Translating psoriasis guidelines into practice: Important gaps revealed

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1 Translating psoriasis guidelines into practice: Important gaps revealed Reva Bhushan, MA, PhD, a Mark G. Lebwohl, MD, b Alice B. Gottlieb, MD, PhD, c Kevin Boyer, MPH, a Elaine Hamarstrom, PhD, a Neil J. Korman, MD, PhD, d Robert S. Kirsner, MD, PhD, e Arthur J. Sober, MD, f and Alan Menter, MD g Schaumburg, Illinois; New York, New York; Boston, Massachusetts; Cleveland, Ohio; Miami, Florida; and Dallas, Texas Background: There is a well-established lack of adherence to evidence-based clinical guidelines. The American Academy of Dermatology (AAD) developed educational sessions entitled Translating Evidence into Practice based on the published guidelines for psoriasis and psoriatic arthritis. Objective: We sought to determine the effectiveness of Translating Evidence into Practice sessions in improving patient care. Methods: Pre- and post-session surveys were administered at Translating Evidence into Practice sessions. A follow-up was administered 6 months after completion of the most recent session, which was 2.5 years after the first session. Results: At both post-session and follow-up, more than 92% of participants believed the sessions had improved their knowledge. The proportion of participants that self-reported assessing disease severity, comorbidities, and quality of life increased at follow-up. Participants self-reported counseling of patients and confidence in treating psoriasis and psoriatic arthritis also increased at post-session and follow-up. Greater than 97% of participants thought the sessions would have a positive impact on their practice whereas 50% reported making a change in practice. Limitations: Lack of a control group, the self-reported nature of the data, and potential participant bias are limitations. Conclusion: The AAD s Translating Evidence into Practice sessions are effective and well received for improving knowledge and practice and can be useful to determine self-reported practice gaps. ( J Am Acad Dermatol 2016;74: ) Key words: assessment of severity; cardiovascular disease; guidelines; metabolic syndrome; practice gaps; psoriasis; psoriatic arthritis; quality of life. From the American Academy of Dermatology, Schaumburg a ; Mount Sinai Hospital, New York b ; Tufts Medical Center, Boston c ; University Hospitals Case Medical Center, Cleveland d ; University of Miami e ; Harvard Medical School, Boston f ; and Baylor University Medical Center, Dallas. g Funding sources: None. Disclosure: Dr Lebwohl is an employee of the Mount Sinai Medical Center, which receives research funds from AbGenomics, Abb- Vie, Amgen, Anacor, Aqua, Canfite Biopharma, Celgene, Clinuvel, Coronado Biosciences, Ferndale, Eli Lilly and Company, Janssen Biotech, LEO Pharmaceuticals, Merz, Novartis, Pfizer, Sandoz, Sun Pharmaceuticals, and Valeant. Dr Gottlieb maintains current consulting/advisory board agreements with Amgen Inc, Astellas, Akros, Centocor (Janssen), Celgene Corp, Bristol Meyers Squibb Co, Beiersdorf Inc, Abbott Labs (Abbvie), TEVA, Actelion, UCB, Novo Nordish, Novartis, Dermipsor Ltd, Incyte, Pfizer, Canfite, Eli Lilly and Company, Coronado, Vertex, Karyopharm, CSL Behring Biotherapies for Life, Glaxo Smith Kline, Xenoport, Catabasis, Mriji Seika Pharma Co Ltd, Takeda, Mitsubishi, and Tanabe Pharma Development America Inc, Genentech. Dr Korman has served on advisory boards or as a speaker for Abbvie, Amgen, Celgene Corporation, Eli Lilly and Company, Janssen Pharmaceuticals Inc, Novartis Pharmaceuticals Corp, and Pfizer Inc. Dr Menter served as consultant or investigator for Abbott Laboratories, receiving honoraria; served on advisory boards or as a speaker for Abbott Laboratories, AbbVie, Amgen, Astellas Pharma US Inc, Centocor Ortho Biotech Inc, Galderma Laboratories LP, Pfizer Inc, and Warner Chilcott, receiving honoraria or fees; and had or has pending grants from Amgen, Celgene Corporation, Centocor Ortho Biotech Inc, and Pfizer Inc. Drs Bhushan, Hamarstrom, Kirsner, and Sober, and Mr Boyer have no conflicts of interest to declare. Accepted for publication November 25, Reprint requests: Reva Bhushan, MA, PhD, American Academy of Dermatology, 930 E Woodfield Rd, Schaumburg, IL rbhushan@aad.org. Published online January 14, /$36.00 Ó 2015 by the American Academy of Dermatology, Inc. Reprinted from J Am Acad Dermatol. 2016;74: R85

2 R86 reprinted from J Am Acad Dermatol Psoriasis vulgaris is a chronic inflammatory disease characterized by erythematous plaques that affects 7.5 million Americans. 1-4 Psoriatic arthritis (PsA) is an inflammatory spondyloarthropathy that develops in 7% to 42% of patients with psoriasis, with 15.5% of patients remaining without a diagnosis. 1,5-7 Both psoriasis and PsA negatively impact patients quality of life (QOL) leaving patients dissatisfied with their treatment. 5,8-12 A German study found that the publication of psoriasis guidelines led to changes in psoriasis treatment decisions by 80% of participating dermatologists. 13 Within 3 years, the quality of care of patients with psoriasis improved. 14 Two additional German studies examining adherence to psoriasis guidelines identified practice gaps regarding the use of or adherence to CAPSULE SUMMARY the guideline in clinical practice. 15,16 Interestingly, one of these studies found that dermatologists who were knowledgeable of the guidelines were more likely to adhere to them. 16 Similar to the findings in Germany, gaps in knowledge and guideline adherence among US dermatologists and dermatologic surgeons have been shown, albeit for conditions other than psoriasis These studies also found that knowledge of the guidelines correlated with adherence The American Academy of Dermatology (AAD) published guidelines for the management of psoriasis and PsA. 2,5,21-24 Upon completion of the guidelines, the AAD began offering Translating Evidence into Practice sessions to attendees of the annual meeting and summer academy meeting as a means to learn about the guidelines. These sessions featured presentations on guideline topics, and the participants were given reference materials based on the guideline recommendations. Our primary objective was to determine if Translating Evidence into Practice sessions were effective at enabling dermatologists to improve patient care. METHODS Translating Evidence into Practice sessions and reference materials Sessions were offered as ticketed events for which attendees could register for a nominal fee. Learning objectives were to: (1) develop skills to treat patients d d d Lack of adherence to clinical guidelines is an issue across medical specialties and has been previously documented for psoriasis. Live educational sessions based on published guidelines can positively impact dermatologists knowledge and self-reported practice patterns. Participation in these sessions facilitates implementation of these guidelines into daily practice. with psoriasis and PsA with an emphasis on decisionmaking criteria that will enable the clinician to individualize therapy based on disease type, extent, response to previous treatments, QOL issues, and comorbidities; (2) recognize and diagnose challenging clinical cases and formulate appropriate evidence-based treatment of patients using the recently published 6 AAD evidence-based guidelines of care for psoriasis, which includes best practices; and (3) address gaps in clinical knowledge and care. Presentation topics were based on the published guidelines and were selected based on the expertise of the psoriasis guideline expert workgroup faculty. Session attendees received reference materials, which consisted of 4 laminated pocket cards, 4 quick reference booklets, a pocket recommendation booklet, and a full set of published guidelines. Participants Attendees of the Translating Evidence into Practice sessions were asked to participate in the study. Those who elected to complete paper forms or who participated using an audience response system were included as study participants. Data collection All pre- and post-session data were collected anonymously via paper forms or audience response system. Unless otherwise indicated, nonresponders were not included in calculations. A follow-up was administered to registered attendees during the fall of 2013 (6 months to 2.5 years after the sessions). Session attendees were notified of the opportunity to participate via and were provided with 2 reminders. All follow-up data were collected anonymously. Statistical analysis Analyses of aggregate data were performed using x 2 tests. RESULTS Demographics and guideline exposure There were 370 participants from 5 sessions, 66 of whom participated in the follow-up resulting in an overall response rate of 18%. Follow-up responses

3 reprinted from J Am Acad Dermatol R87 Abbreviations used: AAD: American Academy of Dermatology PsA: psoriatic arthritis QOL: quality of life were paired to pre- or post-session responses in aggregate according to session, resulting in response rates of 19% to 24% for individual questions. The majority of participants were board-certified dermatologists from the United States who had been in practice for 7 years or longer (Table I). When asked to what extent they read the guidelines before the session, 40.1% reported that they did not read the guidelines and 30.4% only read select sections/ tables/figures (Table I). Practice patterns At pre-session, more than 62% of participants reported using mild/moderate/severe or body surface area, and less than 30% of participants self-reported using Psoriasis Area and Severity Index, physician global assessment, or another severity scale in their practice. There was an increase in the use of each severity scale polled at follow-up (Table II). Assessment of patients for PsA, cardiovascular disease, and metabolic syndrome was reported by 31.2%, 22.0%, and 26.6% of participants, respectively, at pre-session. The self-reported assessment of cardiovascular disease and metabolic syndrome were increased at follow-up (Table II). Of the 65.1% of participants who reported that they assess the QOL of their patients at pre-session, 87.3% reported using patient history to do so whereas much smaller proportions of participants reported using other QOL assessment tools. At follow-up, an increase in assessing QOL was observed along with increases in the use of 3 QOL assessment tools (Table II). Knowledge, counseling, and confidence assessments On average, 52.8% of participants answered clinical case-based questions correctly at presession. This improved to an average of 74.1% correct at post-session (data not shown). When individual questions were analyzed, 54.8% of questions (23 of 42) showed significant improvement (P \.05) from pre-session to post-session as determined by McNemar test (data not shown). At pre-session, 58% to 75% of participants reported currently counseling their patients on smoking cessation, decreased alcohol intake, Table I. Participant demographics Characteristics Pre-session, % (n) Professional status Board-certified dermatologist 65.4 (242) Fellow 9.5 (35) Resident 4.3 (16) NP/PA 5.4 (20) Other (eg, pharmacist) 15.1 (56) No response 0.3 (1) Years in practice (58) (37) (34) $ (224) No response 4.6 (17) Location United States 72.7 (178) International 23.7 (58) No response 3.7 (9) Setting Solo practice 23.0 (85) Dermatology group practice 27.3 (101) Multispecialty group practice 9.7 (36) Academic 19.5 (72) Department of Veterans Affairs 1.4 (5) Military 2.7 (10) Do not see patients 4.6 (17) Other (eg, hospital, industry) 6.5 (24) No response 5.4 (20) Familiarity with guideline Read completely 9.7 (34) Read select sections/tables/figures 30.4 (107) Browsed 19.9 (70) Did not read 40.1 (141) Data for these measures are shown as percent of total responders for each question with the n value representing the number of times an individual response option was selected. NP, Nurse practitioner; PA, physician assistant. changes to diet, and exercise. At post-session, when asked if they were more likely to counsel patients as a result of attending the session, over 87% agreed for each topic. When asked what counseling was routinely performed at the time of follow-up, every topic remained increased compared with pre-session self-reporting, but had decreased compared with post-session intentions (Fig 1). The majority of participants (86.7%) reported confidence in treating psoriasis at pre-session. At post-session, this improved to 89.7% of participants, and further improved to 93.8% at follow-up (Fig 2, A). Similarly, 40.7% of participants were confident in treating PsA at pre-session, which improved to 68.5% at post-session. In contrast to confidence in treating psoriasis, the confidence in treating PsA decreased slightly to 66.7% at follow-up (Fig 2, B).

4 R88 reprinted from J Am Acad Dermatol Fig 1. Percentage of participants who self-report counseling patients, intent to counsel, and revised counseling practice on guideline recommended topics. Data are shown as average percentage of responses from all sessions except AM 2011 with pre-session participant, postsession participant, and respondent N values of 230, 203, and 46, respectively. Statistics shown as P \.01 or P \.001 compared with pre-session. Evaluation At post-session, 97.8% of participants stated that participating in the session improved their knowledge regarding safety and efficacy of available treatments, and 97.2% stated the session would have a positive impact on their practice (Table III). In addition, 92.9% of participants believed that the guidelines could be easily translated into daily clinical practice, and 80.7% indicated that they would definitely recommend the session to their colleagues (Table III). At follow-up, 92.4% of respondents still thought that the session had increased their knowledge, 50% reported making a change in their practice, and 84.2% indicated that the reference materials were useful (Table III). DISCUSSION These data demonstrate that not all dermatologists assess severity and QOL in patients with psoriasis even though both are known to impact patients and treatment decisions. 2,5,8-10,21-24 In addition, many comorbidities are known to be associated with psoriasis and can impact management plans, 2,24-41 yet these data indicate that not all dermatologists assess or counsel their patients with psoriasis about comorbidities or lifestyle changes, which reaffirms and expands upon findings from recent independent surveys. 42,43 In addition to these data, our previously published findings from a performance improvement module where participants audited patient charts indicated deficiencies in documentation of counseling patients in the areas of PsA, alcoholism, cardiovascular disease, metabolic syndrome, and smoking cessation. 44 All together, these studies encourage dermatologists to perform and document a thorough patient history, including assessment of comorbidities and lifestyle choices, for patients suspected to have psoriasis to reduce the burden of psoriasis and PsA. This study differs from the German psoriasis guideline studies discussed above in that there is no measurement before guideline publication and that a formal educational intervention was used The changes in practice and remaining practice gaps reported here support the conclusions of the German studies; however, a follow-up study combining the 2 methodologies to determine impact of publishing a guideline followed by the impact of education based on the same guideline is warranted. Barriers to implementation of guidelines have been previously identified and include patientcentric barriers (eg, risk of complications, refusal of treatment, inconvenience), organizational barriers (eg, cost, not valued), and guideline-specific barriers (eg, lack of knowledge, disagreement with guidelines from other specialties, oversimplification of practice, lack of access, overly complicated/ unclear). 15,16,45,46 The Translating Evidence into Practice session presentations aimed to address lack of knowledge whereas the reference materials aimed to address access and clarity concerns. Most respondents reported feeling more knowledgeable and found the reference materials to be useful; thus, we recommend guideline-based sessions and the

5 reprinted from J Am Acad Dermatol R89 Fig 2. Participant confidence in treating psoriasis and psoriatic arthritis. Participants were asked to rate their confidence in treating psoriasis (A) and psoriatic arthritis (B). Data are shown as the percentage of responses from the AM 2013 session with pre-session participant, postsession participant, and respondent N values of 64, 41, and 15, respectively. creation and distribution of similar materials for all published guidelines. We recognize that a number of factors go into treatment decisions, and that not all factors may be included in clinical guidelines ; however, we believe this study shows that educational sessions and reference materials can improve the quality of patient care where the use of guideline recommendations are deemed appropriate by expert physicians. Physician discretion may account for some of the persistent practice gaps that are observed at follow-up. Future studies should confirm these conclusions by examining the correlation between reported and documented performance improvements and improvements in patient outcome measures after a similar intervention. In addition, it would be interesting to determine if patient treatment satisfaction increases if patients and caregivers are made aware that they are being treated according to clinical guidelines. Limitations of this study include lack of a control group throughout the study. An additional limitation is the self-reported nature of the data as physicians have been shown to be poor at self-assessing

6 R90 reprinted from J Am Acad Dermatol Table II. Participant practice patterns Measure and response options Pre-session, % (n) $6 mo Follow-up, % (n) Use of severity assessment scales* Mild/moderate/severe 69.7 (76) NA BSA 62.4 (68) 73.1 (19) PASI 27.5 (30) 38.5 (10) PGA 10.1 (11) 23.1 (6) Other 2.8 (3) 7.7 (0) Assessment of comorbidities* Psoriatic arthritis 31.2 (34) 26.9 (7) Cardiovascular disease 22.0 (24) 42.3 (11) Metabolic syndrome 26.6 (29) 34.6 (9) Do not assess 1.8 (2) 11.5 (3) Assessment of QOL 65.1 (71) 73.1 (19) Use of QOL assessment tools* Patient history 87.3 (62) 57.7 (15) SF (3) 7.7 (2) DLQI 21.1 (15) 19.2 (5) Skindex 2.8 (2) 3.8 (1) Psoriasis QOL 21.1 (15) 11.5 (3) Salford Index 0.0 (0) 0.0 (0) Koo-Menter 4.2 (3) 7.7 (2) Other 1.4 (1) 0.0 (0) Data are from 2012 summer academy meeting and 2013 annual meeting sessions with participant and respondent N values of 109 and 26, respectively. BSA, Body surface area; DLQI, Dermatology Life Quality Index; NA, Not asked; PASI, Psoriasis Area and Severity Index; PGA, Physician Global Assessment; QOL, Quality of life; SF, Short Form. *Participants were asked to check all response options that applied. Data for these measures are shown as percent of total responders for each question with the n value representing the number of times an individual response option was selected. performance. 48 This is exemplified by the disagreement between the improvement in self-reported counseling rates on smoking cessation observed here and our previous chart abstraction data showing continued deficiencies in this area after participation in an online module. 44 Finally, participant bias is a potential limitation as session attendance was at the attendees expense, not all attendees participated in the study, and not all participants answered every question. Further bias could result from not all questions being asked at every session, and only 18% of participants completing the follow-up survey. We have provided N and n values (see legends for Figs 1 and 2 as well as data in Tables II and III) and indicated the sessions in which questions were asked for transparency of the data presented here. In conclusion, this study showed that case-based clinical guidelines sessions can effectively improve dermatologist s knowledge and confidence in treating psoriasis and PsA. The sessions can also influence change in clinical practice. In addition, the Table III. Evaluation of Translating Evidence into Practice session and reference materials Measure and response options Post-session, % (n) $6 mo Follow-up, % (n) Increase in knowledge of treatments Significant 48.3 (157) 42.4 (28) Somewhat 49.5 (161) 50.0 (33) Same 2.2 (7) 7.6 (5) Impact on practice NA Very positive 67.7 (220) Somewhat positive 29.5 (96) No impact 2.7 (9) Change in topical prescribing NA behavior Yes, dramatic shift 1.6 (1) Yes, somewhat 48.4 (30) No, not at all 50.0 (31) Ease of using guideline NA in daily practice Very easy 34.3 (111) Somewhat easy 58.6 (191) Undecided 4.6 (15) Difficult 2.5 (8) Very difficult 0.0 (0) Would recommend session NA to colleagues Definitely 80.7 (262) Might 18.4 (60) Undecided 0.7 (2) Probably not 0.2 (1) Definitely not 0.0 (0) Usefulness of reference NA materials Very useful 30.2 (19) Useful 54.0 (34) No opinion/neutral 15.9 (10) Not very useful 0.0 (0) Not useful at all 0.0 (0) Data are from all sessions with participant and respondent N values of 325 and 62-66, respectively. NA, Not asked. study identified significant practice gaps among study participants. Assessing comorbidities including PsA will help in reducing practice gaps, effectively improving patient clinical outcome and reducing significant health care cost. We would like to thank Jim Kostecki and Terri Zylo for assistance with surveys. We are grateful to the faculty for making the sessions a success. We would also like to thank the session attendees who participated in the study. REFERENCES 1. National Psoriasis Foundation. Statistics Available from: URL: statistics. Accessed June 16, 2015.

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