Treatment of psoriasis: day care vs. inpatient therapy

Sir, There has been a reduction in dermatology beds countrywide and demands for dermatology services have increased.1 As a consequence, many dermatology departments have now set up day‐care treatment centres for the treatment of psoriasis or eczema, which would previously have required inpatient management. However, there is little information about the results and costs of such day‐care centres. An audit was carried out in the Department of Dermatology at the Royal Hallamshire Hospital to assess the number of weeks of treatment required to clear psoriasis, the results of treatment and the cost for outpatient day care compared with ward admission. Sixty patients with psoriasis were treated with short contact dithranol and broadband ultraviolet B (UVB) at the day centre from April 1995 to March 1996 (i.e. the first 12 months of opening). Data on these patients were obtained from the day centre treatment records. The hospital notes of these patients were examined to assess the response to treatment. The end‐point for psoriasis clearance was defined as 90% improvement. Data on comparable inpatients with psoriasis and their mean length of stay over the year April 1995 to March 1996, were obtained from the Central Sheffield University Hospitals NHS Trust's Department of Medical Information. The inpatients had been treated with Ingram regimen dithranol and broadband UVB. The costs of inpatient and outpatient treatment were calculated using current health economic data based on a survey of eight dermatology departments in the U.K.2 The costs included medical, domestic, portering, nurse staffing, catering, laundry, maintenance and site overheads, but not drugs. Patient costs were excluded. The mean number of treatments performed on all the 60 patients with psoriasis treated in the day centre was 24.7 [95% confidence interval (CI) 20.1–29.1, median 21, range 5–86]. The mean length of time to clear was 8.3 weeks (median 7 weeks). Nine of the 60 patients reviewed failed to attend for follow‐up, and data on the outcome of their treatment were unavailable. They were excluded from further analysis. Forty‐four (86%) of the remaining patients achieved clearance or virtual clearance by the end of treatment. Seven patients (14%) failed to achieve clearance. They had a mean number of 41 treatments (median 39).Their mean length of treatment was 13 weeks (median 13 weeks). All of them subsequently cleared with other treatments, two with PUVA, one with acitretin and four with inpatient admission. Of the four who were admitted, one had had 84 treatments in the day centre before eventually coming into hospital. He had severe chronic plaque psoriasis and had been unable to tolerate PUVA, methotrexate, acitretin and hydroxyurea. Forty‐eight patients with psoriasis were treated on the ward as inpatients between April 1995 and March 1996. The mean length of hospital stay for an inpatient with psoriasis was 12.5 days. There were no treatment failures. The mean cost of treating a patient with psoriasis on a day‐care basis was £1186 (95% CI: £971–1401). The mean cost to treat a patient with psoriasis as an inpatient in the same year was £2681 (95% CI: £2221–3141). The inpatients had a higher mean age of 49 years (median 54 years) compared with the outpatients, who had a mean age of 40 years (median 40 years). They also had more extensive disease, with 58% having more than two‐thirds body surface area affected, 33% having one‐third to two‐thirds body surface area affected, and 9% having less than one‐third body surface area affected. This is compared with only 33% of the outpatients who had more than two‐thirds body surface area affected, 45% who had one‐third to two‐thirds body surface area affected and 22% who had less than one‐third body surface area affected. These data illustrate that clearing a patient's psoriasis in an outpatient treatment centre is considerably slower than clearance as an inpatient. The mean length of treatment was 8.3 weeks as an outpatient compared with 12.5 days as an inpatient. Those patients who failed to clear as outpatients had to endure a mean length of treatment of roughly 3 months before starting second‐line therapy or being admitted to clear their psoriasis. Although the mean cost of treating a psoriatic patient on a day‐care basis was approximately half that of treatment on an inpatient basis, most of the cost of inpatient care was due to the subject taking up a medical bed. Currently, our department is unable to recoup these savings. In this audit we did not assess how patients perceived the day centre or how their attendance at this, or their period as an inpatient, affected the quality of their lives. However, there is already evidence that quality of life is improved by medical admission.3 In conclusion, day‐care treatment of psoriasis may have a lower purchase cost but takes much longer than inpatient treatment, despite the fact that the inpatients tend to be older with more extensive disease. Cost should not be used as an argument for reducing the numbers of dermatology beds still further. Instead, ways of reducing the cost of inpatient care need to be found, the main cause of which is the cost of a medical bed. Furthermore, there are still occasional patients who fail to respond to treatment in a day centre or whose management is not possible in this setting, who will require admission for inpatient treatment. This is an additional important argument for retaining inpatient beds. Conventional inpatient therapy is still an essential therapeutic option in the management of skin disease. A larger randomized study would help assess the validity of our findings.