Physician performance measurement: tiered networks and dermatology (an opportunity and a challenge)

Performance measurement part I: Foundational knowledge for measure development

As medicine is moving toward performance and outcome-based payment and is transitioning away from productivity-based systems, value is now being appraised in healthcare through "performance measures." Over the past few decades, assessment of clinical performance in health care has been essential in ensuring safe and cost-effective patient care. The Centers for Medicare & Medicaid Services is further driving this change with measurable, outcomes-based national payer incentive payment systems. With the continually evolving requirements in health care reform focused on value-based care, there is a growing concern that clinicians, particularly dermatologists, may not understand the scientific rationale of health care quality measurement. As such, in order to help dermatologists understand the health care measurement science landscape to empower them to engage in the performance measure development and implementation process, the first article in this 2-part continuing medical education series reviews the value equation, historic and evolving policy issues, and the American Academy of Dermatology's approach to performance measurement development to provide the required foundational knowledge for performance measure developers.

InflammamiR-146a and -155 Plasma Levels are Associated with Clinical Efficacy of Risankizumab Treatment in Psoriatic Patients: Pilot Study

INTRODUCTION

The key role of microRNAs (miRNAs) in the pathogenesis of psoriasis has been extensively discussed in the literature. Increasing evidence suggests that the analysis of miRNA levels may constitute an innovative approach for exploring the clinical efficacy of anti-inflammatory therapies in patients with psoriasis. However, so far there have been no published studies evaluating the effects of modulating circulating miRNAs and the efficacy of anti-interleukin-23 (anti-IL-23) therapy. The main objective of the present was to evaluate the diagnostic/prognostic relevance of the levels of five circulating candidate miRNAs (miR-21, miR-146a, miR-155, miR-210, miR-378) in psoriatic patients treated with the anti-IL-23 drug risankizumab.

METHODS

A total of eight psoriatic participants were recruited consecutively from January 2021 to July 2021 at the Dermatology Clinic of Università Politecnica delle Marche (UNIVPM) "Ospedali Riuniti" of Marche. Data on anamnestic, clinical and miRNA evaluations before the initiation of risankizumab therapy and after 1 year (January 2021-July 2022) of risankizumab therapy were available for all patients.

RESULTS

A significant reduction in the signs and symptoms in patients treated with risankizumab was observed after 1 year of treatment, suggesting that the drug is effective for treating psoriasis in a context of real-life clinical evaluation. Plasma levels of the two prototypical inflammamiRs, miR-146a and miR-155, were significantly reduced after 1 year of risankizumab therapy. Also, in patients before treatment, a significant positive correlation was found between circulating levels of miR-210 and miR-378 and disease severity scores.

CONCLUSIONS

Our results reinforce the notion that specific circulating miRNAs could have clinical relevance as diagnostic/prognostic biomarkers of psoriatic disease and suggest the potential relevance of these miRNAs as biomarkers of treatment response.

Efficacy of the topical cyclosporine cream assisted by fractional carbon dioxide laser vs topical clobetasol cream for the treatment of plaque psoriasis: Randomized comparative study

BACKGROUND

In mild psoriasis, topical agents remain the mainstay of treatment. However, the available treatments are not satisfactory for a significant proportion of patients in many terms such as efficacy and safety. Because of these deficits, augmentation of therapeutic effect seems desirable.

THIS STUDY AIMS

To evaluate the efficacy of topical cyclosporine cream, delivered by fractional CO₂ laser vs the efficacy of topical clobetasol cream for the treatment of mild to moderate plaque psoriasis.

PATIENTS AND METHODS

Twenty-two patients with chronic plaque psoriasis involving <10% BSA were included in this study. They were randomly allocated into 2 groups. In Group A, patients were instructed to apply cyclosporine cream twice daily for 5 consecutive days per week immediately after fractional carbon dioxide laser session. While in Group B, clobetasol cream was applied twice daily for 5 consecutive days per week until complete clearance or for a maximum of 10 weeks. The efficacy was objectively assisted clinically and by histopathology by using the scores and skin biopsy.

RESULTS

There was a significant improvement of erythema, plaque elevation, and scaling (p < 0.001) with the use of topical cyclosporine cream delivered by the aid of fractional CO₂ laser, compared to base line. However, the improvement was more significant with topical clobetasol cream.

CONCLUSION

Laser-assisted delivery of topical cyclosporine can provide comparable clinical and pathological improvement to that of clobetasol in the psoriatic plaques. These findings were apparent in patients with less widespread disease. However, topical steroid showed more improvement.

Biological Therapies or Apremilast in the Treatment of Psoriasis in Patients with a History of Hematologic Malignancy: Results from a Retrospective Study in 21 Patients

Background

Few studies addressing the safety and efficacy of biological therapy (BT) or apremilast (APR) in patients with psoriasis with a history of hematologic malignancy (HM) exist.

Aim

To describe the tolerance and efficacy of BT and APR in moderate-to-severe psoriasis in patients with a history of in-remission or evolving HM.

Methodology

A retrospective, multicenter chart review of the tolerance and efficacy of BT or APR in patients with moderate-to-severe psoriasis and a clinical history of in-remission or evolving HM.

Results

Twenty-one patients with severe psoriasis and a history of HM were included in France by the GEM Resopso study group. Of the 16 patients treated with one or more BT lines, none showed recurrence of their HM which was considered as stable or in remission, and only 2 patients showed an evolution of their HM which had been considered as stable at the beginning of treatment. In the 10 patients treated with APR, the HM of one patient who also received BT worsened. The 3 evolutions did not impact the treatment with BT or APR. Tolerance was very satisfactory, with a low occurrence of infections. Regarding efficacy, only one patient treated with APR did not achieve any notable clinical improvement.

Conclusion

Despite supportive data regarding tolerance, the heterogeneity of the analyzed population and limited available data, BT and APR should be used with caution in this patient population and investigations on larger cohorts should be conducted to further assess their tolerance in this patient population.

Baseline Characteristics of Patients with Ankylosing Spondylitis and Psoriatic Arthritis Treated with Secukinumab in the Real-World Setting: AQUILA, a Non-Interventional Study

Objective:

AQUILA is an ongoing, multicenter, prospective, Non-Interventional Study (NIS) with secukinumab, designed to evaluate real-world evidence for different aspects of treatment in patients with Ankylosing Spondylitis (AS) and psoriatic arthritis (PsA) in Germany. Here we report the study design and baseline characteristics including comorbidities and prior medication of patients as well as insights into medical care in Germany.

Methods:

Patients (age ≥18 years) with active AS or PsA, who were under secukinumab treatment or just about initiating secukinumab therapy based on medical therapeutic need, are enrolled. Each patient is observed for 52 weeks.

Results:

A total of 572 patients (AS, n = 187; PsA, n = 385) have been recruited in this ongoing study. Mean age, weight, and BMI were similar between the subgroups. About 66.4% of patients had previously received biologics other than secukinumab. Depression was the most common comorbidity (AS, 9.1%; PsA, 15.6%). Plaque psoriasis was also frequently reported (AS, 9.6%; PsA, 62.3%).

Conclusion:

The Non-Interventional Study (NIS) baseline characteristics indicate that the demographics were similar to populations of previous secukinumab trials of AS and PsA patients except to comorbidities and exposure to biologics. A majority of the patients who received secukinumab in this setting had previously received biologics. Comorbidities relating to obesity and cardiovascular disease were particularly evident in PsA patients whereas the elevated depression prevalence was equally distributed.

Quality indicators for responsible use of medicines: a systematic review

OBJECTIVE

All healthcare systems require valid ways to evaluate service delivery. The objective of this study was to identify existing content validated quality indicators (QIs) for responsible use of medicines (RUM) and classify them using multiple frameworks to identify gaps in current quality measurements.

DESIGN

Systematic review without meta-analysis.

SETTING

All care settings.

SEARCH STRATEGY

CINAHL, Embase, Global Health, International Pharmaceutical Abstract, MEDLINE, PubMed and Web of Science databases were searched up to April 2018. An internet search was also conducted. Articles were included if they described medication-related QIs developed using consensus methods. Government agency websites listing QIs for RUM were also included.

ANALYSIS

Several multidimensional frameworks were selected to assess the scope of QI coverage. These included Donabedian's framework (structure, process and outcome), the Anatomical Therapeutic Chemical (ATC) classification system and a validated classification for causes of drug-related problems (c-DRPs; drug selection, drug form, dose selection, treatment duration, drug use process, logistics, monitoring, adverse drug reactions and others).

RESULTS

2431 content validated QIs were identified from 131 articles and 5 websites. Using Donabedian's framework, the majority of QIs were process indicators. Based on the ATC code, the largest number of QIs pertained to medicines for nervous system (ATC code: N), followed by anti-infectives for systemic use (J) and cardiovascular system (C). The most common c-DRPs pertained to 'drug selection', followed by 'monitoring' and 'drug use process'.

CONCLUSIONS

This study was the first systematic review classifying QIs for RUM using multiple frameworks. The list of the identified QIs can be used as a database for evaluating the achievement of RUM. Although many QIs were identified, this approach allowed for the identification of gaps in quality measurement of RUM. In order to more effectively evaluate the extent to which RUM has been achieved, further development of QIs may be required.

The International Dermatology Outcome Measures initiative as applied to psoriatic disease outcomes: a report from the GRAPPA 2013 meeting

In the United States, access to care is the number one issue facing our patients with dermatological conditions. In part, this is because we do not have outcome measures that are useful in clinical practice and available in databases where payers and governmental agencies can compare the performance of physicians and treatments. There is a growing recognition that insufficient attention has been paid to the outcomes measured in clinical trials and subsequently in clinical practice. The International Dermatology Outcome Measures group includes all willing stakeholders: patients, physicians, payers, and pharmaceutical scientists. As reported herein, the group's goal is to develop outcome measures in dermatology that address the needs of all involved.