Abstract
Optimal management of patients with both psoriasis and psoriatic arthritis (PsA) necessitates collaboration among dermatologists and rheumatologists. In this manuscript, we discuss challenges and opportunities for dual care models for patients with psoriasis and PsA and the results of a survey of combined clinics based in North America.
Dermatologists and rheumatologists are involved in the management of psoriatic arthritis (PsA). The importance of collaborative care is increasingly recognized. While practitioners often work in silos of their own specialty, expanding opportunities for collaborative care may increase continuing education, professional development, and practitioner satisfaction, while simultaneously improving care for patients and earlier recognition of arthritis. Organizations studying diseases that combine specialties exist at a national and international level [e.g., the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA)]. However, less is known about the logistics, benefits, and challenges of dual specialty clinics within academic medical centers. Herein we summarize our presentation at the 2016 GRAPPA Annual Meeting, where we discussed the challenges and opportunities for a dual model of care for patients with psoriasis and PsA, and results from a survey of rheumatology-dermatology combined clinics.
MATERIALS AND METHODS
We conducted a cross-sectional survey of centers with dual rheumatology-dermatology clinics. The survey was performed as an anonymous electronic survey using the Research Electronic Data Capture (REDCap). Participants were members of the Psoriasis and Psoriatic Arthritis Clinics Multicenter Advancement Network (PPACMAN) in North America. A rheumatologist and dermatologist were surveyed from each institution. No more than 2 people from each center were included. Academic and private practice clinics in the United States and Canada were identified. Results of the survey were descriptively reported. Comments were presented as themes.
RESULTS
Of 33 physicians identified, 32 completed the survey (response rate of 97.1%), including 16 dermatologists, 14 rheumatologists, and 2 dual-trained physicians, representing 25 combined clinics. One person surveyed was in private practice and the remainder were in academic practices. The majority of respondents reported participating in a psoriasis/PsA combined clinic while 5 respondents participated in a “virtual clinic,” a practice setting where providers are not seeing patients at the same time or in the same place, but have an established referral and communication relationship to facilitate care of these patients.
Most combined clinics (25/27 responses) reported the presence of trainees. Key competencies taught included a skin-focused history and examination, joint-focused history and examination, morphology of skin lesions, differential diagnosis of skin lesions, effect of psoriasis and inflammatory arthritis on quality of life, prescribing topical agents, management of systemic medications/biologics, intralesional steroid use, skin biopsies, arthrocentesis, and management strategies for other joint conditions.
The most commonly identified benefits of combined clinics included improved communication among healthcare teams (100%, 25 responses), excellent training opportunities (n = 23, 92%), and prompt and accurate diagnosis of PsA (92%). More than half of respondents said that combined clinics enabled 1 or more of the following: more frequent monitoring (e.g., of skin and joint manifestations, medications, medication side effects, disease flares), improved recruitment for clinical trials and observational studies, and satisfying and rewarding interactions with colleagues (i.e., learning from colleagues, becoming more “skin aware,” establishing closer ties between colleagues). The most frequently reported challenges included scheduling the right mix of patients, filling both specialists’ schedules appropriately, and demonstrating value to the institution to achieve “buy in.”
Half of the clinics reported advertising the presence of their combined rheumatology-dermatology clinic (i.e., flyers, brochures, online Website). Most clinics provided patient education material. Finally, most respondents (24/26 responses) reported interest in participating in collaborative research opportunities among combined clinics.
DISCUSSION
While the combined clinic model has been previously described1,2, ours is the first broad portrayal of collaborative clinics/centers for psoriasis and PsA across North America. There was variation in the types of care models used (e.g., in-person and “virtual” combined clinics). Challenges included administrative issues and identifying the right patient mix to maximize the time and productivity of both clinicians. However, the benefits were numerous. Beyond the perception of improved patient care and satisfaction, respondents described more opportunities for trainee education and increased professional development and satisfaction. Combined clinics are a promising care model for a variety of reasons including (1) increased collaborative care for patients with complex diseases3,4, (2) increased professional development5,6, and (3) unique training opportunities for medical students, residents, and fellows in a setting where they can learn the importance of communication between patients and providers. Further, such clinics allow the opportunity to study longterm outcomes and outcome measurements in patients with complex diseases.
Limitations of our study include occasional incomplete responses and potential selection bias, i.e., we asked only people actively engaged in the conduct of combined clinics about their advantages and disadvantages. Further, our study was limited to the North American experience and may not reflect other health systems.
Physicians surveyed were members of the PPACMAN, a group of dermatologists and rheumatologists committed to supporting multidisciplinary rheumatology-dermatology care in the form of both in-person and virtual combined clinics. The goals of the PPACMAN include demonstration of this care model, education on collaborative care for patients with PsA and psoriasis, and research to examine the effectiveness of these models. With these survey results, we have a better understanding of how clinics are currently conducted. Future directions include identifying how to best support these care models and strategies to expand/adapt the model for community settings.
Acknowledgment
We thank all the survey participants.
Footnotes
As part of the supplement series GRAPPA 2016, this report was reviewed internally and approved by the Guest Editors for integrity, accuracy, and consistency with scientific and ethical standards.
AO was supported by US National Institutes of Health (NIH) K23 AR063764 and the Rheumatology Research Foundation. JUS is supported by NIH K23 AR064318.
