Supporting Combined Clinics to Improve PsA Care

Psoriatic arthritis (PsA) is the major comorbidity of psoriasis, occurring in up to 30% of this patient population.¹ Many gaps exist in the screening, diagnosis, and management of patients with PsA. Dermatologists are on the front lines of screening patients with psoriasis for PsA, and therefore can have the earliest impact by making a diagnosis in time to prevent potential joint damage. One way to bridge care gaps is through interdisciplinary care models that facilitate education and clinical care between dermatologists and rheumatologists, which is central to improving outcomes for patients with psoriasis/PsA.  

The Psoriasis and Psoriatic Arthritis Clinics Multicenter Advancement Network (PPACMAN) received 501c3 non-profit status in January 2018. The organization’s mission is to nucleate psoriatic disease combined clinics and centers to advance a multilevel approach to psoriatic patients, increase awareness, and accelerate management of the disease.

Why PPACMAN Was Formed

PsA results in functional disability, reduced quality of life, and joint deformities, which can occur early in the disease. Overall, 27% of patients have notable joint erosions within 5 months and 47% within 2 years of symptom onset.¹ Early identification and treatment of PsA is key and has been shown to improve patient response to therapy and lessen disease progression.^1-3 

However, PsA is often underdiagnosed or the diagnosis is delayed.⁴ Despite the development of several tools for PsA screening, the use of these instruments in clinical practice has not been widely adopted.^5,6 The critical barrier to improving early diagnosis is that we do not know how to get physicians to actually screen patients. Many dermatologists do not inquire about musculoskeletal symptoms. In an unpublished study presented at the American Academy of Dermatology meeting on PsA screening, many dermatologists who participated in a traditional didactic intervention did not change their behavior post-intervention. 

Innovative approaches to improve screening and early detection of PsA are needed. We created PPACMAN to improve partnerships between dermatologists and rheumatologists and believe this will expedite more accurate and timely diagnosis of PsA and lead to earlier initiation of appropriate therapy. Also, we think that dermatologists can be trained in a basic screening musculoskeletal exam to detect early signs and symptoms of PsA. We have had several initiatives that trained dermatologists in the basics of hands-on physical joint exams of patients with psoriasis.  

The Benefits of Combining Clinical Care

There are numerous benefits to dermatology and rheumatology partnerships. Dermatologists and rheumatologists each play a key role in the diagnosis and management of PsA. While existing therapies have substantially improved the management of this disease, less than 20% of patients reach remission and, most often, 1 or more aspects of PsA (eg, psoriasis, nail disease, peripheral arthritis, enthesitis, etc) remain active while patients are on therapy.⁶ It is in these scenarios that dual management is most critical. 

Furthermore, while practitioners often work within “silos” of their own specialty, expanding opportunities for collaborative care increases physicians’ continuing education, professional development, and professional satisfaction while simultaneously improving care for patients and earlier recognition of musculoskeletal symptoms.⁷ Despite the fact that collaborative care is recognized as valuable, little is known about the logistics, benefits, and challenges of dual specialty clinics within academic medical centers. 

Goals of PPACMAN

The overarching goals of PPACMAN are to improve early identification of PsA in dermatology practices and enhance comanagement among rheumatologists and dermatologists (and other relevant providers in the care of psoriatic disease patients). PPACMAN aims to accomplish those goals through the development of local-regional partnerships between dermatologists and rheumatologists, as well as more formal, academic combined clinic models. 

The goals of PPACMAN are essentially 3-fold:

• Improve education for health care providers treating patients with psoriatic diseases about the importance of early identification of PsA and value of collaborative care for patients.
• Support the formation of combined multidisciplinary clinical models and local/regional dermatology-rheumatology partnerships.
• Research the effectiveness of these care models, which includes studies to identify mechanisms for improved PsA screening, comorbidity identification and management, and defining ideal care outcomes.

Currently, examples of the work to facilitate these partnerships includes the development of electronic medical record templates for dermatologists and rheumatologists that include key screening tools, outcome measures, monitoring guidance, and treat-to-target strategies for each respective practitioner and cross-discipline. We have a working group interested in defining an “at-risk” psoriasis population with the goal of detecting and potentially preventing PsA disease, and projects focusing on the use of novel technologies in the detection and monitoring of psoriatic disease.

PPACMAN holds its annual meeting each December in New York City. This full-day conference focuses on issues relevant for collaborative care in North America (both within psoriatic disease and beyond), reviewing and refining outcomes for value-based collaborative care, and planning for studies to address effectiveness of collaborative psoriatic disease care.  

Rheumatologists and dermatologists who have an existing combined clinic, or those interested in learning more about how to develop one, should contact PPACMAN Association Manager, Amanda Pacia (Amanda@ppacman.org) for further details and to be added to our mailing list 

For more information about our organization, please visit www.ppacman.org. 

Dr Merola is the president of PPACMAN, the director of the Clinical Unit for Research Innovation and Trials, director of the Center for Skin and Related Musculoskeletal Diseases, associate program director of Harvard Combined Internal Medicine-Dermatology Residency Training Program, and associate professor at Harvard Medical School in Boston, MA.

Disclosure: Dr Merola has served as a consultant and/or investigator for Biogen IDEC, AbbVie, Eli Lilly, Novartis, Pfizer, Janssen, UCB, Samumed, Science 37, Celgene, Sanofi, Regeneron, Merck, and GSK. 

References

1. Gladman DD. Early psoriatic arthritis. Rheum Dis Clin North Am. 2012;38(2):373-386.

2. Kirkham B, de Vlam K, Li W, et al. Early treatment of psoriatic arthritis is associated with improved patient-reported outcomes: findings from the etanercept PRESTA trial. Clin Exp Rheumatol. 2015;33(1):11-19.

3. Gladman DD, Thavaneswaran A, Chandran V, Cook RJ. Do patients with psoriatic arthritis who present early fare better than those presenting later in the disease? Ann Rheum Dis. 2011;70(12):2152-2154.

4. Ogdie A, Weiss P. The epidemiology of psoriatic arthritis. Rheum Dis Clin North Am. 2015;41(4):545-568.

5. Merola JF, Husni ME, Qureshi AA. Psoriatic arthritis screening tools: study design and methodological challenges. Br J Dermatol. 2014;170(4):994-995.

6. Ogdie A, Coates L. The changing face of clinical trials in psoriatic arthritis. Curr Rheum Rep. 2017;19(4):21.

7. Okhovat JP, Ogdie A, Reddy SM, Rosen CF, Scher JU, Merola JF. Psoriasis and Psoriatic Arthritis Clinics Multicenter Advancement Network Consortium (PPACMAN) survey: Benefits and challenges of combined rheumatology-dermatology clinics. J Rheumatol. 2017;44(5):693-694.