Dermatology Life Quality Index (DLQI) as a psoriasis referral triage tool

Dear Editor, Most primary care psoriasis referrals in the U.K. are triaged as ‘routine’, in part because of the prioritization of skin cancer. As a result, patients with severe psoriasis may wait several months to be seen, enduring quality of life (QoL) impairment that could have been reduced. Furthermore, some patients may spontaneously improve by the time they are seen by a specialist, making the appointment unnecessary at that time. Therefore, following approval from the local ethics committee, we conducted a prospective study to evaluate the usefulness of Dermatology Life Quality Index (DLQI) scores in triaging patients with psoriasis referred to our dermatology secondary healthcare services. Local general practitioners (GPs) were provided with DLQI questionnaires when referring patients with psoriasis. Referrals were triaged as ‘urgent’ if the DLQI score was > 10 because this represents a very large effect on a patient's life.1 Those referred with no DLQI scores, either from participating or nonparticipating GPs, were triaged as routine, as a control group. When patients were seen in clinic, we measured their DLQI and Psoriasis Area and Severity Index (PASI) scores, and satisfaction with the waiting time (measured on a five‐point Likert scale from 1, not at all happy to 5, very happy). A power calculation predicted that 20 patients were required in each group to give 80% power to detect a 5‐point difference in PASI score for an alpha significance level of 0·05. The 40 recruited patients had no significant differences in demographics or disease characteristics (Table 1). The median waiting time for the ‘urgent’ group was 88 days [interquartile range (IQR) 66–99], whereas patients triaged as ‘routine’ waited a median 256 days (IQR 228–295). Participants’ characteristics DLQI, Dermatology Life Quality Index; IQR, interquartile range. Participants’ characteristics DLQI, Dermatology Life Quality Index; IQR, interquartile range. As expected, of those patients seen urgently, 60% were ‘happy’ or ‘very happy’ with the waiting time. In contrast, in the routine group no patients were ‘happy’ or ‘very happy’. The median PASI score in the urgent group was 6·2 (IQR 3·5–10·6), compared with 3·85 (IQR 2·8–6·3) in the routine group (no significant difference). The median DLQI score in the urgent group when seen in secondary care was 4 points higher than in the routine group (urgent 16, IQR 12–20 vs. routine 12, IQR 8·5–17). In those triaged as urgent, the median DLQI score was not significantly different from the baseline score at the time of referral (17·5, IQR 13·5–23). Pressures on dermatology secondary care services in the U.K. and a requirement to meet skin cancer waiting time targets result in patients with inflammatory dermatoses having long waiting times. Triaging GP referrals accurately is difficult if information is incomplete and disease severity scores are not given. Asking GPs to determine a severity score involving complete skin examination, such as the PASI, is not practical because of lack of time and insufficient training. However, a QoL questionnaire can easily be completed by patients while the GP documents the consultation. The DLQI is the most commonly used QoL assessment tool in psoriasis trials2 and takes 1–2 min to complete.3 Patients seen urgently due to a baseline DLQI score > 10 at referral had a DLQI score 4 points higher than those referred without a DLQI and seen ‘routinely’. As the minimal clinically important difference for the DLQI is 4 points,4 using a baseline DLQI score > 10 does identify those patients whose psoriasis has a particularly high impact on QoL, compared with an unselected group of psoriasis referrals. One limitation of this study is the lack of a separate group of psoriasis referrals with a DLQI score ≤ 10. However, we found that almost no patients were referred with scores in this range, perhaps because GPs chose not to refer less severely affected patients. The Scottish5 and Malaysian6 guidelines recommend referral for DLQI scores > 5 in patients with psoriasis unresponsive to topical therapy, and, in keeping with our study experience, 65·5% of eligible patients in Scotland were not seen by a specialist.7 It is possible that patients or GPs might inflate DLQI scores to reduce waiting time delays; however, we mitigated this in our study by not specifying the DLQI score triage cut‐off for urgent appointments. Our long waiting time of 256 days for routine referrals reflects pressures on dermatology secondary care services in Wales. While we chose a DLQI cut‐off score of 10 points, as it indicates major impairment of QoL, a different cut‐off score could be selected depending on the attitude and resources of the referral centre. In summary, we have demonstrated that a QoL instrument such as the DLQI can be used as a triage tool. Its use may help GPs quantify psoriasis severity, and ensure that patients whose psoriasis is causing the greatest impact on QoL are seen in a timely manner. A much larger randomized study is needed to evaluate the usefulness of DLQI as a triage tool in dermatology services. We would like to thank Dr M.K. Basra and Professor A.V. Anstey for their contribution to the study protocol and comments on this letter, and we thank Dr Mark Kelson for his comments on the statistical data. E‐mail: abouatwanaa@cardiff.ac.uk Funding sources: a research grant from the Dermatology Forum for Wales.