Treatment patterns and outcomes among adults admitted to hospital in the U.K. due to plaque or erythrodermic psoriasis

DEAR EDITOR, The National Institute for Health and Care Excellence (NICE) identified treatment of moderate-to-severe psoriasis as an area for research. No recent studies have assessed treatment patterns and outcomes among patients hospitalized for psoriasis in the U.K. This study evaluated clinicianand patient-reported outcomes, treatment patterns and hospital length of stay (LOS) in patients admitted to hospital for plaque or erythrodermic psoriasis, and enrolled 61 eligible patients across nine U.K. hospital sites from 15 November 2013 to 2 June 2014. Inclusion criteria included the following: ≥ 18 years; willing and able to provide written informed consent; able to read, understand and complete questionnaires; admitted as an inpatient with plaque or erythrodermic psoriasis. Patients were ineligible if they had participated in an investigational drug trial in the previous 6 months; or had a serious/unstable medical or psychological condition that would compromise participation. Study site personnel recorded eligibility criteria; patient clinical characteristics; clinician-reported outcomes, including Psoriasis Area and Severity Index (PASI), Body Surface Area (BSA) affected by psoriasis, and Physician’s Global Assessment (PGA; 5-point scale) at admission and discharge; psoriasis treatments; and LOS. Patients reported psoriasis-related symptoms; health status [12-Item Short Form Health Survey, v2 (SF-12v2); EuroQoL 5-Dimensions, 3-Levels (EQ-5D-3L)]; mood (Hospital Anxiety and Depression Scale, HADS), productivity (Work Productivity and Activity Impairment, WPAI) and dermatology-related quality-of-life index (Dermatology Life Quality Index, DLQI) at admission, and at discharge, employment status, psoriasis-related symptoms, EQ-5D-3L and DLQI. Study materials were approved by the National Research Ethics Service Committee London-Stanmore (London, U.K.). Descriptive statistics are reported among those responding to each item. Changes in continuous scores/outcomes from admission to discharge are assessed with a paired t-test and summarized for patients with both admission and discharge measures. Multivariate linear regression with the stepwise selection procedure was conducted to ascertain predictors of LOS with candidate predictors (age, sex, PASI score at admission, comorbidities present in ≥ 20% of the sample, duration of psoriasis, and previous hospitalization). Statistical analyses were performed using SAS version 9.3 (SAS Institute Inc., Cary, NC, U.S.A.). The mean age was 45 5 years; 50 8% were male. Mean time since psoriasis diagnosis was 20 0 years. Most (78 7%) had ≥ one previous psoriasis-related hospitalization. The mean number of clinician-diagnosed comorbid conditions was 2 5, with psoriatic arthritis (34 4%), depression (24 6%) and arterial hypertension (21 3%) the most commonly reported. At admission, mean scores indicated substantial impairment in health status, mood and productivity (SF-12v2 physical and mental component summary: 35 4 and 32 1, respectively; HADS: 9 7 anxiety, 9 6 depression; WPAI: 68 7% activity impairment, 79 2% work impairment; see Table 1). Mean PASI improved from admission to discharge (25 2– 12 1), as did EQ-5D-3L (0 34–0 60), total DLQI (20 1–12 0), and psoriasis symptom scores (see Table S1; see Supporting Information). For 35 patients with PASI scores at both admission and discharge, 18 (51 4%) achieved a 50% reduction in PASI (PASI50), and eight (22 9%) achieved a 75% reduction in PASI (PASI75); 16 (45 7%) had a PASI > 10 at discharge. For 47 patients with a DLQI score at both time points, 28 (59 6%) achieved a ≥ 5-point DLQI improvement from admission to discharge. Prior to, during and post-hospitalization, topicals were the most frequently used, followed by systemic therapy, phototherapy and biologics (Table 1 and Table S1; see Supporting Information). The mean (range) LOS was 17 0 (2–71) days. For patients achieving PASI75, the mean LOS was 18 1 vs. 13 1 days for those not achieving PASI75. Multivariate regression analyses (coefficient estimate, P-value) suggest that higher PASI at admission (0 27, < 0 01), arterial hypertension (7 64, 0 03), and time (months) since diagnosis (0 02, 0 05) contributed to longer LOS. In recent years, there has been a decline in the number of overnight hospital stays for psoriasis. Treatments received are consistent with NICE and European clinical guidelines recommending phototherapy or systemic therapy in combination with topicals for moderate-to-severe psoriasis. Nevertheless, the proportion of patients prescribed biologics at discharge was lower than expected, because 68% reported a mean PASI or DLQI score > 10 at discharge after receiving intensive treatment in the inpatient setting. Our inpatient sample may reflect a more complex population with difficult-to-control psoriasis, who may be unresponsive or contraindicated to biologics. Study limitations include the modest sample size, which, based on enrolment logs, represented 57% of patients