Abstract
Objective Psoriatic disease (PsD) is a chronic, multisystem, inflammatory condition characterized by heterogeneous manifestations, including peripheral arthritis, axial involvement, enthesitis, and cutaneous and nail psoriasis. The condition has significant physical, emotional, and psychosocial effects on patients. In Latin America, healthcare disparities exacerbate delays in diagnosis and treatment, increasing the burden of PsD and associated comorbidities. This study aimed to establish regionally adapted criteria for Centers of Excellence (COEs) to optimize PsD care.
Methods A panel of 18 experts in rheumatology and dermatology from 12 Latin American countries developed COE criteria using the Delphi methodology. A narrative literature review informed the process, and criteria were evaluated using a Likert scale. Consensus was defined as ≥ 70% agreement, and an in-person meeting refined unresolved items. The criteria were categorized into structure, process, and outcomes, based on the Donabedian quality evaluation model.
Results Two types of COEs were defined: optimal and model. Optimal COEs require a multidisciplinary team including rheumatologists, dermatologists, nurses, and psychologists. Model COEs expand this team to include gastroenterologists, ophthalmologists, physiatrists, among other specialists. Structural criteria emphasized infrastructure and electronic systems for data management. Process criteria included patient-centered education, multidisciplinary consultations, and psychosocial support. Outcomes focused on standardized clinimetric tools (eg, Psoriasis Area and Severity Index, Disease Activity Index for Psoriatic Arthritis) and the treat-to-target strategy. Approval ratings ranged from 80% to 100%.
Conclusion The consensus establishes a framework for COEs in PsD care in Latin America, addressing structural, process, and outcome criteria to improve clinical outcomes, patient satisfaction, and healthcare system sustainability. These standards provide a roadmap for enhancing PsD management in resource-limited settings.
PLAIN LANGUAGE SUMMARY.
Psoriatic disease (PsD) is a chronic, multisystem inflammatory condition affecting the skin, joints, entheses, and nails, often accompanied by comorbidities such as cardiovascular disease and metabolic syndrome. Beyond its physical impact, PsD imposes significant psychological and social burdens, reducing quality of life. In Latin America, delayed diagnosis, limited access to specialists, and fragmented care pathways worsen its effects, highlighting the need for structured, multidisciplinary care models to improve management and outcomes.
Our study reports a Delphi-based expert consensus to establish criteria for PsD Centers of Excellence (COEs) in Latin America. The framework defines two levels: the Optimal COE, with a core multidisciplinary team, and the Model COE, which expands the team to include additional specialists. Both aim to address the diverse manifestations and comorbidities of PsD, ensuring comprehensive, patient-centered care. The consensus details structural, process, and outcome criteria. Structural standards focus on adequate infrastructure, access to specialized treatments, and robust electronic information systems. Process criteria emphasize coordinated multidisciplinary care, patient education, psychosocial support, and early diagnosis pathways. Outcome measures include standardized clinimetric tools, treat-to-target approaches, and mechanisms for continuous quality improvement, seeking to standardize care delivery and enhance coordination across healthcare settings.
Adopting this framework could transform PsD care in Latin America. Policymakers may use it to guide resource allocation, support certification programs, and design targeted health policies. COEs would also promote research through systematic data collection and dissemination. Its adaptability makes it a valuable model for other chronic inflammatory diseases, fostering sustainable, high-quality multidisciplinary care across the region.
Psoriatic disease (PsD) is a chronic, multisystem, inflammatory condition with a genetic predisposition and multifactorial triggers, primarily affecting the skin and joints. Its clinical manifestations are heterogeneous, involving domains such as peripheral arthritis, axial involvement, enthesitis, dactylitis, cutaneous psoriasis (PsO), and nail PsO.1 Additionally, PsD is associated with other manifestations, divided into related conditions, such as inflammatory bowel disease (IBD) and uveitis, and comorbidities, including cardiovascular disease, obesity, and metabolic syndrome, among others. These factors contribute to the disease burden, affecting not only the physical well-being of patients but also their emotional, social, and interpersonal lives.2
The global prevalence of PsO, one of the primary manifestations of PsD, is estimated to be 2% to 3% among White populations, whereas in Latin America, it is approximately 1%.3,4 The pathogenesis of PsD involves complex interactions between keratinocytes and immune cells, mediated by proinflammatory cytokines, leading to chronic inflammation and damage to the skin, nails, musculoskeletal system, and other organs.5 These manifestations, combined with chronicity, stigmatization, and associated disabilities, underscore the necessity for a comprehensive, multidisciplinary approach to effective management.2
Psoriatic arthritis (PsA), a prominent manifestation of PsD, is a chronic, progressive, and systemic inflammatory disease affecting the musculoskeletal system. PsA often involves peripheral joints, the axial skeleton (spine and sacroiliac joints), entheses, and dactylitis.6 It belongs to the spondyloarthritis group of diseases, known for its diagnostic challenges, especially in Latin America.7,8 These challenges highlight the critical need for enhanced training among primary care physicians and improved care models within rheumatology services across the region.
In Latin America, structural healthcare limitations, including disparities in access to specialists, restricted availability of advanced diagnostic technologies, and limited access to innovative therapies, significantly exacerbate the challenges associated with PsD.9 These systemic shortcomings are further compounded by insufficient training of primary care physicians in recognizing the early signs of PsD, resulting in considerable delays in diagnosis and the initiation of appropriate treatment. These delays not only increase the risk of irreversible disability but also significantly diminish patients’ quality of life (QOL), highlighting the urgent need for targeted strategies to bridge these gaps in care delivery.8,10
Building on the success of the REAL (Red de Excelencia en Artritis para la América Latina)–Pan American League of Associations for Rheumatology (PANLAR) Project for Implementing Centers of Excellence (COEs) for Rheumatoid Arthritis in Latin America, this consensus aims to establish regionally adapted criteria for creating COEs in PsD care.11 The objective of this initiative is to define standards that enable the delivery of high-quality, comprehensive, multidisciplinary care, thereby optimizing clinical outcomes and improving the QOL of patients with PsD in Latin America.
METHODS
A coordinating core group was established, composed of 2 physicians specializing in PsD in addition to 1 health professional with experience in chronic disease management and 1 physician expert in health systems and quality improvement. There was also an expert panel comprising 18 specialists, including 16 rheumatologists and 2 dermatologists, representing 12 Latin American countries. The participating countries and their respective representatives were as follows: Argentina (3 participants), Brazil (1), Chile (1), Colombia (4), Costa Rica (1), Ecuador (1), Mexico (1), Panama (1), Paraguay (1), Peru (2), Dominican Republic (1), and Uruguay (1). Seventeen experts attended the in-person consensus meeting, ensuring robust regional representation.
To ensure methodological rigor, a Colombian consulting firm with expertise in establishing COEs for chronic diseases was engaged to provide methodological support. The consulting firm, along with members of the coordinating core group, conducted a narrative literature review, defined the key categories, designed the proposed questionnaire for validation, and analyzed the results obtained from the expert panel.
The Delphi methodology was used to reach consensus among the panel in defining high-quality care criteria for patients with PsD. A Likert scale was employed to measure the level of agreement or disagreement with each proposed quality criterion. The scale ranged from 0 to 10 (where 0 = strongly disagree, 5 = neither agree nor disagree, and 10 = strongly agree).12
During the first round, the questionnaire was distributed electronically, and responses were analyzed to assess the level of consensus. Criteria achieving agreement ratings ≥ 70% were considered accepted. The second phase involved an in-person consensus meeting attended by 17 specialists, aimed at finalizing criteria that had not reached consensus in the initial round. Discussions during this meeting focused on refining the wording, applicability, and technical feasibility of the criteria. This structured process ensured the development of regionally adapted, evidence-based standards for establishing COE in PsD care, tailored to the healthcare realities of Latin America.
Step 1: narrative literature review. A narrative literature review was conducted using the following electronic databases: PubMed, MEDLINE, SciELO, Embase, and LILACS. The review focused on identifying quality criteria for PsD care and explore literature on the implementation of COEs for the management of rheumatologic conditions. Key reference points included recommendations from the PsO and PsA Clinics Multicenter Advancement Network (PPACMAN) and the Qualitative Initiative to Improve Outcomes (QUANTUM) project. These initiatives offered valuable international expert insights into PsD and were complemented by additional experiences in quality standardization for rheumatologic care.13-19
The identified criteria were organized into 4 categories: initial premises, structural components, processes, and outcomes. This classification aligns with the quality evaluation framework developed by Avedis Donabedian, a widely recognized model for establishing and assessing COEs. The Donabedian framework was chosen for its ability to facilitate a comprehensive evaluation of healthcare quality, ensuring a holistic approach to the development and assessment of high-quality care standards.20
Step 2: questionnaire distribution. An electronic questionnaire was sent to the expert panel, including a proposed list of criteria for review and rating based on relevance and feasibility for care of PsD.
Step 3: data collection and analysis. The results were collected and analyzed to determine the level of consensus, with criteria achieving approval ratings ≥ 70% by the expert panel considered as having reached consensus. A revised version of the questionnaire was then developed to incorporate adjustments to the criteria based on the analysis of round 1 results. Criteria that achieved consensus were identified, whereas those that generated disagreement were compiled for further discussion and refinement during the in-person meeting.
Step 4: in-person consensus meeting. The in-person consensus meeting took place during the 26th PANLAR Congress. The session began with a comprehensive presentation of the round 1 results, highlighting the methodology of the literature review, the categorization of questions according to the Donabedian model, and the demonstrated value of quality improvement through COE certification, as evidenced by PANLAR’s successful initiatives in rheumatoid arthritis (RA). During the meeting, unresolved responses from earlier rounds were discussed, refining their phrasing and technical applicability.
Step 5: final consensus. Consensus was determined based on the percentage of experts in agreement with the recommendations, using predefined Likert scale thresholds established during the process. Criteria that met these agreement thresholds were finalized and incorporated into the framework for establishing COEs for PsD care in Latin America. Items with an agreement < 70% will not be included in the certification manual. Most items reaching ≥ 70% agreement did so in the first Delphi round. Items that did not achieve consensus were discussed and refined during the in-person meeting, where final agreement was obtained. The final approval percentages for all criteria are shown in Tables 1-4.
Human talent criteria for COE in PsD care.
Criteria for structure: human resources and infrastructure.
Criteria for process: care and follow-up.
Criteria for outcomes: care and follow-up.
RESULTS
PsD was defined with 100% consensus as a chronic systemic inflammatory disease of immunological nature, characterized by genetic predisposition and multifactorial triggers. This heterogeneous condition manifests in multiple domains, including peripheral arthritis, axial disease, enthesitis, dactylitis, cutaneous PsO, and nail PsO. PsD is associated with significant comorbidities, categorized as related conditions (eg, IBD and uveitis) and comorbidities (eg, cardiovascular disease). Beyond its physical dimensions, PsD exerts a profound emotional and psychosocial impact on patients, affecting social functioning and interpersonal relationships. Its management requires a multidisciplinary approach tailored to the domains of disease presentation.
Two types of COEs for PsD care were established, focusing on human resources and care processes, and these received an overall approval rating of 92%. The first type, the optimal COE, is designed around a core multidisciplinary team comprising a rheumatologist, dermatologist, nursing staff, and psychological services (Table 1). This team operates through streamlined pathways to ensure efficient access and coordination with other specialties involved in PsD care. Key responsibilities include the following: (1) conducting comprehensive clinical and functional evaluations at admission and during follow-ups; (2) assessing disease activity, functional capacity, and psychological well-being, including screening for affective and anxiety symptoms; (3) implementing individualized and group educational and preventive programs; (4) coordinating consultations with other clinical specialties; (5) delivering pharmacological and nonpharmacological treatments; (6) evaluating physical condition through qualified personnel (eg, physiatrists, occupational and physical therapists); (7) conducting pharmacovigilance assessments and monitoring treatment adherence through pharmaceutical professionals; and (8) training general practitioners and specialists in PsD care within the COE framework.
The second type, the model COE, builds upon the structure of the optimal COE, incorporating all its personnel activities and tasks while expanding its scope to include additional specialties essential for addressing PsD domains, related conditions, and comorbidities. The minimum required team for this advanced model includes physiatrists, gastroenterologists, ophthalmologists, orthopedists, physical therapists, occupational therapists, and pharmaceutical professionals (Table 1). Like the optimal COE, the model COE achieved unanimous consensus (100%).
Tables 1-4 provide a detailed overview of the criteria used to define the standards for each type of COE (ie, optimal and model), divided into criteria for structure, process, and outcomes, and including the percentage of agreement achieved for each indicator.
Structure. The structural requirements for COE in PsD emphasize the need for comprehensive multidisciplinary teams and robust infrastructure (Table 2). The optimal COE requires a core team of rheumatologists, dermatologists, nurses, and psychologists, whereas the model COE expands this to include physiatrists, gastroenterologists, ophthalmologists, occupational therapists, and pharmacists. Infrastructure must include adequate facilities, equipment, and resources, such as access to phototherapy services. A standardized electronic health information system is essential for secure data traceability, outcome monitoring, and continuous quality improvement. These structural elements received approval ratings ranging from 80% to 100%, reflecting strong consensus on their importance.
Process. The COE care model prioritizes a holistic, multidisciplinary approach to address all domains of PsD, including skin and joint involvement, comorbidities, and psychosocial effects (Table 3). Evidence-based clinical pathways ensure consistent, high-quality care, with key components such as patient-centered education, risk management, and mechanisms for early diagnosis and referral. Accessibility is improved through preferential circuits for multidisciplinary consultations, including parallel or joint consultations by dermatology and rheumatology specialists. Nursing and psychological care are integral, focusing on mental health, treatment adherence, and patient satisfaction. These process criteria achieved approval ratings of 80% to 100%, highlighting their critical role in effective disease management.
Outcomes. Outcome criteria focus on rigorous monitoring of disease activity using standardized clinimetric tools such as the Psoriasis Area and Severity Index (PASI), Dermatology Life Quality Index (DLQI), and Disease Activity Index for Psoriatic Arthritis (DAPSA). A treat-to-target (T2T) strategy is recommended to establish personalized treatment goals, emphasizing strict disease control and QOL improvements. Timeliness of care is prioritized, with defined metrics for referral, diagnosis, and treatment initiation. Continuous improvement is ensured through multidisciplinary committees and real-time monitoring of care processes (Table 4). Additionally, COEs are expected to contribute to knowledge dissemination through research and publications, advancing PsD care. These outcome criteria achieved approval ratings of up to 100%, underscoring their significance in achieving superior patient outcomes.
Finally, the REAL-PANLAR group, responsible for developing the COE in PsD project, reached a consensus on the accreditation process that institutions must follow to obtain this certification (Figure). In addition to the classification of criteria by structural, process, and outcome domains, the consensus panel also prioritized specific implementation standards to support consistency across centers. Based on feasibility and clinical value, the consensus panel prioritized specific care models and clinimetric tools to be implemented in COEs. Regarding care models, the parallel joint care model—involving coordinated but sequential consultations by dermatology and rheumatology specialists—was identified as the preferred approach due to its balance between integration and practicality in Latin American settings. The onsite joint model, although ideal, was considered less feasible due to infrastructural limitations, whereas the preferential circuit was deemed less efficient for interdisciplinary coordination. Regarding clinimetric tools, minimum recommended instruments per disease domain were as follows: (1) skin domain: PASI (preferably PASI90 or absolute PASI < 3) and DLQI; (2) peripheral arthritis: DAPSA for activity assessment and minimal disease activity (MDA) as treatment target; (3) enthesitis: Leeds Enthesitis Index (LEI); (4) dactylitis: dactylitis count or Leeds Dactylitis Index; (5) axial disease: clinical judgment with imaging and patient-reported outcomes suggested (no consensus); and (6) function and QOL: Psoriatic Arthritis Impact of Disease and modified Health Assessment Questionnaire. These selections were supported by ≥ 70% agreement, except where otherwise noted, and constitute the minimum standard expected for certification within the COE framework.
Accreditation process to obtain COE status. COE: Center of Excellence, PsD: psoriatic disease; CARPsD: Center of Accreditation for Psoriatic Disease; PASI: Psoriasis Area and Severity Index; DLQI: Dermatology Life Quality Index; DAPSA: Disease Activity Index for Psoriatic Arthritis.
It is important to clarify that several criteria did not reach consensus during the first Delphi round and were further discussed and refined during the in-person consensus meeting. Key examples included the clinical relevance of PASI50 and PASI70, the use of indices such as Salford Psoriasis Index and Bath Ankylosing Spondylitis Disease Activity Index, the application of the T2T strategy, and the feasibility of the onsite joint care model. Final agreement on these items was achieved during the meeting and is reflected in the approval percentages presented in Tables 1-4.
DISCUSSION
PANLAR has successfully accredited COE for RA, certifying 5 institutions across Latin America. This achievement underscores the importance of institutional commitment and multidisciplinary collaboration in meeting high-quality standards in rheumatologic care. Previous experience has shown that certification not only enhances clinical outcomes for patients but also strengthens the organizational culture of institutions, fostering research, and optimizing healthcare processes. However, establishing these centers presents challenges, including the need for rigorous documentation, structural adjustments, and the development of an efficient management model for chronic diseases. Despite these hurdles, the certification of COEs has built patient trust and propelled advancements in rheumatology across the region. This success sets a strong foundation for accrediting new centers focused on axial spondyloarthritis (axSpA), following the same proven model implemented for RA.21
The establishment of COEs for PsD in Latin America aims to address critical gaps in care quality, focusing on improving clinical outcomes, achieving sustained disease remission, and enhancing patient satisfaction while promoting resource sustainability.10,13 These objectives align with the principles of continuous quality improvement, emphasizing standardized care and a multidisciplinary approach tailored to the sociopolitical and healthcare realities of each country.16
The development of COEs builds on international frameworks and experiences, including guidelines from Group for Research and Assessment of Psoriasis and Psoriatic Arthritis, European Alliance of Associations for Rheumatology, and PANLAR, as well as insights from initiatives like the QUANTUM and PPACMAN projects.2,14,18,22,23 These references highlight the importance of integrating evidence-based practices into care models that address the heterogeneous manifestations of PsD, such as peripheral arthritis, axial involvement, enthesitis, dactylitis, and skin and nail PsO. Additionally, the high prevalence of comorbidities, including cardiovascular disease, underscores the need for a holistic and inclusive care model.24 As part of the consensus, the panel identified the parallel joint care model as the most suitable approach for multidisciplinary management in the region, balancing clinical integration with feasibility. In addition, a core set of domain-specific clinimetric tools—including PASI and DLQI for skin involvement, DAPSA and MDA for peripheral arthritis, and LEI for enthesitis—was prioritized to guide standardized assessment and follow-up within COEs.25 However, no tool reached consensus for axial disease activity. This reflects a broader gap in the field, as current indices such as BASDAI or the Axial Spondyloarthritis Disease Activity Score are not validated for PsA-specific axial manifestations. In this context, the panel recommended relying on clinical judgment, supported by imaging and patient-reported outcomes. Future research is needed to better define this domain and inform updates to COE standards.2
In the Latin American context, healthcare systems face structural disparities, including limited access to rheumatologists and dermatologists, delayed diagnoses, and fragmented care pathways. These challenges are compounded by the lack of standardized clinical pathways, as evidenced by experiences in Spain with PsA and axSpA management.13,15 Addressing these gaps requires coordinated efforts to implement clear care circuits and multidisciplinary teams within COEs. Early detection and streamlined referral processes, as demonstrated in European models, are essential for improving patient outcomes.7,10,13
Effective COEs for PsD must incorporate structured multidisciplinary care, involving specialists in rheumatology, dermatology, psychology, and physiotherapy, supported by clinical pharmacists and other allied healthcare professionals. This ensures comprehensive management of all PsD domains, from skin and joint manifestations to psychosocial effects. The Spanish model’s emphasis on patient-centered care—including patient and family education, treatment adherence, and the integration of patient-reported outcomes—offers a valuable blueprint for Latin America.15,18
The implementation of COEs should be guided by robust indicators and evaluation frameworks, as detailed in both the Spanish and Latin American contexts. Key metrics include clinical outcomes (eg, PASI scores for skin involvement, and DAPSA for PsA), timeliness of care, patient satisfaction, and health-related QOL measures. Additionally, continuous training for healthcare providers and the use of standardized clinimetric tools are critical to maintaining high standards of care delivery.26-28
Long-term success for COEs depends on sustained collaboration among healthcare institutions, professional societies, and patient advocacy groups. These partnerships can drive the dissemination of best practices, support the development of localized guidelines, and ensure the scalability of COE initiatives. Further, knowledge generation through research and publication strengthens the evidence base and reinforces the role of COEs as leaders in PsD care.13,20,29
In conclusion, the COE framework represents a transformative approach to PsD care in Latin America. By addressing structural barriers, promoting multidisciplinary and patient-centered care, and using rigorous evaluation frameworks, these centers can significantly improve clinical outcomes and patient QOL. Drawing on international best practices while tailoring strategies to regional contexts ensures that COEs effectively meet the needs of patients and healthcare systems across Latin America.
As a next step, PANLAR will lead the development of a formal certification manual that defines the minimum set of structural, process, and outcome criteria required for accreditation as an optimal or model COE. This manual will include a scoring system, external evaluation procedures, and quality monitoring indicators. In parallel, PANLAR plans to support implementation through training, mentorship, and knowledge-sharing activities, particularly for centers operating in resource-limited settings. Additionally, the long-term vision includes the definition of performance metrics to evaluate clinical outcomes, accessibility, and sustainability. This framework may also be adaptable to other chronic inflammatory diseases, building on PANLAR’s prior experience with RA and axSpA.
Footnotes
CONTRIBUTIONS
All authors contributed substantially to the conception and design of the work and acquisition and interpretation of the data. PSM, RGS, and AO additionally analyzed the data and drafted the initial version of the article. The final article has been revised critically and approved by all the authors, who have given the necessary attention to ensure the integrity of the work.
FUNDING
PANLAR has received an unrestricted grant from Novartis for the development of this project. Payment to the independent qualifying organization was made through PANLAR.
COMPETING INTERESTS
RGS has received consultancy/speaker/research grants from AbbVie, BMS, Janssen, Eli Lilly, Novartis, Pfizer, Roche, UCB, GSK, Biogen, Amgen, Raffo, and Adium. AO has received consultancy/speaker/research grants from AbbVie, Eli Lilly, and Novartis; and consulting fees from AbbVie, BMS, Eli Lilly, Janssen, Moonlake, Novartis, Pfizer, and UCB. FS has received consultancy/speaker/research grants from AbbVie, Novartis, and Janssen. ERS has received consultancy/speaker/research grants from AbbVie, Amgen, BMS, Eli Lilly, GSK, Janssen, Novartis, Pfizer, Sandoz, Roche, and UCB. ALR has received consultancy/speaker/research grants from AbbVie, Eli Lilly, Janssen, and Novartis. AC has received consultancy/speaker/research grants from Sandoz, and Novartis, and is the PANLAR president. JRCA has received consultancy/speaker/research grants from AbbVie, Eli Lilly, Janssen, Novartis, and Pfizer; and is the former president of Grupo Colombiano de Psoriasis. SIV has received consultancy/speaker/research grants from Novartis, AbbVie, and BMS. ALG has received consultancy/speaker/research grants from AbbVie, Eli Lilly, Janssen, Novartis, Pfizer, and Sanofi. JL has received consultancy/speaker/research grants from AbbVie and Novartis. DP has received consultancy/speaker/research grants from AbbVie. CPT has received consultancy/speaker/research grants from AbbVie, AstraZeneca, Eli Lilly, Janssen, and Pfizer. MFUG has received consultancy/speaker/research grants from GSK and AstraZeneca. PAB is employed by the CENCIS Foundation. PSM has received consultancy/speaker/research grants from Novartis, AbbVie, BMS, Janssen, Biopass, Pfizer, and SteinCares. All other authors declare no conflicts of interest relevant to this article.
DATA AVAILABILITY
Data are available upon reasonable request to the corresponding author.
- Accepted for publication August 6, 2025.
- Copyright © 2025 by the Journal of Rheumatology
This is an Open Access article, which permits use, distribution, and reproduction, without modification, provided the original article is correctly cited and is not used for commercial purposes.
