Moderate to severe psoriasis is a chronic, incurable disease, with substantial economic consequences for the health care budget. This is the first study to investigate the treatment patterns and resource utilization of psoriasis in Greece and the economic impact of the introduction of a new biologic treatment option.
The current study consisted of two parts: field work with questionnaires to dermatologists to identify resource use data; and a budget impact model to estimate the costs associated with adding ustekinumab to the current treatment options for psoriasis. The collection of resource use data through face-to-face interviews with physicians, rather than being derived from clinical trials or observational studies, could be criticized on the grounds of subjectivity and be considered a limitation of this study. However, in order to strengthen the validity of the data collected, an expert panel consisting of key opinion leaders was set up to assess the primary results.
The selection of dermatologists to participate in the primary research was mainly based on the level of experience they had with psoriatic patients, the rationale being that physicians with more experience on psoriasis would be able to provide more robust estimates for the parameters investigated in the study. As a result, the estimated eligible patient population entering the model in year 1 is potentially shifted upwards compared to actual numbers, leading to a subsequent overestimate in the budget impact of the related biologic treatments. However, the results of the present study in terms of cost differences across treatments, are not affected, as the eligible population is the same for all treatments and therefore has a proportionate impact on respective budgets.
The results reveal that etanercept is currently the preferred treatment option for moderate to severe psoriasis, followed by adalimumab and infliximab. An interesting finding is that although etanercept and adalimumab are administered at home for the majority of patients, patients more commonly visit hospital-based physicians than the private offices of dermatologists to monitor their treatment progress. This may be attributed to the fact that specialized psoriasis centers are located in some hospitals.
The results also show that resource utilization and related costs increase with disease severity, a finding confirmed by the literature . Moreover, the investigation of the budget impact of adding ustekinumab as a treatment option for psoriasis shows that this would lead to substantial cost savings, even in the first year of its introduction.
The therapeutic benefits of ustekinumab have been confirmed in three large Phase 3 trials in patients with moderate to severe psoriasis [25, 26, 28]. These studies found that a significantly higher proportion of patients receiving ustekinumab compared with placebo or etanercept achieved PASI 75 at 12 weeks. Other efficacy measures, including the Physician’s Global Assessment at week 12, also favored ustekinumab [25, 26, 28]. Moreover, subcutaneous ustekinumab was generally well tolerated [24–26, 28]. Treatment with ustekinumab has also been found to result in significantly improved HRQoL (Dermatology Life Quality Index) [33, 34], lowered depression and anxiety rates based on the Hospital Anxiety and Depression Scale , and improved employability and productivity .
A possible shortcoming of the present study is that hospitalization and outpatient costs may have been underestimated. Social health insurance fund tariffs, which have been used in this model, do not reflect actual costs; actual costs are higher than the amount reimbursed by insurance funds.
Another limitation is that indirect costs were not considered. Indirect costs related to psoriasis include lost work time (i.e., days missed from work) and reduced productivity. Indirect costs increase with disease severity and can be significant . In a UK study, 59.3% of patients with psoriasis who were still working had lost an average of 26 days from work in the previous year because of their psoriasis, and of the 180 patients not working, 33.9% reported not working because of their psoriasis . A study in Germany showed that the mean indirect costs and loss of productivity per patient with psoriasis were €1,310 per year, accounting for 19.5% of total psoriasis costs . However, clinical trials of biologics, including ustekinumab, demonstrate that patients who respond to treatment experience improvements in productivity and reductions in work-day loss. Therefore, the omission of indirect costs in this analysis is unlikely to adversely affect the research findings.
An important finding of this study is that, based on expert opinion, 67.5% of ustekinumab-treated patients will initially be administered the product in hospital rather than at home or in their dermatologist’s private office. This is probably due to physicians’ reservations regarding a new biologic agent. According to the expert panel, reinforcement of ustekinumab’s efficacy and safety data with local dermatologists’ own experience is likely to lead to patients receiving the drug outside of the hospital setting. The expert panel’s opinion was that similar treatment patterns as with etanercept and adalimumab (where 58% and 60% of patients, respectively, perform administration at home) are expected for ustekinumab users in the future.
Two Phase 3 studies of ustekinumab have shown that the drug has a comparable safety profile with self-administration versus administration by a health care professional [25, 26]. A movement toward more frequent administration at home rather than in the hospital setting could further reduce the direct costs of ustekinumab use.
Overall, the present study investigated, for the first time in Greece, the treatment patterns and resource utilization of patients with moderate to severe psoriasis. These findings may be used to inform the development of national treatment guidelines in psoriasis and health policy resource allocation decisions.