- Email: [email protected]
Sustained improvement of the quality of life of patients with psoriasis after hospitalization
858 Brief reports
J AM ACAD DERMATOL NOVEMBER 2000
Sustained improvement of the quality of life of patients with psoriasis after hospitalization Eric Vensel, MD, Theresa Hilley, MD, Jennifer Trent, BA, John R. Taylor, PhD, Robert S. Kirsner, MD, Francisco A. Kerdel, MD, J. Richard Taylor, MD, and Jordan B. Schwartzberg, MD Miami, Florida Psoriasis is a chronic, recurrent, and often disfiguring skin disease that may significantly affect patients’ quality of life. Treatment of psoriasis, including hospitalization, has been shown to improve quality of life. A pilot study of 15 consecutive inpatients and 7 consecutive outpatients with psoriasis were asked to complete the Dermatology Life Quality Index (DLQI) before treatment and 3 months later. Hospitalized patients also completed the DLQI 1 week after discharge. Statistical analysis using t tests compared pretreatment and posttreatment DLQI scores as well as improvement of inpatients versus outpatients. Baseline DLQI scores for hospitalized patients were significantly higher (greater impairment of life quality) compared with oupatients’ quality of life. After discharge, hospitalized patients’ quality of life had significantly improved at 1 week and remained improved at 3 months. (J Am Acad Dermatol 2000;43: 858-60.)
From the University of Miami School of Medicine, Department of Dermatology and Cutaneous Surgery, Cedars Medical Center & Miami Veterans Affairs Medical Center. Reprint requests: Robert S. Kirsner, MD, University of Miami, Department of Dermatology, PO Box 016250 (R-250), Miami, FL 33136. E-mail: [email protected]. 16/54/106512 doi:10.1067/mjd.2000.106512
P
soriasis is a chronic and recurrent skin disorder that affects approximately 1% to 3% of the US population. Psoriasis has a multifactorial origin that is influenced by genetic, environmental, and immunologic factors. It can vary in severity with patients having severe recalcitrant disease often requiring hospital admission.1 Psoriasis is
Brief reports 859
J AM ACAD DERMATOL VOLUME 43, NUMBER 5
Table I. Summary of DLQI scores
Inpatients Outpatients
Baseline
1 wk after discharge
3 mo after discharge
Change from baseline to 3 mo after discharge
% Change from baseline to 3 mo after discharge
15.3a ± 1.0 8.7e ± 1.1
6.9 ± 1.2 N/A
6.5b ± 1.0 6.6f ± 0.6
8.8c ± 1.1 2.1g ± 0.6
60d ± 6.5 10h ± 8.2
N/A, Not applicable. Student t test values are as follows: P = .04 for a vs e; P = .0006 for a vs b; P = .099 for e vs f; P = .99 for b vs f; P = .04 for c vs g; P = .008 for d vs h.
the most frequent cause of hospitalization for dermatology patients.2 Psoriasis significantly affects patients’ quality of life, including such aspects as activities of daily living, emotional perceptions, sexual relationships, decision to have children, and career choices.3-6 Patients with psoriasis often report feeling stigmatized,7 and patients hospitalized for psoriasis report having a higher prevalence of active suicidal ideation than general medical patients.8 Often, the degree of impairment of quality of life is unrelated to the clinical severity of psoriasis as measured by physicians.9,10 Therefore, in addition to monitoring physician-oriented outcome measures, it is also important to determine the effect of treatment on quality of life.11 Hospitalization has been shown to alleviate depression and anxiety in dermatology inpatients.12 In addition, hospitalization also improves life quality as measured by the Dermatology Life Quality Index (DLQI), a validated patient questionnaire that was designed to measure quality of life based on symptoms, feelings, daily activities, leisure, work/school, personal relationships, and treatment.13,14 However, whether improvements in quality of life persist beyond 4 weeks after hospital discharge has not been studied. Therefore we sought to determine whether improvement of psoriasis patients’ quality of life persists after hospitalization.
METHODS After informed consent was obtained, consecutive patients admitted for psoriasis and consecutive outpatients starting phototherapy for psoriasis were enrolled in this study. Inpatients were asked to complete the DLQI upon admission, 1 week after discharge, and 3 months after discharge. The outpatients were asked to complete the DLQI upon initial visit and 3 months later. A DLQI score was calculated based on the answers to the 10 questions. Each of the 4 possible answers to each question is assigned a value from 0 to 3. The values are added to calculate a final DLQI score. A score of 30 represents the greatest impairment of life quality. Statistical analysis was performed using the Student t test.
RESULTS Fifteen inpatients were enrolled (mean age, 54 years; range, 10-80 years), including 4 men and 11 women. Mean hospital stay was 8.6 days. Mean age of the outpatients was 59 years (range, 23-84 years), including 4 men and 3 women. Table I summarizes the DLQI results. Inpatients had significantly higher (P ≤ .01) DLQI scores at baseline compared with outpatients. For patients who were hospitalized, the mean DLQI scores were 15.3 (± 1.0 SE) at baseline, 6.9 (± 1.2 SE) 1 week after discharge, and 6.5 (± 1.0 SE) 3 months after discharge. The mean change was 8.8 (± 1.1 SE). For outpatients, mean DLQI scores were 8.7 (± 1.1 SE) at baseline and 6.6 (± 0.6 SE) at 3 months. The mean change for outpatients was 2.1 (± 0.6 SE). For inpatients, there was a significant difference (P ≤ .01) between initial DLQI scores and DLQI scores 1 week after discharge as well as between initial DLQI scores and DLQI scores 3 months after discharge. There was no significant difference between the 1 week after discharge and 3 months after discharge DLQI scores. For outpatients, the decrease in DLQI scores was not significant, but showed a trend toward significance (P = .099). This result may have been significant if a larger number of outpatients were included. Between inpatients and outpatients, there was no difference between final DLQI scores (after 3 months), but there were significant differences (P ≤ .01) between their change in DLQI scores and percent change in DLQI scores.
DISCUSSION We found that hospitalized patients with psoriasis have a significant impairment in quality of life, more so than do outpatients. We also found that hospitalized patients with psoriasis had a significant improvement in quality of life after hospitalization. This improvement persisted for the duration of our study. At study end, the difference in quality of life diminished and previously hospitalized patients were not significantly different from outpatients. These results of improvement after hospitalization are similar to the results of Kurwa and Finlay,2 who
860 Brief reports
found improved DLQI scores at 1 month. We showed for the first time longer persistence of DLQI scores. Since at the end of the study period patients remained improved, it is not clear how long the effect of hospitalization persists. Future studies are needed to follow up patients longitudinally to determine whether improvement continues to be sustained over longer intervals. It is also unknown what aspects of the hospitalization are associated with improvement. Either improvement in the clinical severity of psoriasis, psychologic effects, or both, could have influenced the quality of life. It is also likely that the effects of psoriasis on patients’ quality of life may influence a physician’s decision to hospitalize a patient with psoriasis. Our comparison group, outpatients receiving phototherapy, differed in pretreatment severity (as measured by the DLQI) of their psoriasis. Inclusion of a control population of nonhospitalized psoriasis patients with a similarly severe impairment of their DLQI, although optimal, was problematic because withholding hospitalization for this group may be perceived as unethical. Other measures of psoriasis severity such as DLQI were not included (although hospitalized patients experienced <50% reduction in baseline PASI scores). Whether physician-oriented measures (such as PASI scores) should be considered the goal standard of outcome measures is a matter for debate. For the purpose of our study, we believed patient-oriented outcomes (DLQI) are an important end point, in and of themselves. Impaired quality of life due to psoriasis may benefit from hospitalization. This effect persists beyond the duration of hospitalization.
J AM ACAD DERMATOL NOVEMBER 2000
REFERENCES 1. Demis DJ, editor. Clinical dermatology. Philadelphia: Lippincott Williams & Wilkins, Inc; 1999. 2. Kurwa HA, Finlay AY. Dermatology in-patient management greatly improves life quality. Br J Dermatol 1995;133:575-8. 3. Gupta MA, Gupta AK. Psoriasis and sex: a study of moderately to severely affected patients. Int J Dermatol 1997;36:259-62. 4. Ramsay B, O’Reagan M. A survey of the social and psychological effects of psoriasis. Br J Dermatol 1988;118:195-201. 5. Koo J. Population-based epidemiologic study of psoriasis with emphasis on quality of life assessment. Dermatol Clin 1996;14: 485-96. 6. Jowett S, Ryan T. Skin disease and handicap: an analysis of the impact of skin conditions. Soc Sci Med 1985;20:425-9. 7. Ginsburg IH, Link BG. Feelings of stigmatization in patients with psoriasis. J Am Acad Dermatol 1989;20:53-63. 8. Gupta MA, Gupta AK. Depression and suicidal ideation in dermatology patients with acne, alopecia areata, atopic dermatitis, and psoriasis. Br J Dermatol 1998;139:846-50. 9. Fortune DG, Main CJ, O’Sullivan TM, Griffiths CEM. Quality of life in patients with psoriasis: the contribution of clinical variables and psoriasis-specific stress. Br J Dermatol 1997;137:755-60. 10. Root S, Kent G, Al-Abadie MSK. The relationship between severity, disability and psychological distress in patients undergoing PUVA treatment for psoriasis. Dermatology 1994;189:234-7. 11. McKenna KE, Stern RS.The outcomes movement and new measures of the severity of psoriasis. J Am Acad Dermatol 1996;34: 534-8. 12. Hurwitz D, Kerdel FA, Kirsner RS. Hospitalization for skin disease improves quality of life. Arch Dermatol 1997;133:797-8. 13. Finlay AY, Khan GK. Dermatology life quality index (DLQI)—a simple practical measure for routine clinical use. Clin Exp Dermatol 1994;19:210-6. 14. Rajagopalan R, Sherertz EF, Anderson RT, editors. Care management of skin diseases: life quality and economic impact. New York: Marcel Dekker; 1998.
J AM ACAD DERMATOL NOVEMBER 2000
Sustained improvement of the quality of life of patients with psoriasis after hospitalization Eric Vensel, MD, Theresa Hilley, MD, Jennifer Trent, BA, John R. Taylor, PhD, Robert S. Kirsner, MD, Francisco A. Kerdel, MD, J. Richard Taylor, MD, and Jordan B. Schwartzberg, MD Miami, Florida Psoriasis is a chronic, recurrent, and often disfiguring skin disease that may significantly affect patients’ quality of life. Treatment of psoriasis, including hospitalization, has been shown to improve quality of life. A pilot study of 15 consecutive inpatients and 7 consecutive outpatients with psoriasis were asked to complete the Dermatology Life Quality Index (DLQI) before treatment and 3 months later. Hospitalized patients also completed the DLQI 1 week after discharge. Statistical analysis using t tests compared pretreatment and posttreatment DLQI scores as well as improvement of inpatients versus outpatients. Baseline DLQI scores for hospitalized patients were significantly higher (greater impairment of life quality) compared with oupatients’ quality of life. After discharge, hospitalized patients’ quality of life had significantly improved at 1 week and remained improved at 3 months. (J Am Acad Dermatol 2000;43: 858-60.)
From the University of Miami School of Medicine, Department of Dermatology and Cutaneous Surgery, Cedars Medical Center & Miami Veterans Affairs Medical Center. Reprint requests: Robert S. Kirsner, MD, University of Miami, Department of Dermatology, PO Box 016250 (R-250), Miami, FL 33136. E-mail: [email protected]. 16/54/106512 doi:10.1067/mjd.2000.106512
P
soriasis is a chronic and recurrent skin disorder that affects approximately 1% to 3% of the US population. Psoriasis has a multifactorial origin that is influenced by genetic, environmental, and immunologic factors. It can vary in severity with patients having severe recalcitrant disease often requiring hospital admission.1 Psoriasis is
Brief reports 859
J AM ACAD DERMATOL VOLUME 43, NUMBER 5
Table I. Summary of DLQI scores
Inpatients Outpatients
Baseline
1 wk after discharge
3 mo after discharge
Change from baseline to 3 mo after discharge
% Change from baseline to 3 mo after discharge
15.3a ± 1.0 8.7e ± 1.1
6.9 ± 1.2 N/A
6.5b ± 1.0 6.6f ± 0.6
8.8c ± 1.1 2.1g ± 0.6
60d ± 6.5 10h ± 8.2
N/A, Not applicable. Student t test values are as follows: P = .04 for a vs e; P = .0006 for a vs b; P = .099 for e vs f; P = .99 for b vs f; P = .04 for c vs g; P = .008 for d vs h.
the most frequent cause of hospitalization for dermatology patients.2 Psoriasis significantly affects patients’ quality of life, including such aspects as activities of daily living, emotional perceptions, sexual relationships, decision to have children, and career choices.3-6 Patients with psoriasis often report feeling stigmatized,7 and patients hospitalized for psoriasis report having a higher prevalence of active suicidal ideation than general medical patients.8 Often, the degree of impairment of quality of life is unrelated to the clinical severity of psoriasis as measured by physicians.9,10 Therefore, in addition to monitoring physician-oriented outcome measures, it is also important to determine the effect of treatment on quality of life.11 Hospitalization has been shown to alleviate depression and anxiety in dermatology inpatients.12 In addition, hospitalization also improves life quality as measured by the Dermatology Life Quality Index (DLQI), a validated patient questionnaire that was designed to measure quality of life based on symptoms, feelings, daily activities, leisure, work/school, personal relationships, and treatment.13,14 However, whether improvements in quality of life persist beyond 4 weeks after hospital discharge has not been studied. Therefore we sought to determine whether improvement of psoriasis patients’ quality of life persists after hospitalization.
METHODS After informed consent was obtained, consecutive patients admitted for psoriasis and consecutive outpatients starting phototherapy for psoriasis were enrolled in this study. Inpatients were asked to complete the DLQI upon admission, 1 week after discharge, and 3 months after discharge. The outpatients were asked to complete the DLQI upon initial visit and 3 months later. A DLQI score was calculated based on the answers to the 10 questions. Each of the 4 possible answers to each question is assigned a value from 0 to 3. The values are added to calculate a final DLQI score. A score of 30 represents the greatest impairment of life quality. Statistical analysis was performed using the Student t test.
RESULTS Fifteen inpatients were enrolled (mean age, 54 years; range, 10-80 years), including 4 men and 11 women. Mean hospital stay was 8.6 days. Mean age of the outpatients was 59 years (range, 23-84 years), including 4 men and 3 women. Table I summarizes the DLQI results. Inpatients had significantly higher (P ≤ .01) DLQI scores at baseline compared with outpatients. For patients who were hospitalized, the mean DLQI scores were 15.3 (± 1.0 SE) at baseline, 6.9 (± 1.2 SE) 1 week after discharge, and 6.5 (± 1.0 SE) 3 months after discharge. The mean change was 8.8 (± 1.1 SE). For outpatients, mean DLQI scores were 8.7 (± 1.1 SE) at baseline and 6.6 (± 0.6 SE) at 3 months. The mean change for outpatients was 2.1 (± 0.6 SE). For inpatients, there was a significant difference (P ≤ .01) between initial DLQI scores and DLQI scores 1 week after discharge as well as between initial DLQI scores and DLQI scores 3 months after discharge. There was no significant difference between the 1 week after discharge and 3 months after discharge DLQI scores. For outpatients, the decrease in DLQI scores was not significant, but showed a trend toward significance (P = .099). This result may have been significant if a larger number of outpatients were included. Between inpatients and outpatients, there was no difference between final DLQI scores (after 3 months), but there were significant differences (P ≤ .01) between their change in DLQI scores and percent change in DLQI scores.
DISCUSSION We found that hospitalized patients with psoriasis have a significant impairment in quality of life, more so than do outpatients. We also found that hospitalized patients with psoriasis had a significant improvement in quality of life after hospitalization. This improvement persisted for the duration of our study. At study end, the difference in quality of life diminished and previously hospitalized patients were not significantly different from outpatients. These results of improvement after hospitalization are similar to the results of Kurwa and Finlay,2 who
860 Brief reports
found improved DLQI scores at 1 month. We showed for the first time longer persistence of DLQI scores. Since at the end of the study period patients remained improved, it is not clear how long the effect of hospitalization persists. Future studies are needed to follow up patients longitudinally to determine whether improvement continues to be sustained over longer intervals. It is also unknown what aspects of the hospitalization are associated with improvement. Either improvement in the clinical severity of psoriasis, psychologic effects, or both, could have influenced the quality of life. It is also likely that the effects of psoriasis on patients’ quality of life may influence a physician’s decision to hospitalize a patient with psoriasis. Our comparison group, outpatients receiving phototherapy, differed in pretreatment severity (as measured by the DLQI) of their psoriasis. Inclusion of a control population of nonhospitalized psoriasis patients with a similarly severe impairment of their DLQI, although optimal, was problematic because withholding hospitalization for this group may be perceived as unethical. Other measures of psoriasis severity such as DLQI were not included (although hospitalized patients experienced <50% reduction in baseline PASI scores). Whether physician-oriented measures (such as PASI scores) should be considered the goal standard of outcome measures is a matter for debate. For the purpose of our study, we believed patient-oriented outcomes (DLQI) are an important end point, in and of themselves. Impaired quality of life due to psoriasis may benefit from hospitalization. This effect persists beyond the duration of hospitalization.
J AM ACAD DERMATOL NOVEMBER 2000
REFERENCES 1. Demis DJ, editor. Clinical dermatology. Philadelphia: Lippincott Williams & Wilkins, Inc; 1999. 2. Kurwa HA, Finlay AY. Dermatology in-patient management greatly improves life quality. Br J Dermatol 1995;133:575-8. 3. Gupta MA, Gupta AK. Psoriasis and sex: a study of moderately to severely affected patients. Int J Dermatol 1997;36:259-62. 4. Ramsay B, O’Reagan M. A survey of the social and psychological effects of psoriasis. Br J Dermatol 1988;118:195-201. 5. Koo J. Population-based epidemiologic study of psoriasis with emphasis on quality of life assessment. Dermatol Clin 1996;14: 485-96. 6. Jowett S, Ryan T. Skin disease and handicap: an analysis of the impact of skin conditions. Soc Sci Med 1985;20:425-9. 7. Ginsburg IH, Link BG. Feelings of stigmatization in patients with psoriasis. J Am Acad Dermatol 1989;20:53-63. 8. Gupta MA, Gupta AK. Depression and suicidal ideation in dermatology patients with acne, alopecia areata, atopic dermatitis, and psoriasis. Br J Dermatol 1998;139:846-50. 9. Fortune DG, Main CJ, O’Sullivan TM, Griffiths CEM. Quality of life in patients with psoriasis: the contribution of clinical variables and psoriasis-specific stress. Br J Dermatol 1997;137:755-60. 10. Root S, Kent G, Al-Abadie MSK. The relationship between severity, disability and psychological distress in patients undergoing PUVA treatment for psoriasis. Dermatology 1994;189:234-7. 11. McKenna KE, Stern RS.The outcomes movement and new measures of the severity of psoriasis. J Am Acad Dermatol 1996;34: 534-8. 12. Hurwitz D, Kerdel FA, Kirsner RS. Hospitalization for skin disease improves quality of life. Arch Dermatol 1997;133:797-8. 13. Finlay AY, Khan GK. Dermatology life quality index (DLQI)—a simple practical measure for routine clinical use. Clin Exp Dermatol 1994;19:210-6. 14. Rajagopalan R, Sherertz EF, Anderson RT, editors. Care management of skin diseases: life quality and economic impact. New York: Marcel Dekker; 1998.