Clinical management decisions are related to the impact of psoriasis on patient-rated quality of life

BACKGROUND: Clinical decisions over psoriasis are based on many factors. Patients' quality of life (QOL) is not directly related to disease severity alone as judged by physical signs, so decisions should not be based on physical assessments alone. This is increasingly important as new potent biological therapies become available. OBJECTIVES: This study aimed to determine whether clinicians' routine decisions in psoriasis correlate with patient-rated QOL. PATIENTS AND METHODS: Over 35 weeks all 687 outpatient psoriasis consultations by 13 clinicians were included. Each patient received a Dermatology Life Quality Index (DLQI) questionnaire following their consultation. Case notes were analysed to assign management decisions taken by clinicians to one of 11 categories. Patient-rated DLQI was correlated with the type of management decision. RESULTS: Three hundred and eighty-three completed DLQI questionnaires were analysed. Within the 'no change to main type of therapy' group the mean DLQI for patients not changing the potency, dose or frequency of main treatment was 8.9. For patients in whom the potency, dose or frequency of main treatment was increased, the mean DLQI was 11.9. For patients in whom the potency, dose or frequency of main treatment was decreased, the mean DLQI was 6.2. Major management decisions were associated with a high mean DLQI such as change of topical therapy (11.2), topical to systemic therapy (14.8), change of systemic therapy (16.7), starting photo(chemo)therapy (13) and requiring hospital admission (14.4). By contrast, patients discharged reported low DLQI values (mean 4.0). The cohort of patients in whom a decision was taken to start day treatment had a surprisingly low mean DLQI of 8.6. Significant differences in mean DLQI were seen in the cohorts classified by type of management decision. For example, when the mean DLQI values in each cohort were compared (Mann-Whitney U-test), significant differences were seen between the cohorts in whom treatment was increased in potency, dose or frequency, compared with the cohorts whose treatment was unchanged (P < 0.05) or decreased (P < 0.01) or who were discharged from clinic (P < 0.01). CONCLUSIONS: In psoriasis there is a relationship between the type of management decision and the patient-rated QOL. However, there is a very wide score scatter for each management decision, challenging the appropriateness of some clinical decisions.