Derm-rheum clinic offers 'one-stop shop' to plug gaps in PsA care, improve outcomes
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The combined “derm-rheum” clinic offers a unique opportunity to streamline care and improve drug access for patients with psoriatic arthritis while enhancing cross-disciplinary education among dermatologists and rheumatologists, noted a speaker at a recent summit.
Historically, dealing with the spectrum of psoriatic disease from a siloed approach to care has limited effective management of the disease, with specialists from either side unsure about how best to address its range of comorbidities, according to Joseph F. Merola, MD, MMSc, director of the Center for Skin and Related Musculoskeletal Diseases at Brigham and Women’s Hospital.
“I think it’s safe to say there still remains some limited awareness of psoriatic arthritis among non-rheumatologists,” Merola told attendees at the 2021 Interdisciplinary Autoimmune Summit. “[On the other hand], rheumatologists don’t always feel comfortable treating the skin element or recognizing its impact on quality of life.”
Gaps to Care
Diagnosis of PsA can be challenging at times, even among experienced rheumatologists, Merola noted, and a delay in recognizing the different domains of disease and their respective treatments can represent a barrier to effective patient care.
“Many dermatologists are just not familiar with doing a musculoskeletal exam,” Merola said. “Part of dermatology residency, historically, doesn’t necessarily include a deep dive into how to do a musculoskeletal exam or a thorough history.”
With regard to management, a lack of familiarity with different domains of the disease, such as how to screen for/diagnose enthesitis or inflammatory back pain with axial involvement, can be challenging for dermatologists.
“Then, of course, the breadth of systemic therapies — which work for which domain, how do they mesh with comorbidities — can lead to further complications and additional challenges,” Merola said.
Likewise, the rheumatologist’s lack of familiarity with different psoriasis presentations, and the range of topicals and combination therapies to optimize skin disease also affect patient outcomes.
“The clear gap for rheumatologists is how to manage the skin,” Alexis Ogdie-Beatty, MD, director of the Psoriatic Arthritis and Spondyloarthritis Program at the University of Pennsylvania, said. “It’s easy enough to treat plaque psoriasis as most of our medicines are going to treat the psoriasis. But when they don’t or when the psoriasis recurs, we are the ones seeing the patient pretty regularly so the patient comes back to ask about psoriasis in their ear or scalp or back, or a big flare of inverse psoriasis or genital psoriasis that they feel comfortable telling me about but they don’t really want to go expose themselves to a dermatologist.
“There is a lot that we hear about as rheumatologists that we may or may not be comfortable treating,” Ogdie-Beatty noted. “For the elbow or knee, that is fairly easy, but when it gets to more complex issues like inverse psoriasis, pustular psoriasis, those are really hard, especially when patients have failed multiple therapies before. This where having a dermatologist across the hallway is so critical.”
Joint Approach
“What is the value of a combined clinic model?” Merola asked. “We’d like think it certainly benefits the patient through education, one-stop shopping, a wider array of therapies; it fact it does seem to get patients more quickly transitioned to appropriate systemic therapy.”
He added, “On the other side, there are multiple benefits to providers almost across the board, those who engage in these activities report increased collegiality, improved work satisfaction, and just being able to learn about the other side of the disease and interact with other colleagues.”
In a 2017 study published in the Journal of Rheumatology, Merola and colleagues conducted a cross-sectional survey of centers with dual dermatology-rheumatology clinics. The researchers noted that the most common reported benefits of combined clinics were improved communication between health care teams, advanced training opportunities and prompt and accurate diagnosis of PsA.
In addition, more than half of the respondents noted that combined clinics enabled more frequent monitoring, improved recruitment for clinical trials and observational studies, and created satisfying and rewarding interactions with colleagues.
“[Under the combined clinic model] we are teaching rheumatology fellows how to get comfortable with the dermatology differential, use of topicals, treat-to-target,” Merola said. “Meanwhile the dermatology residents are learning the rheumatology exam, and getting more comfortable with systemic agents.”
Systemic Challenges
The derm-rheum combined clinic is not without its own obstacles, however. In their 2017 survey, Merola and colleagues reported the most frequent challenges of this approach included scheduling the right mix of patients, filling both specialists’ schedules appropriately and demonstrating the value of the clinic to the academic institution to order to obtain its ‘buy in.’
“One of the challenges is the way in which the American medical system is set up and how payment is processed,” Ogdie-Beatty said. “If you are seeing two specialists in the same room, it’s hard to draw up a bill — you would have to draw up two separate bills, two separate copays. You can’t bill for the same things and you have to have two completely separate notes.”
She noted that although there are many different obstacles in this burgeoning care model, “there are a lot of creative ways that people are doing this too.”
Some creative solutions around challenges in the billing system have included combined clinics where specialists took appointments monthly, twice monthly or weekly. Some clinics have opted for an entirely virtual session. Facilitating communication between the specialists was a “key ingredient” for the success of combined clinic, with each physician either communicating directly with their counterpart through text or “phone a buddy” arrangements, or through the electronic medical record or shared note templates.
“We were recently talking to private practice groups who were sharing patients; one would go to the other practice for half a day every other week, and that fostered collaboration between the dermatology and rheumatology groups as well,” Ogdie-Beatty said.
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Merola JF, Ogdie-Beatty A. Psoriatic Arthritis: Combining Clinics, Combining Efforts, Combining Therapies. Presented at: 2021 Interdisciplinary Autoimmune Summit (IAS). April 15-18, 2021 (virtual meeting).
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