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To the Editor:
Psoriatic arthritis (PsA) is a chronic inflammatory disease involving the skin and joints. It requires detection in primary care, subsequent referral, and initiation of management in secondary care and ongoing joint management. PsA has been associated with greater cardiovascular (CV) disease mortality, morbidity, and atherosclerosis1. The increased CV mortality risk has been shown to be comparable with that of rheumatoid arthritis (RA) and diabetes (risk ratio 1.74, 95% CI 1.32–2.30)2. In addition, risk factors for CV disease, such as hypercholesterolemia, impaired glucose tolerance, and obesity, have all been associated with PsA1,2,3.
We sought to establish the current knowledgebase and lifestyle choices of patients with PsA managed in secondary care. This data could then guide changes to services to assist patients in reducing their risk of CV morbidity and mortality.
A hundred patients diagnosed with PsA sequentially attending a rheumatology outpatient clinic completed an anonymous electronic questionnaire. Patients were asked to fill in this questionnaire in the clinic waiting area on a tablet device or a desktop computer. We enquired about current lifestyle choices, including smoking, alcohol intake, and whether they followed a low-fat diet. In addition, we asked about their awareness of associated health risks and the desire for an annual health assessment. There was also the option for a free text response regarding suggested improvements to the service and their treatment. The questionnaire took a patient about 5 minutes to complete.
Fifty-seven percent of patients were unaware of any additional health risks they faced as a patient with PsA (Figure 1) and 87% said they would appreciate an annual health assessment to screen for diabetes, hypertension, and hypercholesterolemia. Sixteen percent of the questioned patients with PsA smoked, which is less than the UK national average of 20% in 20124. Of these 16 patients who smoked, 14 had considered cessation and 5 wished to be referred to a rheumatology-based smoking cessation service. One percent of the group admitted to a weekly alcohol consumption of over 20 units with 87% consuming 10 units or less. Sixty-nine percent consciously tried to follow a low-fat diet. Interestingly, those patients who were aware of associated health risks were more likely to be nonsmokers and consciously followed a low-fat diet (p values 0.3 and 0.31, respectively).
Pie chart showing the proportion of patients who were unaware of any additional health risks associated with PsA. PsA: psoriatic arthritis.
One of the top 3 unmet patient needs evident in the free text responses was access to information on PsA, advice on lifestyle choices, and information related to associated PsA health risks (mentioned in 7 responses).
It is evident that only a minority of patients were aware of additional health risks associated with PsA, highlighting a need for improvement in patient education and access to information about PsA. Our work has also suggested that patient awareness of health risks was associated with healthier lifestyle choices. An annual health assessment, which is not currently routine practice for those with PsA as it is for RA, could improve personal and public health outcomes.
Given that the current CV risk incurred from PsA has been deemed to be equal to that of RA2, there is a rationale behind its inclusion in widely used primary care tools such as the QRISK2 score5. Consideration of CV risk screening for patients with PsA in primary care has been recommended2,6. Given that in the United Kingdom CV risk scoring and intervention are managed in primary care, general practitioners (GP) would be best placed to assess the CV risk and arrange relevant screening.
It has been demonstrated that there is a need for better education and involvement of patients with PsA in their care7. Information regarding the additional health risks could be imparted verbally, in written form, or through online sources. Lifestyle advice should be tailored to the individual with an emphasis on sustainable changes8. To best facilitate lifestyle changes, it may be helpful for information to be imparted both in the primary and secondary care settings; however, followup on lifestyle interventions would be most accessible in primary care.
Smoking contributes to the absolute CV risk7, and cessation should be promoted in both primary care and secondary care. A smoking cessation service is likely to be more readily accessed by patients if provided through primary care. Additional resources and time spent invested in educating patients with PsA could decrease longterm morbidity and mortality.
Further exploration into the proportion of GP that currently consider the CV risk in patients with PsA would be interesting, given that CV risk screening generally takes place in primary care. A joint approach between the primary care physician and the rheumatologist in educating and screening patients with PsA could help improve knowledgebase and CV health of this at-risk population.
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