A Personalized Approach to Disease Management in Psoriasis - Episode 16
Drs Lebwohl and Groves list support services to help with patient adherence.
Ryan Haumschild, PharmD, MS, MBA: Dr Lebwohl, I’ve got a question for you. We talked about adherence also playing a huge role. We can match the right medication to the right patient based on their unique comorbidities or unique makeup like we’re doing with precision medicine, starting to create pathways for unique medications to better improve outcomes. What support services might help a patient maintain adherence to therapy in the plaque psoriasis space? And how do you reassess them for their adherence? But also, how do you reassess patients with metabolic syndrome and alter their care plan when needed?
Mark Lebwohl, MD: The metabolic syndrome is more complicated because, as my colleagues have said, there are things like diet and exercise, and control of the other features of metabolic syndrome, hypertension needs to be controlled, and the patients need to continue taking their medication, diabetes needs to be controlled. There are many factors that make that more complicated, but it’s so important to do. In terms of administering the psoriasis medications, there have been a number of studies that have looked at text reminders to patients, “Take your injection today.” One of the things that I’m very aware of is, I chair a registry called CorEvitas, which collects data on around 15,000 patients, for years, who are on biologic therapies for psoriasis or systemic therapies for psoriasis. The simple reminder from the study coordinator—we’re obliged to see those patients every 6 months—if the patients haven’t taken their medication, the simple phone call that, “You’re due for your 6-month visit,” seems to trigger the patient to comply with their therapies. It’s just an observation that I’ve made. One of my colleagues who is a world authority on adherence, Steve Feldman, [MD, PhD,] is his name, calls it the dental floss effect. When you have to make an appointment with your dentist, the week before, you start flossing, even though you haven’t done it for a long period before. I think that he’s correct in that. Thus, there are tools that we can use to nudge patients to remind them to adhere to their therapy. I think that’s true.
I love the discussion about artificial intelligence [AI] because I think here, we can remove a human component to some extent, where in my interactions with both my pharmaceutical colleagues and the insurance industry, they have a short attention span. If you take a patient at year 1 and look at that same patient 10 years later, what’s the chance he still has the same insurance? That number is pretty low. They’re looking at their cost for a few years from now, and they really are looking at their costs that year because they know they have that patient that year, but not necessarily the year after. I think with the artificial intelligence, we have an ability to incorporate the whole picture. What’s that patient going to be doing 10 and 20 years from now? Do we want them to keep working? Do we want them to not be spending time going to the cardiologist and having stents put in or a cardiac bypass? And I think that we have an ability to do that with artificial intelligence that takes human error out of it.
Robert Groves, MD: That is such an important point, and you’re absolutely correct. Because turnover is so high in insurance, there is a tendency, if not a directive, to look at outcomes over 1 to 2 years. And that does not begin to approach what’s necessary in population health management. There are some efforts out there to figure out how to share the success over time. Thus, if your insurance company started the person down this road, you continue to get credit for that in some way as that patient moves to other insurance companies. But I think we underestimate the impact of reconfiguring operations in health care. The thing that comes to mind that was astonishing to me when I first ran across this, was a company called Virta Health out there that’s been able to demonstrate in peer-reviewed studies, prospective studies, over 2 years that they can take a population of diabetics and actually reverse their diabetes, take them back to prediabetic levels. These were all comers, insulin-dependent, etc. Drop their hemoglobin A1C [glycated hemoglobin] by a point, weight by at least 5%, and drop 50% of their diabetic medications, including insulin.
Now, how is that possible? Well, they completely rethought the way that care is delivered. They call it continuous remote care. But basically, what they do is they leverage all of the available insights into psychology when they sign people up, finding their real why. “It’s because I want to be around to play with my daughter, it’s not really because I want to look better or lose weight. I want to be here when my grandchildren grow up.” Thus, finding that real reason that motivates patients, leveraging the insights of [BJ] Fogg, [PhD,] and others, and then being in contact with that patient during the early part of a pretty difficult diet for most of us to do, sometimes up to 3 times a day, for weeks and months on end, if necessary. That’s a total rethinking of the way that we have managed diabetics historically. And I think the combination of AI and digital health will allow us to do some things that heretofore have simply not been possible. They follow these folks out for 2 years, 75%-plus are still engaged. That’s also unheard of stickiness, if you will, to a program that’s not that easy to do, unless you have that kind of support. Thus, I think we need to rethink operations in health care in a big way as well.
This transcript has been edited for clarity.