Dermatologists and rheumatologists share a history of caring for patients with psoriatic arthritis (PsA), though the process of communicating exam results and consulting about potential treatments hasn’t always been a smooth one. Now there’s a concerted effort among these specialists to create closer collaborations.
About 30 percent of people with psoriasis develop PsA; having the two diseases means both symptoms and treatment can get complicated. Combined clinics for PsA in which rheumatologists and dermatologists see patients either on the same day — and even at the same time — or on different days but as part of the same care team, are still relatively uncommon. Experts in skin, musculoskeletal and immune-mediated diseases, however, hope to see more of them.
“The complex nature of psoriatic disease – its diagnosis, management, comorbidities, treatment, and impact on quality of life — most often requires a multidisciplinary approach to care [for the best outcomes],” says Joseph F. Merola, M.D., MMSc, a dermatologist and rheumatologist at Brigham and Women’s Hospital, assistant professor at Harvard Medical School in Boston, and member of NPF’s Medical Board.
Merola, along with dermatology and rheumatology colleagues from across the U.S. and Canada, are working through the non-profit Psoriasis and Psoriatic Arthritis Clinic Multicenter Advancement Network (PPACMAN) to support the development of such clinics, which doctors believe will help people with PsA get a diagnosis and appropriate treatment sooner.
Combined care in theory
Merola notes that results of research on combined clinics published in the Journal of Rheumatology in 2017 found patients with psoriatic disease are more satisfied with their care when seen by a dermatologist and rheumatologist together. Physicians in the study reported that combined clinics resulted in improved monitoring of skin and joint symptoms, medication side effects, and disease flares.
Combined care can also provide a more precise picture of your individual disease and the best treatments for it.
Data reported in 2012 in the journal Archives of Dermatological Research found that almost half of patients with psoriatic disease evaluated in a combined clinic got a revised diagnosis. For instance, many received a systemic medication or biologic (instead of a topical drug or phototherapy) that had not been prescribed previously.
The Journal of Rheumatology study included data from 25 combined clinics in the U.S. and Canada; most are part of programs at large academic medical centers.
“There are a few formal combined clinics around the country,” says Merola. “However, we believe that increased local-regional, dermatology-rheumatology partnerships with interactions between the specialists, including better communication, shared clinical notes, and doing virtual or real clinical rounds together, would greatly enhance the care of patients with psoriatic disease.”
Combined care in practice
Evan L. Siegel, M.D., assistant clinical professor of medicine at Georgetown University School of Medicine and a member of NPF’s Medical Board, heard about the combined clinic, or dual-care model, for patients with PsA at a 2016 medical conference and decided he wanted to offer this benefit to patients. He teamed up with dermatologist Benjamin Lockshin, M.D., a member of NPF’s Board of Directors, who is in private practice in Rockville, Maryland. Together, they see patients in their combined rheumatology-dermatology clinic, which is held once a week at Siegel’s office, also in Rockville.
“Rheumatologists and dermatologists sometimes see things a little differently in patients with psoriatic arthritis or other rheumatic conditions involving both the skin and the musculoskeletal system,” says Siegel, who is a member of the PPACMAN steering committee. “They may have differing opinions about diagnosis and appropriate treatment, for example. The beauty of the combined clinic model is the ease of communication between dermatologist and rheumatologist, which brings those differing ideas together in a way that is ultimately beneficial on all fronts to patients.”
Previously, Lockshin and Siegel had collaborated virtually in the care of patients with complex psoriatic disease, but letters and phone calls began to seem inefficient and time-consuming, sometimes delaying the optimized care both wanted to provide, they say.
Patients in their combined clinic, which launched about a year ago, meet separately with each doctor but during the same visit; then rheumatologist, dermatologist and patient come together for the last part of the
appointment to discuss a management plan.
“We have an open dialogue with each other and with the patient. The patient can ask me and Dr. Siegel questions at the same time and hear both our answers, which aren’t always the same,” says Lockshin. “This translates into more comprehensive, holistic care as we learn what issues are of the greatest concern to the patient and together tailor therapy to meet those priorities.”
The response from patients has been excellent, he says. “They like hearing the dialogue between us — it helps them learn more about their disease — and they feel and see that they are getting proper attention to both their skin and joint issues.”
Siegel agrees. “Patients truly appreciate understanding how we came to a decision about which treatment we’re going forward with,” he says. “I think hearing the decision-making process in real time means they are more accepting of the treatment or treatments decided upon.”
Most patients with PsA don’t live near a formal, combined rheumatology-dermatology clinic, but they can — and often do — benefit from collaborative care, says Lawrence J. Green, M.D., a dermatologist in private practice in the Washington, D.C., area who sits on NPF’s Medical Board.
“I specialize in treating people with psoriasis, and a number of my patients have psoriatic arthritis, which means I routinely consult with their rheumatologists to coordinate care,” he says. “My feeling is that it’s common in private practices for dermatologists and rheumatologists to work together on a management plan.”
Patients with PsA should make sure their rheumatologist and dermatologist are communicating, says Green. For instance, physicians should inform one another about treatment changes as well as acute or urgent issues. “If that’s not happening, then it’s time to find a rheumatologist and dermatologist who will work together on your behalf,” he says.
Lockshin adds that advances in understanding psoriatic disease make this kind of collaborative care increasingly important and effective.
“We now have a much better understanding of psoriasis and psoriatic arthritis as systemic, inflammatory conditions that not only affect skin and joints, but also encompass increased risks for heart disease, diabetes, and other conditions. We also have many more good options for treatment than ever before, but they all have slightly different benefits and risks,” Lockshin says. “Having concurrent input from both specialties at the same time has additive benefits for patients and is a more efficient way of delivering high-level care.”
Network aims to extend the reach of dual care
Currently, there are few clinics in North America where patients with psoriasis and psoriatic arthritis (PsA) can see a dermatologist and rheumatologist in the same office. This is why the Psoriasis and Psoriatic Arthritis Clinic Multicenter Advancement Network (PPACMAN) has partnered with the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA), which also advocates for the dual-specialty model of care.
Although the model makes intuitive sense to many physicians and patients, there are practical barriers to these collaborative clinics, according to the results of a study on the benefits and challenges of the combined rheumatology-dermatology clinics published in 2017 in The Journal of Rheumatology. Hurdles include scheduling and billing issues, as well as demonstrating value to the practices and organizations considering the model.
PPACMAN is working to make the process more seamless and effective. The network hopes more information will help lower some of these barriers. PPACMAN gathers data on patient satisfaction and outcomes with the combined care model. It also evaluates ways to improve screening, increase early diagnosis of PsA, and funds training opportunities for dermatologists and rheumatologists. In this observership program, specialists travel to one of the combined clinic sites to learn how to establish these clinics in their own practice or organization.
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