Health-Related QOL and Economic Burden of Chronic Pruritus

Chronic pruritus (CP) has considerable implications for QOL. However, its impact on health-related QOL and economic burden is not fully characterized. We administered a cross-sectional survey 132 patients with CP using the Health Utilities Index Mark 3 instrument. Normative data from healthy adults (n = 4,187) were obtained Joint Canada/US Survey of Health. Quality-adjusted life-year loss costs estimated basis scores versus controls. Patients had lower overall health performance than control (0.56 ± 0.03 vs. 0.86 0.003, P < 0.001). In multivariable regression, was associated worse (coefficient −0.30, 95% confidence interval −0.33 to −0.27), most accentuated in domains pain −0.24, −0.28 −0.21) emotion −0.11, −0.13 −0.10). The reduced score correlated 5.5 average lifetime quality-adjusted life-years lost per patient. Using conservative estimates willingness pay, translated an individual $274,921 societal $88.8 billion. significant impairment. highlights necessity further research into management options. defined by International Forum Study Itch as itch lasting more 6 weeks (Ständer et al., 2007Ständer S. Weisshaar E. Mettang T. Szepietowski J.C. Carstens Ikoma A. al.Clinical classification itch: position paper international forum study itch.Acta Derm Venereol. 2007; 87: 291-294Crossref PubMed Scopus (464) Google Scholar). Several studies demonstrate extent condition, reporting point prevalence ranging 8% 16% range 22–26% European populations (Dalgard 2004Dalgard F. Svensson Holm J.Ø. Sundby J. Self-reported skin morbidity Oslo. Associations sociodemographic factors among study.Br J Dermatol. 2004; 151: 452-457Crossref (117) Scholar; Matterne 2013Matterne U. Apfelbacher C.J. Vogelgsang L. Loerbroks Incidence determinants chronic pruritus: population-based cohort study.Acta 2013; 93: 532-537Crossref (88) Scholar, 2011Matterne Schwarzer Büttner M. Ofenloch R. al.Prevalence, correlates characteristics 2011; 91: 674-679Crossref (149) substantial QOL, often causing physical psychological effects disrupting sleep, concentration, mood (Carr 2014Carr C.W. Veledar Chen S.C. Factors mediating quality life.JAMA 2014; 150: 613-620Crossref (42) Chen, 2012Chen Pruritus. Dermatol Clin. 2012; 30: 309-321Abstract Full Text PDF (13) Schneider 2006Schneider G. Driesch Heuft Evers Luger T.A. Ständer Psychosomatic cofactors psychiatric comorbidity itch.Clin Exp 2006; 31: 762-767Crossref (135) TJ Goon 2007TJ Yosipovitch Chan Y.H. Goh C.L. Clinical generalized idiopathic tertiary referral center Singapore.Int 46: 1023-1026Crossref (26) van Os-Medendorp 2006van H. Eland-de Kok P.C. Grypdonck Bruijnzeel-Koomen C.A. Ros W.J. Prevalence predictors psychosocial pruritic diseases.J Eur Acad 20: 810-817PubMed Wolkenstein 2003Wolkenstein P. Grob J.J. Bastuji-Garin Ruszczynski Roujeau Revuz al.French people diseases: results representative sample.Arch 2003; 139 ([discussion 1619]): 1614-1619Crossref (98) Health-related instruments that assess how condition affects patient’s can be grouped three categories: generic, organ specific, disease and/or specific. Generic instruments, such Short Form 36 or (HUI3), apply all conditions but may less sensitive issues pertaining interest. HUI3 utility measured scale where one reflects perfect zero equivalent death. used (QALYs), which then determination disease. Organ-specific skin-specific our specific comparable different conditions. commonly Dermatology Life Quality Skindex-29, have items related (Chren 1997Chren M.M. Lasek R.J. Flocke S.A. Zyzanski S.J. Improved discriminative evaluative capability refined version Skindex, quality-of-life instrument diseases.Arch 1997; 133: 1433-1440Crossref Finlay Khan, 1994Finlay A.Y. Khan G.K. (DLQI)--a simple practical measure routine clinical use.Clin 1994; 19: 210-216Crossref (3336) Condition-specific are relevant change over time cannot easily compared other diseases. Pruritus-specific been developed include Severity Scale ItchyQoL (Desai 2008Desai N.S. Poindexter G.B. Monthrope Y.M. Bendeck S.E. Swerlick R.A. A pilot pruritus.J Am 2008; 59: 234-244Abstract (138) Majeski 2007Majeski Johnson J.A. Davison S.N. Lauzon Scale: self-report measurement severity.Br 156: 667-673Crossref (82) systematic review assessing pruritus, vast majority published articles pruritus-specific (Chen, There little literature uses generic measures CP. Paul 2011Paul Pieper B. Templin T.N. Itch: association venous disease, pain, life.J Wound Ostomy Continence Nurs. 38: 46-54Crossref (22) Scholar 12 conclude extremity secondary those without pruritus. El-Baalbaki 2010El-Baalbaki Razykov I. Hudson Bassel Baron Thombs B.D. al.Association life disability systemic sclerosis.Arthritis Care Res (Hoboken). 2010; 62: 1489-1495Crossref (36) studied sclerosis reported impaired mental components 36. Whereas headway made understanding impacting through measures, paucity makes it difficult understand compare status relation nondermatologic Furthermore, limited exists. American Academy Dermatology’s (AAD’s) National Burden Skin Disease report annual medical cost $294 million opportunity $107 pruritus-related diseases United States (Lim 2017Lim H.W. Collins S.A.B. Resneck Jr., J.S. Bolognia J.L. Hodge Rohrer al.The States.Am. Acad. 2017; 76: 958-972.e2Abstract (209) Luk 2020Luk K.M. Shaw F.M. Zhang C. Culler S.D. direct indirect care their determining factors.J Invest 2020; 140: 699-701.e5Abstract (4) bear financial $1,067 healthcare year. these methods do account what known intangible costs, stress, depression, anxiety, functional patient family owing These better evaluated use instrument, HUI3. this study, we Ontario reduction impairment quantify US system. Further describing relationship between dermatology-specific forthcoming. Of 161 surveyed, 29 excluded failure complete questionnaire, leaving total included sample. CP, 70.5% female mean standard error age 57.3 1.5 years (Table 1). cohort, 51.5% non-Hispanic White, 40.2% Black. Among 25.8% diagnosis atopic dermatitis (AD), 27.2% dermatologist-derived prurigo nodularis, 25.0% unknown origin. remaining 24.2% another brachioradial notalgia paresthetica, scalp dysesthesia. 76.1% duration >1 year, whereas 34.9% >5 years. Compared population, older (mean 48.9 years, 0.001) likely (70.5% 56.7%, 0.002) Black (40.2% 7.7%, 54.8% respondents hurts time, 53.2% stinging burning time.Table 1Baseline Demographic Characteristics Cohort General PopulationCharacteristicsPatients 132)Frequency (%)General Population 4,187)Frequency (%)P-valueGender Male39 (29.5)1,815 (43.3)0.002 Female93 (70.5)2,372 (56.7)0.002Age (y), SE57.3 1.548.9 0.3 18–2919 (14.4)535 (12.8)0.58 30–393 (2.3)856 (20.4)<0.001 40–4912 (9.1)920 (22.0)<0.001 50–5927 (20.5)738 (17.6)0.40 60–6936 (27.3)529 (12.6)<0.001 70–7922 (16.7)433 (10.3)0.02 >8013 (9.8)176 (4.2)0.002Ethnicity Non-Hispanic White68 (51.5)3,172 (75.8)<0.001 Black53 (40.2)323 (7.7)<0.001 Hispanic0 (0)422 (10.1)<0.001 Asian7 (5.3)113 (2.7)0.07 Other4 (3.0)157 (3.7)0.67Comorbidities Hypertension48 (36.4)1,075 (25.7)0.006 Arthritis20 (15.2)938 (22.4)0.05 Diabetes mellitus15 (11.4)316 (7.5)0.10 Depression10 (7.6)460 (11.0)0.22 Coronary artery disease6 (4.5)287 (6.9)0.30 Stroke4 (3.0)26 (0.6)0.001Abbreviation: pruritus; SE, error. Open table new tab Abbreviation: group 0.56 0.03, general population (0.86 0.00, (Figure consistently when across age, sex, ethnicity strata. nodularis scored slightly subgroups (0.51 0.06 0.55 AD 0.61 0.04 pruritus), although differences statistically significant. similar severity debilitating conditions, stroke bronchitis, (Kleiner-Fisman 2010Kleiner-Fisman Stern M.B. Fisman D.N. Parkinson disease: correlation III Unified Parkinson’s Rating (UPDRS) U.S. male veterans.Health Qual Outcomes. 8: 91Crossref (23) Luo 2009Luo N. J.W. Coons Relative efficiency EQ-5D, HUI2, index measuring united states.Med Care. 2009; 47: 53-60Crossref (46) Torrance 2002Torrance G.W. Raynauld J.P. Walker V. Goldsmith C.H. Bellamy Band P.A. al.A prospective, randomized, pragmatic, outcomes trial evaluating incorporation hylan G-F 20 treatment paradigm knee osteoarthritis (part 2 2): results.Osteoarthr Cartil. 2002; 10: 518-527Abstract Scholar) 2).Figure 2Mean CTCL, cutaneous T-cell lymphoma; HUI3, 3; ICD, implantable cardioverter defibrillator.View Large Image Figure ViewerDownload Hi-res image Download (PPT) unadjusted significantly demonstrated reductions, especially (0.70 0.92 0.0001), 0.02 0.97 cognition (0.89 0.95 0.0006), hearing (0.90 0.99 0.0002). linear regression model, presence 0.30 points (95% [CI] −0.27, adjusted demographic 2) . Other attributes found decreased increased (−0.001, CI −0.002 −0.0007, 0.001), Hispanic (−0.04, −0.06 −0.02, 0.001 both), hypertension (−0.02, −0.04 −0.01, 0.002), (−0.36, −0.43 −0.29, cardiovascular (−0.11, −0.09, depression (−0.22, −0.23 −0.20, arthritis (−0.14, −0.15 −0.12, models domains, single domain scores, (−0.24, −0.21, −0.10, 0001) 3) .Table 2Multivariable Linear Regression Model Association Overall Score Adjusted ComorbiditiesAttributeCoefficient95% CIP-valueCP−0.30−0.33 −0.27<0.001Female0.00−0.01 0.010.981Age−0.001−0.002 −0.0007<0.001Race WhiteRefRefRef Black−0.04−0.06 −0.02<0.001 Hispanic−0.04−0.06 Asian−0.01−0.05 −0.020.417 Other−0.03−0.6 −0.000.023Hypertension−0.02−0.04 −0.010.002Stroke−0.36−0.43 −0.29<0.001Coronary disease−0.11−0.13 −0.09<0.001Depression−0.22−0.23 −0.20<0.001Arthritis−0.14−0.15 −0.12<0.001Abbreviations: CI, interval; Ref, reference. Table 3Multivariable Models Individual Domain Scores CPOutcome VariableCoefficient95% CIP-valueVision−0.01−0.03 0.000.01Hearing−0.09−0.10 −0.08<0.001Speech−0.02−0.03 −0.02<0.001Ambulation−0.06−0.08 −0.05<0.001Dexterity−0.03−0.04 −0.02<0.001Emotion−0.11−0.13 −0.10<0.001Cognition−0.06−0.08 −0.04<0.001Pain−0.24−0.28 −0.21<0.001Abbreviations: 3. Abbreviations: On literature-derived 10–13% estimate represents severe 1% assessed approximately 0.1%. census data, 323,100 cohort. With rate at discount 3% expectancy, shown responsible QALYs 1,776,538 national 4). willingness-to-pay threshold $50,000 QALY derived literature, billion.Table 4Economic CalculationVariableValueCP prevalence1Using literature.0.001Affected population2Derived 2016 Census data.323,100Average lost3Using model discounted expectancy.5.5Population lost4Product affected population.1,776,538$ QALY5Using highly described literature.50,000Individual burden, $6Lifetime individual, product $ divided population.274,921Societal (billions), $7Lifetime QALY.88.81Abbreviations: QALY, life-year.1 literature.2 Derived data.3 expectancy.4 Product population.5 literature.6 Lifetime population.7 QALY. life-year. sensitivity analysis variables rate, loss, prevalence, (Supplementary S1). $110,164‒$826,228, threshold. ranged $4.5 $267.0 billion adjustment prevalence. This demonstrates severe, detrimental 0.56, corresponds criteria (Feng 2009Feng Y. Bernier McIntosh Orpana Validation categories scores.Health Rep. 43-50PubMed level present who experienced (0.60) (Edwards 2010Edwards J.D. Koehoorn Boyd L.A. Levy A.R. Is improving after stroke? comparison utilities indices Canadians 1996 2005.Stroke. 41: 996-1000Crossref (33) greater heart defibrillator (0.64) (Noyes 2009Noyes K. Corona Veazie Dick A.W. Zhao Moss A.J. Examination effect cardioverter-defibrillators life: based multicenter automatic trial-II.Am Cardiovasc Drugs. 9: 393-400Crossref (28) hemodialysis (0.73) (Heidenheim 2003Heidenheim A.P. Muirhead Moist Lindsay R.M. Patient quotidian hemodialysis.Am Kidney Dis. 42: 36-41Abstract 2). dermatologic lymphoma (0.68) (Semenov 2020Semenov Y.R. Rosenberg Herbosa Mehta-Shah Musiek A.C. lymphoma.Br 182: 190-196PubMed Pruritus sometimes even presenting symptom advanced stages (Ahern 2012Ahern Gilmore E.S. Poligone lymphoma: review.J 67: 760-768Abstract (44) 2020Herbosa C.M. Semenov mycosis fungoides Sézary syndrome: instruments.J 34: 995-1003Crossref (11) Given decrement partially driven large show entity, independently impacted adjusting several variables, including gender, race, history hypertension, diabetes, stroke, arthritis, second largest decrease (0.30) (0.36). Our indicate both domain. guidelines represented moderate prevented few activities (Feeny 2002Feeny D. Furlong W. Zhu Z. DePauw al.Multiattribute single-attribute functions system.Med 40: 113-128Crossref (985) 404 veterans 2017Shaw K.M.H. K.H. Wrenn Racial disparities resource utilization veterans.J 77: 63-69Abstract (15) proportion itchy hurt burned stung, consistent findings. Although does refer specifically experiencing frequent hurting, burning, suggest originate sensation. variety (Mills 2012Mills K.C. Kwatra S.G. Feneran A.N. Pearce D.J. Williford P.M. D’Agostino R.B. al.Itch nonmelanoma cancer: important feature squamous cell carcinoma.Arch 148: 1422-1423Crossref Painful stimuli, scratching, reduces sensation (Bin Saif 2012Bin G.A. Alajroush McMichael McGlone al.Aberrant C nerve fibre function scalp.Br 167: 485-489Crossref (17) 2003Ikoma Rukwied Steinhoff Miyachi Schmelz Neurophysiology interaction pain.Arch 139: 1475-1478Crossref addition, exhibit intradermal fiber density levels inflammatory mediators, neurotrophin, lead local sensitization peripheral receptors (Grewe 2000Grewe Vogelsang Ruzicka Stege Krutmann Neurotrophin-4 production human epidermal keratinocytes: expression dermatitis.J 2000; 114: 1108-1112Abstract (103) Sugiura 1997Sugiura Omoto Hirota Danno Uehara Density fine structure nerves various lesions dermatitis.Arch Res. 289: 125-131Crossref (107) Urashima Mihara, 1998Urashima Mihara Cutaneous dermatitis. histological, immunohistochemical electron microscopic study.Virchows Arch. 1998; 432: 363-370Crossref (168) Finally, central cause interpreted intense instead, perpetuating itch‒scratch cycle, seen (Ikoma 2013Kwatra Stander Bernhard Brachioradial trigger generalization itch.Am. 68: 870-873Abstract Overall, scratching itself help explain score. Because refractory conventional therapies, work emphasizes novel strategies maximize patients. Through core outcome set development clarifying diagnostic subgroups, stratifying