The Laundry Bag Project unequal distribution of dermatological healthcare resources for male and female psoriatic patients in Sweden

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1 Oxford, IJD International Blackwell XXX UK Publishing Journal Ltd, of Dermatology 2007 Report Unequal Nyberg, Report Osika, dermatological and Evengård treatment in men and women The Laundry Bag Project unequal distribution of dermatological healthcare resources for male and female psoriatic patients in Sweden Filippa Nyberg, MD, PhD, Ingrid Osika, MA, and Birgitta Evengård, MD, PhD From the Department of Dermatology, Danderyd Hospital, Stockholm, Sweden, and Institution for Health Economics, Linköping University, Linköping, Sweden, and Department of Clinical Bacteriology, Institution for Medicine, Karolinska University Hospital Huddinge, Sweden Correspondence Filippa Nyberg, MD, PhD Department of Dermatology Danderyd Hospital S Stockholm, Sweden The study was carried out as part of quality assessment in the healthcare system provided by Stockholm County Council. Ethical approval was not required. The study was not funded from any external sources. Abstract Background Psoriasis and eczema are common dermatological diseases that occur with approximately equal frequency in men and in women. The aim of this study was to determine whether men and women with dermatological diseases in need of ultra-violet radiation (UV) treatment receive equal care. Methods We conducted a retrospective analysis of records of all patients referred to and seen at our clinic during 2003 with diagnoses of psoriasis or eczema. We performed a gender-based analysis of the number, type, and estimated cost of the treatments given to each patient. We evaluated similar data from a Swedish Psoriasis Association (SPA) treatment center and from the state pharmacy monopoly (Apoteksstatistiken). Results Men with eczema or psoriasis received more help with emollients than did women and were given a greater number of UV treatments. At our clinic and at the SPA center, women constituted 37 and 42%, respectively, of the individuals who received UV treatment; yet, they received only 34 and 36% of the treatments, respectively. Women were prescribed self-care more often than men, with 61% of prescriptions for emollients and 48% of specific topical treatments for psoriasis dispensed to women. Conclusions We discovered previously unrecognized gender differences in standard dermatological treatment for common diagnoses at our hospital. To ensure optimal care for each patient, treatment disparity should be recognized and gender-based analyzes be carried out when planning dermatological health care. 144 Why are the laundry bags in the men s showers always fuller and need emptying more often than the bags in the women s showers? After phototherapy for psoriasis or eczema, patients at the Department of Dermatology at Danderyd Hospital (DH- Derm) use the hospital showers and throw their used towels in the laundry bags. The question about the laundry bags was asked by a nurse at a DH-Derm staff meeting and led to this study examining gender differences in the use of healthcare resources for treatment of two common dermatologic conditions. Gender analyses of public sector budgets and their effect on the lives, opportunities, and financial situations of women and men have gained considerable international attention, 1 4 but in healthcare budgeting, the gender perspective is most often lacking. A cost-comparative analysis based on gender can advantageously be combined with a gender-based medical perspective, where differences between the diseases, symptoms, and treatment of men and women are studied. 5 8 The use by both genders of the outpatient dermatology clinic provided us with an opportunity to examine gender budgeting in our clinic. The diseases that affect the greatest number of patients treated in our outpatient department are psoriasis and atopic eczema, which are as common among women as among men, and hand dermatitis, which is more common among women. One study indicated that women and younger people with eczema and psoriasis have poorer self-rated quality of life than others, based on assessments of self-rated quality of life using the Dermatological Quality of Life Index (DQLI), 9 although two other studies did not show any such difference. 10,11 The DH-Derm follows standard practice in dermatology outpatient care for eczema or psoriasis. In addition to the topical treatment that is always prescribed, ultra-violet radiation (UV) treatment, primarily in the form of narrow- International Journal of Dermatology 2008, 47, The International Society of Dermatology

2 Nyberg, Osika, and Evengård Unequal dermatological treatment in men and women Report 145 band (309 nm) UVB phototherapy, is often an effective treatment for eczema and psoriasis. When the patient first visits the department, the doctor makes an assessment and prescribes a course of treatment, for example, a series of UV treatments at the hospital, normally two to three times a week for 6 8 weeks. All the patients also receive a prescription for topical treatment (e.g. local steroids and calcipotriol cream) and emollients, either to supplement hospital treatment or as a stand-alone treatment. A similar assessment is made in cases of eczema. The patient receives a prescription and might also be prescribed UV treatment. Patients can request assistance in applying the ointments prescribed in connection with the UV treatment. We assessed by gender the number of patients with eczema and psoriasis who had visited our department over a 1 year period. We then evaluated the use of the available resources by patients based on gender, including the number of UV treatments that these patients had received and assistance with application of ointments. Patients and Methods Study population and variables We evaluated patient records to assess gender-based differences in treatment received by patients who received UV treatment at the DH-Derm compared to patients who received similar UV treatment at one of the Swedish Psoriasis Association (SPA) treatment centers in Stockholm. The DH-Derm is one of four dermatology units in Stockholm and has a catchment area of about 350,000. The health system in Sweden is built on a tax-financed health insurance for all citizens. The majority of dermatology patients are seen first in primary care, then referred to a specialist. Possibility for referral is unlimited for the primary care physician, and most patients with moderate to severe psoriasis and eczema will be referred to a specialist in an urban area. There are no private alternatives to the tax-financed health care. Cost maximization is set at SEK 900 (about 126 $US) for medical care, but double that amount (SEK 1800/252 $US) for drugs and medications. After reaching cost maximization in one of those categories, patients are not charged for services in that category (medical care or drugs/medication) for the rest of the year. A visit to the doctor (at SEK 120/17 $US) and 11 UV treatments (at SEK 70/10 $US) qualify the patient for medical care cost maximization. The clinic receives 15,000 outpatient visits per year, including both appointments with dermatologists and treatment sessions supervised by nurses in the UV treatment clinic. The vast majority of patients coming to DH-Derm are referred from primary care. By contrast, individuals visiting SPA centers during the survey period did not need a referral. We initially searched Melior, the computerized medical records system used at DH-Derm, to determine the number of men and women who sought treatment for eczema or psoriasis at the UV treatment clinic. Since psoriasis is a condition that encompasses many different diagnostic codes, we narrowed the search by focusing on the most homogenous diagnosis group within psoriasis. Thus, all DH-Derm medical record notes for patients with psoriasis vulgaris (plaque psoriasis, ICD code L400) were analyzed using the Cliq View software program. The search terms used were diagnosis, prescription, UV treatment (with different wavelengths specified), and bathing. SPA centers are publicly financed clinics run by the SPA. Employees of the SPA centers provided data on the number of men and women treated during a 12 month period and the number of treatments each patient received. We were not able to carry out a financial analysis on the SPA center data. Financial analysis We priced the treatments using codes based on standard calculations of the costs for various treatments, and they are used by the hospital-based dermatology clinics throughout Stockholm. A visit to the doctor (at SEK 120/17 $US) and 11 UV treatments (at SEK 70/10 $US) qualify the patient for medical care cost maximization. Dispensed medications for home treatment Prescriptions for self-care topical treatment are issued to all patients diagnosed with psoriasis and eczema. We assumed that patients who do not receive clinic treatment in addition to self-care use more of these medications than do those who receive treatment in the clinic. We analyzed data from Apoteket, the state pharmacy monopoly in Sweden, concerning medications dispensed for topical skin treatment in the Stockholm County Council (SCC) area. SCC consists of 26 municipalities and has 1.8 million inhabitants. We examined dispensed prescriptions, where patients actually collected their prescriptions from the pharmacy. The medications included in the analysis were emollients, cortisone creams, vitamin D analogs and retinoids for the topical treatment of psoriasis, and psoralen tablets, which are prescribed in connection with psoralen-uva (PUVA) treatment. Statistical analysis The population of Stockholm County (approximately 1.8 million) was taken as the population base for prescriptions. Standardization of raw data was performed using STATISTICA v. 7.0 (StatSoft Scandinavia, Uppsala, Sweden) for the calculation of t-tests with regard to the ratio of women to men receiving treatments. Normal distribution was assumed for both women and men regarding the number of UV treatments. A P-value of < 0.05 was considered to be statistically significant. Results Use of clinic resources As a first step in the analysis, we examined how many patients of each gender had visited DH-Derm in 2003 and been given 2008 The International Society of Dermatology International Journal of Dermatology 2008, 47,

3 146 Report Unequal dermatological treatment in men and women Nyberg, Osika, and Evengård Figure 1 Five-hundred and eighty-six patients diagnosed with eczema (n = 260) and psoriasis (n = 326) at Department of Dermatology at Danderyd Hospital in 2003 (n = number of patients). Slightly more women then men had been diagnosed as eczema sufferers, whereas slightly more men had been diagnosed with psoriasis a diagnosis of eczema or psoriasis (a total of 586 patients, see Fig. 1). We selected these diagnoses because two alternative treatments are offered for these conditions: (i) bathing and/or UV treatment at the hospital; or (ii) self-treatment at home. We analyzed evaluable records of patients given a diagnosis that is treated with baths, UV treatment, and/or self-treatment. Over the period covered in this study, we found 291 women and 295 men with a diagnosis of eczema or psoriasis. No apparent gender differences regarding the severity of symptoms could be concluded from the patient records for these diagnoses. We then analyzed how many patients of each gender with these diagnoses had received treatment at the clinic (Fig. 2). Bathing treatment was administered 456 times to 88 patients. Forty-six female patients (52%) and 42 male patients (48%) received bathing treatment on one or more occasions. Whole-body UV treatment was administered on 2140 occasions to 126 patients diagnosed with psoriasis or eczema. Significantly more men (79; 63%) than women (47; 37%) Figure 2 Numbers of women and men receiving bathing treatment and UV treatment for the whole body, Department of Dermatology at Danderyd Hospital, 2003 received whole-body UV treatment for psoriasis or eczema (P < ). To make our figures comparable with other clinics performing UV treatment for psoriasis, we analyzed the number of treatments per individual diagnosed with psoriasis vulgaris (L400), that is, common psoriasis, the numerically largest group (Table 1). We noted that women (n = 38) constituted 44% of the individuals receiving UV treatment, yet received only 768 (38%) of the total number of UV treatments administered (n = 2012). SPA treatment centers Our analysis indicated that men received a greater number of treatments at DH-Derm than did women with a comparable diagnosis. To see whether the gender-distorted treatment statistics at DH-Derm might reflect a general pattern (Table 2), we investigated treatment at an SPA center. At the SPA center we studied, treatments were performed on a population of 646 individuals, consisting of 374 men (58%) and 272 women (42%). Women received 5429 treatments (36%). Thus, although 42% of the individuals who received treatment were women, only 36% of the treatments were Table 1 Treatment of women and men with psoriasis, Department of Dermatology at Danderyd Hospital, 2003 Number of individuals Percentage Number of treatments Number of treatments/patient (mean value) Percentage (P < 0.05) Women Men Table 2 Treatment of women and men with psoriasis, Swedish Psoriasis Association center, 2003 Number of individuals Percentage Number of treatments Number of treatments/patient (mean value) Percentage (P < ) Women Men International Journal of Dermatology 2008, 47, The International Society of Dermatology

4 Nyberg, Osika, and Evengård Unequal dermatological treatment in men and women Report 147 Table 3 Dispensed prescriptions in Stockholm County Council (in SEK and approximately in $US) Medication Women Men Total Percentage of women Emollients 28,710,886 SEK 15,407,701 SEK 44,118,587 SEK ,000 $US 2,160,000 $US 6,180,000 $US P < Topical corticosteroids 17,593,176 SEK 15,527,124 SEK 33,120,300 SEK 53 2,500,000 $US 2,200,000 $US 4,700,000 $US D05AX a 5,426,634 SEK 7,388,241 SEK 12,814,875 SEK ,000 $US 1035,000 1,795,000 P < Oxsoralen b 100,862 SEK 76,046 SEK 176,908 SEK 57 14,100 $US 10,600 $US 24,700 $US P < Total 51, SEK 38, SEK 90,230,670 SEK 57 7,294,100 $US 5,405,600 $US 12,699,700 $US P < a Topical treatment for psoriasis (calcipotriol with/without corticosteroid combination). b Psoralen tablets for PUVA treatment. performed on women, indicating the same gender inequalities seen at DH-Derm. Follow-up These findings were discussed with DH-Derm employees at various meetings during 2003, and a follow-up was performed regarding UV treatments carried out on psoriasis patients during Of the 1062 UV treatments administered to 110 patients with psoriasis in 2004, 489 treatments (46%) were given to 54 women (49%). Although the difference in gender distribution of patients receiving UV treatment prescribed by the doctors in 2004 did not reach statistical significance, the higher number of treatments given to male psoriatic patients translated to higher healthcare expenditure for male patients compared to female patients. Financial analysis of the number of treatment episodes For patients visiting DH-Derm in 2003, the total cost for bathing and UV treatment of whole body was SEK 611,405 (85,600 $US) for men and SEK 386,743 (54,150 $US) for women. Analysis of Apoteket s statistics on dispensed medications The total value of medications dispensed to women was greater than the total value of medications dispensed to men (Table 3). Any occurring cost maximization has not been included in the calculation. The greatest difference was seen with emollients, where 65% of all prescriptions within SLL were dispensed to women. In the age group of 0 10 years, more boys than girls were given emollients, but in all other age groups, women outweighed men, with the greatest differences seen in the age groups of and years. Fifty-three percent of the total cortisone cream prescriptions within SLL were dispensed to women, and 58% of the prescriptions for vitamin D analogs (DO5AX) were dispensed to men. More oxsoralen was dispensed to women than to men. Overall, for the skin medications in question, SEK 13,432,446 (approximately 1 9 million $US) more was spent on medications dispensed to women than on medications dispensed to men in SLL during the observed year. Discussion Our study showed substantial gender differences in the treatment received by women and men for two of our most common skin diseases. A typical course of treatment for a psoriasis patient includes about treatments. The treatment course is normally discontinued after consultation between the patient and doctor or experienced treatment staff member. Although gender-based analysis showed the average number of treatments for each group to be within a normal range of treatments, the average number of treatments administered to women in our study was significantly less than the average number of treatments administered to men. It follows therefore that the treatment costs also exhibit substantial gender differences. If women received the same number of treatments per individual as men, the resources put into women s treatment would have to increase by 56%. In 2003, women received treatment worth SEK 216,209 (30,300 $US), too little based on comparison with the diagnoses and costs of the men s treatment, that is, 22% of the total treatment budget. Assuming that women administer more self-care in the home than men, we can express this in terms of women who treat themselves at home, subsidizing 22% of the publicly financed dermatology department budget for the treatment of the diseases discussed here. Taking the number of treatments administered to women as the norm and treating men in the same way would save SEK 219,350 (30,800 $US) per year, the equivalent of 22% of the treatment budget. Our analysis cannot provide an overall picture of the cost of all psoriasis treatment, nor can it highlight any 2008 The International Society of Dermatology International Journal of Dermatology 2008, 47,

5 148 Report Unequal dermatological treatment in men and women Nyberg, Osika, and Evengård gender differences among the most seriously ill patients. The medications included in the pharmacy data (Apoteksstatistiken) we analyzed are prescribed as treatment not only for the conditions we studied here but also for other skin diseases. Another drawback is that the statistics do not cover medications for systemic treatment, for example, methotrexate and cyclosporine, which are often prescribed to 5 10% of psoriasis patients with severe systemic disease. However, despite these caveats, the pharmacy statistics reinforce our impression of the fact that medical skin treatment for women differs from that administered to men. In total, women were dispensed skin medications to a value of SEK 13.5 million more than men within SLL. Much of the cost for treatment and for medications is financed from public money. Further research is necessary, however, to establish the amounts women and men actually pay for their treatments and their medication in monetary terms. Cost maximization is set at SEK 900 (about 126 $US) for medical care, but double that amount (SEK 1800/252 $US) for drugs and medications. After reaching cost maximization in one of those categories, patients are not charged for services in that category (medical care or drugs/ medication) for the rest of the year. A visit to the doctor (at SEK 120/17 $US) and 11 UV treatments (at SEK 70/10 $US) qualify the patient for medical care cost maximization. Given that cost maximization for drugs and medications requires twice the expenditure required for cost maximization for medical care, individuals might be better off financially receiving treatment at a clinic rather than administering self-care in their own homes. To our knowledge, this is the first investigation of its kind; consequently, we have not been able to compare our findings with results obtained by other researchers. We have chosen to study eczema and psoriasis because of the availability of data on UV treatment and prescriptions, but our method should also be applied to other diagnoses. We do not know whether similar gender-based differences in use of healthcare resources exist in other countries. A recent review from the UK showed an equal number of men and women receiving outpatient UV treatment, but the study did not also compare men and women based on the number of treatments received. 12 In a survey of what patients themselves think causes their psoriasis, more women than men identified stress as a contributory or aggravating factor, 13 whilst no gender differences were found in how psoriasis treatment was felt to affect quality of life. 14 The belief that stress affects skin symptoms means that the patient can him/herself exert influence as a lifestyle choice. The fact that women believe this more often than men could lead them to taking/being given greater responsibility for their disease than men. Our findings indicate that public resources fund the treatment of men s skin diseases to a much greater extent than women s skin diseases, whilst women treat themselves in the home to a much greater extent than men without any public funding. This self-care is invisible in economic terms since it is not covered in the Swedish National Accounts and Sweden s GDP calculations. A study from northern Sweden indicated that high treatment costs at the dermatology department/clinic was cited more often by women than by men as a reason for treatment discontinuation. 9 The fact that on average women have fewer financial resources may also be a factor behind the differences in treatment strategies for men and women. Our study provides a basis for the assumption that there are gender differences in compliance with self-treatment using skin medications and UV treatment. A feasible way to help change the figures we have reported would be to set up eczema and psoriasis schools, where men and women would learn the importance of regularly applying emollient on their skin and of undergoing UV treatment. There are already eczema schools at dermatology clinics for children with eczema and their parents, and we were unable to see the same inequalities in prescribing patterns in the children s group we studied. An alternative explanation would be previously not recognized gender differences in the severity of the studied skin disorders. The Psoriasis Area and Severity Index (PASI) is the most widely used tool to assess psoriasis disease severity in clinical trials, although it is generally considered too time-consuming for use in routine clinical practice. Simple clinical tools to facilitate consistent evaluation of disease severity at the beginning and end of each treatment could reveal possible gender differences. In summary, we have shown substantial differences in the treatment costs for women and men with common dermatologic diagnoses in Sweden. A working group has been appointed to analyze treatment statistics at all the dermatology clinics/departments in Stockholm. 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