Dr Kenneth Lim answers questions on how an audit of psoriasis care at a GP practice in Surrey improved outcomes for patients
Read this article to learn more about:
- why an audit of psoriasis management was performed at a GP practice in Redhill, Surrey
- how NICE guidance on psoriasis was successfully implemented following the audit
- changes in clinical practice that led to better management of psoriasis.
Q What prompted the audit of the diagnosis and management of psoriasis?
A Psoriasis is one of the least understood skin conditions that general practitioners see and treat on a regular basis. It has a relapsing and remitting nature and affects 1.3–2.6% of the population in the UK.1
Although specific guidelines on psoriasis exist, management of the condition varies widely either through misinformation or lack of understanding. It is also absent from Quality and Outcomes Framework (QOF) requirements, hence there is little incentive for GPs to do regular audits on the correct treatment of people with psoriasis. To this end, we conducted an audit in the diagnosis and management of psoriasis at our GP practice in Redhill, East Surrey, to reinforce the recommendations made in national guidance and improve the care of patients with the condition.
Q What were the aims of the psoriasis audit?
A The aim of the audit was to determine if our practice was following NICE Clinical Guideline (CG) 153 on Psoriasis: assessment and management2 and NICE Quality Standard (QS) 40 on Psoriasis.3 We also hoped to identify ways of improving our management pathway for these patients and raising awareness of the correct approach to managing psoriasis.
Q How did you carry out the audit?
A The audit was done in two phases: the initial phase and the re-audit. In the initial phase, patients who had been diagnosed with psoriasis or reviewed between January 2015 and April 2016 were included in the study. These totalled 31 patients with a split of 16 males and 15 females. After the initial audit, the findings were presented to the practice team and suggestions were made to improve the documentation and assessment of patients with psoriasis registered at our practice, as well as our treatment pathways. The initial findings prompted the creation of a special series of 'psoriasis clinics' to review and optimise treatments for people with a diagnosis of psoriasis.
In the re-audit phase, 42 patients (22 females, 20 males) were recruited. These were patients who had been newly diagnosed or reviewed for psoriasis between April 2016 and July 2016.
Q What criteria did you use to measure psoriasis assessment and management at the practice?
A The criteria for the audit were based on recommendations made in NICE CG153 and NICE QS40 and covered:2,3
- site—people with psoriasis should have the site of their psoriasis recorded to determine the most appropriate management
- severity—people with psoriasis should have the severity of their psoriasis graded using the Physician's Global Assessment score (see Table 1, below).4,5 This is a 7-point score ranging from 0 (clear skin), to 6 (very severe), case of psoriasis. A score of 4 (moderate) or more should trigger a review by a dermatologist in secondary care
- surface area—people with psoriasis should have the body surface area (BSA) of their psoriasis documented using the 'rule of nines' that is commonly used when determining the surface area of burns. A BSA of 10% or more warrants a review by a dermatologist2
- significance to patient—people with psoriasis should be offered an assessment of the impact on their physical, psychological, and social wellbeing. This should be documented in the form of questions, such as how psoriasis affects their daily living and family life and if it causes problems with their mood
- systemic impact—symptoms of fever and malaise should be treated with due diligence in patients with psoriasis as these can herald the development of erythrodermic psoriasis or severe pustular psoriasis, both of which require immediate treatment in a specialist ward
- treatment—people with psoriasis should be offered the optimum treatment for their type of psoriasis. If topical treatments are started, adults should have a follow-up appointment 4 weeks later to ensure that their treatments are working.
|Score||Severity||Signs and symptoms|
|0||Clear||Clear skin, no evidence of disease|
|1||Almost clear||Possible plaque elevation with occasional scaling and erythema|
|2||Mild||Slight elevation of plaques with fine scale and mild erythema|
|3||Mild–moderate||More elevation of plaque with frequent scaling and defined erythema|
|4||Moderate||Moderate elevation seen with coarser scales and moderate erythema|
|5||Severe||Prominent elevation with hard borders, very coarse scale and bright red discoloration|
|6||Very severe||Very noticeable and visible plaque elevation with thick scales covering almost all lesions and extreme erythematous discoloration|
We also assessed the likelihood of people with psoriasis having any of the five most commonly associated co-morbidities (see Table 2, below).
|Co-morbidity||Method of assessment|
|Cardiovascular disease||Measure blood pressure, cholesterol, and QRISK® 26 score|
|Mental health||Ask relevant questions on mood. The PHQ-9 depression test questionnaire,7 DLQI,8 or GAD-79 can be used if necessary|
|Inflammatory bowel disease||Ask questions about bowel symptoms and check for any per rectal bleeding|
|Non-melanoma skin cancer||Identify the presence of any unusual skin lesions (for more information see our top tips on skin cancer)|
|Psoriatic arthritis||Use PEST10 scoring system|
|PHQ-9=Patient Health Questionnaire 9; DLQI=Dermatology Life Quality Index; GAD-7=Generalised Anxiety Disorder questionnaire 7; PEST=Psoriasis Epidemiology Screening Tool|
Q What areas for improvement were identified by the initial audit?
A The results from the initial audit and the re-audit are shown in Table 3 (below).
|Audit criteria||Percentage of patients (%)|
|Initial (n=31)||Re-audit (n=42)|
|Site of psoriasis recorded||90.3||95.2|
|Severity of psoriasis graded using the Physican's Global Assessment score||3.2||71.4|
|BSA affected by psoriasis documented||0||54.8|
|Patient asked about the impact of psoriasis on their life||3.2||71.4|
|Patients assessed for systemic impact||6.5||71.4|
|Patients offered correct treatment for their psoriasis||48.4||78.6|
|Follow-up appointment arranged for 4 weeks after a topical treatment started||37.9 (11 patients were brought back for follow up, from 29 eligible patients)||64.1 (25 patients were brought back for follow up, from 39 eligible patients)|
|Common co-morbidities assessed:
|BSA=body surface area|
It was clear from the initial audit that the practice was deviating from the recommendations made in NICE CG153. To correct this, the following changes to practice were introduced:
- all doctors were required to:
- familiarise themselves with the assessment points and treatment options for psoriasis. This was achieved by sharing the audit results and clinical recommendations via email and printed leaflets (see also Figure 1, below for an algorithm on assessment and treatment, developed for local use)
- record the site, severity, surface area, significance to patient, systemic impact, treatments offered, and five co-morbidities assessments. To facilitate this, a psoriasis template for the practice computer system was introduced (see Box 1, below) so that doctors could simply enter the necessary information via drop-down menus, and even draw the affected areas on an onscreen human figure
- arrange a follow-up appointment for adults 4 weeks after topical treatments were started. This was easy to implement as the template reminded doctors to do this if they commenced treatment
- doctors would be prompted to fill in the psoriasis template whenever they keyed the word 'psoriasis' into the case record
- a series of psoriasis clinics were introduced. These were designed to allow patients at the practice who had previously been diagnosed with psoriasis to come in for a review of their skin and to determine if they were at risk of developing any comorbidities. We also checked their current medications to ensure they had the right treatment for their psoriasis.
Box 1: Practice computer template for psoriasis history taking
- Type of psoriasis
- Site affected
- Severity (using PGA score)
- Surface area (expressed as percentage of total body area)
- Significance to patient
- DLQI score
- [free text for further information]
- Systemic impact
- any recent illness?
- psoriatic arthritis
- any joint aches or stiffness either now or in the past?
- if yes—start PEST score. A score of 3 or more will warrant a referral to a rheumatology specialist
- conduct joint examination if appropriate
- any joint aches or stiffness either now or in the past?
- is the patient a smoker?
- prompt for smoking cessation (it is one of the triggers for psoriasis flare-ups)
- cholesterol and cholesterol/HDL ratio level
- QRISK® 2 score
- any family history of cardiac disease?
- conduct cardiovascular examination if appropriate
- is the patient a smoker?
- any history of low mood or anxiety?
- if yes, conduct a PHQ-9 or GAD-7 questionnaire
- alcohol consumption
- any illicit drug usage?
- any suicidal ideation?
- any history of low mood or anxiety?
- inflammatory bowel disease
- any abdominal pain, change in bowel habits?
- any rectal bleeding?
- any family history of bowel disease?
- conduct abdominal examination if appropriate
- non-melanoma skin cancer
- check for any signs of unusual skin lesions
- any history of skin cancers in the family?
- psoriatic arthritis
- Was treatment started for this patient today?
- What is the follow up for this patient? (4 week, urgent referral to specialist, same-day admission, no treatment required).
PGA=Physician's Global Assessment; DLQI=Dermatology Life Quality Index; PEST=Psoriatic Epidemiology Screening Tool; HDL=high-density lipoprotein; BMI=body mass index; PHQ-9=Patient Health Questionnaire; GAD-7=Generalised Anxiety Disorder questionnaire 7
Q What were the results of the re-audit after the changes had been implemented?
A On the whole the re-audit phase showed improvements in the assessment and treatment of people with psoriasis (see Table 3, above) reflecting the implementation of several changes to clinical practice made after the initial audit.
While it is difficult to establish if this audit has brought about any cost savings, the end goal is to ensure that people with psoriasis have the right treatment and are cared for appropriately. By doing this, we can reduce the number of visits they request and ensure that any comorbidities are detected early. For example, psoriatic arthritis is a major, and fairly common complication of psoriasis—about 14% of people with psoriasis go on to develop psoriatic arthritis at some time in their lives.11 In the re-audit phase, we managed to identify at least five patients (12%) with early signs of psoriatic arthritis and they were subsequently referred to a rheumatology specialist. Given that end-stage psoriatic arthritis can be as debilitating as rheumatoid arthritis, the approach that we have adopted will definitely improve the overall health outcomes for these patients.
Q Who led the psoriasis audit and how did you get the relevant stakeholders on board?
A I proposed and led the audit having had an interest in psoriasis management in general practice for a while. Most of the partners at the practice were interested to see how they fared in treating psoriasis and were keen to improve their practice, so it was not difficult to convince them to accept the recommended changes in practice following the initial audit. I emphasised that, while there were no immediate cost savings to changing our practice, we were practising good preventative medicine by reducing the severity of associated complications such as psoriatic arthritis, depression, inflammatory bowel disease, and cardiovascular disease.
Q What costs were incurred by changes to the service, and how was it funded?
A No costs were incurred as the recommendations sought to streamline psoriasis history taking and improve our understanding of the most appropriate treatments for each type of psoriasis.
Q Was any additional staff training required?
A A presentation of the results of the initial audit and the suggested changes to practices was given to the practice staff, and the slides used were made available for staff to refer to afterwards. An abbreviated version of the recommendations that doctors could refer to during consultations was also provided.
Q What advice would you give to GP practices looking to perform a similar audit in their own locality?
A I would encourage GPs to conduct similar audits to determine their efficacy in treating psoriasis as the benefits of well-treated psoriasis extend beyond the patient's physical health, to their mental health and emotional wellbeing. To GPs looking to conduct a similar audit I would recommend the following:
- familiarise yourself with guidance on diagnosing, assessing, and treating psoriasis and understand the key points of taking a psoriasis history
- a full psoriasis history may take longer than the usual 10 minutes accorded to each patient so a special psoriasis clinic may help facilitate this. In our surgery, our psoriasis clinic allocated 15 minutes per patient to allow time for history taking, examination, and management
- develop a template that lists the questions you will be asking each patient and also the kind of examinations you will be performing. We introduced a template (see Box 1, above) that came up as a prompt whenever a doctor entered psoriasis-related words into the patient's digital notes. This served as a reminder of the right questions to ask and the examination points needed
- ask patients to complete the Dermatology Life Quality Index (DLQI) either before or after a consultation to save time
- engage with your local dermatology unit to find out about referral pathways and availability of same day appointments (e.g. for severe erythrodermic psoriasis).
- Parisi R, Symmons D, Griffiths C, Ashcroft D. Global epidemiology of psoriasis: a systematic review of incidence and prevalence. J Invest Dermatol 2013; 133 (2): 377–385.
- NICE. Psoriasis: assessment and management. Clinical Guideline 153. NICE, 2012. Available at: www.nice.org.uk/cg153
- NICE. Psoriasis. Quality Standard 40. NICE, 2013. Available at: www.nice.org.uk/qs40
- Feldman S, Krueger G. Psoriasis assessment tools in clinical trials. Ann Rheum Dis 2005; 64 (suppl. 2): ii65–ii68.
- Langley R, Ellis C. Evaluating psoriasis with Psoriasis Area and Severity Index, Psoriasis Global Assessment, and Lattice System Physician's Global Assessment. J Am Acad Dermatol 2004; 51: 563–569.
- QRISK® website. www.qrisk.org
- Patient website. Professional reference. Patient Health Questionnaire (PHQ-9). patient.info/doctor/patient-health-questionnaire-phq-9 (accessed 9 February 2017).
- Cardiff University website. Department of Dermatology. Dermatology Life Quality Index (DLQI). sites.cardiff.ac.uk/dermatology/quality-of-life/dermatology-quality-of-life-index-dlqi/ (accessed 7 February 2017).
- Patient website. Professional reference. Generalised Anxiety Disorder Assessment (GAD-7)patient.info/doctor/generalised-anxiety-disorder-assessment-gad-7 (accessed 10 February 2017).
- British Association of Dermatologists. Psoriasis Epidemiology Screening Tool. Available at: www.bad.org.uk/shared/get-file.ashx?id=1655&itemtype=document
- Ibrahim G, Waxman R, Helliwell P. The prevalence of psoriatic arthritis in people with psoriasis. Arthritis Rheum 2009; 61 (10): 1373–1378. G