TYPE Original Research PUBLISHED 26 January 2023 DOI 10.3389/fpubh.2023.1000776 The social value of a PASI 90 or OPEN ACCESS PASI 100 response in patients with moderate-to-severe plaque EDITED BY Hai Fang, Peking University, China REVIEWED BY Hongguo Rong, psoriasis in Spain Beijing University of Chinese Medicine, China Jose Luis Trillo-Mata, Health Area Pharmacy Manager, Spain Paulina Maravilla-Herrera1 , María Merino1*, *CORRESPONDENCE Santiago Alfonso Zamora2 , Jesús Balea Filgueiras3 , María Merino maria.merino@weber.org.es José Manuel Carrascosa Carrillo4 , Olga Delgado Sánchez5,6 , SPECIALTY SECTION Francisco Dolz Sinisterra7 , Antonio García-Ruiz8 , This article was submitted to Health Economics, Pedro Herranz Pinto9 , Antonio Manfredi2 , José Martínez Olmos10 , a section of the journal Paloma Morales de los Ríos Luna11 , Lluís Puig12,13 , Sandra Ros14 and Frontiers in Public Health RECEIVED 22 July 2022 Álvaro Hidalgo-Vega15,16 ACCEPTED 09 January 2023 1 Department of Health Outcomes Research, Weber, Madrid, Spain, 2 Department of Management, Psoriasis PUBLISHED 26 January 2023 and Psoriatic Arthritis Patient and Family Association (Acción Psoriasis), Barcelona, Spain, 3 Department of CITATION Pharmacy, Ferrol University Hospital Complex, La Coruña, Spain, 4 Department of Dermatology, Germans Maravilla-Herrera P, Merino M, Alfonso Trias i Pujol University Hospital, Badalona, Spain, 5 Department of Management, Spanish Society of Hospital Zamora S, Balea Filgueiras J, Carrascosa Pharmacy (SEFH), Madrid, Spain, 6 Department of Pharmacy, Son Espases University Hospital, Illes Balears, Carrillo JM, Delgado Sánchez O, Dolz Spain, 7 Department of Management, Doctor Peset University Hospital, Valencia, Spain, 8 Health Economics Sinisterra F, García-Ruiz A, Herranz Pinto P, and Rational Use of Medicines, Department of Pharmacology and Clinical Therapeutics, Biomedical Manfredi A, Martínez Olmos J, Morales de los Research Institute of Malaga (IBIMA), University of Malaga, Malaga, Spain, 9 Department of Dermatology, La Ríos Luna P, Puig L, Ros S and Hidalgo-Vega Á Paz University Hospital, Madrid, Spain, 10 Andalusian Public Health School (EASP), Granada, Spain, 11 (2023) The social value of a PASI 90 or PASI 100 Department of Nursing, Gregorio Marañón University Hospital, Madrid, Spain, 12 Department of response in patients with moderate-to-severe Dermatology, Santa Creu i Sant Pau Hospital, Barcelona, Spain, 13 Universitat Autònoma de Barcelona, plaque psoriasis in Spain. Barcelona, Spain, 14 Psychologist, Departments of Dermatology and Rheumatology, and Cardiac Transplant Front. Public Health 11:1000776. Unit, Santa Creu i Sant Pau Hospital, Barcelona, Spain, 15 Department of Economic Analysis and Finances, doi: 10.3389/fpubh.2023.1000776 University of Castilla-La Mancha, Toledo, Spain, 16 Fundación Weber, Madrid, Spain COPYRIGHT © 2023 Maravilla-Herrera, Merino, Alfonso Zamora, Balea Filgueiras, Carrascosa Carrillo, Introduction: Psoriasis is a chronic disease involving the skin, which significantly Delgado Sánchez, Dolz Sinisterra, García-Ruiz, impacts the quality of life. Disease severity and treatment efficacy (i.e., response) are Herranz Pinto, Manfredi, Martínez Olmos, Morales de los Ríos Luna, Puig, Ros and assessed through the Psoriasis Area and Severity Index (PASI). A PASI 75 response, Hidalgo-Vega. This is an open-access article i.e., an improvement of at least 75% with respect to the baseline PASI score, has distributed under the terms of the Creative traditionally been used as a therapeutic benchmark in clinical trials. Therapeutic Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is advances have made PASI 90 or PASI 100 responses possible in most patients treated permitted, provided the original author(s) and with some biologics. A greater response may generate social value beyond clinical the copyright owner(s) are credited and that outcomes that would benefit both patients and society. the original publication in this journal is cited, in accordance with accepted academic practice. Methods: A 1-year economic model was applied to estimate the impact of having a No use, distribution or reproduction is PASI 75, PASI 90, or PASI 100 response in four areas of analysis (quality of life, activities permitted which does not comply with these terms. of daily living, work productivity, and out-of-pocket expenditures) and the social value of having a PASI 90 or PASI 100 response in comparison with a PASI 75 response. A mixed-methods approach based on the scientific literature, a focus group with patient, and an advisory committee with psoriasis stakeholders was used. The model included three different scenarios: having a PASI 90 vs a PASI 75 response; a PASI 100 vs a PASI 90 response; and a PASI 100 vs a PASI 75 response. A sensitivity analysis was included. Results: The annual economic impact per patient with moderate-to-severe plaque psoriasis having a PASI 75 response was estimated at Ł 6,139, mainly related to labour productivity losses and quality of life reductions. Having a PASI 90 or a PASI 100 response would reduce this impact to e3,956 or e1,353, respectively. Accordingly, the social value of having a PASI 90 instead of a PASI 75 response was estimated at e2,183, and e4,786 with a PASI 100 response. Frontiers in Public Health 01 frontiersin.org Maravilla-Herrera et al. 10.3389/fpubh.2023.1000776 Discussion: A PASI 90 or PASI 100 response would have a lower economic impact and a greater social value than a PASI 75 response for patients with moderate-to-severe plaque psoriasis. KEYWORDS social return, socioeconomic impact, psoriasis, Psoriasis Area and Severity Index (PASI), quality of life, out-of-pocket (OOP) expenses, activities of daily living 1. Introduction patients who have not achieved an optimal therapeutic response may be reduced by increasing the degree of response. Therefore, Psoriasis is a chronic non-communicable disease that can cause achieving a PASI 90 or PASI 100 response in patients with moderate- systemic inflammation and is associated with multiple comorbidities to-severe plaque psoriasis may reduce this economic impact, which (1). It is a painful, pruritic, and disabling disease that involves the skin translates into a social value gain. Estimating the social value from a and nails, causing a significant impact on the quality of life of patients holistic perspective can help to understand how achieving a greater (1). Psoriasis can occur at any age but normally appears before the age PASI response may improve different aspects of the patients’ lives, of 40 (2). Approximately 2.3% of the Spanish population is affected by considering both tangible and intangible aspects that are meaningful this condition; plaque psoriasis is the most common form of psoriasis for patients. accounting for 90% of all cases (3, 4). To our knowledge, no other study to date has analyzed the social The clinical diagnosis of psoriasis is based on the assessment value of achieving a PASI 90 or PASI 100 response in patients with of the patient’s history and the presence of skin lesions with moderate-to-severe plaque psoriasis in Spain. characteristic morphology and distribution (5). Disease severity is usually assessed through the Psoriasis Area and Severity Index (PASI), which combines an evaluation of the severity of the lesions with 2. Materials and methods erythema, infiltration, and peeling, scored on a scale of 0 to 4 (0 = none, 1 = mild, 2 = moderate, 3 = marked, and 4 = very An economic model with a one-year time horizon was applied marked) and the percentage of skin involved on the head, trunk, to estimate the economic impact of having achieved a PASI response upper limbs, and lower limbs. Moderate or severe disease can be of 75, 90 or 100, and the social value of having achieved a complete defined by a PASI score of 5–10 or a PASI score of >10, respectively or almost complete response in patients with moderate-to-severe (6). In Spain, 29.5% of patients with psoriasis have a diagnosis plaque psoriasis in Spain. The economic impact was estimated from of moderate-to-severe plaque psoriasis (7). According to this data, a social perspective and included costs related to the following four nearly 300,000 inhabitants of Spain suffer from moderate-to-severe areas of analysis: (1) reduction in quality of life (including the need plaque psoriasis (7). for informal care and quality-adjusted life-years lost because of the Moreover, the PASI is also used to assess the efficacy of treatment. disease); (2) impact on activities of daily living, defined by the For example, a PASI 75 response means an improvement in the PASI activities patients stop doing or their willingness to pay to improve score of at least 75% with respect to the baseline (pre-treatment) PASI this sphere; (3) work productivity losses, i.e., missing working score (6). Previously, achieving a PASI 75 response was considered a hours due to the disease (medical visits and/or sick leaves); and relevant therapeutic goal, yet nowadays achieving a PASI 90 response (4) psoriasis-related out-of-pocket expenditures; in three different or even a PASI 100 response is possible given recent therapeutic response scenarios: (1) a PASI 75 response compared to a PASI 90 advances (5, 8–10). Accordingly, the optimal therapeutic response response; (2) a PASI 90 response compared to a PASI 100 response; may be defined by the equivalent of PASI 90 or PASI 100 responses in and (3) a PASI 75 compared to a PASI 100 response (Figure 1). clinical trials. The course of the disease, the morphology, the severity, The economic impact generated by a patient with a PASI 75, and the body surface area involved are different for each patient and PASI 90, or PASI 100 response was estimated by multiplying the may not only have an impact on the clinical dimension but also the outcomes associated with presenting each response (Table 1) by their personal, work-life, social, and intimacy dimensions of the patient financial value or financial proxy (Table 2) within each area of analysis (10–13). Therefore, disease management should be personalized and (Figure 1). Moreover, the social value was estimated by subtracting patient-centered, with a clear therapeutic goal agreed upon between the economic impact (i.e., associated costs) of presenting a PASI 75 clinician and patient (1). or PASI 90 response from the economic impact of a more complete According to the literature, benefits outside the clinical response, according to the three different scenarios (Figure 1). Both dimension may be achieved by setting more ambitious therapeutic the economic impact and the social value are reported per patient objectives, as patients with improved skin clearance further report and year, expressed in 2021 euros (e). Unit prices prior to 2021 were emotional, psychological, and social functioning improvements (14– updated to the year 2021 according to the corresponding general or 16). Accordingly, the economic impact (i.e., related costs) associated medical Consumer Price Index whenever needed (20). with a poor quality of life or work productivity losses in psoriasis The economic model was developed using a mixed-methods approach to gather relevant information from the scientific literature, a focus group (FG) with patients, and an advisory committee with Abbreviations: DLQI, Dermatology Life Quality Index; FG, Focus Group; PASI, experts. First of all, a literature review was carried out on the Psoriasis Area and Severity Index; PSI, Psoriasis Symptom Inventory. PubMed R search engine by combining PASI response terms (PASI Frontiers in Public Health 02 frontiersin.org Maravilla-Herrera et al. 10.3389/fpubh.2023.1000776 FIGURE 1 PASI scenarios and areas of analysis. 75, PASI 90, and PASI 100) and their synonyms with an extensive list literature and validated by the advisory committee. A sensitivity of impact terms (cost, resource, impairment, pain, itch, burn, sting, analysis was carried out to test the strength of the model when varying cracking, redness, scaling, flaking, anxiety, depression, caregiving, assumptions as follows: the reference scenario, the lower limit or work productivity, activities of daily living, quality of life, suicide, best-case scenario (that which would result in a lower impact) and bullying, sex, relationships, and leisure) and their synonyms through the upper limit or worst-case scenario (that which would result in AND/OR Boolean operators, to identify and extract data on the a greater impact). Outcomes, financial values, or financial proxies economic impact of having achieved a PASI 75, PASI 90, or PASI 100 included in the sensitivity analysis are displayed in Table 3. response. The search retrieved 383 studies of which 14 were selected Given the nature of this study, approval by an institutional review as they included relevant information in line with the purpose of board or an ethical review board was not required. Nevertheless, the study. These studies did not include information on the impact study procedures were in accordance with the Declaration of on healthcare resource consumption and costs generated by patients Helsinki 1975/83. with different PASI responses. Thereafter, a FG comprising six patients with moderate-to- severe psoriasis from different regions in Spain was carried out 3. Results to understand the impact of the disease on the patients’ lives, especially within the four areas of analysis, their unmet needs, their The annual economic impact of having a PASI 75 response in willingness to pay for symptom improvement, and their perceived patients with moderate-to-severe psoriasis was estimated at e 6,139 benefits of having obtained a PASI 90 or PASI 100 response per patient. A PASI 90 response would result in a smaller economic in terms of quality of life, physical and emotional state, labor impact (e 3,956) and even lower with a PASI 100 response or productivity, activities of daily living, informal care, and out-of- completely clear skin, estimated at e 1,353 per patient (Table 4). pocket expenditures. Finally, an advisory committee comprising a Regarding the quality of life associated with the need for informal multidisciplinary group of twelve experts representing the main care, a PASI 75 response would involve an annual cost of e 246, stakeholders regarding psoriasis in Spain (dermatologists, nurses, higher than the estimated cost associated with a PASI 90 response psychologists, pharmacists, hospital managers, health economists, (e 105). On the contrary, patients with PASI 100 response would policymakers, and patients) was created to discuss and agree on the not generate informal care costs. Similarly, the economic impact most appropriate inputs, obtained from the literature review and the associated with the number of quality-adjusted life-years lost by FG (e.g., study selection based on the quality of the methods), that patients with moderate-to-severe psoriasis would be higher in those would be included in the model to quantify the social value of a PASI with a PASI 75 response (e 441) than in those with a PASI 90 or PASI 90 or PASI 100 response with respect to a PASI 75 response. 100 response (e 252 and e 210, respectively) (Table 4). In the absence of relevant data, sensible assumptions were Concerning the impact of moderate-to-severe psoriasis in made following a conservative approach, supported by the scientific activities of daily living, according to the results in Table 4, a PASI 75 Frontiers in Public Health 03 frontiersin.org Maravilla-Herrera et al. 10.3389/fpubh.2023.1000776 TABLE 1 Outcomes by areas of analysis and PASI responses. Outcome PASI 75 PASI 90 PASI 100 Quality of life (a) Probability of obtaining a PSI score > 0 (i.e., presenting severe signs and symptoms) (14).‡ 0.86 0.74 0.35 (b) Average days per year in which patients with psoriasis on biological treatment needed assistance (17). 9.60 9.60 9.60 (c) Hours of informal care per day in which a patient with moderate-to-severe psoriasis needs assistance.† 4.00 2.00 0.00 ∗ ∗ Annual hours of informal care per patient with moderate-to-severe psoriasis. (a b c) 33.10 14.15 0.00 # (a) Average utility of the Spanish population (18). 0.912 0.912 0.912 (b) Average utility of patients with moderate-to-severe psoriasis (19). 0.891 0.900 0.902 Quality-adjusted life-years lost per patient with moderate-to-severe psoriasis. (a-b) 0.021 0.012 0.010 Activities of daily living Probability of obtaining a DLQI score > 1 (i.e., having an impact on activities of daily living) (20).‡ 0.48 0.26 0.13 Work productivity (a) Probability of having a job among patients with moderate-to-severe psoriasis (21). 0.65 0.65 0.65 (b) Annual hours of productivity loss per working patient with psoriasis in Spain.‡ (i/ii∗ iii) 474.33 315.31 87.00† (i) Annual hours of productivity loss per patient with psoriasis in the UK (22). 179.92 119.60 NA (ii) Annual hours of productivity loss per worker in the UK (23).# 33.00 33.00 NA # (iii) Annual hours of productivity loss per worker in Spain (24). 87.00 87.00 87.00 ∗ Annual hours of productivity loss per patient with psoriasis in Spain. (a b) 308.32 204.95 56.55 Out-of-pocket expenditures (a) Probability of having out-of-pocket expenditures on hydrating cream and make-up among patients with moderate-to-severe 0.49 0.44† ∗ 0.40†∗ psoriasis (25). (b) Number of annual out-of-pocket expenditures on hydrating cream and make-up per patient with moderate-to-severe psoriasis 4.00 4.00 4.00 requiring them.† ‡ Number of annual out-of-pocket expenditures on hydrating cream and make-up per patient with moderate-to-severe 1.97 1.78 1.58 psoriasis. (a∗ b) (a) Probability of having out-of-pocket expenditures on psychology and nutrition among patients with moderate-to-severe psoriasis 0.11 0.99†∗ 0.88†∗ (25). (b) Number of annual out-of-pocket expenditures on psychology and nutrition consultations among patients with 4.00 4.00 4.00 moderate-to-severe psoriasis requiring them.† ‡ Number of annual out-of-pocket expenditures on psychology and nutrition consultations among patients with 0.44 0.39 0.35 moderate-to-severe psoriasis. (a∗ b) (a) Probability of having out-of-pocket expenditures on dermatology consultations among patients with moderate-to-severe psoriasis 0.036 0.032†∗ 0.029†∗ (25). (b) Number of annual out-of-pocket expenditures on dermatology consultations among patients with moderate-to-severe psoriasis 2.00 2.00 2.00 requiring them.† ‡ Number of annual out-of-pocket expenditures on dermatology consultations among patients with moderate-to-severe 0.072 0.065 0.058 psoriasis. (a∗ b) † Assumption. ‡ Included in the sensitivity analysis. # PASI was not considered. NA: not applicable, as the annual hours of productivity loss per worker in Spain were assumed for patients with a PASI 100 response. ∗ The probability used in PASI 90 and PASI 100 was reduced by 10 and 20% with respect to PASI 75, respectively. DLQI, Dermatology Life Quality Index; NA, not applicable; PSI, Psoriasis Symptom Inventory (a patient-reported outcome measure for assessing the severity of plaque psoriasis symptoms). Bold values represent the final equation, and italic values (exemplified by letters) represent the variables taken into account in the final equation. response would have a higher economic impact (e 534) than a PASI Concerning the social value, obtaining a PASI 90 response instead 90 (e 292) or PASI 100 response (e 143). of a PASI 75 response would represent an added social value of e Regarding work productivity losses in patients with moderate-to- 2,183 and more than double with a PASI 100 response (e 4,786). severe psoriasis, the associated economic impact would be higher in Additionally, obtaining a PASI 100 response instead of a PASI 90 those patients with a PASI 75 response (e 4,759), compared with a response would imply an additional social value of e 2,603 (Figure 2). PASI 90 (e 3,163) and PASI 100 response (e 873) (Table 4). This tendency was observed in all four areas of analysis. Finally, patients with a PASI 75 response would generate an The greatest proportion of the social value attained when annual cost of e 160 in out-of-pocket expenditures, slightly more obtaining a PASI 90 or PASI 100 response instead of a PASI than those with a PASI 90 or PASI 100 response (e 144 and e 128, 75 response would be attributed to work productivity gains respectively) (Table 4). (73.1 and 81.2% of the social impact, respectively). Similarly, Frontiers in Public Health 04 frontiersin.org Maravilla-Herrera et al. 10.3389/fpubh.2023.1000776 TABLE 2 Financial values or proxies by areas of analysis. Financial value or financial proxy Unit cost Quality of life Minimum wage per hour for a household employee, as a financial proxy for an hour of informal care (26).† e 7.43 ‡ Incremental cost-effectiveness threshold per quality-adjusted life-year, as a financial proxy for quality of life (27). e 21,000.00 Activities of daily living (a) Average annual expenditure per person on bars and cafeterias in Spain (28).† e 260.00 † (b) Average annual expenditure per person on recreational, sports, and cultural activities (28). e 117.42 † (c) Willingness to pay per patient with moderate-to-severe psoriasis for an improvement in their sexual life (21). e 745.80 Annual expenditure per person on the social, leisure, and sexuality domains. (a + b + c) e 1,123.22 Work productivity Average wage per normal working hour in Spain (29). e 15.43 Out-of-pocket expenditures (a) Average cost of a hydrating cream for psoriasis.∗ e 10.00 (b) Average cost of make-up to cover up psoriasis lesions.∗ e 45.00 # Average cost of a hydrating cream and make-up per patient with psoriasis. (a+b) e 55.00 (a) Average cost of a private psychology consultation in Spain.∗ e 50.00 ∗ (b) Average cost of a private nutrition consultation in Spain. e 50.00 # Average cost of a psychology and a nutrition consultation per patient with psoriasis. (a+b) e 100.00 Average cost of a private dermatology consultation in Spain. ∗ e 100.00 † Financialproxy. ‡ Included # Reference in the sensitivity analysis. cost for PASI 75 response. A lower amount has been estimated for patients with PASI 90 and PASI 100 response (10% and 20% respectively). ∗ Market price. QALY, quality-adjusted life-year. Bold values represent the final equation, and italic values (exemplified by letters) represent the variables taken into account in the final equation. TABLE 3 Outcomes, financial values, or financial proxies included in the sensitivity analysis. Outcome, financial value, or financial proxy Worst-case Reference Best-case scenario scenario scenario Quality of life Probability of obtaining a PSI score > 0 with a PASI 75 response (14). 0.78† 0.86 0.95‡ † Probability of obtaining a PSI score > 0 with a PASI 90 response (14). 0.66 0.74 0.81‡ Probability of obtaining a PSI score > 0 with a PASI 100 response (14). 0.32† 0.35 0.39‡ Incremental cost-effectiveness threshold per quality-adjusted life-year (27). e 11,000 e 21,000 e 30,000 Activities of daily living Probability of obtaining a DLQI score > 1 with a PASI 75 response (20). 0.43† 0.48 0.52‡ Probability of obtaining a DLQI score > 1 with a PASI 90 response (20). 0.23† 0.26 0.29‡ Probability of obtaining a DLQI score > 1 with a PASI 100 response (20). 0.11† 0.13 0.14‡ Work productivity Annual hours of productivity loss per patient with psoriasis in Spain with a PASI 75 response (22–24). 426.90 474.33 521.77 Annual hours of productivity loss per patient with psoriasis in Spain with a PASI 90 response (22–24). 283.78 315.31 346.84 Annual hours of productivity loss per patient with psoriasis in Spain with a PASI 100 response (24). 78.30 87.00 95.70 Out-of-pocket expenditures Number of annual out-of-pocket expenditures on hydrating cream or make-up per patient with 2.00 4.00 6.00 moderate-to-severe psoriasis requiring them.# Number of annual out-of-pocket expenditures on psychology or nutrition consultations among patients with 2.00 4.00 6.00 moderate-to-severe psoriasis requiring them.# Number of annual out-of-pocket expenditures on dermatology consultations among patients with 1.00 2.00 3.00 moderate-to-severe psoriasis requiring them.# † Variation of−10% with respect to the reference scenario. ‡ Variation of +10% with respect to the reference scenario. # Assumption. Abbreviations: DLQI, Dermatology Life Quality Index; PASI, Psoriasis Area Severity Index; PSI, Psoriasis Symptom Inventory (a patient-reported outcome measure for assessing the severity of plaque psoriasis symptoms). Frontiers in Public Health 05 frontiersin.org Maravilla-Herrera et al. 10.3389/fpubh.2023.1000776 TABLE 4 Economic impact by area of analysis and PASI response in the reference scenario. PASI 75 PASI 90 PASI 100 Annual cost of the impact on quality of life (a + b) e 686.94 e 357.14 e 210.00 (a) Quality of life: costs associated with the need for informal care e 245.94 e 105.14 e 0.00 (b) Quality of life: costs associated with quality-adjusted life-years lost e 441.00 e 252.00 e 210.00 Annual cost of the impact on activities of daily living e 533.53 e 292.04 e 142.65 Annual cost of work productivity loss e 4,758.81 e 3,163.37 e 872.84 Annual cost of out-of-pocket expenditures e 159.61 e 143.64 e 127.68 Total annual cost per patient e 6,138.88 e 3,956.19 e 1,353.17 Bold values represent the final equation, and italic values (exemplified by letters) represent the variables taken into account in the final equation. 88% of the social value attained when obtaining a PASI 100 estimated that if a patient achieves a PASI 90 or 100 response, instead response instead of a PASI 90 response would be attributed of a PASI 75 response, e 330 and e 477 of social value would be to work productivity gains. Improvements in the quality of generated per year, respectively. life, activities of daily living, and reductions in out-of-pocket According to the patients in the FG, the area of activities of expenditures would account for 15.1, 11.1, and 0.7% of the daily living generates the largest impact on patients’ lives. Not being total social value attained when obtaining a PASI 90 response able to do activities because of lesions in exposed areas (e.g., sports instead of a PASI 75 response, and for 10, 8.2, and 0.7% of or having intimate relationships, among others) may have a great the social value attained when obtaining a PASI 100 response psychological impact or lead to stigmatization (31). Contrary to the instead of a PASI 75 response. For those patients obtaining information collected in the FG, this area was not one of major a PASI 100 response instead of a PASI 90 response, the impact, possibly associated with its subjectiveness and difficulty of social value in these areas would be 5.7, 5.7, and 0.6%, assessment. Accordingly, results may not reflect the whole impact this respectively (Figure 3). area represents on patients. One of the most frequently used methods According to the sensitivity analysis, the greatest variability to assess this is contingent valuation through the willingness to pay. of the economic impact was associated with a PASI 100 Several studies have observed that in patients with dermatologic response, which could decrease by 20% to e 1,088, or conditions, willingness to pay for improving certain spheres of their increase by 23% to e 1,609. Meanwhile, the economic impact lives (including activities of daily living) could vary when treatment associated with a PASI 75 or PASI 90 response could decrease improved their condition (32–35). Accordingly, the results of the by 14% in the worst-case scenario or increase by 16% in present study showed a greater economic impact associated with a the best-case scenario. The corresponding social value would PASI 75 response (e 534) than that of a PASI 90 (e 292) or PASI 100 vary accordingly. response (e 143). The greatest impact of psoriasis has been associated with the area of work productivity, as previous studies have shown that 4. Discussion productivity losses reflect the overall impact of psoriasis (22, 36, 37). According to our results, achieving a PASI 90 or PASI 100 response, Having a PASI 90 or PASI 100 response would generate a compared to a PASI 75 response, would translate into an additional higher social value and have a lower economic impact for patients social value of e 1,595 and e 3,886, respectively. with moderate-to-severe plaque psoriasis compared with a PASI 75 Concerning out-of-pocket expenditures, despite psoriasis response. According to the overall results, the economic impact of a treatment being covered by the Spanish National Health System, PASI 75 response would be 66 and 78% higher than PASI 90 or 100 there is still room for improvement. Health services may vary response, respectively. depending on the area of residence or may not cover all of the In terms of quality of life, this study aligns with previous research patient’s needs, having them pay to address them on their own indicating that psoriasis patients with greater improvements from (38). According to Richard et al. (25) out-of-pocket expenditures the baseline PASI scores are less severely affected, have reduced of patients with psoriasis in France were more than twice the symptomatology, and consequently present a better quality of life expenditures for other medical conditions. In Spain, patients (14, 20, 30). On one hand, this impact may be reflected as the in the FG mentioned that their out-of-pocket expenditures are cost of informal care or assistance in activities of daily living. usually related to private health care (dermatology, psychology, and According to the information collected from the FG and the scientific nutrition), personal care products or services (hydrating cream, literature, psoriasis symptomatology interferes with household and make-up, and hairstyling), or special clothing, among others. basic activities, therefore some patients may need help to accomplish This situation may imply private financing from the patients that, them (17). On the other hand, Pickard et al. (19) indicated that according to the results, may have a greater impact on patients who the utility of patients that achieved a PASI 75 response was slightly only achieve PASI 75 response. smaller than for patients who achieved a PASI 90 or PASI 100 The present study has some limitations. First, there was a response. Regarding the quality of life, the results of the present study lack of scientific literature regarding the impact of psoriasis on Frontiers in Public Health 06 frontiersin.org Maravilla-Herrera et al. 10.3389/fpubh.2023.1000776 FIGURE 2 Potential social value according to PASI scenarios, areas of analysis, and total. FIGURE 3 Distribution of social value according to areas of analysis and PASI scenarios. patients’ lives according to different levels of the PASI response. when quantifying the economic impact of the disease and the Relevant information was found in only 14 studies out of 383 social value of achieving better PASI responses. Finally, despite the revised. Specifically, there was a lack of information on healthcare small number of representatives of psoriasis patients in the FG resource consumption and costs, work productivity, and out- and experts in the advisory committee, all data and information of-pocket expenditures in Spanish psoriasis patients: regarding collected from these groups were supported by scientific literature. work productivity losses, British figures were extrapolated to the The results in this study should be taken with precaution when Spanish context; concerning out-of-pocket expenditures, only those interpreted, always considering the sensitivity analysis. In this regard, mentioned by patients in the FG were considered. Moreover, the the sensitivity analysis considered variations in most especially reduced number of studies and the large differences between them relevant parameters (i.e., ±10% for probabilities), variations based further hindered the use of statistical analyses to compare PASI on the scientific literature available, and variations for assumptions responses. Second, the impact of psoriasis may vary from patient based on information provided by the FG. Including the remaining to patient and hence be experienced in different ways according variables in the sensitivity analysis to test the strength of the to each reality. Therefore, a conservative approach was adopted model would have implied making additional assumptions that may Frontiers in Public Health 07 frontiersin.org Maravilla-Herrera et al. 10.3389/fpubh.2023.1000776 have biased the results and hindered the conservative approach of Funding this study. Despite these limitations, this study adds an understanding of This study received funding from UCB Pharma. The funder was the impact of the disease from the patient’s perspective. Several not involved in the study design, collection, analysis, interpretation studies have highlighted the importance of considering the social of data, the writing of this article or the decision to submit it perspective in health economic analyses since it ideally captures for publication. health impacts that are particularly important for the understanding of health interventions and the effects on the population (39–41). Nevertheless, future studies are encouraged to assess the impact of Acknowledgments new therapeutic goals on healthcare resource consumption and costs, with respect to the investment required to achieve such goals. The authors would like to thank Dr. Teresa Martín Lorenzo for Considering the patient’s view may add relevant information to providing scientific writing assistance and all psoriasis patients who psoriasis-related economic evaluations, giving a wide view of the participated in this study for their time and contribution. Finally, the impact of the disease from a multidimensional perspective. authors would like to thank the Acción Psoriasis association for their kind collaboration. 5. Conclusions Conflict of interest Achieving PASI 90 or PASI 100 responses would have a lower economic impact, in comparison to a PASI 75 response, and hence PM-H and MM are employed by the consultancy firm Weber, generate a greater social value in terms of improved quality of life and which received funding from UCB Pharma for the development of activities of daily living, and reduced labor productivity losses and this project. SA, JB, JC, OD, FD, AG-R, PH, AM, JM, PM, LP, and SR out-of-pocket expenditures for patients. This could be very significant received fees from the consultancy firm Weber for the participation in not only for patients but also for their families and society at large. the project. The remaining author declares that the research was conducted in the absence of any commercial or financial Data availability statement relationships that could be construed as a potential conflict of interest. The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation. Publisher’s note Author contributions All claims expressed in this article are solely those of the authors and do not necessarily represent those of PM-H, MM, and ÁH-V conceived and designed the research. their affiliated organizations, or those of the publisher, PM-H and MM acquired the data. PM-H, MM, SA, JB, JC, OD, FD, the editors and the reviewers. 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