Assessing the effect of demographic background on willingness to initiate a biologic

To the Editor: Although biologics have improved outcomes for psoriasis patients, undertreatment remains an issue.1Armstrong A.W. Robertson A.D. Wu J. Schupp C. Lebwohl M.G. Undertreatment, treatment trends, and treatment dissatisfaction among patients with psoriasis and psoriatic arthritis in the United States: findings from the National Psoriasis Foundation surveys, 2003-2011.JAMA Dermatol. 2013; 149: 1180-1185Crossref PubMed Scopus (249) Google Scholar Racial and ethnic differences can influence patients' decisions to seek psoriasis treatment2Bray J.K. Cline A. McMichael A.J. Feldman S.R. Differences in healthcare barriers based on racial and/or ethnic background for patients with psoriasis.J Dermatolog Treat. 2019; ([epub ahead of print]): 1-5https://doi.org/10.1080/09546634.2019.1687824Crossref Scopus (1) Google Scholar; however, the effect of demographics on willingness to receive biologics is not well characterized. Understanding the relationship between demographics and willingness to initiate biologics may identify groups at risk for undertreatment. After institutional review board approval, an online survey was completed by 298 subjects older than 18 years with self-reported psoriasis, after recruitment through Mechanical Turk.3Buhrmester M. Kwang T. Gosling S.D. Amazon's Mechanical Turk: a new source of inexpensive, yet high-quality, data?.Perspect Psychol Sci. 2011; 6: 3-5Crossref PubMed Scopus (6693) Google Scholar Subjects rated their willingness on a 1 (not willing) to 10 (completely willing) scale to receive a biologic. All subjects received information regarding efficacy and route of administration (Table I). Age, sex, race/ethnicity, education level, current treatment status, and psoriasis diagnosis duration were assessed (Table I). Outcome measures were analyzed via single-factor analysis of variance and 2-group t tests. Using an α level of .05, and assuming at least 100 subjects would be in each group, we had 95% power to detect an effect size of 0.5 between any 2 groups.Table ISummary of baseline characteristics and demographic informationVariableAll subjects (n = 298)Patient Age, mean (SD), y35.3 (10.8) Female sex (%)195 (65.4)Ethnicity (%) White208 (69.8) Black33 (11.1) Hispanic or Latino17 (5.7) Native American7 (2.4) Asian or Pacific Islander20 (6.7) Other13 (4.4)Education level (%) No schooling completed1 (0.34) High school graduate106 (35.6) Bachelor's degree139 (46.6) Master's degree34 (11.4) Professional degree13 (4.4) Doctorate degree5 (1.7)Currently receiving treatment (%) Yes169 (57) No129 (43)All subjects were presented with the following question: “A drug is available that has an 80% chance of nearly completely alleviating your psoriasis. In clinical trials, most adults experienced 75% and even 90% skin clearance in just a few months. The drug is given by injection under the skin 1 time every 2 weeks for 4 months. How willing would you be on a 1 (not willing) to 10 (completely willing) scale to receive this medication?” Open table in a new tab All subjects were presented with the following question: “A drug is available that has an 80% chance of nearly completely alleviating your psoriasis. In clinical trials, most adults experienced 75% and even 90% skin clearance in just a few months. The drug is given by injection under the skin 1 time every 2 weeks for 4 months. How willing would you be on a 1 (not willing) to 10 (completely willing) scale to receive this medication?” Subjects aged 18 to 30 years (mean 7.0; standard deviation [SD] 2.11), 30 to 40 years (mean 7.0; SD 2.4), and 40 to 50 years (mean 6.6; SD 2.5) reported greater willingness to receive a biologic compared with subjects older than 50 years (mean 5.7; SD 3.0; P = .03) (Fig 1). Men (mean 7.3; SD 2.2) reported a greater willingness compared with women (mean 6.5; SD 2.5; P < .01). Subjects who were currently receiving treatment for psoriasis (mean 7.1; SD 2.2) reported greater willingness compared with those who were not receiving treatment (mean 6.2; SD = 2.6; P < .01). There were no significant differences between race/ethnicity, education, and diagnosis duration. Women are less satisfied with biologics and experience more adverse effects.4van der Schoot L.S. van den Reek J.M.P.A. Groenewoud J.M.M. et al.Female patients are less satisfied with biological treatment for psoriasis and experience more side-effects than male patients: results from the prospective BioCAPTURE registry.J Eur Acad Dermatol Venereol. 2019; 33: 1913-1920Crossref PubMed Scopus (13) Google Scholar Older patients tend to use helplessness or hopelessness as a coping strategy for psoriasis.5Miniszewska J. Juczynski Z. Ograczyk A. Zalewska A. Health-related quality of life in psoriasis: important role of personal resources.Acta Derm Venereol. 2013; 93: 551-556Crossref PubMed Scopus (25) Google Scholar These findings may contribute to why female and older subjects reported being less willing to receive biologics compared with men and younger individuals. Individuals who are currently receiving treatment may be more willing to start a biologic, possibly because of dissatisfaction with a current regimen or because patients receiving treatment already have an existing experience of the safety of the recommended treatments for psoriasis. The online study may tend to represent more technology-savvy psoriasis patients. Lack of documentation of diagnosis by a dermatologist is a limitation. Body surface area of involvement or arthritic symptoms were not reported, nor was the reasoning for subjects' responses. Subject-reported willingness may not correlate with actual medication-receiving behavior. However, the study still provides qualitative information on how poor biologic acceptance may be related to demographics. A larger sample size might have had more power to detect statistical significance, but our study had sufficient power to rule out a large effect size. In all age groups, there is a wide range of willingness to receive biologics (Fig 1), and this variation may play a role in undertreatment. Psoriasis is often associated with serious comorbidities, and an unwillingness to receive biologics could result in outcomes much worse than just the skin disease. Thus, although some demographics may tend to have a greater willingness to receive biologics, providers may want to prepare to address various levels of willingness in all patients.

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