Early PsA Screening for Patients With Psoriasis Could Save Millions, Hampered by Lack of Clinical Data
Psoriatic arthritis is often a painful comorbidity for patients with psoriasis — and an expensive one at that. A 2016 study published in Actas Dermo-Sifiliográficas found the disease comes with a price tag to the tune of US$15,000 per patient in Europe. However, that price is also based on biologic drug use that can be as much as 80% cheaper than those in the United States or Canada.
Across the pond, PsA treatment in Canada faces many of the same challenges as it does in the U.S., with progression of the disease eventually requiring pricey biologics. However, a group of researchers found that a relatively simple addition to doctors’ visits for patients with psoriasis could offer both major cost savings and improved quality of life for patients: PsA screening via questionnaire.
What health care providers and advocates in the political sphere need to bolster support for screening is difficult to obtain: proof of effectiveness. Because Canada does not currently have a screening system in place, researchers cannot produce hard data on screening — that is where Nicolas Iragorri, MSc, of the University of Calgary, and colleagues come in.
In their study published in Arthritis Care & Research, Iragorri and colleagues found that, if early therapy with DMARDs can slow disease progression and delay expensive biologic treatment, early screening for psoriatic arthritis among patients with psoriasis could save $220 million each year in Canada and improve quality of life.
Healio Rheumatology spoke with Iragorri about the benefits of screening and the next steps for making it a reality, both in Canada and beyond.
Q: What screening tools for PsA are currently utilized in Canada?
Iragorri: Canada does not have a validated screening program in place for psoriatic arthritis. Mostly dermatologists use questionnaires, just basic questionnaires, such as the ones that we evaluated: the [Psoriatic Arthritis Screening and Evaluation]; the [Early Psoriatic Arthritis Screening Questionnaire]; the [Toronto Psoriatic Arthritis Screening Tool] and the [Psoriasis Epidemiology Screening Tool]. Then, based on the results, they move on to diagnostic testing.
Q: Without PsA screening, at what point are patients usually diagnosed with PsA?
Iragorri: Most patients are identified by dermatologists and then referred to a rheumatologist when there are already symptoms — namely joint pain and swelling. We actually partnered with a couple of rheumatologists at the University of Calgary who explained how this process was done. Since PsA is very similar to other rheumatological diseases, it is hard to home in on the diagnosis. Patients are sent to the rheumatology office when the symptoms are already there, so it is not the head start that screening could provide. That is where our study came in.
Q: In Canada, what drug treatments are offered to PsA patients at the start of treatment?
Iragorri: Depending on the line of therapy and how far into their disease they are diagnosed, patients are usually recommended to start with milder and cheaper treatment, such as conventional DMARDs — methotrexate, for instance, is a therapy that is common among PsA patients at the beginning of the disease.
Once the disease progresses — we know the disease progresses inevitably into chronic disease — rheumatologists start using biologics. There are several different biologics that are approved by the different Canadian health care systems. In Canada, we have 13 different health care systems: one per province. Based on whether patients are responding to the treatment or not, they might switch to another treatment or use two at the same time.
Q: In your study, how effective was screening compared with the standard no screening protocol?
Iragorri: It depends on how you measure effectiveness. If we are talking about clinical effectiveness, screening is not going to prevent disease. If you have the disease, you will be picked up by screening; however, screening will not be effective at delaying the disease. It has to be followed up with effective treatment. We are assuming that the treatment that follows early diagnosis is expected to delay the disease progression.
All patients with PsA, no matter where they are in the disease continuum, are going to progress; some at a faster pace, some at a slower pace. What we are saying is that screening enables early therapeutic occurrence and could delay disease progression, perhaps delay that point at which patients require more expensive treatment like the biologics. That is where the effectiveness comes in, and if you want to talk about cost-effectiveness, the next point of the model is how does that affect cost and everything else?
Q: Speaking of cost-effectiveness, can you explain how that aspect of the study was conducted? How did you determine the potential cost savings?
Iragorri: Health economists measure effectiveness in terms of quality of life years (QALY): We consider expected lifetime for a patient and we consider the quality of the life for each patient, so it’s a two-dimensional measure. We compare different alternatives. We have the status quo, or the current practice, and we compared it to different screening scenarios and we estimated the cost to obtain an additional QALY of 5 years to each scenario. And that that yields the lowest would represent a cost-effective option.
To translate that into noneconomic jargon: By implementing a screening program, we are expected to delay that moment in which biologics are needed. We are expecting patients to use biologics in their lifetime. We are not expecting to cure the disease. We know it’s a chronic disease and screening will not prevent it. But we know that by using the screening we are reducing the need to employ more expensive drugs. It’s not only cost effective, but we estimated that screening would, in the long run, yield cost savings.
Implementing a screening program has up front costs — you have to train people, you have to deliver the questionnaire in every dermatology clinic — but then, when you see that patients are actually getting better, that is when the cost savings will come into play. It does not mean that right off the bat you are going to get people better and you are going to save money, but that is not usually the case for any screening program.
Q: What do you see as the next steps to implement this?
Iragorri: The next step is to strengthen this evidence. Once we have actual clinical data backing the model, we can be more certain about what we are saying in terms of cost reduction, in terms of quality of life improvements. Researchers in the U.K. have already started a clinical trial that seeks to evaluate how early screening might be effective and cost-effective for psoriasis patients. Once they are done with the study, we will be able to use the data that they extracted to address some of the uncertainty, mostly around how effective we expect screening to be.
We are convinced that screening would yield cost savings eventually and increase quality of life but clinical data backing it up will make it better. We tried to turn over every rock to get the best quality data, which I’m confident we did, so I’m excited that people are talking about it and hopefully this leads to action — in the U.S., in Canada and the U.K.
Q: What is the take-home message for rheumatologists and dermatologists?
Iragorri: The conclusions are very clear: We need to start screening psoriasis patients for psoriatic arthritis. In most of the different guidelines for clinicians, it is recommended but not being done at a health care system level.
Dermatologists are in a very privileged position to spearhead this initiative as they can systematically identify patients with the telltale psoriasis symptoms, and it costs almost nothing. If patients are going to a dermatologist or even to primary care provider, it’s easier for them to be referred to rheumatology based on whether the screening tools determine it is necessary.
We are not only talking about improving quality of life but also reducing the cost on the health care system, so we need to work in tandem with primary care, with dermatology, with rheumatology, to achieve what you would think is a very intuitive process, to make screening work in a systematic way.
In Canada, we have many accessibility issues. It is harder to see a specialist, so we put in place triage measures that adequately help patients navigate a specialist based on need and risk that would free up resources and improve quality of life overall, which is true for any area in health care. – by Amanda Alexander
Iragorri N, et al. Arthritis Care Res. 2019;doi:10.1002/acr.24110.
For more information:
Nicolas Iragorri can be reached at Teaching, Research and Wellness Building, 3280 Hospital Drive NW, Calgary, Alberta T2N 4Z6; email: email@example.com.
Disclosure: Iragorri reports funding from the National Institute for Health Research.