‘Real decisions’ on psoriasis care from informed clinicians

‘Without some understanding of the economics of healthcare derived not from classical theory but from experience of the real healthcare economy, with clinical decisions as its principal units, those trying to oppose continued commercialisation and industrialisation of the NHS can only wring their hands and agonise, leaving real decisions to the industrialisers and commercialisers’. So said Dr Julian Tudor Hart in his excellent book on the political economy of healthcare.¹

Some costs for treating psoriasis are easily identifiable and familiar to dermatologists, while others are more opaque. For example, the drug costs of conventional licensed systemic therapies are available in the British National Formulary (a rapid reference book on prescribing and dispensing which is updated every 6 months) and are generally agreed to be expensive (ciclosporin), modestly expensive (acitretin) or cheap (methotrexate). However, this fails to provide the whole cost as these drugs require monitoring for toxicity which often includes regular visits to see the local consultant dermatologist (a costly resource) or a clinical nurse specialist (also a costly resource). Additionally there are direct and indirect patient costs associated with regular clinic visits for drug toxicity monitoring and costs to employers and the wider economy from lost working time.

Occasional ‘drug holidays’ to minimize or recover from adverse effects may lead to an acute flare of psoriasis and a spell of inpatient care. The costs of psoriasis inpatient care are hard to define as they depend on duration of admission and intensity of nursing care and the primary or adjunctive therapies. In 2008, Woods et al.² published a four-centre review of current psoriasis inpatient care. The mean length of stay for all patients in this study was 19 days. Current costs for inpatient care in the National Health Service are not available, but were reported to be £300–400 per 24 h in a general medical ward in 2004.³ Thus, 19 days of inpatient care at £300–400 per day gives a range of £5700–7600, and is assumed to be higher now. These costs should be balanced against the value of inpatient care in the management of psoriasis.⁴

This month’s edition of the British Journal of Dermatology includes two papers on systemic therapies for psoriasis that provide important new information of relevance to the debate on the health economics of psoriasis treatment in Britain’s National Health Service.^5,6 The first, a comprehensive health economic evaluation of conventional systemic and biological therapies for moderate to severe psoriasis, sought to determine cost-effectiveness and optimal treatment sequence.⁵ Despite being less beneficial than biological therapies, methotrexate and ciclosporin were confirmed as the first two treatments in the optimal sequence. Of the biological therapies, adalimumab emerged from this study as the most cost-effective, followed by etanercept, infliximab and then efalizumab.

The second paper describes experience of fumaric acid esters for psoriasis from a large tertiary referral dermatology centre in London.⁶ Despite being a first-line systemic treatment for severe psoriasis in Germany, fumaric acid esters remain unlicensed in the U.K. and have to be imported. This means they are costly – estimated by Wain et al.⁶ to be £5500 per patient-year. According to these authors, their undoubted efficacy and fewer side-effects compared with ciclosporin and methotrexate go some way towards mitigating their higher U.K. costs. They conclude by stating that fumaric acid esters are a useful treatment option for severe chronic plaque psoriasis, and may allow dose reduction and withdrawal of more toxic systemic therapies. This paper is important as it includes data from ‘the real healthcare economy’.

It is heartening that dermatologists and others are contributing so actively to the health economic debate. For a more complete picture of psoriasis care, researchers should now focus on the health economic evaluation of inpatient care, psoriasis day care (outpatient attendance at a dermatology day-care unit) and phototherapy.