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Barriers to Accessing Dermatologists and Rheumatologists for Patients With Psoriasis and Psoriatic Arthritis: Impact and Solutions

April W. Armstrong, MD, MPH

Professor of Dermatology and Associate Dean
Department of Dermatology
Keck School of Medicine of USC
Associate Dean for Clinical Research
Department of Dermatology
Director
Clinical Research Support, Southern California Clinical and Translational Science Institute (SC CTSI)
Vice Chair
Director,
Clinical Trials and Outcomes Research
Director, Psoriasis Program
Los Angeles, California


April W. Armstrong, MD, MPH, has disclosed that she has received consulting fees from AbbVie, Aslan, Boehringer Ingelheim, Bristol-Myers Squibb, Dermavent, Dermira, EPI Health, Incyte, Janssen, Leo, Lilly, Novartis, Ortho, Parexel, Pfizer, Regeneron, Sanofi, Sun, and UCB and funds for research support from Bristol-Myers Squibb, Dermavent, Dermira, Lilly, Leo, Pfizer, and UCB.


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Philip Mease, MD, MACR

Clinical Professor
School of Medicine
University of Washington
Director
Rheumatology Research
Swedish Medical Center
Providence St Joseph Health
Seattle, Washington


Philip Mease, MD, MACR, has disclosed that he has received consulting fees from AbbVie, Amgen, Boehringer Ingelheim, Bristol-Myers Squibb, Galapagos, Gilead Sciences, GlaxoSmithKline, Janssen, Lilly, Novartis, Pfizer, Sun, and UCB; funds for research from AbbVie, Amgen, Bristol-Myers Squibb, Galapagos, Gilead Sciences, Janssen, Lilly, Novartis, Pfizer, Sun, and UCB; and fees for non-CME/CE services from AbbVie, Amgen, Janssen, Lilly, Novartis, Pfizer, and UCB.


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Released: August 20, 2021

In this expert commentary, based on the “Psoriasis/Psoriatic Arthritis Update: A Team-Based Approach to Elevated Care” program, dermatologist April W. Armstrong, MD, MPH, and rheumatologist Philip Mease, MD, MACR, discuss the problem of access to dermatologists and rheumatologists and associated issues for patients with psoriasis. Download the webinar slides to share with colleagues.

Defining the Problem

April W. Armstrong, MD, MPH:
For patients with psoriasis, there continues to be a problem with access to board-certified dermatologists. It can take anywhere from a few weeks to a few months, depending on the patients’ location and their insurance, to see the dermatologist. Therefore, nurse practitioners (NPs) and physician assistants (PAs) are important members of the care team for patients with psoriasis in many parts of the country. However, patients with Medicaid insurance in the United States especially have trouble accessing dermatologists or advanced practice providers.

One of the root problems of access is that many dermatology offices do not accept certain types of insurance. For example, I think that most patients with Medicaid are being seen at academic centers. Another aspect of the problem is that psoriasis management has become quite complex with the number of treatment options that we have. Although most dermatologists are conversant with certain aspects of the treatment, the sheer number of medications now available make it difficult for anyone to keep up. In addition, the office staff/administrative support required for obtaining access to some biologics can be a burden that many practices are not able to take on. These issues influence the dermatology practice and then academic centers will get referrals for some of those patients. Also, a lot of dermatologists practice in urban areas, so patients in rural or geographically remote areas often have a difficult time accessing dermatologists.

Philip Mease, MD, MACR:
I would say that close to 100% of rheumatologists are ready to roll up their sleeves and take care of appropriately referred patients, but there are several issues that create long waits and shortages. The urban vs nonurban distribution is also an issue in rheumatology. For example, in our clinic, a routine new patient wait is approximately 1 month, but we can get an urgent patient, such as a patient with severe vasculitis, lupus, polymyalgia rheumatica, or a gout attack, in almost immediately. This is because we have 2 NPs and 1 PA, which allows us the flexibility to accommodate a quick initial visit just for an injection into a flaring joint. I would say access is very good in urban Seattle, but if you go to eastern Washington state, the wait for a new patient to get into the clinic can be up to 1 year.

Projections show that in the next few decades, there will be an extreme shortage of rheumatologists. Therefore, rheumatologists will increasingly become focused and specialized in just the autoimmune inflammatory diseases and primary care physicians (PCPs) will take care of patients with primary fibromyalgia, primary osteoarthritis, or gout. However, PCPs are spread thin and have little time for their clinic visits. I think that a patient with complicated osteoarthritis or fibromyalgia requires a longer clinic visit, creating a gap for care of these patients. Rheumatologists in urban areas will continue to see patients with a condition like psoriatic arthritis.

Telehealth Visits

Philip Mease, MD, MACR:
Telehealth has increased our ability to access patients and for us to have a much broader reach. For us, the silver lining to the pandemic is that we’re more able to see people from nonurban areas and see them in a quick and efficient manner. We would see patients for telehealth visits—if needed, they would get their labs and/or imaging studies done at a local facility in their region—and in this way, we were able to accomplish a surprising amount with both return visit patients and new patients. For example, in a patient with an actively swollen metacarpal joint, we were able to see the swelling of joints. We were able to assess dactylitis by visual inspection. However, we were not able to do a full entheseal examination.

April W. Armstrong, MD, MPH:
Compared with rheumatology, it is easier to monitor patients for disease severity in dermatology. I think that telemedicine is actually best for more laboratory-based medical fields such as endocrinology. One limitation to telemedicine in dermatology is that we need very good resolution when looking at lesions or if we are trying to determine if a patient has a skin cancer. However, in terms of patients with psoriasis, I think telemedicine is actually a great tool to monitor patients in between office visits. As long as patients get a full skin check at their annual visit, you can actually get a very good idea of how their psoriasis is going in terms of looking at the images via telehealth visits. In the pandemic, I saw most of my patients with psoriasis through telemedicine and my patients liked it. As the pandemic is evolving, many of them want to stay on telemedicine so that they don’t have to travel so far to come and see me. However, I think periodic in-person visits are important, especially for our patients on systemic medications where you do need to have a full skin check to make sure that they don’t have any signs of cutaneous malignancy.

Although I do telehealth for both a new patient and follow-up patients, my preferred modality of seeing new patients is still in person and I find that telehealth works better in the follow-up setting.

Implications of Delayed Diagnosis or Treatment

April W. Armstrong, MD, MPH:
In terms of psoriasis disease progression while waiting to see a dermatologist, it is the patient’s mental health that is affected. Psoriasis, as with most skin diseases, is highly visible and so chronic mental health impact is present. Patients may not be able to engage in social activities that they would otherwise want to be a part of.

Cumulative life course impairment includes the concept that if the patient is not treated over a period of time, the social stigma and the psychological and social burdens all increase over time to a degree that the patient can no longer cope with it. This is relevant here as one may think that as soon as the patient has been treated, the lesions could go away, and in general, psoriasis doesn’t typically scar. But there is a cumulative life course impairment paradigm because patients are accumulating the mental health burden of having missed career opportunities or opportunities in their social development and social circles that cannot be recovered—the patient’s life course is probably altered because of lack of treatment for psoriasis.

Philip Mease, MD, MACR:
Patients with psoriatic arthritis who can’t see a rheumatologist for a year will deteriorate. Studies have shown that a delay of 6 months between symptom onset to the first rheumatologist visit affects the development of peripheral joint erosions and long-term physical function. Both studies show that catching the disease earlier and effectively treating it when it was still more malleable was more likely to achieve low disease activity or remission, and this is a highly important goal. Once you’ve got a damaged joint, there is no going back.

Patients with psoriatic arthritis are likely to have some degree of depression in relation to their disease process. We know from pain neurophysiology studies that the longer a painful condition is allowed to proceed in the body, in certain individuals, changes in the genetics of neurotransmitter production in the central nervous system can occur and result in some degree of central sensitization.

Potential Solutions: Building Good Relationships

Philip Mease, MD, MACR:
The referring physician needs to build good relationships with the rheumatologists and the dermatologists in their community, but what are the opportunities for meeting? There might be certain situations where the rheumatologists and dermatologists are in the same building or they are in an academic center where there is an established rheumatology/dermatology clinic, which allows knowledge of each other, friendship, and close collegial relationships. However, the bulk of clinical care is in the more siloed private practice community. In this case, it is important to actively reach out by making contact when you hear about a dermatologist in the community who is interested in medical dermatology and interested in seeing patients with psoriasis. With each call, and also with our clinical notes that go back and forth, we can teach one another. For example, when a rheumatologist sees a patient who has been referred by a dermatologist (or vice versa), our detailed clinical notes are sent back to the dermatologist. In this way, we get a feeling for each other and we develop friendships.

The Use of PAs and NPs

April W. Armstrong, MD, MPH:
Often, because of the delay in seeing dermatologists, with good training and supervision, the NPs and PAs have a critical role in caring for our patients with psoriasis.

Philip Mease, MD, MACR:
I think that rheumatologists have found the use of NPs and PAs to be a plus. How they are utilized varies from practice to practice. In my clinic, each new patient is first seen for 30 minutes by the NP or PA, who then presents the case to me, like a fellow would in an academic setting. Then, I spend 10-30 minutes with the patient, depending on the complexity of the case. The NP is responsible for recording the visit in the electronic record, tracks labs, and so forth. Their help allows me to see more patients and keep up with the demand without very long waits.

Rheumatology/dermatology Clinics

April W. Armstrong, MD, MPH:
At USC, patients with psoriasis and psoriatic arthritis are seen at our rheumatology/dermatology clinic, but the clinic also includes a number of other diseases that could benefit from rheumatology/dermatology collaboration such as patients with subacute cutaneous lupus erythematosus progressing to systemic lupus erythematosus and patients with dermatomyositis. For the clinic to be financially feasible and run efficiently, 2 providers need to show up in the same space. Before the clinic visit, patients need to know that they may need to make 2 copays, because they are seeing 2 providers.

Training Approaches for PCPs

Philip Mease, MD, MACR:
I think that the minimal psoriasis or psoriatic arthritis training in medical school is a gap. The training in residency is also minimal unless residents take a 1-month elective in their third year in rheumatology or dermatology. From my perspective, PCP training is also a gap area and there is a need for more education of PCPs about our disease. Currently, this training depends on the PCP reading the rheumatologist’s notes in the electronic record and the rare phone call back and forth. For example, if I’m very concerned about patients’ metabolic syndrome and I want better control of their hypertension or more multidimensional approaches to obesity management or hyperlipidemia management, then I’ll make a pointed effort of making sure patients draw the PCP’s attention to the section of the electronic record note where I emphasize how hypertension is a common comorbidity of psoriatic arthritis that they need to attend to.

April W. Armstrong, MD, MPH:
I think there are quite a few opportunities for training in dermatology. However, the educational opportunities need to be focused not only on how to identify psoriatic arthritis and potentially do joint exams but also on how we can better incorporate joint exams into the workflow. Since dermatology clinics are high volume, it is important to understand the high-yield aspects for screening, detection, and diagnosis and how we can optimize clinic flow so that these different aspects can occur in the clinic. I also think virtual on-demand education accessible at the point of care would be very helpful for dermatologists who need immediate answers (as they are with the patient) or who may not have the opportunity to attend meetings. Although I think that collaboration with our frontline PCPs is essential, I also think collaboration with pharmacists—in terms of accessing medication, understanding how specialty pharmacy works for the systemic medications, and administrative aspects—is important. I think not understanding can be a barrier to people becoming more comfortable with these medications.

Your Thoughts?
In your practice, are your patients with psoriasis and psoriatic arthritis delayed in their first visits with a rheumatologist and/or dermatologist? Please answer the polling question and leave a comment below.

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