Improving Specialty Care Delivery in Chronic Skin Disease April W. - - PowerPoint PPT Presentation

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Improving Specialty Care Delivery in Chronic Skin Disease April W. - - PowerPoint PPT Presentation

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Improving Specialty Care Delivery in Chronic Skin Disease April W. Armstrong, MD, MPH Associate Dean of Clinical Research Vice Chair and Professor of Dermatology University of Southern California Los Angeles, California November 1, 2018

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Improving Specialty Care Delivery in Chronic Skin Disease

April W. Armstrong, MD, MPH

Associate Dean of Clinical Research Vice Chair and Professor of Dermatology University of Southern California Los Angeles, California

November 1, 2018

#PCORI2018

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2 • November 1, 2018

No relevant conflict of interest specific to this presentation.

Other disclosures: Research investigator and consultant to AbbVie, BMS, Janssen, Novartis, Lilly, Pfizer, Regeneron, Sanofi, Leo, Modernizing Medicine, Science 37, and/or Ortho Dermatologics.

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3 • November 1, 2018

Outline

  • Discuss evidence gaps
  • Provide study overview
  • Highlight key study findings
  • Explore what is needed to change practice
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4 • November 1, 2018

Evidence Gap

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5 • November 1, 2018

Lack of regular access to specialists results in poor health care outcomes

  • Skin diseases account for 30% of all physician office visits.
  • Lack of regular access to dermatology providers results in poor healthcare outcomes
  • Many psoriasis patients have comorbidities that require management by specialists and

PCPs.

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6 • November 1, 2018

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7 • November 1, 2018

Lack of validated instruments in teledermatology studies

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8 • November 1, 2018

Study Design

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9 • November 1, 2018

Intervention

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10 • November 1, 2018

Example of an Online Encounter

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11 • November 1, 2018

Specific Aims

  • Study Type: Pragmatic, randomized controlled equivalency trial
  • Specific aims:
  • To determine whether CCH results in equivalent improvements in

psoriasis disease severity compared to in-person care

  • To determine whether CCH results in equivalent improvements in

quality of life compared to in-person care

  • To determine whether CCH results in better access to specialists

compared to in-person care

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12 • November 1, 2018

Trial Design

In-person visit frequency determined by patient and provider. Online visit frequency determined by patient and provider. Confirmation of Eligibility and Informed Consent Baseline demographic and clinical characteristics, psoriasis severity, quality-of-life, and mental health assessments Randomization In-Person (Control) Month 3: Psoriasis severity, quality-of-life, mental health, and access-to-care assessments. Month 6: Psoriasis severity, quality-of-life, mental health, and access-to-care assessments. Month 9: Psoriasis severity, quality-of-life, mental health, and access-to-care assessments. Month 12: Psoriasis severity, quality-of-life, mental health, and access-to-care assessments. Qualitative assessment of online intervention (online group only). Patients undergo training on taking digital images

  • f skin lesions and accessing online platform

Online, Collaborative Connected Health (Intervention) Baseline Visit

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13 • November 1, 2018

Baseline Patient Demographics and Clinical Characteristics

Characteristics Online n (%) In-Person n (%) Total n (%) Sex Male 75 (50.7) 74 (50.0) 149 (50.3) Female 73 (49.3) 74 (50.0) 147 (49.7) Race American Indian / Alaska Native 3 (2.0) 2 (1.4) 5 (1.7) Asian 13 (8.8) 6 (4.1) 19 (6.4) Black / African American 5 (3.4) 3 (2.0) 8 (2.7) Pacific Islander 3 (2.0) 2 (1.4) 5 (1.7) White 90 (60.8) 97 (65.5) 187 (63.2) Other 36 (24.3) 36 (24.3) 72 (24.3) Ethnicity Hispanic or Latino 46 (31.1) 54 (36.5) 100 (33.8) Prior Psoriasis Treatment Topical Therapy 98 (66.2) 102 (68.9) 200 (67.6) Light & Laser Therapy 52 (35.1) 53 (35.8) 105 (35.5) Non-Biologic Systemic Therapy 54 (36.5) 60 (40.5) 114 (38.5) Biologic Therapy 32 (21.6) 27 (18.2) 59 (19.9) Baseline Psoriasis Severity PASI: mean [95% CI] 4.68 [3.96-5.41] 4.40 [3.80-5.00] blank BSA: mean [95% CI] 9.71% [7.35-12.07] 7.67% [6.14-9.21] blank PtGA: mean [95% CI] 2.18 [2.00-2.35] 2.15 [1.98-2.32] blank

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14 • November 1, 2018

Changes in Psoriasis Severity (PASI) over Time

Changes in psoriasis severity (PASI) are equivalent between online and in-person groups

PASI: -0.27 (95% CI -0.85, 0.31) PASI equivalence margin δ

  • 6.5

δ 6.5

  • 0.27

Armstrong et al, JAMA Network Open

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15 • November 1, 2018

Changes in Psoriasis Severity (BSA) over Time

Changes in psoriasis severity (BSA) are equivalent between online and in-person groups

BSA: -0.05% (95% CI -1.58%, 1.48%) BSA equivalence margin δ

  • 6.5

δ 6.5

  • 0.05

Armstrong et al, JAMA Network Open

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16 • November 1, 2018

Changes in Psoriasis Severity (Patient Global Assessment) over Time

Comparison of Patient Global Assessment between online and in-person groups

PtGA: -0.11 (95% CI -0.32, 0.10) PtGA equivalence margin δ

  • 0.25

δ 0.25

  • 0.11

Armstrong et al, JAMA Network Open

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17 • November 1, 2018

Specific Aims

  • To determine whether CCH results in equivalent improvements in

psoriasis disease severity compared to in-person care

  • To determine whether CCH results in equivalent improvements in

quality of life compared to in-person care

  • To determine whether CCH results in better access to specialists

compared to in-person care

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18 • November 1, 2018

Changes in Quality of Life (Skindex-16) over Time

Changes in quality of life (Skindex-16) are equivalent between online and in-person groups

Skindex-16: -0.83 (95% CI -5.18, 3.51) Skindex-16 equivalence margin δ

  • 7.0

δ 7.0

  • 0.83

Armstrong et al, Journal of Investigative Dermatology

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19 • November 1, 2018

Changes in Quality of Life (DLQI) over Time

Changes in quality of life (DLQI) are equivalent between online and in-person groups

DLQI: -0.45 (95% CI -1.29, 0.38) DLQI equivalence margin δ

  • 2.5

δ 2.5

  • 0.45

Armstrong et al, Journal of Investigative Dermatology

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20 • November 1, 2018

Specific Aims

  • To determine whether CCH results in equivalent improvements in

psoriasis disease severity compared to in-person care

  • To determine whether CCH results in equivalent improvements in

quality of life compared to in-person care

  • To determine whether CCH results in better access to specialists

compared to in-person care

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21 • November 1, 2018

Differences in access to care between online and in-person groups:

Average total distance traveled and waiting time per person during the year

Ford et al, Telemedicine and e-Health

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22 • November 1, 2018

Patient Perspectives

“Yes [online visits] are efficient because they are on the spot. They are there when one most needs them. For me this is what

  • matters. The service is fast and
  • accessible. When one needs

them, they are there fast.” “That was, for me, very

  • easy. I’m very comfortable

being online, and it was well designed –so easy to

  • use. I think it was fairly

intuitive.” “[Online care] has actually helped me out a lot, so it’s kind of cool. I’m glad I found your study. It’s been working really well. I notice significant improvement. It’s awesome.” “It was almost no difference, particularly with these skin conditions. If the physician is capable of making an assessment online, the treatment is going to be the same regardless. I don’t see a problem with it.”

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23 • November 1, 2018

Considerations for implementation

Telehealth technology Reimbursement Medicolegal considerations Workforce considerations

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24 • November 1, 2018

Conclusions

  • Online model produced equivalent outcomes in disease severity

and quality of life and superior access to care.

  • Patient-centeredness: increased patient engagement and

comprehensive specialist support.

  • Transformative and applicable to other chronic diseases.
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25 • November 1, 2018

Learn More

  • www.pcori.org
  • info@pcori.org
  • #PCORI2018
  • https://armstronglab.usc.edu/
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26 • November 1, 2018

It takes a village!

  • April W. Armstrong, MD, MPH
  • Paulina M. Young, BS
  • Cindy J. Chambers, MD, MAS,

MPH

  • Emanual Maverakis, MD
  • Michelle Y. Cheng, MD
  • Cory A. Dunnick, MD
  • Mary-Margaret Chren, MD
  • Joel M. Gelfand, MD, MSCE
  • David J. Wong, MD, PhD
  • Brittany M. Gibbons, MPH
  • Caitlin M. Gibbons, MSSW
  • Josefina Torres, MD
  • Andrea C. Steel, MD
  • Elizabeth A. Wang, BA, BS
  • Caitlin M. Clark, BS
  • Sanminder Singh, BS
  • Heather A. Kornmehl, BS
  • Reason Wilken, MD
  • Aleksandra G. Florek, MD
  • Adam R. Ford, BS
  • Chelsea Ma, MD
  • Nazanin Ehsani-Chimeh, MD
  • Sucharita Boddu, MD
  • Mayumi Fujita, MD, PhD
  • Cesar Rivas-Sanchez
  • Brenda I. Cornejo, BA
  • Laura C. Serna, BA
  • Eric R. Carlson MS
  • Christianne J. Lane, PhD
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27 • November 1, 2018

Patient-Centered Outcomes Research Institute (PCORI) Award (IHS-071502-IC)

Jason Kao, BS Soneet Dhillon, BS National Psoriasis Foundation State Network of Colorado Ambulatory Practices and Partners High Plains Research Network California Association of Rural Health Clinics Los Angeles Network California Primary Care Association Psoriasis Patient Advocacy Council American Telemedicine Association Group for Research and Assessment of Psoriasis and Psoriatic Arthritis American Academy of Dermatology

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Thank you

April W. Armstrong, MD, MPH

Associate Dean of Clinical Research Vice Chair and Professor of Dermatology University of Southern California Los Angeles, California