Multiple aspects of psoriatic disease addressed with combined clinic model

Psoriatic disease management needs input from both rheumatologists and dermatologists, and a growing number of practitioners have begun to combine clinics or collaborate efforts with their fellow specialists.

“Psoriatic disease affects several different domains, including the skin and the joints. Psoriasis is not one disease — it’s multiple different diseases,” Christopher T. Ritchlin, MD, MPH, professor and chief of the division of allergy, immunology and rheumatology at the University of Rochester Medical Center, said.

“A lot of patients with psoriasis have complicated disease that involves different comorbidities, such as obesity, metabolic syndrome, psychiatric problems, Crohn’s disease, uveitis, etc,” Francisco Tausk, MD, professor of dermatology at the University of Rochester Medical Center, said. “Psoriasis really is a systemic disease, not just a disease of the skin, and a lot of patients have complicated disease, and they require different doctors to take care of their problems.”

Ritchlin and Tausk lead the team at the Psoriasis Center at the University of Rochester Medical Center, a location that takes a multidisciplinary approach to treating psoriatic disease. In addition to Ritchlin’s rheumatology expertise and Tausk’s specialization in dermatology, the office includes a psychiatrist and a social worker along with links to endocrinology, cardiology, gastroenterology and ophthalmology to treat all the issues related to psoriatic disease.

The Rochester clinic is one of approximately 20 combined clinics in the United States. A 2017 survey of combined clinic practitioners published in the Journal of Rheumatology found benefits to the model, including improved communication, increased training opportunities and faster diagnosis of psoriatic arthritis (PsA); however, the evolving treatment model is not without its challenges.

Bridging treatment gaps

Biologics have been a game changer in the treatment of psoriasis, but the treatment of PsA has not evolved at the same rate, leaving a treatment gap, according to Ritchlin.

“In arthritis, we really need to up our game and achieve deeper states of response,” he said. “There are 13 drugs approved by the Food and Drug Administration for psoriatic arthritis, and yet, our clinical trial outcomes really have not significantly improved since Phil Mease performed his first trial with etanercept in 2000, so that’s a big gap for us.”

Combined clinics may be able to help bridge this gap by allowing specialists to work together and develop combined treatment plans for the full range of disease.

“It’s a big unmet need,” Jose U. Scher, MD, a rheumatologist at NYU Langone Medical Center, said. “The question is, ‘How do we tackle those that have to do more intensive treatments?’ Having other specialists in the same room will be quite helpful because not only can we target the skin inflammation, but also arthritis or axial disease. Psoriatic arthritis is a multidomain, multicytokine disease. Why are we not combining medications?”

Combined clinics can also help to identify psoriatic arthritis faster, according to Andrea L. Neimann, MD, MSCE, clinical assistant professor at Ronald O. Perelman Department of Dermatology at NYU Grossman School of Medicine.

“One of the [treatment] gaps is early identification and management in psoriatic arthritis in patients with long-standing psoriasis,” she said. “Quite a high percentage of patients with psoriasis have concomitant psoriatic arthritis, and unless practitioners have that in mind, this may be missed.”

Having a team of experts following up with both the patient and each other could allow practitioners to catch the signs and symptoms of disease earlier.

Another treatment gap in psoriatic disease management includes a failure to keep comorbidities at a minimum, most notably obesity and depression.

This is why the Rochester Psoriasis Center employs a psychiatrist as well as a nutritionist and has consults with a social worker.

“The main gap is that when you have fragmented health care where the doctors don’t really talk to each other, the treatment becomes much more difficult,” Tausk said. “We’re able to bridge that gap of being both together and discussing among ourselves with the patients to reach a better solution. I think this clinic has been extremely effective just because of that fact.”

Treatment outcomes and patient satisfaction

While objective data detailing the treatment outcomes of combined clinics do not fully exist yet due to the small number of clinics and their relatively short existence thus far, subjectively many clinicians see a marked improvement in patient satisfaction.

“In general, our patients have been more adherent to their treatment plans. We see them return to dual clinics more often, or at least at the right time,” Scher said.

Zelma C. Chiesa Fuxench, MD, MSCE, assistant professor of dermatology at the University of Pennsylvania Perelman School of Medicine, agreed. In her clinic, she has seen patients have drastic improvements in psoriatic disease due to earlier diagnosis.

“Being able to collaborate with my rheumatology colleagues early on allows me to select a more appropriate treatment option vs. just guessing,” she said. “In the long run, that helps me treat both conditions. Working with the rheumatology team is critical to bring both the skin and joint symptoms into control because it has an impact on quality of life. Overall, I think it’s led to better patient outcomes.”

Advancing research

Collaboration can also benefit in research settings as more is understood about psoriatic disease and its inflammatory nature.

“Combined clinics create an atmosphere of collaboration, facilitate the generation of research ideas and help identify gaps and challenges in patient care that help generate important questions for trial outcomes and treatment strategies,” Neimann said.

At the Rochester Clinic, Ritchlin and Tausk are involved in multiple studies supported by the National Psoriasis Foundation and the NIH.

“The only reason we’re able to carry out these studies and include patients with psoriasis and PsA is that we have a close relationship with dermatology, and we are constantly going back and forth referring patients,” Ritchlin said. “Having that kind of communication is vital to the success of research programs and recruitment. It’s really a critical element to how we can carry out this research and try to move the field forward.”

Looking at just one aspect of the disease limits potential for research opportunities, whereas looking at psoriatic disease as a whole allows for more nuanced developments.

“Without the two ends of the spectrum, psoriatic arthritis and psoriasis, we won’t be able to advance research,” Scher said. “Right now, there are wonderful examples of how combined clinics can lead to potentially paradigm-shifting collaborations.”

Approximately 20% of patients with psoriasis go on to develop PsA. Learning which patients could develop more serious disease is a crucial element to the future of psoriatic disease research. Therefore, having dermatologists and rheumatologists working together to figure this out, as well as how to possibly prevent disease progression, can only benefit patients.

“This is a perfect opportunity to have these specialties working together to study the natural course of the disease,” Chiesa Fuxench said. “Having the combined clinic may allow you the opportunity to study that course of disease in the long term.”

Training the next generation of specialists

This paradigm shift to thinking of psoriatic disease comprehensively also affects new specialists coming up in the ranks. Previously, dermatology or rheumatology residents may have studied with their specialty-specific counterparts, but the next generation could benefit by working alongside each other.

“It is crucial for dermatologists to be familiar with psoriatic arthritis, being able to diagnose it and being able to incorporate it into the treatment of psoriasis,” Tausk said. “The only way to take care of the patient with psoriasis is to see him as a whole, not to fragment each different tissue and having a specialist for each one.”

This could be especially important in smaller practice settings and more remote areas where patients may not have as much access to multiple specialists.

“I’m fortunate because I work in an environment with rheumatologists across the hall, but what if I was a dermatologist working in a smaller community-based practice?” Chiesa Fuxench said. “Wouldn’t I want to have those skills to better diagnose psoriatic arthritis? Wouldn’t I want to be comfortable knowing how to do a more full or detailed joint exam and knowing what to look for? This is why I think it’s critical to have these combined clinics. We’re moving from the realm of this not just being a skin disease but a systemic disease, and we need to assess all those symptoms.”

Addressing challenges

Combined clinics have multiple benefits for patients and practitioners, but they are not without their challenges. The main problems facing those who decide to embark on starting or joining a shared clinic include issues with scheduling and billing.

First, a dermatologist generally sees many more patients in a day than a rheumatologist might. Therefore, scheduling joint visits can get tricky.

“The reality is that these multidisciplinary clinics don’t happen every day. They’re often just a few times a month, and there is a logistical challenge with scheduling just with the nature of the specialties,” Neimann said.

Billing and reimbursement can present a host of challenges. For combined clinics where patients see both practitioners at the same time, they will often have two copays or multiple bills.

“We double bill because they’re seeing two specialists,” Ritchlin said. “These are things you need to work out. In some institutions, there are more barriers to that than others. The logistical issues that may be present at a particular institution or private practice need to be overcome.”

For those not in a large institutional setting, this might mean using a referral system rather than a true combined clinic.

Chiesa Fuxench recommended having a system in place with trusted co-specialists who will work to treat the patients jointly.

“The first step is to identify a group of providers that you can refer to,” she said. “Establish those open bridges of communication to get your patients in as quickly as possible.”

In all, the process of treating patients in a combined clinic has shown more net benefits in the short time they have been in effect, but practitioners should be aware of these challenges before beginning or joining a combined practice.

“The concept is very simple: to get a rheumatologist and dermatologist together in the same room. It’s not very complicated, and the advantages are enormous,” Tausk said.

“The combined clinic model is going to continue to develop with novel approaches and strategies to improve outcomes for patients with psoriatic disease,” Ritchlin said. “I think we’re going to see a lot more of these clinics come into being.”

• References:
• Haberman R, et al. Curr Rheumatol Rep; 2018;doi:10.1007/s11926-018-0785-6.
• Okhovat JP, et al. J Rheum. 2017;doi:10.3899/jrheum.170148.
• Soleymani T, et al. Curr Rheumatol Rep. 2017;doi:10.1007/s11926-017-0706-0.

• For more information:
• Zelma C. Chiesa Fuxench, MD, MSCE, can be reached at Perelman Center for Advanced Medicine, 3400 Civic Center Blvd., 7th Floor, Philadelphia, PA 19104; email: zchi@pennmedicine.upenn.edu.
• Andrea L. Neimann, MD, MSCE, can be reached at 240 East 38th St, 11th Floor, New York, NY 10016; email: andrea.neimann@nyulangone.org.
• Christopher T. Ritchlin, MD, MPH, can be reached at Allergy, Immunology & Rheumatology Division, 601 Elmwood Ave., Box 695, Rochester, NY 14642; email: christopher_ritchlin@urmc.rochester.edu.
• Jose U. Scher, MD, can be reached at NYU Langone Orthopedic Center, 333 E. 38th St., 4th Floor, New York, NY 10016; email: jose.scher@nyulangone.org.
• Francisco Tausk, MD, can be reached at 400 Red Creek Drive, Suite 200, Rochester, NY 14623; email: francisco_tausk@urmc.rochester.edu.