aAaron M. Secrest, MD, PhD; bAli Matinrazm, MD, MPH; bLaura K. Ferris, MD, PhD
aDepartment of Dermatology, University of Utah, Salt Lake City, Utah; bDepartment of Dermatology, University of Pittsburgh, Pittsburgh, Pennsylvania
Disclosure: Dr. Ferris has served as an investigator for Janssen, Amgen, Abbott, Pfizer, Celegene, and LEO Pharmaceuticals. Drs. Secrest and Matinrazm report no relevant conflicts of interest.
Objective: To determine which factors (i.e., cost, efficacy, safety, and method of delivery) influence choice of psoriasis treatment by patients and how patients obtain information regarding treatment options. Design: Anonymous survey. Setting: Specialty Psoriasis Clinic at an academic dermatology department over a six-month period. Participants: Convenience sample of 40 psoriasis patients. Measurements: Participant demographics, psoriasis treatment history, sources of information about treatment options, factors influencing treatment choices, and knowledge of treatment costs. Results: The mean (±SD) patient age and duration of psoriasis was 50 (±17) and 19 (±17) years, respectively. Factors influencing patient’s choice of psoriasis treatment were, in order of importance: efficacy (90% very important), safety/side effects (65%), patient’s own cost (53%), then total treatment cost (46%), frequency of use (37%), and method of medication delivery (i.e., topical, oral, or injection; 17%). Eighty percent of patients reported not knowing the total cost of any psoriasis treatments. The patient’s dermatologist was identified as both the most important (90%) and the most influential (75%) source of information for selecting psoriasis treatments, with the internet being the second most important source. Conclusion: Patients, in large measure, are unaware of the costs for different psoriasis treatments. Efficacy, safety, and out-of-pocket costs are the most important factors to patients in deciding on a psoriasis treatment. (J Clin Aesthet Dermatol. 2014;7(12):30–33.)
Psoriasis is a chronic inflammatory disease with significant impact on quality of life. Biologic therapies, although expensive, may reduce disease burden., One study exploring factors influencing dermatologists’ psoriasis treatment decisions reported that side effect profile, then medication cost, were the most important treatment-specific factors influencing their choice of psoriasis therapies. However, there are little data on which factors influence treatment decisions from the patients’ perspective and how patients obtain information about medications to participate in the decision-making process. The authors developed a survey to explore these factors.
Return patients (age ?18 years) who were currently on at least one psoriasis medication seeking continued care at the authors’ specialty psoriasis clinic at an academic center between February 15, 2011, and August 15, 2011, were asked to complete an anonymous survey exploring participant demographics, psoriasis treatment history, sources of information about treatment options, factors influencing treatment choices, and knowledge of treatment costs. The survey was piloted on five patients with psoriasis for understandability prior to data collection. Forty-two of 43 surveys (98% response rate) were completed. Reasons for not participating were not obtained. Two surveys were excluded because key variables were missing, leaving 40 surveys for analysis. Analyses were performed using SPSS Statistics 19.0 (IBM, Somers, New York). The study was exempted from review by the University of Pittsburgh Institutional Review Board.
The mean (±SD) patient age was 50 years (±17 years) and duration of psoriasis was 19 years (±17 years) years, respectively. The cohort was mostly female (70%) and Caucasian (93%) patients. All patients had some form of healthcare coverage, including private insurance (70%), Medicaid (7%), Medicare (5%), or a combination (18%). Eighty-five percent paid copays for medications (monthly median [range] = $10 [3–324]); the remainder reported no copay.
When asked about factors influencing their choice of psoriasis treatment, patients rated, in order of importance, efficacy (90% very important), safety/side effects (65%), patient’s own cost (53%), then total treatment cost (46%), frequency of use (37%), and method of medication delivery (i.e., topical, oral, or injection; 17%) Figure 1. Eighty percent of patients did not know the total cost of any psoriasis treatments, although most were aware of their copay amount for treatments they had used Table 1. In general, patients tended to underestimate the cost of psoriasis treatments.
When asked about information sources used to help them choose among psoriasis treatments, patients relied heavily on their dermatologist for information (93%), but obtained information from many sources, including the internet (25%), primary care doctors (20%), family members (18%), print material (15%), pharmacists (13%), support groups (8%), advertisements (8%), and friends (3%). The patient’s dermatologist was identified as both the most important (90%) and the most influential (75%) source of information for selecting psoriasis treatments.
In this preliminary study, the authors found that psoriasis patients rate efficacy, followed by safety, as the most important factors in choosing treatments for their disease. Frequency and method of use were rated as less important factors in choosing a therapy, although other studies have shown that this can impact compliance with a therapy. Interestingly, patients in this study were largely unaware of the total cost of psoriasis treatments, and total cost was rated as less important than the direct cost to the patient. While patients prioritized their own out-of-pocket costs over the total cost, nearly half of surveyed patients did give total medication cost as an important factor in choosing a psoriasis therapy. However, because patients were more likely to accurately estimate the total cost of methotrexate, but to underestimate the cost of biologics, it is not clear if the magnitude of cost differential between therapies was fully grasped by most patients. Patients get their information from many sources, most of which do not clearly define cost. One limitation of this study is that the cost of medications is difficult to locate. The authors referenced the average wholesale pharmacy (AWP) price. This, however, does not take into account the complexity of medication pricing, manufacturer rebates, office visits, laboratory monitoring, and insurance versus wholesale drug costs. Downstream costs or savings are also difficult to quantify. More expensive biologics can, in some cases, afford a net cost savings by decreasing psoriasis-related hospitalizations. Given the importance of efficacy to patients and the common practice of direct-to-consumer marketing of more expensive therapies, patients play an increasing role in choosing their treatments with their dermatologists. These factors, as well as manufacturer rebates, laboratory monitoring (or the lack thereof), medication samples, wholesale drug discounts, and many others, have roles in the complexity of total medication costs and should be addressed with patients when appropriate. With a finite amount of healthcare dollars, and the availability of less expensive medicines that may be appropriate, medication costs, along with efficacy and safety, should be part of the discussion of therapy options with the patient.
Dr. Secrest was supported by a training grant from the National Institute of Diabetes and Digestive and Kidney Diseases (F30-DK082137).
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