Psoriasis Clinical Trial Travel Challenges

In this exclusive interview with The Dermatologist, Drs Hao Feng and Eric Beltrami discussed the travel and time burdens surrounding psoriasis clinical sites following their study, “Differential Patient Travel Distance and Time to Psoriasis Clinical Trial Sites.”

Hao Feng, MD, is a board-certified dermatologist with expertise in Mohs surgery, laser surgery, and cosmetic dermatology. He is an associate professor and director of laser surgery and cosmetic dermatology at UConn Health in Farmington, CT.

Eric Beltrami, MD, is a recent graduate from UConn School of Medicine in Farmington, CT.

The Dermatologist: How exactly is travel distance and time to reach a psoriasis clinical trial site a potential barrier to trial participation?

Dr Feng: Essentially, we know the importance of clinical trials for various reasons. Firstly, they allow for innovation in medications that are provided to patients. Psoriasis is a common dermatologic disease. Some people have mild disease, some people have more severe disease, and some people respond to one medication but not another. Clinical trials serve as a foundation to expand treatment options for patients, and, certainly, there are also patients who cannot afford existing medications. The biologics have revolutionized the treatment of psoriasis, thanks to the hard work done in clinical trials.

We also know in studies for psoriasis, there is a disparity in terms of the fact that not all racial and ethnic groups are equally represented in these clinical trials. Although that has been reported, the exact reasons have not been potentially explored. There are hypotheses and so forth. We thought that one essential component is how far a patient must travel to a clinical trial site. We know that these clinical trial sites are not located in all dermatology practices, and they're concentrated in specific areas. So, naturally, that involves a potential barrier for these potential clinical trial patients to participate. As you can imagine, if a trial site is far away from where you live, you're certainly at a disadvantage in terms of accessing that clinical trial site and the potential medications. And that may contribute to some of the disparities we see in the existing literature. If we can show that, then it provides a point at which we can correct the disparity. It's an actionable item. That's why we decided to pursue the study, to test this hypothesis.

The Dermatologist: How does the geographic maldistribution of physicians, particularly dermatologists, across the country impact access to health care in rural areas?

Dr Feng: We know that all physicians and dermatologists included are geographically maldistributed across the country. Most physicians tend to be in urban centers and less so in rural areas. So, there's really a big difference in terms of the density of dermatologists and other physicians. Certainly, that plays a role, and it's something I think we observed in our study.

The Dermatologist: Your study noted that travel burden was significantly greater among Native American and Black races, individuals without a college education, and Veterans Affairs beneficiaries. Why exactly is this the case?

Dr Beltrami: This was one of our major findings in the study. Regarding race, we found that Native American and Black races were associated with significantly higher travel distances relative to all other races. Specifically, for example, the median travel distance nationally for White patients was about 22 minutes compared to 35 minutes for Black patients and 39 minutes for Native American patients. That’s a significant difference. And all of those reached statistical significance as well.

Regarding educational attainment, this was interesting. Those without a bachelor's degree or higher traveled at least 40% longer distances than those with a college education. And this is, again, nationally. For Veterans Affairs beneficiaries, we also saw the greatest disparity in the amount of travel burden they have relative to other insurance types. They travel an average of 31 miles or 39 minutes. And then if we want to make a comparison to the group that experiences the least disparity in general, the privately insured patient, they travel about 20 miles or 28 minutes. There's definitely a difference there.

Regarding why exactly we saw these findings in the study, again, I think it kind goes back to the maldistribution of the physicians and the clinical trial sites at which these psoriasis medications are tested. But also, we know the populations themselves, such as the veteran population and the Native American population, are also distributed in a way that is not congruent with the way we distribute the clinical trials currently. Basically, if they live farther away, that's probably why we saw them having these longer travel distances. If they don't live near an urban area and live in a rural area, of course, they're going to have these longer distances. Being able to look at this nationally really paints a good picture. It's hard to say at an individual level based on our results, but we can see that for large populations of people, large demographics like these disparities are persisting and do exist.

The Dermatologist: How can investigators aim to increase travel funding for underrepresented groups and diversity recruitment to promote access to psoriasis clinical trials?

Dr Feng: We can have observations of the lack of diversity or inappropriate diversity. This really gets to the question of what can we do about it? What are things that we can address now [based on what] we identified as a potential barrier in the recruitment of a diverse clinical trial participant pool?

I think the first thing is to recognize that travel distance and time, in fact, play a role in this. When investigators are designing a trial and they're interested in obtaining a diverse and representative sample of the US population for their trial, it's important for them to think about ways to mitigate the issue right now. That could come in a variety of different ways. Number one is potentially recruiting dermatology practices that are more rural and closer to these underrepresented patients. Certainly, that decreases the travel distance and provides a little bit more extra incentive for patients to come.

Secondly, if that's not always possible because of the infrastructure (not all dermatology practices have the infrastructure to conduct these long-term clinical trials), then investigators really need to think about providing travel vouchers, maybe gas reimbursements, and really playing an active role in finding those who don't necessarily live right next to these clinical trial sites. All these things can potentially increase the recruitment of a more diverse population.

And of course, it's important that as dermatologists, we also let our colleagues in nearby areas know about these clinical trial opportunities so the knowledge of a clinical trial being performed is not simply isolated to the center nearby. I think dermatology offices can also make an active effort in reaching out to their colleagues nearby to say, "Hey, there are these trials that we're offering, and maybe an extra incentive in terms of a stipend or gas reimbursement for these patients to come and join." I think these are some of the potential opportunities to mitigate these transportation difficulties or the results that we're seeing.

The Dermatologist: Are there any additional tips or insights you would like to share with your dermatologist colleagues regarding patient travel distance and time to psoriasis clinical trial sites?

Dr Beltrami: We want to drive home the dual benefit of having increased awareness of this disparity that we've highlighted for both physicians and patients. As we've talked about, clinical trials play such an important role in getting patients high-quality treatments, especially for psoriasis. At the same time, as our treatment options for psoriasis continue to advance and we continue to have these clinical trials, we need the trials that are developing these medications to be reflective of all the patients who we would potentially prescribe the medications to.

If dermatologists are more mindful of transportation as an extrinsic determinant of obtaining care, a potential barrier, we may ultimately improve the quality of individual patients' lives by including them in the study while also producing higher quality and more representative clinical trial data, which would benefit physicians and all patients in dermatology. We're proud of being able to publish this and get this information out there and highlight this disparity, and, hopefully, it's now a call to action, and we can all start to address it better.

Reference
Masison J, Beltrami EJ, Feng H. Differential patient travel distance and time to psoriasis clinical trial sites. Arch Dermatol Res. Published online May 11, 2023. doi:10.1007/s00403-023-02633-2