Recognizing Barriers to Access Psoriasis Biologics

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Although biologic agents have offered transformation therapeutic advantages to patients with psoriasis unresponsive to traditional treatments, a recent review aimed to recognize barriers when it comes to biological therapies. Researchers behind the review found that barriers and disparities included increase age, race, socioeconomic status, location, cost and insurance, and insufficient knowledge.¹

Background

Psoriasis has been known to affect patients’ quality of life (QoL), including vocational impairment, decreased sexual functioning, and suicidal ideation.² With this in mind, the researchers behind this review stated that early assessment and treatment of psoriasis and comorbid diseases are imperative to regaining lost QoL.

Biologics tailored to target specific inflammatory pathways have allowed patients to restore a semblance of their pre-disease QoL due to their high efficacy profile; however, researchers noted there remains a gap in treatment of moderate to severe psoriasis. In 2017, the US National Health and Wellness Survey reported that 59% of insured individuals diagnosed with mild to severe psoriasis were not treated for it in the previous year, suggesting to researchers a significant barrier in acquiring and utilizing biologic therapies.³ They stated that defining current barriers to acquiring biologics is crucial to identifying existing disparities and optimizing treatment outcomes in moderate to severe disease.

Methods

Starting with a comprehensive search of MEDLINE, Embase, and Web of Science, researchers put the initial 2684 articles through a rigorous screening process resulting in the selection of 18 studies that conformed to their inclusion criteria. Two additional studies were found through reverse-citation searching and included in subsequent synthesis. Researchers employed varied study designs, including cross-sectional studies (n=9), retrospective studies (n=9), mixed-methods studies (n=1), and qualitative free-listing studies (n=1).

Increased Age

Researchers found the most cited barriers included increased age, race, socioeconomic status, rural location, cost and insurance, and insufficient knowledge. Through their investigation, they found information suggesting an inverse relationship between increased age and inclination to initiate biological therapy. They suggested this was due to several factors including increased comorbidities, possibility of adverse events, cognitive impairments, and physical limitations. Researchers also made note of the underrepresentation of elderly individuals within clinical trials, leading to a lack of data on safety and efficacy within that population.

Race and/or Ethnicity

The review also found significant disparities in obtaining biologics amongst different racial and/or ethnic groups, particularly for Black and Hispanic populations. Researchers could not identify a singular cause to this but suggested that the lack of skin of color representation in medical education materials is an ongoing systemic challenge, as well as underrepresentation in clinical trials and among medical professionals. The review added that further research is needed to comprehend this discrepancy.

Socioeconomic Status

Various factors surrounding decreased socioeconomic status were noted to be barriers to biologics prescription for patients with moderate to severe psoriasis including level of education, income, occupation, and English proficiency. To bridge this gap, researchers suggested the use of tools such as ADISKAP 1.0 (in atopic dermatitis) may be useful as screening tools to identify vulnerable populations with health literacy deficits who may need additional support. They also discovered that while occupations such as managers were positively correlated with biologics use, those with an annual income below 150% of the federal poverty line were identified as experiencing an independent risk factor due to the high cost of the drug.

Rural Location

Researchers found that geographic disparities can also pose challenges in accessing biological treatments. According to one study, the density of dermatologists in the US in urban areas can be up to 40 times greater than in rural zones.⁴ Consequently, this led researchers to conclude that those residing in rural or remote areas not only face long distance as an inhibitor factor to specialized care, but also longer wait times and limited access to contemporary therapies. To address these issues, researchers suggested incentivizing dermatological practice in rural areas, enhancing telemedicine for remote consultations, and increasing awareness about psoriasis and biologic therapies.

Cost and Insurance

Despite having health care professionals willing to prescribe them, high out-of-pocket expenses and challenges to secure insurance coverage was noted as a “significant” barrier to biologic access. To remedy this, researchers found a cost-effective alternative that has recently emerged through the development of biosimilars that showed equal efficacy and safety to their biological counterparts.⁵ They stated that providers must stay aware of these existing alternatives moving forward to increase overall access.

Knowledge and Education

Through their investigation, researchers found that inadequate knowledge may impede access to biologics. They reported that patients with increased access to medical advice and more acquaintances with psoriasis were more likely to know about the drug and be open to the idea of using them. To address this barrier, researchers suggested that more educational incentives targeted toward both health care practitioners and patients alike may decrease potential safety concerns and further advance treatment outcomes. They noted that additional research into the effect of incentives on safety concerns is needed.

Conclusion

Researchers behind this review identified several barriers to adequate care, including a lack of awareness of health care practitioners, lack of specialists, lack of standardized diagnosis and treatment tools, discrimination against patients, and high cost of biologics. They noted the results also brought to light additional barriers and disparities associated specifically with biologics access, including increased age, race, socioeconomic status, and rural location. Researchers stated that the extent of these disparities is still unknown, and further research is needed to define the true burden of disease among underrepresented groups and minority populations.

References

1. Wan, V., Habibi, A., Mija, L.A., et al. Disparities and barriers to the access of biologics in moderate-to-severe adult psoriasis. Int J Dermatol. https://doi.org/10.1111/ijd.17236
2. de Arruda LH, De Moraes AP. The impact of psoriasis on quality of life. Br J Dermatol. 2001;144 Suppl 58:33-36. doi:10.1046/j.1365-2133.2001.144s58033.x
3. Armstrong, A.W., Koning, J.W., Rowse, S. et al. Under-treatment of patients with moderate to severe psoriasis in the United States: Analysis of medication usage with health plan data. Dermatol Ther (Heidelb) 7, 97–109 (2017). https://doi.org/10.1007/s13555-016-0153-2
4. Feng H, Berk-Krauss J, Feng PW, et al. Comparison of dermatologist density between urban and rural counties in the United States. JAMA Dermatol. 2018;154(11):1265-1271. doi:10.1001/jamadermatol.2018.3022
5. Mulcahy AW, Hlavka JP, Case SR. Biosimilar cost savings in the United States: initial experience and future potential. Rand Health Q. 2018;7(4):3. Published 2018 Mar 30.