Clinical study =:=:::;::::=:·_-:,_:_:,:,: ::?\:/:f:t Ology; ··. Y:::df- . life, .. idity, ·· cfex · ' ogy Time spent on treatment Time spent on treatment in dermatolngy- how much tirne do outpatients use arul -is it a measure of morbidity? G. B.E. Jemec and L. Kynemund ABSTRACT lntroduction. The impact of skin disease on patients is varied. Time appears to be an important element in the assessment of the impact of chronic recurrent diseases such as skin diseases. In addition, data about the tirne spent on treatment has not previously been described in spite of its obvious importance to general patient management in dermatology. Materials and methods. The total tirne spent on treatment, including tirne spent on visiting the physician and obtaining drugs from the pharmacy, was therefore investigated in a sample of consecutive outpatients in employment (n=53) and healthy controls (n=41 ). Results. Patients spent an average of 2.4 minutes (95% confidence interval: 1.9 - 2.8 minutes) while healthy controls spent 0.9 min (95% confidence interval: 0.7 -1.2) per day treating skin disease (P<0.001). No correlation between tirne spent and disease, duration, quality-of-life (Dermatology Ufe Quality lndex) or patient age was found. Discussion. The observation suggests that tirne alone is not an appropriate surrogate measure in a mixed group of patients. Additional studies are therefore necessary to delineate the usefulness of tirne spent on treatment (TSOT). This should be done in more uniform groups of patients and using other objective measures of morbidity. Finally the data presented suggest that TSOT in itself may not be a major factor in patients' assessment of treatments. Introduction Measuring morbiclity causes inherent problems in clermatology where chronic-recurrent cliseases of low mortality predominate. Routine clinical bedsicle assess- ment is neither sufficiently explicit nor accurate, ancl semi-quantitative measures cleveloped for specific clisea- ses , e.g. PASI score, are not generally applicable (1, 2). A need for a reliable general methocl of n\orbiclity quan- tification therefore exists in clermatology. One approach is the use of patients' assessments of quality-of-life (QOL), e.g. the clermatology life quality index (DLQI) (3). Studies have documentecl a positive correlation between QOL questionnaires ancl clinical Acta Dermatoven APA Vol 10, 2001, No 1 ------------------------------- - 17 Time speni on lreatment aspects of disease severity, e .g. irnproved QOL after treatment or physician-patient consensus about QOL (3, 4, 5). Skin diseases often require considerable therapeutic effort by the patient, i.e. daily application of ointments. The ti.me spent towards cure of the skin disease therefore represents an investment of tirne. It may be speculated that the tirne patients spend on the treatment of their disease, (tirne spent on treatment, TSOT), reflect the importance they attach to their clisease. A simple calcu- lation of TSOT coulcl therefore hypothetically give an easy objective, continuous scale measure of morbidity in dermatological patients. In acldition this stucly provicles indicative data des- cribing the tirne dermatological patients spend on treating their disease. This information bas not previo- usly been available, though it is of relevance to the assessment of self-treatment strategies in dermatology. Materials and methods A total of 53 consecutive adult patients were studied at their first visit to the dermatological clinic at Roskilcle ''Hospital, ancl compared with 41 healthy controls. Pati- ents in retirement were not included in order to accen- tuate the choice in tirne allocation macle by each patient. For assessment of QOL the DLQI was chosen because of its ease of use, and previous wicle use in the assess- ment of morbidity of skin diseases. Each patient was questioned about the TSOT and asked to fill in a questionnaire quantifying the TSOT over the past 3 months. This incluclecl time clirectly spent in self-care , as well as tirne spent on visiting pharmacy, general practitioner, practicing specialist or hospital. Descriptive statistics were used, ancl comparisons were made using Spearman rank correlation and Mann- Whitney test w here appropriate. Results The patients spent an average of 2.4 minutes (95% confidence interval: 1.9 - 2.8 minutes) ancl controls 0.9 min (95% conficlence interval: 0.7-1.2) per cl ay treating their skin disease (p<0.001). The mean age was 43.3 (39.9 - 46.7) years and mean DLQI score of patients was 10.8 (8.6 - 13.1). Mean clisease cluration was 11.2 (8 .2 - 14.2) years. The most frequent cliagnoses were eczerna (20/ 52), psoriasis (13/ 52) ancl folliculitis/ acne (7 / 52). Patienls with visible lesions clid not have reduced QOL in comparison to those with hidden lesions. No significant correlations were found between TSOT ancl DLQI, diagnosis, age or clisease cluration. Discussion The absence of significant correlations between the TSOT and the other parameters studiec.l suggests that TSOT is not useful asa surrogate single overall measure of rnorbidity. Many other factors also play a role for QOL in dermatological patients, e.g . subjective symptoms, and these may overshadow the importance of this general TSOT registration without invalidating the core concept of using tirne as a rneasure. In addition, rnethodological factors in the present study rnay have influenced the conclusion. The different tirne frame of the DLQI (1 week) and the TSOT (3 rnonths) was not thought to invalidate the conclusion since the diseases are chronic recurrent and active at the time of the consultation. On the o ther hanc.l the inclusion of time spent on acquiring the prescribed medicine, i. e. tirne spent at the prescribing physician and the pharrnacy, include a range of variables that are not under the imrnediate cont:rol of the patient ancl may therefore act as potential confounders. The inclusion of clifferent pacient groupings adcls strength to the general observation of TSOT, but does not make allo- wance for the area involved, i.e. a large affected area on the bocly may not cause as rnuch morbiclity asa srna- ller involvecl area in the face , although the TSOT may be longer. Finally the results do not take into account the p ossible uncler-treatrnent by patients , i.e. TSOT may be low but treatment rnay be ineffectual and morbiclity therefore high. The data presentecl also have immecliate practical irnplications, which w arrant further investigation. In terrns of treatrnent, the data suggest that it rnay be speculatec.l that tirne spent on self-treatrnent is a less critical parameter in pacient managernent. Modes of the- rapy that are efficient but relatively cumbersome may therefore have a greater leve! of acceptance arnong pa- tients than cornmonly expected by dermatologists . The psychological effects of such treatments may compen- sate for their efficacy. It is also unlikely that the relation- sbip between TSOT ancl rnorbidity is linear and a cut-off point is likely to exist. No significant differences were found between groups of dermatological patients, su- ggesting that the findings are more likely to be general than disease specific. In conclusion this study bas presented new data on TSOT, which are of immediate practical relevance in the planning of treatment, and may serve as the basis for further investigation of TSOT as a measure of morbiclity in more uniform groups of patients. Acknowledgement The au thors woulcl like to thank Professor AY Finlay, Cardif, UK for the use of the DLQI questionnaire. Clini ca l s tudy 18 ----------- ------------------ - - - - --Acta Dermatoven APA Vol 10, 2001, No 1 Clinical study Time speni on treatment E F' E E C E S l. Jemec GBE, Wulf HC. Assessment of morbidity from skin diseases. Br J Dermatol 1997; 137:157-8. 2. Jemec GBE, Wulf HC. The applicability of clinical scoring systems: SCORAD and PASI in psoriasis and atopic dermatitis. Acta Dermatovenerol (Stockh) 1997; 77: 392 - 394 AUTHORS' ADDRESSES 3. Finlay AY. The dermatology life quality index, in Rajagopalan R, Sherertz EF, Anderson RT: Care management of skin diseases. New York: Marcel Dekker, 1998, 85 - 94. 4. Salek MS, Finlay AY, Luscombe DK et al. Cyclosporin greatly improves the quality of life in adults with severe atopic dermatitis. Br J Dermatol 1993; 129: 422 - 430. 5. Jemec GBE, Wulf HC: Patient-doctor consensus on quality-of-life in dermatology. Ciin Exp Dermatol 1996; 21: 177 - 179. Gregor B.E. Jemec, MD, D.Med.Sci., Div. oj Dermatology, Dept. oj Medicine, Roskilde Hospital, Denmark. Line Kynemund, MD, same address Acta Dermatoven APA Vol 10, 2001, No 1 ------- --- ----- -------- - ----- --- 19