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Management of a Chronic Skin Disease in Primary Care: An Analysis of Early-Career General Practitioners’ Consultations Involving Psoriasis

1 GP Synergy, Regional Training Organisation, Liverpool, NSW, Australia 2 The University of Newcastle, School of Medicine and Public Health, Callaghan, NSW, Australia 3 GP Synergy, Regional Training Organisation, NSW & ACT Research and Evaluation Unit, Mayfield West, NSW, Australia 4 The University of Queensland Faculty of Medicine, Primary Care Clinical Unit, Brisbane, QLD, Australia 5 Hunter Medical Research Institute, Clinical Research Design, IT and Statistical Support Unit (CReDITSS), New Lambton, NSW, Australia 6 Eastern Victoria GP Training, General Practice Training Organisation, Melbourne, Australia 7 The University of Melbourne, Department of General Practice, Melbourne, VIC, Australia 8 University of Tasmania, School of Medicine, Hobart, TAS, Australia 9 General Practice Training Tasmania (GPTT), Regional Training Organisation, Hobart, TAS, Australia


Introduction
Psoriasis is an autoimmune and autoinflammatory condition resulting in chronic inflammation of the skin and, typically, a prolonged clinical course. There are different phenotypes associated with varied genetics, immune pathophysiology and symptoms [1]. The most common type, chronic plaque psoriasis, comprises 90% of cases [2]. Other types of psoriasis include guttate psoriasis, generalised pustular psoriasis, palmoplantar psoriasis and erythrodermic psoriasis [3]. Psoriasis can also be classified into two types according to age at onset.
Type I psoriasis is the more common type, comprising 75% of all cases, and is associated with early onset (before age 40) and more severe disease (HLA-Cw*0602 positive.) Type II psoriasis is HLA-Cw*0602 negative, and occurs later in life [4].
There is a wide variation in the prevalence of psoriasis among different populations. Variations in prevalence may be attributable to study design (eg population-based versus hospital based, or self-reported versus clinician-diagnosed) or to geographic and environmental factors [5]. It is clear that Australia has a particularly high prevalence of psoriasis [6]. Psoriasis in Australian Aboriginal people, however, is rare or absent [7].
The burden of psoriasis on individuals can include significant physical, social and psychological impacts [8,9].
Psoriasis is associated with lifestyle factors including obesity, smoking and alcohol use [10]. Independent of these risk factors, psoriasis is associated with multiple medical comorbidities including psoriatic arthritis (30%), inflammatory bowel disease, metabolic syndrome, non-alcoholic fatty liver disease, cardiovascular disease, myocardial infarction, diabetes, chronic renal disease and stroke [11][12][13][14]. Psychiatric and psychosocial comorbidities and impairment of quality of life are common and problematic [9,15,16]. Additionally, treatments for psoriasis can have adverse effects involving multiple systems [8]. Thus, given the prevalence, chronicity, and physical and psychosocial comorbidities of psoriasis, it is vital that general practitioners (GPs) are continually engaged in -and have expertise in -the management of psoriasis.
Australian GPs (family physicians) encounter psoriasis with a frequency of approximately 0.2 in every 100 patient visits [17]. Patients' experiences of GP consultations for psoriasis may often be negative, with many finding that GPs have limited knowledge and, more importantly, limited appreciation of its impact on patients' lives [18].
Registrars are early-career GPs practising within a national specialist general practice training program. They are establishing what may be long-lasting practice patterns in a clinical context of having been underprepared for managing skin disease by their undergraduate and junior doctor experiences [19][20][21]. An understanding of consultation and management patterns, as with skin disease in general, can lead to a better understanding and improvement of psoriasis management in the community setting [22].
In this study, we aimed to establish the frequency and associations of psoriasis consultations in registrars' clinical experience. In view of the chronicity of psoriasis, we were particularly interested in the associations of factors related to the continuity of care.

Materials and Methods
This was a cross-sectional analysis of data from the Registrar Clinical Encounters in Training (ReCEnT) study.

ReCEnT
ReCEnT is an ongoing multi-site cohort study of Australian GP registrars. Participants are registrars in the 3 compulsory general-practice-based training terms of Australian GP vocational training. Registrars practice within an apprenticeship-like training model [23], but with considerable site cohort study of Australian GP registrars' experiences during vocational training. In ReCEnT, 60 consecutive consultations are recorded 3 times (6-monthly) during each registrar's training. The outcome factor for this analysis was a problem/diagnosis being psoriasis, and independent variables were related to registrar, patient, practice and consultation factors. This study analysed 17 rounds of data collection (2010-2017) using univariate and multivariable regression.
Results: Data from 1,741 registrars regarding 241,888 consultations and 377,980 problems/diagnoses were analysed. Psoriasis comprised 0.15% (n=550) of all problems/diagnoses (95% CI, 0.13-0.16). Significant patient multivariable associations of a problem/diagnosis being psoriasis included age, gender, being new to a practice or a registrar, and psoriasis being an existing problem rather than a new diagnosis. Significant registrar associations included seeking in-consultation information/assistance, not scheduling a follow-up appointment, prescribing medication, and generating learning goals.
Conclusions: Australian registrars have modest training exposure to psoriasis and may find psoriasis management challenging. Furthermore, continuity of care (essential for optimal chronic disease management) was modest. The findings have implications for GPs' approaches to the management of psoriasis more widely as well for general practice education and training policies. The methodology has been described elsewhere [24].
Briefly, registrars undertake data collection once per 6-month training term as an integral component of their educational program [25]. The data are used to compose detailed written feedback reports for registrar reflection on their clinical practice and educational and training needs. Registrars may provide written informed consent for their de-identified data to also be used for research purposes. Initial data collection involves registrar demographic, educational, and work experience, plus characteristics of the practice in which they are currently working.
Approximately mid-way through the training term, registrars record the details of 60 consecutive patient consultations on a paper-based Case Report Form. As data collection is designed to reflect a 'normal' week of general practice, consultations in a specialised clinic, eg vaccination clinic, are excluded. Only office-based consultations (not home visits or nursing home visits) are recorded.

Outcome Factor
The outcome factor in this study was a problem/diagnosis being 'psoriasis'. 'Psoriasis' was defined as the ICPC-2 code S91 001 (Psoriasis). In ReCEnT, problems/diagnoses are coded according to the International Classification of Primary Care, second edition classification system (ICPC-2 plus) [26]. Table 2  The frequencies with which medicines were prescribed for psoriasis, and with which referrals were made, were calculated. The frequency with which sources of in-consultation information or assistance were sought was also calculated.

Independent variables listed in
Statistical analyses were programmed using STATA 14.0 and SAS v9.4. P values <.05 were considered statistically significant.

Ethics Approval
The ReCEnT project has approval from the University

Results
The study analysed data from a total of 1,741 registrars (response rate, 96.0%). The demographics of participating registrars are presented in Table 1 Table 2 presents the characteristics associated with a problem/diagnosis being psoriasis in the 1,741 registrars' practices. Table 3 Table 4 for the list of most commonly prescribed medications.

Associations of Psoriasis Problems/Diagnoses Managed by Registrars
Only 180 patients with psoriasis problems/diagnoses (34%) had seen the registrar previously (for any reason), and for only 199 psoriasis problems/diagnoses (36%) was follow-up organised. In 89% of instances, this was with the registrar personally.
When seen for psoriasis, 13% of patients were referred to a dermatologist, with 9% of new diagnoses being referred and 15% of previously diagnosed patients being referred.
In-consultation information or assistance was accessed for 29% of psoriasis problems/diagnoses. The sources of in-consultation assistance or information used were electronic sources (64%), the registrar's supervisor (33% of instances), hard-copy sources (6%), and specialists (4%).

Patient Demographics Associated with Psoriasis
Our study showed that a patient being between the ages of 15 and 64 years was significantly associated with the problem/diagnosis being psoriasis (compared to younger or older patients). This is consistent with a previous study that found low rates of psoriasis in the paediatric population, with a peak starting at age 20 and declining after 60 [29].
Although previous studies have not found any consistent difference in prevalence by gender [6], our study showed a lower likelihood of registrars seeing psoriasis in females. A possible explanation is that psoriasis has been found to be more severe in males than in females, and our finding may reflect healthcare-seeking behaviours rather than community prevalence [30].

Associations of a Psoriasis Problem/Diagnosis
The registrar being in term 3 (vs. term 1) of their training was significantly associated with a psoriasis problem/diagnosis. This, again, may reflect the paucity of dermatological experience and expertise of registrars entering general practice and increasing confidence and comfort in addressing psoriasis with more experience.
A large number of medications was prescribed by registrars for psoriasis. Most were (appropriately) topical steroids and vitamin D analogues. This (together with the strong association of psoriasis problems/diagnoses with in-consultation assistance-seeking) suggests that, despite their lack of experience in this area, consultation with information sources and the GP registrars' supervisor may facilitate appropriate treatment.

Implications for the Management of Psoriasis as a Chronic Disease
This study found a strong association of consultations for psoriasis being for existing psoriasis. However, there were also strong associations of the patient being new to the practice, new to the registrar, and less follow-up appointments being organised. This suggests that these patients may have inconsistent provision of primary care for this problem.
That is, there is low continuity of care (to some extent informational and management continuity but, especially, low interpersonal continuity) [31,32]. This is contrary to findings of patients with chronic disease in general within this study population, where chronic disease is associated with greater continuity of care [33]. This is of considerable importance as psoriasis is a chronic disease with much associated morbidity (both psychosocial co-morbidity and high levels of co-morbid non-dermatological physical disease) [8,9,11,15,16] [18]. Further associations in our study may support this interpretation. We found a strong association with the prescription of medicines and specialist referral. An interpretation may be that many patients receive episodic care, often prompted by the need to renew psoriasis prescriptions and referrals,. They may be seeking a convenient prescriber performing a routine, discrete administrative task rather than a GP involved in ongoing, considered management of their chronic disease. Possible sequelae of such a situation are different providers delivering uncoordinated medicine regimens that do not facilitate a logical progression of treatment based on response to past medications [34][35][36]. Furthermore, holistic care of patients is likely to be compromised with a lack of addressing physical and psychosocial morbidities.
Lack of continuity of care will also compromise shared decision-making which has been advocated in the management of skin conditions in general [22] and in psoriasis management [37] in particular.
In this context, our finding that when registrars do organise a follow-up appointment for psoriasis, it is usually with themselves (rather than another GP in the practice) should be noted. It may suggest that they appreciate the importance of, and are attempting to facilitate, interpersonal continuity of care for psoriasis.

Implications for Education and Training
As we found evidence suggesting that registrars see little psoriasis in practice over the course of GP vocational training, targeted education and training in this area may be required.
This could be addressed through structural changes within practice, appointment scheduling and policy regarding follow-up, along with concurrent patient education regarding the needs for continuity of care for management of their psoriasis, including shared decision-making and self-management [22].

Conclusions
We have identified educational and organisational aspects of registrar psoriasis management that could be optimised with changes at a registrar, practice and patient level. Registrars see relatively little psoriasis in practice during vocational training, and evidence was found to suggest that registrars are finding psoriasis care challenging. This suggests opportunity for more education and training in this area. We also found evidence that psoriasis (a chronic disease with frequent comorbidity), despite registrars' attempts, did not show the same pattern of continuity of care that is usually seen in optimal chronic disease management.