can identify that PRISM is able to determine differences of quality of life between patients with chronic skin conditions as atopic dermatitis and psoriasis (high burden of disease) and basal cell carcinoma (low burden of disease) as good as the DLQI. In comparison with the other PRO instruments PRISM could not show a significant correlation. The missing correlation with patient data and illness specific evaluation tools indicates that the terms quality of life and burden of disease are multidimensional constructs which are difficult to assess. Conclusions: We can conclude that for the assessed diseases PRISM is a valuable tool with a very high reliability. In this context, utilization of PRISM has a high medical relevance. As a nonverbal visualization tool PRISM is easy to understand for children and adolescents as well as foreigners who cannot use PROs in their mother tongue. In addition, PRISM is a very fast PRO tool as it takes \3 min to be performed. PRISM offers an easy and fast method to obtain first reliable data regarding the burden of disease and life quality.
Chronic hand eczema in the Clinical Practice Research Datalink (CPRD): Prevalence, incidence, comorbidities, and initial treatment Martin M. Crane, MS, PhD, GlaxoSmithKline, Research Triangle Park, NC, United States; David J. Webb, MS, GlaxoSmithKline, Uxbridge, United Kingdom; Elizabeth D. Watson, DVM, MPH, GlaxoSmithKline, Research Triangle Park, NC, United States; Timothy Cunliffe, MD, South Tees Hospitals NHS Foundation Trust, Middlesborough, United Kingdom; John English, MD, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom Background: Self-report adult prevalence of hand eczema (HE) is 10%, incidence/prevalence of HE, chronic HE (CHE) or steroid-refractory CHE (SR-CHE) in a population-based patient-care setting are lacking. Objective: Estimate 10-, 5- and 1-year lifetime and period prevalence of HE, CHE and SR-CHE in a primary care population using a cross-sectional design; estimate incidence of each; and describe initial therapy using a cohort approach. Methods: Our study population consisted of all patients in the Clinical Practice Research Datalink with up-to-standard medical records for 3 time periods; 2000-10, 2005-10, and 2010-11. HE was defined as any of 12 diagnoses (6 specific to the hand, 6 for contact dermatitis). HE became CHE if any of these 12 or 3 additional diagnoses occurred $90 to $365 days after first HE and if the patient was prescribed 1 course of potent topical steroids. CHE patient became SR-CHE if (a) referred to dermatologist or (b) prescribed phototherapy, systemic immunomodulators, oral corticosteroids, alitretinoin or acitretin. CHE and SR-CHE criteria were applied for each occurrence of an HE diagnosis during the relevant time period. Selected comorbidities were examined. Results: Ten-, 5- and 1-year cohorts consisted of 1.4, 3.2 and 4.1 million persons; incidence was based on 3.3 million person-years. One-year prevalence of HE was 0.397% in adults; incidence of HE was 2.88 per 1000 person-years. Steroidrefractoriness occurred in about one-half of CHE patients. One-, five- and ten-year period prevalences of SR-CHE in adults were 0.008%, 0.036% and 0.072%; lifetime prevalences were 0.071%, 0.080%, and 0.098%. Estimates for all conditions were higher in females than males. About one-third of HE patients had diagnoses specific for the hand; the remainder had diagnoses associated with contact dermatitis. Oral immunosuppressives were initially prescribed for 0.44% of newly diagnosed HE. Hypertension was the most prevalent condition (13%). Conclusion: The proportion of adults seeking medical care for HE is a fraction of those who self-report HE. SR-CHE is rare, as is initial use of oral immunosuppressives in treatment of HE. Major limitations are that accuracy of dermatologic diagnoses in CPRD not easily verified, severity cannot be determined, widely accepted definitions for CHE and SR-CHE are not currently available and not all contact dermatitis involves the hand. Given these limitations, we provide an initial set of population-based estimates.
Commercial support: None identified.
Research funded by GSK. Drs Crane, Webb, and Watson are employees of GSK.
MAY 2015
J AM ACAD DERMATOL
AB95
1702 Assessment of burden of disease in patients with psoriasis, atopic dermatitis and basal cell carcinoma using Pictorial Representation of Illness and Self-Measure (PRISM) Matthias Hofmann, PhD, Department of Dermatology, Venereology and Allergology, Frankfurt, Germany; Nina Pliquet, MD, Department of Cardiology, Angiology, Pneumology, Nephrology and Internistic Intensive Care, Hanau, Germany; Konstantinos Fotiou, PhD, Department of Dermatology, Venereology and Allergology, Frankfurt, Germany; Roland Kaufmann, MD, Department of Dermatology, Venereology and Allergology, Frankfurt, Germany; Diamant Thaci, MD, Comprehensive Center for Inflammation Medicine, L€ ubeck, Germany Introduction and
432 Biologic use and associated factors in a nationally representative sample of Medicare patients with psoriasis Junko Takeshita, MD, PhD, University of Pennsylvania, Philadelphia, PA, United States; Joel Gelfand, MD, MS, University of Pennsylvania, Philadelphia, PA, United States; Penxiang Li, PhD, University of Pennsylvania, Philadelphia, PA, United States; Lionel Pinto, MS, Amgen Inc, Thousand Oaks, CA, United States; Xinyan Yu, MD, MS, University of Pennsylvania, Philadelphia, PA, United States; Preethi Rao, MS, University of Pennsylvania, Philadelphia, PA, United States; Hema Viswanathan, PhD, Amgen Inc, Thousand Oaks, CA, United States; Jalpa Doshi, PhD, University of Pennsylvania, Philadelphia, PA, United States Purpose: Treatment of psoriasis in the elderly is poorly understood and represents an important research gap. This study was aimed at examining biologic treatment utilization and associated factors in a nationally representative sample of Medicare patients with psoriasis. Methods: This retrospective cross-sectional study used the 5% random sample Medicare claims files to examine beneficiaries with continuous fee-for-service Medicare Part A and B coverage and stand-alone Part D plan enrollment in 2010. Patients who had at least 2 claims for psoriasis (ICD-9 code 696.1) were included in the analysis. The receipt of phototherapy, oral systemic and/or biologic therapy was used as a proxy to define moderate to severe psoriasis. Logistic regression was used to identify factors associated with biologic use. Results: A total of 4107 patients had at least 2 psoriasis claims, representing a prevalence of 0.5%. About 28% (n ¼ 1145) of all psoriasis patients received treatments indicative of moderate to severe psoriasis. Biologics were used by 433 patients (11% of all psoriasis patients; 38% of patients with moderate to severe psoriasis) and were distributed as follows: adalimumab 35%, alefacept 1%, etanercept 47%, infliximab 21%, and ustekinumab 6% (patients could have claims for more than one specific biologic). Among biologic users, 28% used a physicianadministered biologic covered under the Part B medical benefit and 82% used a selfadministered biologic covered under the Part D drug benefit. Similar patterns of biologic use were found when psoriasis was identified based on at least one dermatologist claim of 696.1. In multivariate analyses among patients with moderate to severe psoriasis, older age and malignancy were associated with lower odds of biologic use. As compared to patients with minimal out-of-pocket costs given lowincome subsidies (LIS) under Part D, patients without LIS had 70% lower odds of biologic use (OR 0.32, 95% CI 0.12-0.87). Patients with concomitant psoriatic arthritis had 4-fold higher odds of using biologics (OR 4.15, 95% CI 2.93-5.87). Conclusions: Only a third of Medicare patients with moderate to severe psoriasis used a biologic in 2010. Results suggest that younger age, having LIS under Part D, and presence of psoriatic arthritis were positively associated with biologic use. Higher out-of-pocket costs among patients without LIS may limit access to biologics among Medicare Part D patients with moderate to severe psoriasis. 100% is Sponsored by Amgen Inc
1196
Objectives: Patient reported outcome (PRO) measurements are the main tool to obtain data of life quality. In the current study, the nonverbal visualization tool PRISM was utilized to assess the burden of disease in patients with psoriasis, atopic dermatitis or basal cell carcinoma. PRISM features higher expressiveness in regard to burden of disease measurements compared to standard patient-reported outcome measurements as DLQI, EQ-5D and SF-36. Patients and methods: In total 90 patients with psoriasis (n ¼ 30), atopic dermatitis (n ¼ 30) or basal cell carcinoma (n ¼ 30) were included in a prospective study at the Department of Dermatology, Venereology and Allergology in Frankfurt. PRO assessments were performed in all patients utilizing DLQI, EQ-5D and SF-36 as well as the visualizing instrument PRISM in regard to their quality of life and burden of disease. For assessment of PRISM, all patients received a white, A4-sized square plate and were asked to place a disk representing their disease in relation to a disk representing their ‘‘self’’ on it. Results: Data obtained with DLQI and PRISM feature a significant high correlation (rs ¼ -0.56) corroborating earlier data of our group. Furthermore, we can identify that PRISM is able to determine differences of quality of life between patients with chronic skin conditions as atopic dermatitis and psoriasis (high burden of disease) and basal cell carcinoma (low burden of disease) as good as the DLQI. In comparison with the other PRO instruments PRISM could not show a significant correlation. The missing correlation with patient data and illness specific evaluation tools indicates that the terms quality of life and burden of disease are multidimensional constructs which are difficult to assess. Conclusions: We can conclude that for the assessed diseases PRISM is a valuable tool with a very high reliability. In this context, utilization of PRISM has a high medical relevance. As a nonverbal visualization tool PRISM is easy to understand for children and adolescents as well as foreigners who cannot use PROs in their mother tongue. In addition, PRISM is a very fast PRO tool as it takes \3 min to be performed. PRISM offers an easy and fast method to obtain first reliable data regarding the burden of disease and life quality.
Chronic hand eczema in the Clinical Practice Research Datalink (CPRD): Prevalence, incidence, comorbidities, and initial treatment Martin M. Crane, MS, PhD, GlaxoSmithKline, Research Triangle Park, NC, United States; David J. Webb, MS, GlaxoSmithKline, Uxbridge, United Kingdom; Elizabeth D. Watson, DVM, MPH, GlaxoSmithKline, Research Triangle Park, NC, United States; Timothy Cunliffe, MD, South Tees Hospitals NHS Foundation Trust, Middlesborough, United Kingdom; John English, MD, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom Background: Self-report adult prevalence of hand eczema (HE) is 10%, incidence/prevalence of HE, chronic HE (CHE) or steroid-refractory CHE (SR-CHE) in a population-based patient-care setting are lacking. Objective: Estimate 10-, 5- and 1-year lifetime and period prevalence of HE, CHE and SR-CHE in a primary care population using a cross-sectional design; estimate incidence of each; and describe initial therapy using a cohort approach. Methods: Our study population consisted of all patients in the Clinical Practice Research Datalink with up-to-standard medical records for 3 time periods; 2000-10, 2005-10, and 2010-11. HE was defined as any of 12 diagnoses (6 specific to the hand, 6 for contact dermatitis). HE became CHE if any of these 12 or 3 additional diagnoses occurred $90 to $365 days after first HE and if the patient was prescribed 1 course of potent topical steroids. CHE patient became SR-CHE if (a) referred to dermatologist or (b) prescribed phototherapy, systemic immunomodulators, oral corticosteroids, alitretinoin or acitretin. CHE and SR-CHE criteria were applied for each occurrence of an HE diagnosis during the relevant time period. Selected comorbidities were examined. Results: Ten-, 5- and 1-year cohorts consisted of 1.4, 3.2 and 4.1 million persons; incidence was based on 3.3 million person-years. One-year prevalence of HE was 0.397% in adults; incidence of HE was 2.88 per 1000 person-years. Steroidrefractoriness occurred in about one-half of CHE patients. One-, five- and ten-year period prevalences of SR-CHE in adults were 0.008%, 0.036% and 0.072%; lifetime prevalences were 0.071%, 0.080%, and 0.098%. Estimates for all conditions were higher in females than males. About one-third of HE patients had diagnoses specific for the hand; the remainder had diagnoses associated with contact dermatitis. Oral immunosuppressives were initially prescribed for 0.44% of newly diagnosed HE. Hypertension was the most prevalent condition (13%). Conclusion: The proportion of adults seeking medical care for HE is a fraction of those who self-report HE. SR-CHE is rare, as is initial use of oral immunosuppressives in treatment of HE. Major limitations are that accuracy of dermatologic diagnoses in CPRD not easily verified, severity cannot be determined, widely accepted definitions for CHE and SR-CHE are not currently available and not all contact dermatitis involves the hand. Given these limitations, we provide an initial set of population-based estimates.
Commercial support: None identified.
Research funded by GSK. Drs Crane, Webb, and Watson are employees of GSK.
MAY 2015
J AM ACAD DERMATOL
AB95