Impaired quality of life of adults with skin disease in primary care

Abstract

Background Although 75% of skin problems are managed exclusively in primary care, most information on the impact of skin disease on quality of life is hospital based. Objectives To examine the ease of use of the Dermatology Life Quality Index (DLQI) in primary care and to measure the handicap levels found, analysed by skin disease, sex and age. Methods The handicap levels identified were compared with those published for patients with the same conditions attending hospital clinics. Some conditions that rarely present in secondary care were also studied. Results The overall mean ± SD DLQI score was 7·37 ± 5·71 (women 7·8 ± 5·8, n = 196; men 6·8 ± 5·6, n = 145). The scores for separate diseases were similar in ranking and only slightly lower than those in hospital‐based studies. The possibility of bias towards surveying an unrepresentative sample of patients is discussed. There was no correlation between age and DLQI score. Conclusions The DLQI proved easy to use in general practice. The impact of skin diseases on the quality of life of patients seen in primary care is comparable with that of patients seen in secondary care. This information could be used to inform the planning of services for these patients.

In the U.K., more than 75% of skin problems are managed exclusively in primary care.¹ These patients are usually considered by many general practitioners (GPs), and assumed by hospital clinicians, to be those with trivial conditions or milder disease. Little thought and scant resources are given to planning services for them. Most information regarding the impact of skin diseases on quality of life is hospital based, measuring handicap levels of patients selected to attend specialist dermatology clinics,²,³ although community‐based studies of patients with psoriasis have demonstrated the extent of disability in this group.⁴,⁵ A validated questionnaire designed to measure the impact of skin disease on quality of life, the Dermatology Life Quality Index (DLQI),⁶,⁷ now allows comparison between different diseases and in different environments.

The aims of this study were to examine the ease of use of the DLQI in general practice and to measure the impairment of quality of life in the patients seen.

Patients and methods

All 190 GP members of the Primary Care Dermatology Society were invited to take part in this study, of whom 40 agreed. Each GP recruited sequential patients aged 18 years or over presenting in their surgeries with a skin problem during a 2‐week period in February 1997, until a maximum of 10 patients had completed a DLQI. The DLQI questionnaires were completed by the patients alone, without any assistance from the GP. Sequential recruitment involved all patients who mentioned a skin problem during their consultation, whether or not this was the primary reason for the consultation. The age, sex and diagnosis were recorded, along with the total number of patients seen in the surgery by the GP over the period of patient recruitment. The DLQI consists of 10 questions, each having four responses scored from 0 to 3, giving a maximum score, representing maximum handicap, of 30.

In this situation, where individual questions are answered on an ordinal 0–3 scale, the mean value is not a measure of central tendency. However, median values are not helpful in indicating whether there are any likely differences between men and women when they are predominantly 0 or 1. To give a clearer view of possible differences in response, the mean values have been given alongside the median values. The analysis of the data for men vs. women was conducted using a non‐parametric test, the Mann–Whitney U‐test, which takes into account the ordinal nature of the data.

Ethical permission for this study was given by the Local Research Ethics Committee (Bro Taf Health Authority) in Cardiff.

Results

All of the 40 GPs who agreed to take part returned data, representing 418 dermatological consultations over the recruitment period. Three GPs had not recorded the total number of consultations, but for those who did they represented 5·2% of all consultations (range 1–50%). Twenty‐two returned data on 10 patients, and 18 returned data on a mean of 6·8 patients each, giving a total of 341 DLQIs (82% of eligible patients). GPs were not asked to record why a DLQI was not returned, so it is not known whether these patients refused to participate or did not return the questionnaire. There were, however, no reports of patient resistance to participation in the survey.

The mean ± SD DLQI over all 341 completed questionnaires was 7·37 ± 5·71 (minimum 0, maximum 26). The median value was 6 (upper quartile 10, lower quartile 3), suggesting a small positive skew in the data distribution. However, the 84th percentile, which corresponds to the mean + 1 SD in the normal distribution, was 13 and the 16th percentile, which corresponds to the mean − 1 SD, was 2. These values are close to the mean ± SD found here (7·37 + 5·71 = 13·08; 7·37–5·71 = 1·66), suggesting that the distribution is close to the normal distribution. The data are therefore presented as the mean ± SD in this paper, and in this form allow comparison with other previous publications in this area.

The results are summarized in Table 1, which also lists the mean published DLQI scores seen in similar diagnostic groups of patients referred to hospitals. The mean ± SD DLQI for women was 7·8 ± 5·8 (n = 196) and for men was 6·8 ± 5·6 (n = 145). Table 2 gives the differences between men and women and between the various aspects of impairment. The highest scoring questions relate to unpleasant symptoms and to feelings of embarrassment and self‐consciousness. Women scored significantly higher in questions 2 (embarrassment and self‐consciousness) and 4 (influence of skin disease on choice of clothes). The difference for question 5, the effect on leisure and social activities, was also significant. Men scored higher on one question only: how much their participation in sport was affected, but the difference was not significant. There was no obvious correlation between age and DLQI score (Spearman’s rank correlation coefficient − 0·0985, 95% confidence limits − 0·2034, 0·0086).

Discussion

The DLQI was easy to use in general practice. It was acceptable to the patients, who found it quick and easy to complete: all but one of the patients completed the entire questionnaire correctly. Scoring was also quick and simple. We cannot rule out the possibility that the GPs who agreed to participate were not only members of the Primary Care Dermatology Society, but those with the greatest interest and expertise in dermatology, who might be managing more complex cases in the community than the average GP. This could have resulted in unintended bias towards surveying the more severely disabled patients. On the other hand, it is likely that in many practices patients with skin problems would regularly consult the most interested and informed doctor in that practice.

The scores demonstrated high levels of dermatological disability. For conditions that have been assessed by hospital‐based DLQI surveys, the average scores in general practice were similar in ranking and only a little less in magnitude (atopic eczema mean score 11·0 compared with 12·5 for hospital outpatients). For psoriasis the mean score of 10·2 was higher than the mean score for hospital outpatients (8·9). This study also provides information about some common conditions that are seen more often in general practice, e.g. scabies 8·6, pityriasis rosea 6·6. As these are mean scores, it is clear that many individual patients seen in primary care experience levels of disability higher than many of those who are referred to specialists. The demonstration that there was no correlation between age and DLQI score confirms that dermatological disability can be a significant burden at any age. These results may surprise both primary and secondary care practitioners who might have assumed that the problems referred to specialist clinics generally affect patients more severely than those managed by GPs. The comparable levels of disability seen in patients managed in primary care and those deemed to warrant referral to specialist clinics raises the still unanswered questions of what factors determine referral, and their appropriateness.

The DLQI has already been used to assess response to therapy: it is an appropriate outcome measure for use in primary care to study the effectiveness of management and for audit and planning of services.⁸,⁹ The large numbers of patients with skin diseases who are being managed in primary care, and the severity of the impact on their quality of life, suggest that they deserve more resources and may benefit from more focused services. The impact of the introduction of such services could be measured using quality of life as an outcome measure. There is a unique opportunity for primary care teams to study the effectiveness of the dermatological services they provide and to collaborate with hospital dermatology departments to compare care in different settings, including shared care systems.

Completing the DLQI allows patients to express their problems and feelings in a structured manner, and may help practitioners to be more aware of their patients’ problems and patients to feel that these are recognized. In some cases the assessment may direct attention to coping strategies as well as to clinical management.

Most GP registrar training programmes do not include the opportunity for further dermatological training. The level of impairment in quality of life demonstrated by this study suggests that such training would be a useful preparation for general practice.

Acknowledgments

This study was initiated and funded by the Primary Care Dermatology Society. We thank all the members who contributed to it. This work was presented at the annual meeting of the British Association of Dermatologists in July 1998.

References