Vaccination recommendations for adults receiving biologics and oral therapies for psoriasis and psoriatic arthritis: Delphi consensus from the medical board of the National Psoriasis Foundation.

BACKGROUND: For psoriatic patients who need to receive nonlive or live vaccines, evidence-based recommendations are needed regarding whether to pause or continue systemic therapies for psoriasis and/or psoriatic arthritis. OBJECTIVE: To evaluate literature regarding vaccine efficacy and safety and to generate consensus-based recommendations for adults receiving systemic therapies for psoriasis and/or psoriatic arthritis receiving nonlive or live vaccines. METHODS: Using a modified Delphi process, 22 consensus statements were developed by the National Psoriasis Foundation Medical Board and COVID-19 Task Force, and infectious disease experts. RESULTS: Key recommendations include continuing most oral and biologic therapies without modification for patients receiving nonlive vaccines; consider interruption of methotrexate for nonlive vaccines. For patients receiving live vaccines, discontinue most oral and biologic medications before and after administration of live vaccine. Specific recommendations include discontinuing most biologic therapies, except for abatacept, for 2-3 half-lives before live vaccine administration and deferring next dose 2-4 weeks after live vaccination. LIMITATIONS: Studies regarding infection rates after vaccination are lacking. CONCLUSION: Interruption of antipsoriatic oral and biologic therapies is generally not necessary for patients receiving nonlive vaccines. Temporary interruption of oral and biologic therapies before and after administration of live vaccines is recommended in most cases.

Administrative Burden and Costs of Prior Authorizations in a Dermatology Department.

Importance: Insurance companies use prior authorizations (PAs) to address inappropriate prescribing or unnecessary variations in care, most often for expensive medications. Prior authorizations negatively affect patient care and add costs and administrative burden to dermatology offices. Objective: To quantify the administrative burden and costs of dermatology PAs. Design, Setting, and Participants: The University of Utah Department of Dermatology employs 2 full-time and 8 part-time PA staff. In this cross-sectional study at a large academic department spanning 11 clinical locations, these staff itemized all PA-related encounters over a 30-day period in September 2016. Staff salary and benefits were publicly available. Data were analyzed between December 2018 and August 2019. Main Outcomes and Measures: Proportion of visits requiring PAs, median administrative time to finalize a PA (either approval or denial after appeal), and median cost per PA type. Results: In September 2016, 626 PAs were generated from 9512 patient encounters. Staff spent 169.7 hours directly handling PAs, costing a median of $6.72 per PA. Biologic PAs cost a median of $15.80 each and took as long as 31 business days to complete. The costliest PA equaled 106% of the associated visit's Medicare reimbursement rate. Approval rates were 99.6% for procedures, 78.9% for biologics, and 58.2% for other medications. After appeal, 5 of 23 (21.7%) previously denied PAs were subsequently approved. Conclusions and Relevance: Prior authorizations are costly to dermatology practices and their value appears limited for some requests. Fewer unnecessary PAs and appeals might increase practice efficiency and improve patient outcomes.

Evaluation of the Physician Global Assessment and Body Surface Area Composite Tool for Assessing Psoriasis Response to Apremilast Therapy: Results from ESTEEM 1 and ESTEEM 2.

BACKGROUND: The Physician Global Assessment and Body Surface Area (PGAxBSA) composite tool is a simple, effective alternative for measuring psoriasis severity. OBJECTIVE: To evaluate the product of PGAxBSA as a sensitive alternative to the Psoriasis Area and Severity Index (PASI) for assessing disease severity and therapeutic response with data collected from the phase 3 ESTEEM 1 and 2 trials. METHODS: This post hoc analysis included 836 patients randomized to apremilast 30 mg BID at baseline (ESTEEM 1, n=562; ESTEEM 2, n=274). Spearman correlation coefficients were used to compare PGAxBSA, PASI, and the Dermatology Life Quality Index (DLQI). Concordance between PGAxBSA and PASI was evaluated for 50%/75%/90% improvement from baseline at week 16. RESULTS: In ESTEEM 1 and 2, PGAxBSA and PASI exhibited significant positive correlations for measuring disease severity at baseline (r≥0.757) and week 16 (r≥0.807). At week 16, ≥79% concordance was observed between PGAxBSA and PASI for 75% and 90% improvement from baseline; greater concordance (>88.0%) was observed using 50% improvement from baseline. At week 16, PGAxBSA and PASI were moderately correlated with DLQI. LIMITATIONS: Analysis was limited to patients with baseline BSA ≥10% and static PGA ≥3. CONCLUSIONS: In patients with moderate to severe psoriasis, PGAxBSA is correlated with PASI and sensitive to therapeutic response.

J Drugs Dermatol. 2017;16(2):147-153.

Standardizing training for psoriasis measures: effectiveness of an online training video on Psoriasis Area and Severity Index assessment by physician and patient raters.

IMPORTANCE: Because the Psoriasis Area and Severity Index (PASI) is the most commonly used and validated disease severity measure for clinical trials, it is imperative to standardize training to ensure reliability in PASI scoring for accurate assessment of disease severity. OBJECTIVE: To evaluate whether an online PASI training video improves scoring accuracy among patients with psoriasis and physicians on first exposure to PASI. DESIGN: This equivalency study compared PASI assessment performed by patients and PASI-naive physicians with that of PASI-experienced physicians at baseline and after standardized video training. The study was conducted from March 15, 2011, to September 1, 2011. SETTING: Outpatient psoriasis clinic at University of California, Davis. PARTICIPANTS: Forty-two psoriasis patients and 14 PASI-naive physicians participated in the study. The scores from 12 dermatologists experienced in PASI evaluation were used as the criterion standard against which other scores were compared. MAIN OUTCOME MEASURES: Aggregate and component PASI scores from image sets corresponding to mild, moderate, and severe psoriasis. RESULTS: After viewing the training video, PASI-naive physicians produced equivalent scores for all components of PASI; patients provided equivalent scores for most PASI components, with the exception of area scores for moderate-to-severe psoriasis images. After the online video training, the PASI-naive physicians and patients exhibited improved accuracy in assigning total PASI scores for mild (Mean(experienced physician) - Mean(PASI-naive physician): 1.2; Mean(experienced physician) - Mean(patient): -2.1), moderate (Mean(experienced physician) - Mean(PASI-naive physician): 0; Mean(experienced physician) - Mean(patient): -5.7), and severe (Mean(experienced physician) - Mean(PASI-naive physician): -5.1; Mean(experienced physician) - Mean(patient): -10.4) psoriasis, respectively. CONCLUSIONS AND RELEVANCE: Use of an online PASI training video represents an effective tool in improving accuracy in PASI scoring by both health care professionals and patients. The video-based online platform for disseminating standardized training on the use of validated instruments in dermatology represents a novel form of standardized education.

Psoriatic arthritis screening tools.

Psoriatic arthritis (PsA) is an inflammatory arthritis associated with psoriasis, with an indolent and progressive course. A delay in diagnosis and treatment may lead to an erosive arthropathy, leading further to physical disability and deformity. To help clinicians screen for PsA, the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) has led an effort to develop and validate 3 PsA screening tools. Administration of a well designed screening tool can increase detection of PsA, help determine the prevalence of PsA in a given population, record clinical data for genotype-phenotype studies, and track response to therapy. The development and validation of these screening tools was a major focus at the GRAPPA annual meeting at Boston in September 2007; we summarize that portion of the meeting.