Implications of treatment resistant severe psoriasis for benchmarking quality of care

In this issue, Schmitt-Egenolf and colleagues report that a substantial proportion of psoriasis patients undergoing systemic treatment of psoriasis still have severe disease (1). Their findings are congruous with previous report that, in real life practice, most patients undergoing systemic, even biologic, treatment still do not have clearing or even almost clearing of their psoriasis (2).

With the growing effort to document and improve quality of health care services, treatment targets are being promulgated. The Medical Board of the National Psoriasis Foundation has proposed a treatment target of 1% or less body surface area (BSA) to evaluate treatment response (3). Is this realistic when even with systemic treatments so many patients still have severe disease, much less not achieving a <1% BSA of remaining disease level of success? Is it a reasonable standard when we know that patients are often non-adherent to the treatments we prescribe (4)?

We dermatologists are very good at what we do, and we like to know that we are very good at what we do. If we choose a 1% BSA cutoff as a measure of success, we are not going to be successful a lot of the time, maybe most of the time. We will be failing a lot of the time by this standard. I would argue that that is totally ok and is the way things should be.

The proposed standard does not ask that we achieve the 1% BSA level of success all the time, only that we use 1% BSA as a cutoff for assessing success. If we were to choose a lower standard, one that is easily and always reached, the resulting metric would be useless as a tool to further improve the quality of the medical care we provide (whether we think of that as prescribing better medicines or as we do a better job getting patients to take the medicines we prescribe, each of which is of considerable importance).

If we are to commit ourselves to objectively measuring our outcomes and continuously improving the quality of what we do, we will need to use metrics that don’t have ceiling effects that limit our ability to detect changes in the quality of care we office. One thing is for sure. Even with the new drugs we have at our disposal, it will not be easy getting a high proportion of psoriasis patients to clearing of all but 1% or less of BSA. Let’s see how good we really are and how good we can be.