By Abby Van Voorhees, MD, September 01, 2015
In this month’s Acta Eruditorum column, Physician Editor Abby S. Van Voorhees, MD, talks with Alexa B. Kimball, MD, MPH, about her recent JAMA Dermatology article, “Using the Physician Global Assessment in a Clinical Setting to Measure and Track Patient Outcomes.”
Dr. Van Voorhees: What prompted your interest in studying the impact of physician global assessment (PGA) scoring in clinical practice? Isn’t the PGA generally a research tool in psoriasis clinical trials? What was known about its validity in acne outcomes?
Dr. Kimball: Our field needs to proactively and aggressively develop outcome measures for a number of constituents, including patients and payers, to demonstrate the value of the care we deliver. These metrics can be hard to design since our data is often qualitative, in contrast to, for example, blood pressure measurements or hemoglobin A1C levels. I chose the PGA because it has been so widely used, is a validated scoring system, and was designed to be easy to interpret by clinicians. I therefore hoped it would also be easy to use in routine clinical practice, which turned out to be the case.
Dr. Van Voorhees: What patients did you study, and for how long? How did you incorporate physicians documenting the PGA for their patients? How successful were you at getting the clinicians to perform PGAs on their patients?
Dr. Kimball: We have collected information on all patients who were diagnosed with an ICD-9 code corresponding to acne or psoriasis for several years now. In the beginning we added this information to the billing sheet so all it required was a quick check mark by the provider; when we moved to the electronic charge capture we were able to present the request as a mandatory pop-up. As a result our completed data set has been near perfect. I was very mindful to minimize the physician burden as much as possible given all the other activities that we’re facing currently.
Dr. Van Voorhees: What did you find in psoriasis? How about acne? Do you think that these are improvements that we’d expect to see in all types of clinical dermatology practices?
Dr. Kimball: We found that, as might be expected for a tertiary academic center, about two-thirds of our new acne and psoriasis patients had moderate to severe disease. Both groups improved over three months with 14.6 percent of the acne cohort graded as effectively clear at three months compared with 2.1 percent at baseline. Similarly, at three-month follow-up, 22.3 percent of the psoriasis cohort was graded as effectively clear, compared with 3.1 percent at baseline. We can also see the seasonal variation with patients with both acne and psoriasis experiencing better grades in the summer than in the winter. We really don’t know how these numbers compare to other practice areas and how much opportunity there is to improve, although clearly there is quite a bit.
What’s most exciting to me is that it provides a basis for many kinds of future comparison. First, it allows us to understand the distribution of severity in our patient population and how it matches the epidemiologic data. As I would have expected, we see a relatively more severe group of patients. Within our practice, however, we would also anticipate that some people would see patients with more severe psoriasis than others. As a result those providers are more likely to use more biologics, for example, and spend more money per patient. We could also use it to track, for example, how the introduction of new medications or treatments affects our ability to improve care. [pagebreak]
Dr. Van Voorhees: What about the satisfaction of the patients? How did this correlate with the PGA results?
Dr. Kimball: We haven’t made the step to correlate these yet because of the anonymity of our patient satisfaction data collection but it’s a highly relevant question. Treatment success is of course not the only thing that contributes to patient satisfaction, but it surely matters and is increasingly being requested and presented.
Dr. Van Voorhees: An editorial accompanied your paper in JAMA Dermatology. What were your thoughts about the points that were raised? Do you feel that data collection should be done locally or do you see it as part of a more centralized platform such as the registry that the Academy is developing? What are the benefits/disadvantages of the different approaches?
Dr. Kimball: There’s no question we will be accountable for providing this kind of information in the future and the registry is a very important first step preparing us for that inevitability. I am very excited that we are creating a system to aggregate this data in a standardized and interpretable way. At the end of the day it should also allow us to improve patient care by testing interventions, managing variation, and demonstrating the value of the important work that we do. We’ve also just had a brief piece accepted for publication showing how seasonal variation in severity for both psoriasis and acne was readily apparent in this data set.
Dr. Van Voorhees: What are the practical implications for the practicing dermatologist? Should we all be performing PGAs on our acne and psoriasis patients as a matter of course?
Dr. Kimball: First, if you need to develop a quality initiative for your practice to satisfy an administrative request and/or if you think there is an opportunity to improve the care you deliver — this would be an easy program to implement that has value for your patients. You could use it to answer, for example, whether your patients are getting to their treatment goals. Are all your providers, including advance practice clinicians, achieving similar success rates? Are there educational interventions that might improve the results? Data like this often illuminates patterns we couldn’t see before and opens up conversations that can be enormously valuable to providers and patients alike.
Alexa B. Kimball, MD, MPH, is professor of dermatology at Harvard Medical School and medical director for the Massachusetts General Physicians Organization. Her article appeared in JAMA Dermatology, 2015 Apr;151(4):375-81. doi: 10.1001/jamadermatol.2014.3513.