Tackling the Problem
Dr. Gelfand explains that he “had no plans to try and tackle this problem. It’s a really hard problem, which is taking a population of people at risk for an outcome who were not getting properly treated, and then narrowing that evidence-to-practice gap.”
But when NPF announced the PPI grant, Dr. Gelfand realized it was an incredible opportunity. “If we could improve blood pressure management and cholesterol management, diet, and exercise in people living with psoriasis, we could substantially improve their well-being, health, and longevity, potentially,” he says.
The initial idea was to have dermatologists screen people for cholesterol levels and prescribe a statin when needed. Previous research by Alexa Kimball, M.D., president and CEO of Harvard Medical Faculty Physicians at Beth Israel Deaconess Medical Center, using a clinical trial population had shown that a small percentage of people with psoriasis who should be on a statin were not actually taking one. With the help of Rinad Beidas, Ph.D., who is founder and director of the Penn Implementation Science Center at the Leonard Davis Institute and associate director at the Center for Health Incentives and Behavioral Economics, Dr. Gelfand and his team did a series of engagement work.
The ﬁndings from their quantitative interviews with patients, dermatologists, and rheumatologists were that these issues matter a lot. “Stakeholders, clinicians, and patients would all like better education and screening for cardiovascular risk factors in the context of receiving care for psoriatic disease,” Dr. Gelfand says. “But it would be difﬁcult for rheumatologists or dermatologists to really meaningfully engage in the treatment of cardiovascular risk factors.”
A good point was brought up during these interviews: If dermatologists and rheumatologists are treating lipids of patients, but not blood pressure, then maybe they aren’t really doing the patient a favor by solving only part of the problem. This led to a crucial next step for the research team – a stakeholder meeting at the NHLBI. Here different experts came together, all trying to tackle a similar problem, and the concept of a care coordinator was introduced in this context as a potential solution.
What Is a Care Coordinator?
A care coordinator is a person who helps patients navigate the complex needs of their health care management. “In the ﬁeld of general medicine, this model has been shown repeatedly to be very effective,” Dr. Gelfand says.
For example, a care coordinator could help a patient with diabetes and depression navigate among behavioral health, endocrinology (the study of the system that controls hormones in the body), and internal medicine. “They get better outcomes not only on their depression but also their diabetes. Their A1Cs get better, and their mood gets better – really powerful ﬁndings,” he says.
In the U.S. health care system, patients with psoriasis are in a unique situation. “They are sort of stuck in a specialty care system, which is not really well-geared to manage prevention of heart disease at all and not well-connected to their primary care doctors,” says Dr. Gelfand. “They are getting a lot of their focused care in psoriatic disease.”
One innovation Dr. Gelfand and the team proposed to NPF was that a centralized care coordinator could be embedded in the Patient Navigator Center at NPF. “The idea here is that the dermatologist or rheumatologist would do what we encourage them to do, which is the standard of care in the guidelines: Educate the patient about the fact that psoriatic disease puts him at higher risk for cardiovascular risk factors and cardiovascular events, and order simple screenings checking for diabetes, cholesterol levels, and blood pressure. If any of those things are abnormal, refer them to the care coordinator,” Dr. Gelfand explains.
If this part of the project were to come to fruition, the role of the care coordinator could be to speak with patients, review their risk factors, calculate their risk of having cardiovascular disease during the next 10 years as well as during their lifetime, and compare that with what the risk optimally should be. The care coordinator could also provide a series of recommendations and connect the individual back with the relevant provider.
“I think leveraging what we learned during the pandemic about virtual care, telemedicine, video consultations, etc., is a real opportunity for us as researchers and clinicians and the NPF as advocates to really advance the well-being of patients more holistically,” Dr. Gelfand says.
His ultimate vision for this type of care is to see it generalized to other aspects of health care for patients with psoriasis, such as behavioral health or rheumatology. Going beyond that, this care could help patients with other medical conditions and considerations.
PPI Team Science
Collaboration is a key part of PPI and the foundation of this research work. “I think a lot of the discovery in medicine is often at the edges of different disciplines that haven’t been connected to each other,” Dr. Gelfand says.
The PPI team working beside Dr. Gelfand includes:
Alexis Ogdie-Beatty, M.D., MSCE, is a rheumatologist who will be using her expertise to help lead considerations for patients with PsA.
Dr. Beidas, Ph.D., is a clinical psychologist and implementation scientist and has done this work in other ﬁelds before.
Dr. Mehta, M.D., MSCE, FAHA, is a prevention cardiologist who speaks to patients daily about diet, exercise, medical therapy, and more. His insights and others will be used to build the scripts for the care coordinator.
Dr. April Armstrong, M.D., MPH, is a dermatologist who has been very engaged in studies using telemedicine. She will be helping to determine how best to use simple approaches to bring care to patients, such as a collaboration with Lemonaid Health, a telehealth medicine service.
Dr. John Barbieri, M.D., MBA, is a dermatologist and epidemiologist who will be helping to strategize how complex care is delivered in the U.S. health care system.