Patient-provider disconnect in psoriasis

The patient-provider relationship in psoriasis care is plagued by various disconnects, shows a review published online October 15 in the American Journal of Clinical Dermatology.

Over the past two decades medical literature reflects an increasing emphasis on patient-centered care. In shared decision-making, healthcare professionals discuss treatment risks and benefits with patients in an attempt to bolster outcomes by considering both medical evidence and patient preferences.

"It's significant that shared decision-making is becoming a topic in psoriasis research and care," said Marie Hamilton Larsen, R.N., Ph.D., the lead author of the review and a pediatric nurse and researcher with the Institute of Health and Society, University of Oslo, Norway.

As a chronic illness, psoriasis requires patients to make many decisions throughout the course of their care.

Patient-centered care and shared decision-making in psoriasis and related research remains in its infancy, Dr. Larson and her colleagues wrote. The systematic literature review revealed few randomized controlled studies with comparable outcome measures to warrant meta-analysis. Investigators discussed findings in terms of analytic themes important to shared decision-making.

Researchers found a clear lack of constructive communication between providers and patients. While patients seek to be treated as individuals and have their doctors acknowledge the burden of living with psoriasis, that rarely happens, the review shows.

"Patients frequently do not know enough about treatment options to make informed decisions," Larsen et al. wrote. A previous review found that patients frequently underestimate their ability to grasp complex clinical information and to provide helpful information about themselves such as their personal experiences and preferences. "This lack of knowledge and self-efficacy challenges some basic shared decision-making concepts, such as open information exchange and partnership," the authors wrote. A diabetes study showed that patients who left a consultation with unanswered questions and inadequate information were less inclined to participate in shared decision-making.

To bridge the gap between patients' lack of knowledge and physicians' limited time and skills, investigators recommended using decision aids, and using the entire healthcare team as decision facilitators.

In the former area, a small 10-patient pilot study provides early evidence supporting the use of decision aids in psoriasis. Published in the March 2014 Journal of Cutaneous Medicine and Surgery, the study showed that an educational decision aid increased patients' knowledge, reduced decisional conflict and helped patients self-select treatments appropriate to their psoriasis severity. A seperate review of healthcare costs and savings showed that patients who participate in shared decision making tend to choose less invasive treatment options.

There is little evidence to support an interdisciplinary approach in psoriasis because nearly all the literature produced to date addresses relationships between patients and general practitioners or dermatologists, the authors wrote.

Dr. Larsen said she was encouraged to find that in a survey of 70 dermatologists published in the July 2011 Journal of Cutaneous Medicine and Surgery, 63 percent reported sharing in clinical decision-making. "That was higher than we expected. But when you ask the patients, they maybe have not understood that they actually participated in shared decision-making." The fact that part of the study took place in Canada, the nation which has progressed furthest in implementing shared decision-making, may have positively skewed results, she added.

It would be helpful if dermatologists would educate general practitioners about shared decision-making and the disease of psoriasis itself, the authors recommended. When physicians use shared decision-making, it may be easier for them to comprehend what patients really need and value.

"If patients don't relate to the treatment decisions that the doctors recommend, they won't adhere to the treatment. It's important to try to close that gap between the preferences of the patients and the treatments that are suggested. That may be part of the answer for the huge adherence problems in psoriasis," Larson et al. wrote.

REFERENCE
Marie Hamilton Larsen RN, PhD, Kare Birger Hagen MSc, PhD, Anne Lene Krogstad MD, PhD, Astrid Klopstad Wahl RN, PhD. "Shared Decision Making in Psoriasis: A Systematic Review of Quantitative and Qualitative Studies," American Journal of Clinical Dermatology. October 2018.