Dermatol Ther (Heidelb) (2023) 13:245–268 https://doi.org/10.1007/s13555-022-00846-3 ORIGINAL RESEARCH Elevating the Standard of Care for Patients with Psoriasis: ‘Calls to Action’ from Epicensus, a Multistakeholder Pan-European Initiative Jan Koren . Jo L. W. Lambert . Simon F. Thomsen . Helen McAteer . Gabriella Fabbrocini . Valeria Corazza . Denis Jullien . Matthias Augustin . Richard B. Warren . Menno A. de Rie . Elizabeth Lazaridou . Lluı́s Puig . Loı̈c Guillevin . Marius Grosser . Wolf-Henning Boehncke Received: August 10, 2022 / Accepted: October 27, 2022 / Published online: December 9, 2022  The Author(s) 2022 ABSTRACT stakeholders: patients, clinicians and payors, and define ‘Calls to Action’ designed to achieve Introduction: Despite advances in treatment the identified changes. options and the management of patients with Methods: Eight themes relevant to elevating psoriasis, considerable unmet needs remain. the standard of care were identified from an Our objective was to identify ways to elevate the insights-gathering questionnaire completed by standard of care for patients with psoriasis by all three stakeholder groups. A modified Delphi combining the perspectives of three important exercise gained consensus on statements informed by the insights. Statements were then used to inspire ‘Calls to Action’ – practical steps Supplementary Information The online version contains supplementary material available at https:// that could be taken to realise the desired chan- doi.org/10.1007/s13555-022-00846-3. ges and elevate the standard of care. J. Koren V. Corazza EUROPSO, Polzela, Slovenia Italian Psoriatic Association Friends of the Corazza Foundation (APIAFCO), Bologna, Italy J. L. W. Lambert (&) Department of Dermatology, Ghent University, D. Jullien Vijverpark Ingang 52 - UZ Gent, De Pintelaan 185, Department of Dermatology, Hospices Civils de 9000 Gent, Belgium Lyon, Edouard Herriot Hospital, 69003 Lyon, France e-mail: jo.lambert@uzgent.be D. Jullien S. F. Thomsen INSERM U1111 - CIRI, Lyon-1 University, 69007 Department of Dermatology, Department of Lyon, France Biomedical Sciences, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark M. Augustin Health Care Research in Dermatology and Nursing, H. McAteer University Medical Center Hamburg-Eppendorf, Psoriasis Association, Northampton, UK Hamburg, Germany G. Fabbrocini R. B. Warren Section of Dermatology - Department of Clinical Dermatology Centre, Manchester NIHR Biomedical Medicine and Surgery, University of Naples Federico Research Centre, Salford Royal NHS Foundation II, Naples, Italy Trust, University of Manchester, Manchester, UK 246 Dermatol Ther (Heidelb) (2023) 13:245–268 Results: In total, 18 European experts (10 der- including by healthcare commissioners, so that matologists, 3 payors and 5 patient representa- funding priorities are assessed appropriately. tives) took part in the Delphi process. Conclusion: This unique initiative identified a Consensus was reached on statements relating practical ‘Call-to-Action Framework’ which, if to all eight themes: improve healthcare systems implemented, could help improve the standard to better support multidisciplinary team work- of care for patients with psoriasis. ing and digital services, real-world data genera- tion and optimal use, improve patient access, Keywords: Consensus; Delphi; Multistake- elevate quality-of-life measures as the most holder; Psoriasis; Standard of care important outcomes, involve patients in patient-centred and personalised approaches to Key Summary Points care, improve the relevance and reach of guidelines, education, and multistakeholder The treatment, care and management of engagement. ‘Calls to Action’ common to all patients with psoriasis remains three stakeholder groups recognised the need to suboptimal. capitalise on the shift to digital healthcare, the need for consistent input into registries to The Epicensus programme was designed to generate real-world evidence to support guide- establish the current state of care from a line development, and the necessity of educat- uniquely multistakeholder perspective ing patients on the benefits of reporting (dermatologists, payors and patient outcomes to generate real-world data. The representatives). enormous quality-of-life burden and psycho- A consensus exercise identified areas and logical impact of psoriasis, as well as the clinical aspects of care that need improving. needs of patients must be better understood, The results revealed that despite advances in treatment options and the M. A. de Rie Amsterdam UMC, Department of Dermatology, management of patients with psoriasis, University of Amsterdam, Amsterdam, The some unmet needs and barriers to Netherlands improvements in the standard of care E. Lazaridou identified a decade ago still exist. 2nd Department of Dermatology-Venereology, The aim of Epicensus is to effect positive Aristotle University School of Medicine, Thessaloniki, Greece change, and here we report ‘Calls to Action’ based on the consensus L. Puig statements that, if implemented, should Department of Dermatology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de elevate the standard of care and therefore Barcelona, Barcelona, Spain make progress towards optimal management of patients with psoriasis. L. Guillevin Assistance Publique-Hôpitaux de Paris, Hôpital Cochin, Université Paris Descartes, Paris, France M. Grosser German Psoriasis Association, Seewartenstraße 10, 20459 Hamburg, Germany INTRODUCTION W.-H. Boehncke Division of Dermatology and Venereology, Geneva Psoriasis, an immune-mediated, chronic University Hospitals, Geneva, Switzerland inflammatory disease primarily affecting the W.-H. Boehncke skin and causing scaling, pain, itching and Department of Pathology and Immunology, Faculty burning, is now widely accepted to be systemic of Medicine, University of Geneva, Geneva, in nature with manifestations beyond the skin Switzerland [1, 2]. Patients with psoriasis can experience Dermatol Ther (Heidelb) (2023) 13:245–268 247 serious comorbidities including psoriatic with increased disease symptoms and severity arthritis (PsA), cardiometabolic syndrome, and reductions in QoL and work productivity inflammatory bowel disease and psychological [27]. disorders [1–5]. Barriers to optimal care include the discrep- Psoriasis is complex, requiring multidisci- ancies between the heterogeneous patient pop- plinary, personalised care [4, 6–8]. Combined ulation encountered in clinical practice and the dermatology and rheumatology clinics can uniform population enrolled in clinical trials successfully improve the diagnosis and man- [28, 29], and healthcare system differences agement of challenging cases and enable early including waiting times and variation in the detection and treatment of PsA [9]; however, availability of and access to advanced therapies this remains a significant practice gap [10, 11]. including biologics and small molecules. It has been suggested that the multidisciplinary To alleviate the sustained burden, an eleva- team (MDT) approach should be the norm tion in the standard of care (SoC) is warranted rather than the exception, potentially expand- but the range of unmet needs suggests that ing beyond dermatology, rheumatology and changes to achieve this would be multifaceted. gastroenterology [4]. Indeed, a study is cur- A study by the Group for Research and Assess- rently recruiting to explore whether an inter- ment of Psoriasis and Psoriatic Arthritis disciplinary combined clinic (including nurses (GRAPPA) and KPMG identified and explored and psychologists) is more effective than usual areas in which care for patients with PsA could siloed care [12, 13]. Furthermore, the coron- be improved and improvement indicators were avirus disease 2019 (COVID-19) pandemic has defined [30]. Similarly, the aim of the Epicensus highlighted inadequacies in infrastructure and programme was to identify ways in which the inequities in healthcare access [14]. Clinical SoC could be elevated from the perspective of pathways have had to adapt to continue to three important stakeholders: patients, clini- provide care for patients [15]. cians and payors. Here, we report a Delphi Despite advances in treatment options [16] exercise performed to gain an up-to-date con- and management [17], substantial unmet needs sensus on key themes related to elevating the remain [6, 18, 19]. The physical and psycho- SoC for patients with psoriasis from a unique, logical multi-morbidities continue to exert far- multistakeholder perspective. Having identified reaching, negative consequences on patients these areas, we also report ‘Calls to Action’ and society including stigmatisation, work inspired by the consensus statements, which are absenteeism, relationship difficulties and designed to bring about the identified changes. increasing out-of-pocket healthcare costs [2, 20–22]. Patients with psoriasis and physical or psychological comorbidities experience an METHODS increased clinical burden, worse quality of life (QoL) and greater economic burden than those The Epicensus programme is a pan-European, without comorbidities [2]. Healthcare costs multistakeholder initiative aimed at elevating associated with psoriasis increase over time as the SoC for patients with psoriasis. By bringing the disease progresses [23], and compared with together clinicians (dermatologists), payors and matched controls, patients with psoriasis expe- patient representatives, a broad picture of the rience higher healthcare costs and a greater current state of care was generated to inform negative impact on income and employment how this could be elevated from the different [24]. Disease burden is also affected by plaque stakeholder perspectives. The participating location. Visible plaques and plaques in sexu- stakeholders are shown in the supplementary ally-sensitive areas [2, 25] and plaques on the material. The goal was to generate ‘Calls to hands, feet or genitalia increase work absen- Action’ that, if implemented, could improve the teeism [21]. Low patient–physician concor- overall SoC. The first phase of the programme dance regarding satisfaction with psoriasis was a questionnaire (see the electronic supple- management often occurs [26] and is associated mentary material) designed to gather insights 248 Dermatol Ther (Heidelb) (2023) 13:245–268 around psoriasis care and changes needed to information and responses to open-ended improve it, which was completed by all stake- questions included in the ‘discussion points’ holder groups. Responses were collated, anal- below for each theme. ‘Calls to Action’ that ysed qualitatively and eight key themes relevant were common to only two groups are presented to elevating the SoC were identified (Table 1). in the electronic supplementary material This informed the second phase: a Delphi (Table S2). This manuscript is formed of the exercise to achieve consensus agreement on opinions of the authors themselves. There was statements arising from the insights. Consensus no need to collect any type of patient data. was defined as C 75% selecting ‘agree’ or Hence, the approval of an Ethics Committee ‘strongly agree’. Since the objective was to gain was not required. Consent was obtained from multistakeholder consensus, but the stakehold- all participants as they were contracted by UCB ers were not equal in number, individual votes Pharma to take part in this programme. were weighted so that each stakeholder group had an equal impact on the overall percentage Discussion Points calculated. To progress towards an elevation in the standard of care, the third phase was a Improve Healthcare Systems to Better Support multistakeholder meeting in which ‘Calls to MDT Working and Digital Services (Table 2) Action’, inspired by the consensus statements, were developed to achieve the improvements Consensus Statements and Open-Ended Ques- (Fig. 1). The electronic supplementary material tions Consensus was achieved on all state- contains further detailed information on the ments except one. Initial disagreement around programme including the participants’ back- the focus on mental health was resolved by grounds (Table S1) and the Delphi voting. modifying the statement to clarify that it should be one of the aims of an MDT approach. The composition of the MDT is discussed below RESULTS (see ‘Improve the relevance and reach of guidelines’). Respondents Open-ended questions on the topic of ‘digi- tal healthcare’ revealed different interpretations One of the three payors only took part in the of the term. It encompasses a broad range of third Delphi e-survey while one clinician was activities as indicated by the penultimate con- unable to take part in the third Delphi e-survey. sensus statement in Table 2. Stakeholders felt Therefore, 17 stakeholders answered each that teleconsultations and virtual consultations question except where an answer was omitted cannot fully replace face-to-face appointments; by one stakeholder and the percentage agree- they must complement each other. While tele- ment was calculated out of 16 responses. The phone consultations can be convenient, fre- weighting used to calculate the consensus quently constituting perfectly adequate follow agreement was adjusted accordingly. up, virtual ‘Facetime’-style appointments are not always an improvement, proving awkward Consensus Statements and ‘Calls for physicians and patients alike if more inti- to Action’ mate areas are involved. Appropriate patients for digital healthcare were identified as those Statements, percentage consensus agreement, comfortable with the technology (‘tech-savvy’), and ‘Calls to Action’ common to all stakeholder whose disease status is appropriate (e.g. stable) groups are presented in the Tables. Statements as well as those for whom travel is difficult (e.g. used to inspire ‘Calls to Action’ are highlighted living in rural areas). Less suitable patients are alongside the corresponding ‘Calls to Action’. usually older, unfamiliar with the technology or These tables are complemented by and should with disabilities or conditions (e.g. dementia) be read in conjunction with the further that prevent them from using digital media, as Dermatol Ther (Heidelb) (2023) 13:245–268 249 Table 1 Eight themes identified from the insights-gathering questionnaire that were used to inform the subsequent Delphi exercise Theme Description of current situation and possible solutions/needs Improve healthcare systems to better support • Healthcare systems are not designed to facilitate efficient diagnosis, MDT working and digital services referral, delivery and monitoring of treatment • Evidence-based changes to existing care pathways are needed to improve early diagnosis, referral, patient-centric and MDT care • Improvements are needed in MDT healthcare delivery at all points in the care pathway, from primary care to specialist clinics (digital and face-to-face), specialist pharmacists and nurses • Adopt digital healthcare to improve service provision Real-world data generation • Robust datasets from well-designed studies and real-world data/ evidence (including assessments of value over time including durability and the impact in difficult-to-treat patients) support the incorporation of novel medicines into treatment guidelines and their adoption as standards of care • Patients want to be involved in collaborative working to inform data generation, publications, guidelines and policies Improve patient access • All aspects of access need improvement from earlier, equitable and sustained access to innovative treatments as well as access to the right HCP at the right time to enhance the patient experience Elevate quality of life measures as the most • Clinicians and patients value outcomes that satisfy patient goals as the important outcomes most important measures of treatment success • The elevation in the SoC in psoriasis should be a tangible improvement in the holistic burden of psoriasis on patients and carers Involve patients in patient-centred and • Patients want to be partners at the centre of decision-making by being personalised approaches to care well informed and having their voices heard • Personalisation of care: an individualised approach to assessment and treatment, taking account of the holistic impact of psoriasis including tailored, clinical and cost-effective treatments to ensure timely intervention and value for patients Improve relevance and reach of guidelines • Guidelines to support MDT approaches and integrated clinical and health economic guidelines are lacking • Real-world evidence, clinical and health economic guidelines and budget optimisation will facilitate the adoption of novel treatments • Guidelines must be supported by clinical data (trial and RWD), economic and operational considerations, and monitored to track the value over time 250 Dermatol Ther (Heidelb) (2023) 13:245–268 Table 1 continued Theme Description of current situation and possible solutions/needs Education • Awareness of the disease and its comorbidities is lacking • A focus on broader healthcare professional education will drive elevations in standards of care • Patient misconceptions and anxiety can be alleviated by rapid provision of suitable information Multistakeholder engagement • Recognise and explore optimal ways to establish multistakeholder initiatives • Engaging payors in partnership initiatives may be possible and strengthened when multistakeholder in nature • Strengthen the role of patients, patient advocacy groups (PAG) and payor input to research and development (R&D) and broader data generation initiatives The themes are presented in priority order as voted by the stakeholders HCP healthcare professional, MDT multidisciplinary team, PAG patient advocacy group, R&D research and development, RWD real-world data, SoC standard of care well as newly diagnosed patients or those with filling gaps in knowledge left by strict clinical unstable disease. However, it was felt that these trial inclusion criteria, resulting in a paucity of patients are in the minority and that sometimes data in special populations (e.g. elderly, chil- it is stakeholders, not patients, who fail to dren, pregnant/breast-feeding women, those embrace the digital shift. with cancer or other comorbid diseases). ‘Calls to Action’ Stakeholders agreed that ‘Calls to Action’ Stakeholders advocated the supporting adoption of digital care will involve development of national registries. Incentivis- education, training, collaboration, and support ing clinicians to report RWD consistently or among healthcare professionals (HCPs), payors making contribution mandatory, looking for and patients, not only in how to use the tech- opportunities to engage pharmacists in RWD nology, but also to understand the benefits it generation activities, highlighting the impor- provides to enhance engagement and support tance of real-world evidence (RWE) to all an elevation in the SoC. stakeholders and educating patients on the value of RWE so that they proactively provide Real-World Data (RWD) Generation information were discussed. The need to cap- and Optimal Use (Table 3) ture a standard/minimal set of outcomes including patient-reported outcomes (PROs) Consensus Statements and Open-Ended Ques- was noted. tions Stakeholders suggested that patients cared most about the effectiveness and sus- Improve Patient Access (Table 4) tained efficacy of treatments and QoL followed by the safety and tolerability of treatments and Consensus Statements and Open-Ended Ques- having clear skin. RWD was seen as critical in tions Some stakeholders repeated their view Dermatol Ther (Heidelb) (2023) 13:245–268 251 Fig. 1 A flow chart to show the phases of the Epicensus was smaller but included some individuals new to the programme. A large pool of stakeholders completed the programme to test agreement with the statements with questionnaire to gain as broad a perspective as possible. The additional participants. SoC standard of care number of stakeholders who completed the Delphi exercise that psychological support does not need to be when adopted early, was considered key to mandatory; however, it should be available if achieving this. needed. The right number of experienced staff, MDTs, good levels of funding and reimburse- Elevate Quality-of-Life Measures as the Most ment, flexible prescribing, access to all/innova- Important Outcomes (Table 5) tive medicines and involving patients in decisions were all identified as features of Consensus Statements and Open-Ended Ques- healthcare systems that offer equitable patient tions Consensus was reached that QoL mea- access. sures should be elevated as the most important outcomes and that validated measures and tools ‘Calls to Action’ Rapid access to well-in- to assess QoL exist and should be used consis- formed, equitable care would be supported by tently. Stakeholders identified the three most ensuring that health-service commissioners valuable measures as the Dermatology Life better understand the clinical needs of patients Quality Index followed by the Psoriasis Dis- with psoriasis, so they reassess funding priori- ability Index and the Psoriasis Index of QoL ties. Generating evidence of the value of bio- from a list of 11 suggestions with the option to logics and biosimilars including their cost- add others. While most stakeholders (n = 14/17; effectiveness, especially in the long-term and 82.4%) agreed that the existing tools effectively 252 Dermatol Ther (Heidelb) (2023) 13:245–268 Table 2 Consensus statements and ‘Calls to Action’ to improve healthcare systems to better support MDT working and digital services Statement Weighted ‘Calls to Action’: all stakeholders consensus must… agreement (%) The existing psoriasis care pathway is entrenched but it 96.7 NA needs to change to facilitate improvements in standards of care Evidence-based changes to existing care pathways are 100 NA needed to improve the management of patients living with psoriasis An effective multidisciplinary approach requires a shift in 93.3 NA mindset and a shift in infrastructure A focus of any multidisciplinary approach to elevating 73.3 NA standards of care in psoriasis should be on the impact on the mental health status of patients Assessing the impact on the mental health status of patients 96.7 NA should be one of the aims of any multidisciplinary approach to elevating standards of care for patients living with psoriasis Healthcare infrastructure needs to change to facilitate the 100 NA establishment of clinics with enough adequately skilled HCPs from all essential specialities to create an efficient care pathway to manage patients with psoriatic disease effectively and in a timely manner Digital healthcare has a role to play in helping to elevate the 93.3 NA SoC for patients living with psoriasis Digital healthcare needs to be carefully integrated into the 96.7 NA care pathway Only certain patients living with psoriasis will be 76.7 NA suitable for digital healthcare, while others would benefit from face-to-face appointments Dermatol Ther (Heidelb) (2023) 13:245–268 253 Table 2 continued Statement Weighted ‘Calls to Action’: all stakeholders consensus must… agreement (%) Digital healthcare encompasses the use of 95.8 • Support adoption of digital care for technology in its broadest sense to enhance equitable (and timely) access to MDT and improve all aspects of care healthcare/management of patients by supporting patients and HCPs through: facilitating a continuous dialogue between patients and their HCPs; supporting self- assessment and monitoring tools for patients to enable consistent recording of data; storing and sharing data and documentation; facilitating communication between HCPs of different specialities; appropriate use of telemedicine and virtual consultations; and facilitating administration for both HCPs and patients, at all stages of the patient journey Digital healthcare should be made as 100 accessible as possible to all patients with psoriatic disease and/or their caregivers to maximise the number of patients who can benefit from it Italics indicates a statement which did not reach consensus. Underline indicates ‘Calls to Action’ and the statements (in bold–underline) they were inspired by HCP healthcare professional, MDT multidisciplinary team, NA not applicable and specifically capture all relevant aspects of most important existing tools, including those QoL, a few dermatologists noted that existing that are most relevant to payors, and agreeing tools (except the Patient Benefit Index (PBI)) fail on a consistent method of collecting high- to consider the patient perspective or psycho- quality data are crucial to address the burden logical impact or that the visibility of lesions is psoriasis places on QoL and elevate the SoC. not adequately or specifically assessed. While stakeholders acknowledged that the concept of Involve Patients in Patient-Centred Cumulative Life Course Impairment (CLCI) has and Personalised Approaches to Care (Table 6) potential clinical value, an actual measure to capture it is needed. Consensus Statements and Open-Ended Ques- tions All statements relating to patient-cen- ‘Calls to Action’ Stakeholders remain moti- tricity achieved 100% consensus, highlighting vated to improve upon existing QoL tools pos- how critical patient-centricity and patient voice sibly by incorporating them into a new, are. However, stakeholders noted that patients universal tool. Identifying and prioritising the must be free to choose if they wish to 254 Dermatol Ther (Heidelb) (2023) 13:245–268 Table 3 Consensus statements and ‘Calls to Action’ for real-world data generation and optimal use Statement Weighted ‘Calls to Action’: all stakeholders must… consensus agreement (%) Real-world data are needed to support 100 • Support the development of national registries; the rapid incorporation of novel ensure that data collection is regular and medicines into clinical guidelines and consistent to support the rapid incorporation of the refinement of clinical practice novel medicines into clinical guidelines and the Outcomes that are most important to 90 refinement of clinical practice patients are the most important to measure and collect in routine clinical practice RWD is vital to help inform clinicians 100 of the real-world effectiveness and safety (including long-term data) of different treatments in ‘real’ patients, that is, those who are often excluded from clinical trials Underline indicates ‘Calls to Action’ and the statements (in bold–underline) they were inspired by RWD real-world data participate in shared decision-making and their cardiologists. Some suggested that additional decision respected. specialists were unnecessary, while others felt diabetologists/endocrinologists, obstetricians ‘Calls to Action’ Stakeholders agreed that and gynaecologists would provide further valu- patients are uniquely placed to provide valuable able input to support guidance and thus information beyond that of their own disease improve the relevance and utility of guidelines. and treatment progress. Their knowledge and Barriers to implementing guidelines were iden- experience of healthcare systems could provide tified as the organisation of the healthcare sys- information which may be utilised to help ele- tem (e.g. lack of MDT pathways), complexity of vate the SoC. Establishing standard ways to guidelines, the speed with which they are capture their views is needed. updated in a rapidly changing field and regional differences. Overall, 71% of stakeholders Improve the Relevance and Reach believed that changes at the healthcare system of Guidelines (Table 7) level should be prioritised to realise the most rapid elevation(s) in the SoC, while 29% would Consensus Statements and Open-Ended Ques- prioritise changes at the physician level. tions Consensus was reached that dermatolo- gists and rheumatologists should share the ‘Calls to Action’ To improve the relevance management of patients with psoriasis and reach of guidelines, a harmonised approach depending on disease manifestations. Essential to their development is needed, encompassing MDT members needed to develop multidisci- all aspects of the disease (psychological, plinary guidance to support an MDT approach comorbidities etc.) and all patient subgroups were identified as rheumatologists and derma- (e.g. elderly) while incorporating the patient tologists followed by psychologists, general perspective and experiences and with regular practitioners, gastroenterologists and reviews and updates to include clinical and Dermatol Ther (Heidelb) (2023) 13:245–268 255 Table 4 Consensus statements and ‘Calls to Action’ to improve patient access Statement Weighted ‘Calls to Action’: all stakeholders must… consensus agreement (%) Access to innovative treatments is currently 96.7 NA suboptimal Access to psychological support services should be a 76.7 NA mandatory part of the treatment pathway for all patients living with psoriasis Early intervention, with effective 100 • Raise the profile of psoriasis so commissioners re- biologic treatments, may provide evaluate funding and convince them of the long- long-term value for patients and term cost savings from the balanced use of healthcare systems biologics if adopted early in treatment Healthcare systems should be designed 100 • Endorse a patient-centred approach to care based to deliver equitable access to on the clinical needs of patients, backed by up-to- dedicated specialist centres for all date evidence and data patients living with psoriasis The main barriers to equitable access to 100 optimal psoriasis care are country- specific and operate at a national level. Therefore, they need to be addressed at a national level In my role, I have a key role in ensuring 95.8 equity of access to optimal care for all patients living with psoriatic disease Underline indicates ‘Calls to Action’ and the statements (in bold–underline) they were inspired by NA not applicable health economic RWD (especially patient-rele- benefit from more education and indicate a vant data). preference for multistakeholder training and educational initiatives. Education (Table 8) Multistakeholder Engagement (Table 10) Consensus Statements and Open-Ended Ques- tions The importance of education was high- Consensus Statements and Open-Ended Ques- lighted by 100% consensus for all statements. tions Current lack of patient involvement in Suggested education topics are summarised in many industry activities was confirmed. Stake- Table 9. holders felt industry could best support patient involvement through funding in various forms ‘Calls to Action’ The ‘Calls to Action’ reflect (unrestricted grants, independent research, the consensus that all stakeholders would reimbursing patients’ time/expertise, 256 Dermatol Ther (Heidelb) (2023) 13:245–268 Table 5 Consensus statements and ‘Calls to Action’ to elevate quality of life measures as the most important outcomes Statement Weighted ‘Calls to Action’: all stakeholders must… consensus agreement (%) The negative impact on quality of life 100 • Improve own knowledge of existing QoL tools and daily functioning is the greatest and how to use them source of the cumulative burden of • Work towards developing newer QoL/PRO disease on patients living with measurement tools to capture data consistently, psoriasis including cumulative disease burden QoL measures should be elevated as the 83.3 most important clinical outcomes for patients with psoriasis assessed in clinical trials and clinical practice There are validated QoL tools and 76.6 measurements in existence that should be used consistently to assess the QoL of patients living with psoriasis Underline indicates ‘Calls to Action’ and the statements (in bold–underline) they were inspired by PRO patient-reported outcome, QoL quality of life sponsoring patient meetings to disseminate framework. This will enhance patient engage- research findings, podcasts, publications, sym- ment and education, desirable factors in nar- posia for patients as well as training/education). rowing the gap between patients and industry. Other suggestions included industry supporting registries and educating patients on the need to report data, supporting patients to help payors understand patient needs, promoting partici- DISCUSSION pation of patient research partners (patients who actively participate in research teams The ultimate aim of the pan-European Epicen- alongside and on an equal basis with profes- sus programme is to elevate the SoC for patients sional researchers) in activities of groups such as with psoriasis by creating a multistakeholder GRAPPA and becoming involved in clinical trial ‘Call-to-Action Framework’ to stimulate and design. However, this should complement but drive positive change. Local adoption could never replace industry support of physicians encourage different stakeholders to collaborate themselves. and implement activities that align with the ‘Calls to Action’ to bring about these changes. ‘Calls to Action’ Patients should be involved Insight gathering identified eight key themes at all stages from (research and development) that were explored through a modified Delphi R&D to RWD and RWE generation, so that their technique. Consensus statements were used to knowledge, experience and perspectives can be inspire ‘Calls to Action’, developed by each harnessed to add value. Critical to the success of stakeholder group separately but discussed patient involvement is ensuring that outcomes together to find those common to all stake- and data are communicated back to patients holder groups. These common ‘Calls to Action’ appropriately within the local regulatory are summarised in Table 11. Dermatol Ther (Heidelb) (2023) 13:245–268 257 Table 6 Consensus statements and ‘Calls to Action’ relating to involving patients in patient-centred and personalised approaches to care Statement Weighted ‘Calls to Action’: all stakeholders must… consensus agreement (%) Patients living with psoriasis, and their families, need 100 NA to be listened to and heard by ensuring they have the time and space to voice their concerns and opinion Care for patients living with psoriasis 100 • Support patient involvement in health should be built on a holistic approach authority meetings, legislative processes and that puts the patient at the very centre regulatory decisions and actively encourages patients to • Capture RWD and patient-reported engage in all aspects of their care experiences to identify challenges, needs and Patients living with psoriasis should play 100 issues for patients and carers a valued role in decisions not only at the individual patient level but also at the system level Patients are a valuable, under-used 100 source of vital information; for example, their experience of the patient pathway and administrative processes that determine medical care and treatment and how they could be improved, which could help elevate the SoC at the system (infrastructure) level Underline indicates ‘Calls to Action’ and the statements (in bold–underline) they were inspired by NA not applicable, RWD real-world data, SoC standard of care During the COVID-19 pandemic, utilisation and patients to maximise success. Enabling of digital healthcare increased and widespread access and upskilling all users of the technolo- adoption of various technologies accelerated gies is essential [31] and requires additional [31]. Stakeholders agreed that capitalising on funding. Governance of ‘sensitive’ data is a this shift to digital and wider technology will be potential hurdle to implementation. key to elevating the SoC for patients with pso- A coordinated effort to set up or support riasis by providing additional communication national registries was a clear ‘Call to Action’. channel options as long as: it is made as widely The coordinated development of collaborative accessible as possible (for clinicians and patients databases systematically recording clinically alike), patients understand its value, and it does relevant outcomes including PROs was consid- not increase clinicians’ workload. This must be ered key to supporting guidelines and clinical a collaborative effort between clinicians, payors practice. In France, the Transparency 258 Dermatol Ther (Heidelb) (2023) 13:245–268 Table 7 Consensus statements and ‘Calls to Action’ relating to improving the relevance and reach of guidelines Statement Weighted ‘Calls to Action’: all stakeholders consensus must… agreement (%) Guidelines that integrate clinical data (both 93.3 • Endorse development of integrated, trial and real-world) with health economic harmonised, flexible and regularly data are lacking updated guidelines Standards of care in psoriasis would be 96.7 elevated with the use of guidelines that consider clinical data, including real-world data, and health economic evidence Measuring the real-world clinical and health 96.7 economic value of treatments in psoriasis over time is critical to ensure that standards of care can be elevated Standards of care would be improved if 100 guidelines better reflected the need for a multidisciplinary/multi-stakeholder approach to the management of psoriasis Dermatologists and rheumatologists should 86.6 share the management of patients with psoriasis Multidisciplinary guidance should be 96.7 developed by a multidisciplinary team, including input from patients The practical gaps between guidelines and their 96.7 NA implementation need to be addressed to elevate standards of care in psoriasis In my country, national/regional guidelines are more 93.3 NA relevant to clinical practice than international guidelines Underline indicates ‘Calls to Action’ and the statements (in bold–underline) they were inspired by NA not applicable Commission integrated data from the national important, but adequate data protection must real-life registry of biotherapies (PSOBIOTEQ), be in place. using it as the basis for its recommendations in In terms of assessing QoL measures, or more January 2022 to move several biologics from broadly, PROs, stakeholders agreed that existing third-line treatments into the second line [32]. tools could be used, but visibility of lesions is Educating patients on the value of RWD and not adequately or specifically assessed. Given evidence so they proactively contribute is the impact of visible lesions on QoL and work Dermatol Ther (Heidelb) (2023) 13:245–268 259 Table 8 Consensus statements and ‘Calls to Action’ relating to education Statement Weighted ‘Calls to Action’: all stakeholders must… consensus agreement (%) Patients should have access to high 100 • Focus on a broader healthcare professional quality, comprehensive disease education adapted to the needs of the information that is available on demand healthcare providers in different formats with the • Encourage and pursue multistakeholder opportunity to ask questions and seek collaborations and education opportunities clarification if required • Support education and collaboration to Enhanced education and awareness of 100 better understand and manage comorbidities psoriasis in general practice is needed to improve appropriate referral to a dermatologist, timely diagnosis and earlier intervention through multidisciplinary, holistic care and effective treatments Dermatologists should be aware of the 100 spectrum of comorbidities and their impact on patients living with psoriasis, so that further specialist advice can be sought in a timely manner Payors and healthcare professionals 100 should better appreciate the total impact and cumulative disease burden posed by psoriasis over the lifetime of patients living with this disease Underline indicates ‘Calls to Action’ and the statements (in bold–underline) they were inspired by absenteeism [2, 21, 25], this is one obvious relevant parties are likely to be the most bene- omission to address with a new, freely accessible ficial. However, as noted here and previously tool. [34], barriers to their implementation, includ- Giving patients the opportunity to be ing incomplete knowledge of guidelines, their involved in shared decision-making was seen as complexity, and the complexity of psoriasis important, but shared decision-making in pso- itself must be overcome. Literature supports an riasis needs more research to overcome existing MDT approach to psoriatic disease manage- barriers and demonstrate potential benefits [33]. ment. A report from Portugal showed the many Opinion varied on additional specialists different models of combined dermatol- needed in the MDT, possibly reflecting differ- ogy–rheumatology clinics in existence, but fur- ences between countries. In France, for ther evaluation of obstacles and benefits is instance, internists are often consulted when needed to optimise care [35]. A working group patients present with multi-organ diseases. explored barriers to best practice in PsA, con- Guidelines that incorporate input from all cluding that a fully integrated, collaborative, 260 Dermatol Ther (Heidelb) (2023) 13:245–268 Table 9 A table to show the education topics* that each stakeholder would most benefit from Patient GP Payor Dermatologist Comorbidities Availability and efficacy of Cumulative life impact of psoriasis New innovative treatments and innovative, systemic on patients and associated cost to their mechanism of action treatments society of such a chronic disease (absence from work, management of comorbidities) and the positive impact in the long term of early effective treatment initiation Safety of Comorbidities PROs and the patient’s treatments perspective and experience (current and innovative) Efficacy of Early diagnosis of PsA, when Optimal use of treatment in treatments referral should be made, and subpopulations – women of (current and the impact of delays on childbearing age, planned innovative) patients pregnancy, children, different comorbidities (rheumatological conditions (particularly PsA), mental health issues, metabolic and cardiovascular comorbidities) Lifestyle Guidelines and treatment information algorithms Early recognition of PsA *Topics and comorbidities (for dermatologists) shown are those mentioned at least three times by stakeholders in response to open-ended questions and are arranged in descending order of frequency PROs patient-reported outcomes, PsA psoriatic arthritis multidisciplinary, patient-focused approach is examining whether patients with psoriasis or required for optimal care [36], and in psoriasis, PsA recognised that they were being monitored Eissing and colleagues suggest that addressing for comorbidities associated with their condi- related barriers simultaneously is required to tion. It concluded that patient education needs effect change [34]. to be improved owing to discrepancies between All stakeholders require education on patient responses and physician records about comorbidities; clinicians so they are aware of the presence and treatment of comorbidities the full range and consult the appropriate spe- [37]. cialists as needed, payors so they understand Stakeholders agreed that multistakeholder the broader implications of psoriasis on initiatives are beneficial; performing activities patients, and the healthcare system and in siloes only perpetuates existing knowledge patients so they understand the full extent of gaps and barriers to collaborative working. their condition. This agrees with a study Central to this is educating and motivating Dermatol Ther (Heidelb) (2023) 13:245–268 261 Table 10 Consensus statements and ‘Calls to Action’ relating to multistakeholder engagement Statement Weighted ‘Calls to Action’: all stakeholders must… consensus agreement (%) Multistakeholder initiatives are likely 86.2 • Encourage multistakeholder engagement as to be the most successful type of broadly as possible; for example, in planning collaboration with the processes, research, R&D initiatives, clinical trial biopharmaceutical industry design, decision-making and RWD generation Engagement initiatives between payors, 100 while ensuring that patients are involved, heard patients/patient groups and and educated along the way healthcare professionals that are focused on elevating standards of care in psoriasis can be supported by the industry, provided there are shared goals, clear governance and a sustained commitment from all parties R&D efforts and real-world data 100 generation initiatives would be of more value if input from patients/patient advocacy groups was routinely sought Patients and patient advocacy groups 89.2 are underutilised, their valuable and necessary input into R&D and RWD generation is lacking, and industry could do more to support such activities Industry should support patient/patient advocacy 89.2 NA group involvement in R&D by facilitating their engagement in clinical trials from the beginning (planning and design stage) and beyond Industry should aid patient/patient advocacy group 89.2 NA involvement in RWD generation by supporting registries and helping to inform and educate patients on the importance of contributing to (national/independent/transverse) registries Underline indicates ‘Calls to Action’ and the statements (in bold–underline) they were inspired by NA not applicable, R&D research and development, RWD real-world data 262 Dermatol Ther (Heidelb) (2023) 13:245–268 Table 11 A summary of the ‘Calls to Action’ common to all stakeholders, per theme, to bring about an elevation in the SoC for patients with psoriasis Theme ‘Calls to Action’ Improve healthcare systems to better support • Support adoption of digital care for equitable (and timely) access to MDT working and digital services MDT care Real-world data generation and optimal use • Support the development of national registries; ensure that data collection is regular and consistent to support the rapid incorporation of novel medicines into clinical guidelines and the refinement of clinical practice Improve patient access • Raise the profile of psoriasis so commissioners re-evaluate funding and convince them of the long-term cost savings from the balanced use of biologics if adopted early in treatment • Endorse a patient-centred approach to care based on the clinical needs of patients, backed by up-to-date evidence and data Elevate QoL measures as the most important • Improve own knowledge of existing QoL tools and how to use them outcomes • Work towards developing newer QoL/PRO measurement tools to capture data consistently, including cumulative disease burden Involve patients in patient-centred and • Support patient involvement in health authority meetings, legislative personalised approaches to care processes and regulatory decisions • Capture RWD and patient-reported experiences to identify challenges, needs and issues for patients and carers Improve the relevance and reach of guidelines • Endorse development of integrated, harmonised, flexible and regularly updated guidelines Education • Focus on a broader healthcare professional education adapted to the needs of the healthcare providers • Encourage and pursue multistakeholder collaborations and education opportunities • Support education and collaboration to better understand and manage comorbidities Multistakeholder engagement • Encourage multistakeholder engagement as broadly as possible; for example, in planning processes, research, R&D initiatives, clinical trial design, decision-making and RWD generation while ensuring that patients are involved, heard and educated along the way MDT multidisciplinary team, PRO patient-reported outcome, QoL quality of life, R&D research and development, RWD real-world data patients to participate in the widest range of communicated back to patients. However, activities, from R&D to clinical trials and while patient advocacy groups (PAGs) have a beyond, with outcomes and data role in clinical trial design, etc., careful Dermatol Ther (Heidelb) (2023) 13:245–268 263 planning is required, as their capacity is limited, tackled, such as multistakeholder engagement and therefore, they are unable to be involved in and the relevance and reach of guidelines. all initiatives. The Epicensus programme has several The ‘Calls to Action’ span a broad range of strengths, notably the inclusion of three key areas pertinent to psoriasis care and vary widely stakeholder groups involved in the care and in their ease and speed of potential implemen- management of psoriasis: clinicians (dermatol- tation. ‘Calls to Action’ relating to education ogists), payors and patient representatives, and could be quick to implement. Some aspects of over ten countries across Europe are repre- digital healthcare and other technologies are sented, bringing a truly pan-European perspec- already being utilised and these could be built tive. There was input from a large cohort of upon and refined in line with the ‘Calls to stakeholders and the opportunity for discussion Action’. Others, however, including the devel- both within and across stakeholder groups opment of guidelines, may be more complex allowed for a unique depth of alignment on the and time consuming to implement. Initial ‘Calls to Action’. Taking place throughout 2021, groundwork may be necessary, for example, to this initiative has benefited from lessons agree upon the specialist input needed as well as learned during the COVID-19 pandemic in consultation with payors to agree upon the data terms of innovative ways to optimise clinical needed to support early adoption of innovative practice, patient support and care. Limitations therapies. include the relatively large number of clini- Several ‘Calls to Action’ are intercon- cians, represented solely by dermatologists, nected. The need for consistent recording of compared with the payors and patient repre- PROs links several themes. It is integral to sentatives (mitigated by establishing a weighted improving digital healthcare, RWD and RWE consensus and having a lead from each stake- generation and input into registries. Digitally holder group to ensure equal representation in upskilled patients consistently collecting PRO discussions). The low number of payors also data may also contribute to the relevance of meant that the diversity of European healthcare guidelines by providing data via registries or systems was not comprehensively covered, but other RWE studies. Educational tools and extending discussion of the ‘Calls to Action’ to reminders texted to patients improved clinical more members of the under-represented stake- outcomes, adherence, and the patient–physi- holder groups would help to allay this limita- cian relationship in a pilot study [38], sug- tion. Not all the consensus statements were gesting that improving education and digital discussed at the Consensus Council meetings. healthcare could have positive effects. For example, appropriate integration of psy- Another study compared a structured, multi- chological screening or support so it is readily disciplinary, patient education programme accessible to patients was agreed upon but ‘Calls with usual psoriasis care and found that while to Action’ were not generated. A more complete QoL and disease severity did not differ ‘Call-to-Action Framework’ could be established between the groups, compared with usual if the remaining statements were used to gen- care, the educational intervention improved erate ‘Calls to Action’. Having an industry patient knowledge of psoriasis and patient sponsor can be seen as a limitation, but the satisfaction with disease management which, questionnaires and Delphi e-surveys were com- nonetheless, are valuable outcomes [39]. This pleted by stakeholders independently and the may lead to patients becoming more knowl- sponsor did not take an active part in the edgeable, engaged, and motivated to con- Consensus Council meetings. tribute to discussions aimed at improving Themes highlighted by this initiative align MDT working and the patient pathway, well with other studies. Interviews conducted thereby impacting other ‘Calls to Action’. with dermatology outpatients with psoriasis Improved education and healthcare systems revealed how the burden of psoriasis beyond could lead to an improvement in patient the skin is not adequately addressed in consul- access and enable other areas to then be tations, including the psychosocial impact of 264 Dermatol Ther (Heidelb) (2023) 13:245–268 the disease. The study concluded that patient This in turn could help alleviate the long-term education to improve knowledge and self- costs and cumulative life-long burden that this management is necessary and structural chan- chronic, incurable disease places on healthcare ges to dermatology services are needed [40]. systems and patients. Overlap with issues in psoriasis care identified a decade ago include the reach of guidelines, consistent use of assessment tools and improv- ing access to new therapies and ongoing care ACKNOWLEDGEMENTS [41], highlighting the enduring need for action The authors would like to thank Anusha Patel to adequately address long-standing challenges. for her participation in the Delphi voting, Results of a German national programme in contributions at the Consensus Council meet- psoriasis between 2004 and 2017 demonstrated ings and for critical review of the manuscript. that a coordinated programme targeting specific They would also like to thank Marcello Pani and goals can successfully contribute to better David Trigos for their participation in the Del- quality of care [42, 43]. A similar systematic phi voting and contributions at the Consensus approach to determine improvements after Council meetings. In addition, the authors implementation of initiatives designed to would like to thank the clinicians, payors and address the ‘Calls to Action’ presented here patient representatives who completed the would be valuable. questionnaire providing valuable insights to initiate this programme. RBW is supported by CONCLUSIONS the Manchester NIHR Biomedical Research Centre. The fact that this programme highlights that areas identified for intervention a decade ago Funding. This programme, and the journal’s remain unaddressed is a timely wake-up call – Rapid Service fee, was funded by UCB Pharma. simply recognising an area of unmet need is not sufficient to effect change. Practical steps must Medical Writing and Editorial Assis- now be taken to implement change that trans- tance. Medical writing and editorial assistance lates into improvements in the management of were provided by Laura Harrington PhD, Ogilvy patients with psoriasis that contribute to an Health UK and funded by UCB Pharma. elevation in the standard of care. Therefore, the hope is that the Epicensus ‘Call-to-Action Author Contributions. All the authors con- Framework’ provides the focus and impetus for tributed to the Delphi exercise and participated all stakeholders involved in the care of people in the Consensus Council meetings and the with psoriasis to engage in coordinated activi- generation of Calls to Action. The first draft of ties to address the ‘Calls to Action’ and elevate the manuscript was written by Laura Harring- the standard of care. This next stage of the ton, PhD, under direction from the authors, and programme will take us nearer our vision of a all authors critically reviewed the manuscript truly integrated, collaborative, patient-centric for important intellectual content and approved approach to psoriasis management where the final draft. patients are diagnosed early, managed by the right specialists incorporating digital healthcare Disclosures. All authors received an hono- as appropriate, supported by relevant educa- rarium from UCB for participating in the Delphi tion, and treated promptly with innovative surveys and the Consensus Council meetings. therapies. In addition, patient-relevant data will Jan Koren, Valeria Corazza, Menno A de Rie, be consistently collected using robust, specific and Marius Grosser have no other competing tools to generate RWE to inform guidelines that interests to declare. Jo Lambert has received are widely disseminated and followed, elevating grants/contracts from AbbVie, Almirall, Cel- the standard of care for patients with psoriasis. gene, Eli Lilly, Janssen-Cilag, LEO Pharma, Dermatol Ther (Heidelb) (2023) 13:245–268 265 Novartis, UCB; consulting fees from AbbVie, Ingelheim, BMS, Celgene, Janssen, Lilly, LEO, BMS, Celgene, Eli Lilly, Janssen-Cilag, LEO Novartis, Pfizer, Sanofi, Sun Pharma and UCB. Pharma, Novartis and UCB; and payment/ Elizabeth Lazaridou has received research grants honoraria for activities such as lectures/presen- to her department from AbbVie, Genesis tations/speaker bureaus from AbbVie, Almirall, Pharma, Janssen, LEO, Lilly, Novartis, Pfizer and BMS, Janssen-Cilag, Pifzer and UCB. Simon F UCB; honoraria for activities such as lectures/ Thomsen has received research support from presentations/speaker bureaus from AbbVie, Janssen, LEO Pharma, Novartis and UCB; and Genesis Pharma, Janssen, LEO, Lilly, Novartis has served on advisory boards for Eli Lilly, and UCB; support for attending meetings and/ Janssen, LEO Pharma, Novartis, Pfizer, UCB, or travel from AbbVie, Janssen, LEO, Lilly and Union Pharmaceuticals; and as a speaker for UCB; and has participated on a Data Safety LEO Pharma, Novartis and UCB and has been Monitoring Board or Advisory Board for AbbVie, the recipient of a travel grant to GUF and EADV Genesis Pharma, Janssen, LEO, Lilly, Novartis, from Novartis. Helen McAteer has received core Pfizer and UCB. Lluı́s Puig has received funding support, paid to her employer, from grants/support paid to his institution from Abbvie, Almirall, Amgen, Eli Lilly, Janssen, LEO AbbVie, Almirall, Amgen, Boehringer Ingel- Pharma, Novartis and UCB; and honoraria, paid heim, LEO Pharma, Lilly, Novartis, Pfizer, Sanofi to her employer, from Amgen and Novartis. and UCB; consulting fees from Abbvie, Almirall, Gabriella Fabbrocini has been principal investi- Amgen, Boehringer Ingelheim, Bristol Myers gator of clinical trials sponsored by and/or has Squibb, Janssen, Leo-Pharma, Lilly, Novartis, received personal fees from AbbVie, abiogeny, Pfizer, Sandoz, Sanofi, and UCB; and payment/ Almirall, Celgene, Eli Lilly, LEO Pharma, honoraria for activities such as lectures/presen- Novartis, Sanofi and UCB. Denis Jullien reports tations/speaker bureaus for Janssen, Lilly and personal fees from UCB, during the conduct of Novartis. Loı̈c Guillevin has served as a consul- the study; personal fees and non-financial sup- tant for Boehringer Ingelheim, Certara, ESAI, port from Abbvie, personal fees and non-finan- GSK, Lilly, Novartis, Novo Nordisk, Roche, cial support from Janssen-Cilag, personal fees Sanofi, UCB Pharma. Wolf-Henning Boehncke and non-financial support from UCB, personal has received payment/honoraria for activities fees and non-financial support from Novartis, such as lectures, presentations, speaker bureaus personal fees from Almirall, personal fees and and has participated on Data Safety Monitoring non-financial support from Lilly, personal fees Boards/Advisory Boards for AbbVie, Almirall, from MEDAC, personal fees from Celgene, per- BMS, Celgene, Janssen, LEO, Lilly, Novartis, sonal fees from Bristol Myers Squibb, personal Pfizer and UCB. fees from Boehringer Ingelheim, outside the submitted work. Matthias Augustin has received Compliance with Ethics Guidelines. This consulting fees from AbbVie, Almirall, Amgen, manuscript is formed of the opinions of the Biogen, Boehringer Ingelheim, Celgene, Cen- authors themselves. There was no need to col- tocor, Eli Lilly, GSK, Hexal, Janssen, LEO lect any type of patient data. Hence, the Pharma, Medac, Merck, MSD, Mundipharma, approval of an Ethics Committee was not Novartis, Pfizer, Sandoz, UCB Pharma and required. Consent was obtained from all par- Xenoport. Richard B Warren has received ticipants as they were contracted by UCB grants/contracts from AbbVie, Almirall, Janssen, Pharma to take part in this programme. Lilly, LEO, Novartis, Pfizer and UCB; consulting fees from AbbVie, Almirall, Amgen, Arena, Data Availability. Data sharing is not Astellas, Avillion, Biogen, Boehringer Ingel- applicable to this article as no datasets were heim, BMS, Celgene, DiCE, GSK, Janssen, Lilly, generated or analysed during the current study. LEO, Novartis, Pfizer, Sanofi, Sun Pharma, UNION and UCB; payment/honoraria for Open Access. This article is licensed under a activities such as lectures/presentations/speaker Creative Commons Attribution-NonCommer- bureaus from AbbVie, Almirall, Boehringer cial 4.0 International License, which permits 266 Dermatol Ther (Heidelb) (2023) 13:245–268 any non-commercial use, sharing, adaptation, 7. Grine L, de la Brassinne M, Ghislain PD, et al. distribution and reproduction in any medium A Belgian consensus on the definition of a treat-to- target outcome set in psoriasis management. J Eur or format, as long as you give appropriate credit Acad Dermatol Venereol. 2020;34(676–684): to the original author(s) and the source, provide 20200102. https://doi.org/10.1111/jdv.16104. a link to the Creative Commons licence, and indicate if changes were made. The images or 8. Maul JT, Navarini AA, Sommer R, et al. 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