Medical resource consumption of moderate/severe psoriasis in a private health organization of Buenos Aires, Argentina,

Anais

Brasileiros

de

Dermatologia

www.anaisdedermatologia.org.br

INVESTIGATION

Medical

resource

consumption

of

moderate/severe

psoriasis

in

a

private

health

organization

of

Buenos

Aires,

Argentina

夽,夽夽

María

Laura

Galimberti

,

Aldana

S.

Vacas

,

Barbara

A.

Hernández

,

María

L.

Bollea

Garlatti

,

María

J.

Cura

,

Ricardo

L.

Galimberti

DermatologyDepartment,HospitalItalianodeBuenosAires,BuenosAires,Argentina Received6November2018;accepted19April2019

Availableonline6December2019

KEYWORDS Argentina; Costofillness; Psoriasis

Abstract

Background: Despitetheeconomicburdenofpsoriasisforpatientsandsocieties,scant infor-mationexistsregardingtheimpactandburdenofthediseaseinArgentina.

Objective: Theobjectiveofthisstudywastoestimatemedicalresourceconsumptionanddirect healthcarecostsforpatientswithmoderate/severepsoriasisinBuenosAires,Argentinafrom theperspectiveofthepayer.

Methods: Adultswithmoderate/severepsoriasis(severitywas definedasreceivingsystemic treatment),duringJanuary2010---January2014,aged18yearsandolder,membersoftheItalian HospitalMedicalCareProgramwithatleast18monthsoffollow-upwereincluded.Alldataon hospitalizations,drugprescription,outpatientepisodes,consultations,andinvestigations/tests inthe12monthsbeforeinclusioninthestudywereconsideredfortheestimationofmedical resourceconsumptionanddirecthealthcarecosts.First-quarter2018costswereobtainedfrom theIHMCPandconvertedintoUSdollars(usingtheJanuary2018exchangerate).

Results: Atotalof791patientswereincluded.Themeanageatdiagnosiswas34±12years. Almost65%ofthepatientshadadermatologistastheirusualsourceofcare,43%hadinternists, and14%hadrheumatologists.TheaverageyearlydirectcostwasUS$5326(95%CI:4125---7896) perpatientperyear.

Studylimitation: Thesinglecenterdesignandtheretrospectivenaturearethemain limita-tions.

夽 _{Howtocitethisarticle:GalimbertiML,VacasAS,HernandezBA,GarlattiMLB,CuraMJ,GalimbertiRL.Medicalresourceconsumption}

ofmoderate/severepsoriasisinaprivatehealthorganizationofBuenosAires,Argentina.AnBrasDermatol.2020;95:20---4.

夽夽_{StudyconductedattheDermatologyDepartment,HospitalItalianodeBuenosAires,BuenosAires,Argentina.} ∗_{Correspondingauthor.}

E-mail:maria.galimberti@hospitalitaliano.org.ar(M.L.Galimberti).

https://doi.org/10.1016/j.abd.2019.04.007

0365-0596/©2020SociedadeBrasileiradeDermatologia.PublishedbyElsevierEspa˜na,S.L.U.ThisisanopenaccessarticleundertheCC BYlicense(http://creativecommons.org/licenses/by/4.0/).

Conclusion: ThisisthefirstArgentinestudythatevaluatedthecostsofmoderate/severe pso-riasisbytakingintoconsiderationthedirectmedicalcostsofthedisease.

©2020SociedadeBrasileira deDermatologia.PublishedbyElsevierEspa˜na,S.L.U.Thisisan openaccessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).

Introduction

Psoriasisisachronicinflammatoryimmune-mediated prolif-erativeskindisorderthatpredominantlyinvolvestheskin, nails,andjoints.1,2

In2014,MemberStatesoftheWorldHealthOrganization (WHO)recognizedpsoriasisasaseriousnon-communicable disease and adopted the resolution of the World Health Assembly(WHA),whichcallsformultilateraleffortstoraise awareness andfight stigma.The worldwideprevalence of psoriasisisestimatedtobeapproximately1---3%.2,3

Although psoriasis is not usually a life-threatening disease, several studies have shown that it has a signifi-cant impactonmedicalresourceconsumption inaffected patients.4,5

Despitetheeconomicburdenofpsoriasisforthepatient and for society as reported by several authors,6---8 _scant

informationexistsregardingtheimpactandburden ofthe diseaseinArgentina.Tobetterunderstandthisimpact,the objective of this study was toestimate medical resource consumptionanddirecthealthcarecostsforpatientswith moderate/severepsoriasisinBuenosAires,Argentinafrom theperspectiveofthepayer.

Methods

A retrospective, epidemiological, and observational study wasconducted.Thepopulationstudiedincludedthe mem-bersoftheItalianHospitalMedicalCareProgram(IHMCP), aprepaidhealthmaintenanceorganization.TheIHMCP pro-vides comprehensive medicaland health services through two main hospitals and 24 medical offices to more than 164,456 members, primarily located in the urban areas within theautonomous city of Buenos Airesin Argentina. The city covers an area of 202km2 _{and has a subtropical}

climate. It is located on the western bank of the Río de la Plata and has a population of 2,890,151.9 _{All patients}

whowerediagnosedwithmoderate/severepsoriasis (sever-ity was defined as receiving systemic treatment) during January2010---January2014,18yearsandolder,whowere members of the IHMCP and with at least 18 months of follow-up, were included in the study.6 _{Multiple methods}

ofcase retrievalwereusedtoensurecomplete ascertain-ment:(1) patientsincluded indermatology databases;(2) patientswiththeInternationalClassificationofPrimaryCare codeintheIHMCPcomputer-basedpatientrecordsystem; and(3)patientswiththeInternationalClassificationof Dis-eases,Ninth Revisioncode onadmissiontohospital.Each potentiallyeligiblesubjectunderwentastandardprocedure (clinicalexamandbiopsy)toconfirmthediagnosisby derma-tologyexperts.Thestudyprotocolandquestionnairewere approvedbytheEthicsCommitteebeforetheinitiationof thestudy.

Resourceutilization

Data on hospitalizations, drug prescription, out-patient episodes,consultationswithgeneral or specialist medical practitioners, and investigations/tests in the 18 months beforetheinclusioninthestudywerecollectedfrom elec-tronicrecordsoftheincluded patients.Electronicrecords ofIHMCPpatientsprovidedailyroutineinformationontheir diseasesandtherapies.

Costs

Costs were calculated using the bottom-up approachand grouped by perspective. To obtain the annual cost per patientperyear, annualizedresources weremultipliedby the irrespectiveunit costs. January 2018 unit costs were derivedfromtheIHMCP.Theunitcostsin Argentinepesos were converted to US dollars using the January 2, 2018 exchangerate(US$1=AR$19.23).Unit costsderived from the IHMCP were compared with those from the public sources of Argentina, including the National institute of StatisticsandSurveys,9_{theNationalCostDatabase}

(Nomen-clador Nacional),10 _{and the Public Price List of Drugs}11

to avoid significant differences. For the direct analysis cost, systemic therapy was stratified into the following: (a)biologic systemictreatment; (b) non-biologicsystemic treatment;and(c)othersystemictreatmentthatincluded UVandPUVAtherapy.Unitcostsareshownintable1. Statisticalanalysis

Patients’ demographic and disease characteristics, as well as resource utilization and costs, were analyzed using descriptive statistics (percentage, mean, and SD). Confidence intervals (95%) were estimated by using non-parametricbootstrapping.Anon-parametricstatisticaltest (Wilcoxon---Mann---Whitney test) for independent samples wasusedtodeterminewhetherdifferencesbetween com-parisonsperformedwerestatisticallysignificant(p<0.05). Statav.10.1 software(Stata Corp.--- CollegeStation,TX, UnitedStates)wasusedfortheanalysis.

Results

Patientcharacteristics

Atotalof791patientswereincludedinthestudy.Themean ageatdiagnosis was34±12years,49%werewomen,and themeandiseasedurationwas10±16years.Otherpatient characteristicsarepresentedintable2.

Thepatientsweretreatedwithbiologicandnon-biologic medications.Patientsarepresenteddescriptivelyintable3.

Table1 UnitcostsinUSdollars.

Unitcosts USdollars

Specialistconsultation,dermatology 36

Generalconsultation 26

Specialistconsultation,rheumatology 34

Emergencyroomcare(day) 110

Hospitaladmissions(day) 186

PUVAtherapy(percycleof24sessions) 1745 UVB(percycleof24sessions) 2153

Cyclosporine(monthlycosts) 312

Methotrexate(monthlycosts) 26

Acitretin(monthlycosts) 74

Etanercept(monthlycosts) 2398

Adalimumab(monthlycosts) 2389

Ustekinumab(monthlycosts) 2480

Infliximab(monthlycosts) 3968

Certolizumab(monthlycosts) 2294

Golimumab(monthlycosts) 2250

Table2 Baselinecharacteristicsofpatientsenrolled.

n 791

Malesex 387

Femalesex 404

Meanage(years±SD) 34±12

Yearssincediagnosis,SD 10_±16

Palmoplantar,n(%) 31(4) Guttate,n(%) 55(7) Plaques,n(%) 672(85) Pustulosa,n(%) 16(2) Erythrodermic,n(%) 16(2) SD,standarddeviation.

Table3 Treatmentreceivedbyincludedpatients.

n %

Patientswhoreceivedsystemicbiologic treatment

99 12.5

Patientswhoreceivedsystemic non-biologictreatment

675 85

Patientswhoreceivedothersystemic treatment(PUVAandUVB)

323 41

Resourceutilization

Almost65%ofthepatientshaddermatologistastheirusual sourceofcare,43%hadinternists,and14%had rheumatol-ogists.Only8%ofthepatientshadhadanemergencyroom admission to manage psoriasis symptoms. Data on other resourceutilizationbypatientsarepresentedintable4. Costs

Directcostswereobtainedfromresourceconsumption, as previouslydescribed.Themostrelevantsourceofcostswas themedicaltreatmentreceived,followedbyphysician vis-its.TheaverageyearlydirectcostperpatientwasUS$5326 (95%CI:4125---7896).

Allcostsobtainedfromresourceutilizationarepresented intable4.

Discussion

Withtheintroductionofbiologicsoverthepastyears,there has been amarked shiftin treatment modalitiesthat has resultedinagreatneedfor theupdatingofcosts.8_{This is}

thefirststudyperformedinArgentinaandintheregionthat evaluatesthecostsofpsoriasisbytakingintoconsideration thedirectmedicalcostsofthediseaseinthe moderate-to-severestage.Meanannual costperpatientwasestimated atUS$5326.

This study is consistent with previous cost-of-illness studies performed in Germany and some European countries.6,8,12_{InGermany,Jungenetal.evaluatedprimary}

dataon1158patientscollectedinarealcaresetting(a ran-domsamplefrom132centersacrossGermany).8_Themean

costwasD 5543 (medianD 2030).8_{The totalcostsfound}

byotherauthorsrangefromD 1079perpatientperyearin Spain,fromD 387toD 6398inSwitzerland(including bio-logics),andD 11,434inItaly(PASI>20).13_{Variationsincosts}

canbeexplainedbyyearofdata,differencesinhealthcare systems(especiallypricingofmedication),and methodolog-icaldifferences suchaspayerperspective andseverity of disease.13 _{InGermany, in moderate-to-severeplaque-type}

psoriasis,theout-of-pocketcostswereestimated tobeD 794 per year onaverage (15% of the mean total costs of that study).6 _{Berger et al. estimated D 562 (20% of the}

meantotalcostsofthatstudy).14_{Anotherstudyperformed}

in nine states of the United States, which included 200 patients with moderate-to-severe psoriasis and evaluated healthcareresourcesforsixmonths,showedthatthedirect costin that populationwasUS$ 11,291 andindirect costs wereUS$2101.12_{Inthatgroupofpatients,79.5%were}

pre-scribed one or more biologic medications for psoriasis to controlthedisease.12

Thepresentstudyhasmanylimitations.First,the sam-ple involves patients from only one center. Therefore, a largersamplethatinvolvesmorecenterswouldbenecessary togeneralizetheresults.Thesecond limitationistheway theinformationwasobtained(retrospectively,bycollecting informationfrommedicalrecords).Nevertheless, consider-ingthatthepatientsfromtheIHMCPareseensolelyinits owncentersandthatallmedicalrecordsareregistered,the possibilityofbiasislow.Thethirdlimitationisthatindirect costswerenotobtained.

In Argentina, this is the first study designed to cap-ture the economic burden of the disease. The important and novel informationprovidedabout thedisease-related economic burden is the main contribution of this study to the existing literature for psoriasis both in Argentina and the regionin terms of costs in a developing country. This information is a valuable tool for relevant and wise decision-making in the field by understanding the exact behaviorofthediseaseinthelocalsetting,andis supple-mentarytotheuse ofinformationfromEuropeandNorth America,wherebothresourceutilizationandcostsmaybe quitedifferentfromthoseobservedinadevelopingcountry likeArgentina.2,7

Table4 Resourceutilizationandannualdirectmedicalcostsofincludedpatients(n=791). n=791

Resourceconsumption Annualdirectmedicalcosts

Resources Unit %(n)ofresource

utilizationa Mean±SDof resource utilizationa Mean 95%CI Specialist consultation, dermatology Visits 65(1536) 0.7(0.3) 16.3 9---21.2

Generalconsultation Visits 47(1583) 1.01(0.6) 12.3 8.5---15.5

Specialist consultation, rheumatology

Visits 14(331) 0.1(0.01) 5.2 3.1---7.2

Emergencyroomcare Visits 8(189) 0.09(0.01) 2.5 1.1---3.7

Hospitaladmissions Days 14(330) 0.08(0.009) 4.1 2.1---5.8

Systemicbiologic treatment Patients 12.5(99) NA 3450 3113---4560 Systemicnon-biologic treatment Patients 85(675) NA 1097 867---1234 Othersystemic treatment(PUVA andUVB) Patients 41(323) NA 867 1123---1879

Totaldirectmedical costs(US$)

--- --- --- 5326 4125---7896

a _{Resourceutilizationisbypatientperyear.CI,confidenceinterval;NA,notapplicable.}

Conclusion

In conclusion, the study provides important information about the economic burden of the disease in Argentina. Futureresearchperformedhereaswellasinothercountries oftheregion,takingintoconsiderationdirectandindirect costs of the disease, willexpand knowledge and improve managementofthediseaseintheregion,anissueofgreat importance.

Financial

support

Nonedeclared.

Authors’

contribution

María Laura Galimberti: Approval of the final version of the manuscript; conception and planning of the study; elaboration and writing of the manuscript; obtaining, analyzing, and interpreting the data; effective participa-tion in research orientation; intellectual participation in propaedeuticand/ortherapeuticconductofthecases stud-ied;criticalreviewoftheliterature;criticalreviewofthe manuscript.

Aldana S. Vacas: Approval of the final version of the manuscript;obtaining,analyzing,andinterpretingthedata; criticalreviewoftheliterature.

BarbaraA. Hernández: Approvalof the finalversion of themanuscript;obtaining, analyzing,andinterpretingthe data;criticalreviewoftheliterature.

MaríaL.BolleaGarlatti:Approvalofthefinalversionof themanuscript;obtaining, analyzing,andinterpretingthe data;criticalreviewoftheliterature.

María J. Cura: Approval of the final version of the manuscript;obtaining,analyzing,andinterpretingthedata; criticalreviewoftheliterature.

RicardoLGalimberti:Approvalofthefinalversionofthe manuscript;obtaining,analyzing,andinterpretingthedata; criticalreviewoftheliterature.

Conflicts

of

interest

Nonedeclared.

Acknowledgements

TheauthorswouldliketoacknowledgeLeidyV.Gomez San-tana, Maria C. Quintero Viana, Daniela Capacho Estrada, AgustinEstofan,GinaC.PizarroGuevara,IvonneA.Buitrago Gonzalez,KarenY.CuetoSarmiento,andMarinaAbed Dick-sonfortheircontributioninthedevelopmentoftheresearch project.

References

1.DograS,MahajanR.Psoriasis:epidemiology,clinicalfeatures, co-morbidities,andclinicalscoring.IndianDermatolOnlineJ. 2016;7:471---80.

2.Parisi R, Symmons DP, Griffiths CE, Ashcroft DM. Identifica-tionandManagementofPsoriasisandAssociatedComorbidiTy (IMPACT)projectteamGlobalepidemiologyofpsoriasis:a sys-tematicreviewofincidenceandprevalence.JInvestDermatol. 2013;133:377---85.

3.WHO.Apps.who.int.Globalreportonpsoriasis.Availablefrom:

https://apps.who.int/iris/bitstream/handle/10665/204417/97 89241565189eng.pdf?sequence=1&isAllowed=y> [accessed 16.04.18].

4.AugustinM, Radtke MA.Quality of life inpsoriasis patients. ExpertRevPharmacoeconOutcomesRes.2014;14:559---68.

5.KimballAB,GielerU,LinderD,SampognaF,WarrenRB,Augustin M.Psoriasis:istheimpairmenttoapatient’slifecumulative?J EurAcadDermatolVenereol.2010;24:989---1004.

6.SchöffskiO,AugustinM,PrinzJ,Rauner K,SchubertE,Sohn S,etal.Costsandqualityoflifeinpatientswithmoderateto severeplaque-typepsoriasisinGermany:amulti-centerstudy. JDtschDermatolGes.2007;5:209---18.

7.Yu AP, Tang J, Xie J, Wu EQ, Gupta SR, Bao Y, et al. Economic burden of psoriasis compared to the general

populationandstratifiedbydiseaseseverity.CurrMedResOpin. 2009;25:2429---38.

8.Jungen D, Augustin M, Langenbruch A, Zander N, Reich K, Strömer K, et al. Cost-of-illness of psoriasis --- results of a Germancross-sectionalstudy.JEurAcadDermatolVenereol. 2018;32:174---80.

9.Indec.gob.ar. Censo Nacional de Población, Hogares y Viviendas 2001. Available from: https://www.indec.gob.ar/ indec/web/Nivel4-Tema-2-41-134[accessed16.06.18]. 10.Msal.gob.ar. Nomenclador Único Programa de Desarrollo de

SegurosProvincialesPúblicosdeSalud(PDSPS).Availablefrom:

www.msal.gob.ar/sumar/images/stories/pdf/nomenclador.pdf

[accessed7.06.18].

11.Ar.kairosweb. Kairos Argentina. Available from:

https://ar.kairosweb.com/[accessed24.05.18].

12.SchaeferCP,Cappelleri JC, ChengR, Cole JC,Guenthner S, FowlerJ,etal.Healthcareresourceuse,productivity,andcosts amongpatientswithmoderatetosevereplaquepsoriasisinthe UnitedStates.JAmAcadDermatol.2015;73:585---93,e3.

13.RahoG,KolevaDM,GarattiniL,NaldiL.Theburdenof mod-erateto severe psoriasis:an overview. Pharmacoeconomics. 2012;30:1005---13.

14.BergerK,EhlkenB,Kugland B,AugustinM.Cost-of-illnessin patientswithmoderateandseverechronicpsoriasisvulgarisin Germany.JDtschDermatolGes.2005;3:511---8.