Steps towards implementation of protocolized dose reduction of adalimumab, etanercept and ustekinumab for psoriasis in daily practice

Figures & data

Figure 1. Dose reduction protocol.

Abbreviations: PASI: Psoriasis Area and Severity Index; DLQI: Dermatology Life Quality Index.

Figure 2. Summary and timeline of the implementation strategy.

Abbreviations: T: time in months.

Table 1. Baseline characteristics of participating hospitals and usual care procedures.

	Hospital 1	Hospital 2	Hospital 3
Hospital type	Non-academic	Non-academic	Non-academic
PASI performed	Yes	No	Yes
PASI calculation available in electronic health record	Yes	No	No
DLQI performed	Yes	No	Yes
DLQI calculation available in electronic health record	Yes	No	No
DR performed	Yes	Yes	Yes
Time per outpatient visit (dermatologist), minutes	10	10	10
Time per outpatient visit (nurse/nurse practitioner), minutes	20	15	30
Mean number of outpatient visits for psoriasis patients on biologic treatment per year	3	2	3
Total number of patients per biologic
Adalimumab	29	152	75
Etanercept	6	11	12
Ustekinumab	179	37	78

Abbreviations: PASI: psoriasis area and severity index; DLQI: dermatology life quality index; DR: dose reduction.

Table 2. Summarized characteristics of involved healthcare providers.

Characteristic	Total N = 10
Sex (female)	8
Age (years), median (range)	58.5
Profession
Dermatologist	3
Nurse practitioner	3
Nurse	2
Medical assistant	2
Professional experience (years)
5–10	2
10–15	1
15–20	2
>20	5
Experience with biologic treatment (years)
0–5	2
5–10	1
10–15	2
15–20	5
Experience with biologic DR (yes)	7

Data are presented as N unless otherwise indicated. Abbreviations: DR: dose reduction.

Table 3. Overview of (sub)themes and corresponding quotes resulting from the interviews.

	Theme	Subtheme	Quote
Barriers	Healthcare providers’ barriers	Lack of awareness and familiarity	“Everyone knows about the DR protocol, but from experience we have learned that it declines, specifically with the dermatologists. Therefore, I recall it from time to time, for example within staff meetings.” [HCP9]
		Lack of knowledge and disbeliefs about DR	“At first, I thought it to be a large step for those patients: how will I explain this to patients if I think to myself that it won”t be possible? You will convey these feelings to your patients somehow.” [HCP4]
	Patients unwillingness to try DR	Positive experiences with biologic treatment	“Effects are so good, and they have so little side effects of the medication, that”s the largest advantage of biologics over for example methotrexate. And they are so happy with that.” [HCP2]
		Patients’ disbeliefs about DR	“Look, there are patients who are saying: this might be a financial advantage for the hospital. Then I just think, well yes, it is an advantage for the hospital but it is also beneficial for yourself.” [HCP7]
		Fear of disease flares	“People who don”t dare it at all; you can”t convince them. They are so afraid to get back to the situation of having so much limitations in daily life. They just don”t dare it.” [HCP2]
	Practical issues	Incompatibility of the DR protocol with current practice	“Patients visit the doctor or the nurse practitioner at least once a year, but at the doctors” consultation, PASI or DLQI scores are not performed. It”s just because all patients are scattered across different locations and different colleagues, DR is more difficult to apply.” [HCP1]
		Complexity of the DR protocol	“We then just check with the patient how they think it”s going, what they think themselves, and if you see during the physical examination that the psoriasis is cleared, you can decide to start dose reduction.” [HCP3]
		Lack of time	“The consulting hours are very busy and you have different patients every 10 min. The challenge is to sit down and really take the time to explain these things.” [HCP6]
		Lack of available resources	“Your system must be in order to make sure you won”t lose time when processing PASI and quality of life scores, that kind of things. That it just works efficiently, that”s the most important thing because then it will be possible to integrate it into your consultations.” [HCP2]
Facilitators	Healthcare providers’ facilitators	Positive beliefs in the concept of DR	“Less injections are beneficial for patients. Furthermore, dose reduction will reduce costs, which is a good thing as consequently, we can keep prescribing biologics for patients who need them. [….] Yes, I can only see advantages of dose reduction.” [HCP5]
		Awareness and familiarity with DR	“If you will just keep informing each other and everyone will keep paying attention to dose reduction, then I think it will be possible. The whole team, all involved colleagues and dermatologists should stay involved.” [HCP8]
		Access to knowledge and education	“A clear explanation on beforehand is very important. It will make sure that you will be convinced about dose reduction yourself. This is important, as patients will feel it when you will not be convinced yourself. So I think that understanding dose reduction and being convinced about it yourself is very important.” [HCP4] “Such a protocol as was proposed, maybe with reminders or mentioning it again in another staff meeting in order to get the information into everyone”s heads again. Or through an article in our dermatologists” magazine, or at conferences. Yes, those should be the communication channels I think. Or maybe also a webinar.” [HCP6]
	Availability of assistance for healthcare providers	Availability of tools and guidance	“Well, it helps when you are having clear guidance on how to apply dose reduction. And that it is nationally acknowledged, so that you are not doing it randomly.” [HCP8]
		Available staff for support	“From experience, educating patients can best be delegated to nurse practitioners or nurses. You can shortly address dose reduction to patients and the nurse will do the refinements. It just takes too much time. Patients may have a lot of questions and before you know it 10 min will be gone, while you already are running out of time.” [HCP6]
		Availability of resources	“What helps is when your system works well, in a way that you can just work efficiently.” [HCP2]
	Providing support for patients	Patient involvement in the decision-making process	“In one consultation, we prepare patients toward dose reduction. As such, they will have the possibility to think about it and they will get used to it. Within the next visit, we will start with dose reduction. As such, patients can get used to the idea.” [HCP10]
		Patient education	“We have leaflets on our desks and at the time of discussing dose reduction I present the leaflet to the patient. You can also point out the steps. It is just a really clear description and also measurable. Maybe it sounds stupid, but it”s not a black-and-white copy but in real colors, that may also play a role. Speaking for myself, a colorless copy will provide less confidence than a clear leaflet in full color.” [HCP1]
		Patients positive attitudes toward DR	“And eventually, everyone will feel the need to use less medications, that is some kind of a standard opinion in my experience. People want to take as little as possible.” [HCP2]

Abbreviations: DR: dose reduction; HCP: healthcare provider.

Figure 3. Flow chart of included patients, patients eligible for DR and patients starting DR during the intervention period.

Patient data were collected in 2 hospitals. Abbreviations: DR: dose reduction. DR eligibility was based on the following criteria: plaque psoriasis, sustained low disease activity ≥6 months, use of the standard maintenance dose ≥6 months, low impact of psoriasis on patients’ dermatology-related quality of life, no failed previous DR attempt.

Data availability statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.