Advances in dermatology and venereology ActaDV Acta Dermato-Venereologica ActaDV This isan open access article under the CC BY-NC license.www.medicaljournals.se/acta the prevalence of PN using publicly maintained database assess to potential is there funded, publicly are clinics dermatology all and insurance NHF have 91%) mately In Poland, where the majority of the population (approxi­ little knowledge about the disease burden as a result (4). with scarce, are PN of prevalence and incidence the on to be more prevalent in older patients (3). Reliable data tends disease the but PN, by affected be may children) National Health Fund (NHF). All age groups (including the to activities clinical the reporting for physicians Polish the by used is it as purpose, study the for used is term entity,this distinct a as PN considers (ICD-10) International Classification of Diseases, Tenth Revision the as However, (2). patients of group this in observed be may types, lesion skin other also but nodules, only not that indicating prurigo, of subtypes umbilicated or tions of prurigo, including papular, nodular, linear, plaque P gmail.com adamandrzejreich@ E-mail: Poland. Rzeszów,PL-35-055 2, Szopena ul. Corr: Acta DermVenereol 2020;100:adv00155. Accepted May 11,2020;EpubaheadofprintMay 18,2020 Di- seases; populationsurveillance; prurigo. of Classification International epidemiology; Key words: prurigo nodularis mayinitially bemisdiagnosed. with patients of one-third than more Thus, physician. referring the by misdiagnosed initially were patients of Dermatology at the University of Rzeszów, 43.1% Department of the at identified cases nodularis prurigo 58 of analysis an In trend. overall the followed largely data Regional population. 100,000 per cases 9.26 to 9.04 from increase small a with stable, relatively ned ce of all prurigo diagnoses over the same period remai 6.52 cases per 100,000 population. The total prevalen the 2016–18, periodprevalence of prurigo nodularis increased from 5.82 to the For (L28.2). prurigo other and diagnostic codes for prurigo nodularis (L28.1) and Poland using publicly maintained database case records in nodularis prurigo of prevalence the assessed study of life, with little known about disease prevalence. This quality and treatment for challenges significant sents Department of Dermatology, University ofRzeszów,Poland Anna RYCZEKand AdamREICH Prevalence ofPrurigoNodularisinPoland Prurigo nodularis skincondition isachronic that pre of chronic prurigo, as it covers various clinical presenta has been proposed as an umbrella term for various forms Recently,(1). life prurigo” of “chronic quality term the patient’s and treatment for challenges significant poses Journal Compilation ©2020ActaDermato-Venereologica. characterized byhighlypruritic, nodular lesions.PN condition achronicskin is (PN) rurigo nodularis dm ec, eatet f emtlg, nvriy f Rzeszów, of University Dermatology, of Department Reich, Adam INVESTIGATIVE REPORT - - - - with Yates correction. 3.22 to 2.74 per 100,000 population. The overall preva the prevalence of other prurigo decreased slightly, from per 100,000 population (Table I ). Over the same period, lish population increased slightly, from 5.82 to 6.52 cases For the period 2016–18, the prevalence of PN in the Po RESULTS seen by a specialist as an outpatient were compared using a χ assigned either an L28.1 or L28.2 diagnostic code and who were paired a using diagnosis and sex by compared and statistics descriptive using analysed was code diagnostic L28.2 or L28.1 an assigned were who patients of age referral. after dermatologist consultant the by The assigned code (i.e. the diagnostic code on the referral letter) with the diagnostic diagnosis primary the at assigned code diagnostic the compared tology at the University of Rzeszów for the period 2016–18, and Derma of Department the in PN to due hospitalized were who patients for accessed were data specialists, and physicians care termine the difference in the rates of diagnosis of PN by primary de to order In rates. prevalence calculate to used were numbers Case prurigo. other to L28.2 and PN to relating L28.1 with des, co diagnostic ICD-10 on based identified were Cases 2016–18. period the for prurigo other or PN for of year each treated number patients the to relating NHF the from requested were data analysis, epidemiological observational, retrospective, this For MATERIALS ANDMETHODS single clinicinPoland. a at specialist dermatology a by made PN of diagnosis post-referral any and physician) referring the by made between the initial diagnosis (i.e. a discrepancy pre-referral diagnosis any was there whether assess to was tive prevalence of PN using such data. A secondary objec secondary Adata. such using PN of prevalence the determine to aimed study This prurigo. other and PN for codes diagnostic of entry the on based records in general. need to raise awareness of the disease among physicians 18. Patients are often misdiagnosed initially, indicating the 6.52 cases per 100,000 population over the period 2016– lence of prurigo nodularis inPoland increased from 5.82 to to be underestimated. This paper describes that the preva often lacking and, therefore, prevalence numbers are likely impaired. Awareness of the disease among physicians is laris is challenging and quality of life of patients is severely highly pruritic, nodular lesions. Treatment of prurigo nodu Prurigo nodularis is a chronic skin condition that causes SIGNIFICANCE Acta DermVenereol 2020;100: adv00155 -test. The number of patients of number The t-test. doi: 10.2340/00015555-3518 2 test 1/4 ------Advances in dermatology and venereology ActaDV Acta Dermato-Venereologica ActaDV www.medicaljournals.se/acta age 61.9 vs. 60.8 years; 60.8 vs. 61.9 age (mean PN with males than older significantly were PN IQR: interquartilerange. Table II.Ageofpatientswithadiagnosisprurigonodularisor otherprurigoandstratifiedaccordingtosex(2016–18) 57.6 years, respectively; vs. (61.5 prurigo other with patients of that than higher than thoseforotherprurigo(L28.2). higher 5-fold to up were that L28.1) of code diagnostic provinces) had PN diagnosis rates (based on a recorded (administrative voivodships Śląskie and Podkarpackie Mazowieckie, Małopolskie, Kujawsko-Pomorskie, the followed the overall trend, although it was observed that over the 3-year observation period. Regional data largely increase from 9.04 to 9.26 cases per 100,000 population lence of prurigo remained relatively stable, with a small a Table I.PrevalenceofprurigonodularisinPolandandbreakdownprevalenceaccordingtoregionaldifferences 2/4 ICD-10: InternationalClassification of Diseases, 10 Females vs.males Females vs.males Overall Total numberofpeople living in Poland, 1,000 Total numberofdiagnosedcases Zachodniopomorskie Wielkopolskie Warmińsko-Mazurskie Świetokrzyskie Śląskie Pomorskie Podlaskie Podkarpackie Opolskie Mazowieckie Małopolskie Łódzkie Lubuskie Lubelskie Kujawsko-Pomorskie Dolnośląskie Regional prevalence Total prevalence per 100,000 population (L28.1 +L28.2) Prevalence per 100,000 population Prevalence, % As on December 31 of therespective year based on Polish Agency of Statistics. The mean age of patients with PN was significantly was PN with patients of age mean The A. RyczekandReich L28.2 L28.1 L28.2 L28.1 Diagnostic code p < p 0.001); overall, females with < 0.01), and approximately and 0.01), a th Revision; L28.1: ICD-10 diagnostic code for prurigo nodularis; L28.2: ICD-10 diagnostic code for other prurigo. n 2,179 vs.1,201 4,754 vs.2,235 3,380 6,989 58.3 (20.0) vs.56.2(22.6) 61.9 (15.3) vs.60.8(16.0) 57.6 (21.0) 61.5 (15.5) Mean (SD) Age, years L28.2 L28.1 L28.2 L28.1 L28.2 L28.1 L28.2 L28.1 L28.2 L28.1 L28.2 L28.1 L28.2 L28.1 L28.2 L28.1 L28.2 L28.1 L28.2 L28.1 L28.2 L28.1 L28.2 L28.1 L28.2 L28.1 L28.2 L28.1 L28.2 L28.1 L28.2 L28.1 L28.2 L28.1 – L28.2 L28.1 L28.2 L28.1 – Diagnostic code referring physician; the remaining 25 patients (43.1%) patients 25 remaining the physician; referring referral letter, and were thus correctly diagnosed by the 33 (56.8%) were referred with a diagnosis of PN on the patients, 58 the Of period. observation the during PN with diagnosed were patients referred 58 Rzeszów, of (p by a specialist only, with the remainder seen as inpatients prurigo diagnosed, only 328 (9.7%) were outpatients seen remainder seen as inpatients. Of the 3,380 cases of other cases were outpatients seen by a specialist only, with the diagnosed during the observation period, 5,945 (85.1%) cases PN 6,989 the PN orotherprurigo(TableOf II). twice as many females than males were diagnosed with In the Department of Dermatology at the University the at Dermatology of Department the In < 0.001 forPNvs.otherprurigo). 1,238 2,236 2016 Year ofdiagnosis 68 59 78 127 22 98 38 57 58 291 12 28 22 72 51 113 35 40 92 272 95 383 132 121 16 34 162 134 28 90 329 317 9.04 3.22 5.82 0.003221 0.005818 38,433.0 63 [0–97] (48, 72) vs. 62 [0–93](45,72) 64 [0–97] (54, 72) vs. 63 [0–95](54,70) 63 [0–97] (47, 72) 64 [0–97] (54, 71) Median [min–max](IQR) Age, years 1,091 2,248 2017 68 66 78 106 27 65 38 43 48 283 7 31 19 84 36 147 38 33 63 280 87 429 97 116 14 42 147 118 39 109 285 296 8.69 2.84 5.85 0.002839 0.005849 38,433.6 1,051 2,505 2018 67 71 66 116 23 79 28 39 47 311 20 45 35 96 52 212 45 38 51 295 85 432 74 125 16 33 130 173 20 111 292 329 9.26 2.74 6.52 0.002736 0.006522 38,411.1 < 0.01 < 0.01 < 0.001 p-value Advances in dermatology and venereology ActaDV Acta Dermato-Venereologica ActaDV voivodships, but up to 5-fold higher for PN vs. other vs. PN for higher 5-fold to up but voivodships, most in rate similar a at occurring coding with Poland, of (provinces) voivodships different across consistent code of L28.1) and other prurigo (L28.2) were not diagnostic always recorded a on (based PN of rates diagnosis relative the Furthermore, PN. than other diagnosis a with clinic dermatology the to referred were PN with similar asreportedelsewhereforPN(6,7). mean age of a patient with PN in Poland (61.5 years) is further.this The on speculate to unable are we limited, are population, general the for that including data, as However, (5). physicians among awareness disease of lack a to due underestimation, an be to this believe tors investiga the 2016; in USA the in discharges hospital leaving fewerpatientswith“otherprurigo”. better awareness and better detecting of PN by physicians of frequency of other prurigo types may be related to the PN observed over time accompanied by a slight decrease of prevalence higher the that suggested also be could It “prurigo simplex” might also be reported under this code. ferent pathophysiology as “prurigo simplex subacuta” or to, chronic prurigo. For instance, such conditions of dif types of pruriginous conditions, including, but not limited to be emphasized that the code L28.2 refers to different has It L28.2). of code diagnostic recorded a on (based prurigo other with diagnosed those in decrease slight a and L28.1) of code diagnostic recorded a on (based 2018, with a slight increase in those diagnosed with PN and 2016 between population Polish the in stable ned other and unspecified dermatitis (L30; (Z03.8; out ruled conditions and diseases pected L29.9; code diagnostic (ICD-10 unspecified pruritus, included PN, than and were other thus initially disorder misdiagnosed. Misdiagnoses skin a of diagnosis initial an had Overall, the prevalence of any prurigo diagnosis remai population. 100,000 per cases 6.52 is Poland in PN of prevalence estimated the data, (2018) current on Based DISCUSSION abscess, furuncleandcarbuncleoftheface(L02.0). cutaneous and (Z87), conditions and diseases other of subcutaneous tissue unspecified (L98.9), personal history and skin the of disorder (L97), classified elsewhere not tissue (L98.8), non-pressure chronic ulcer of lower limb subcutaneous and skin the of disorders specified other specified, otherwise not skin the on lesions papulous transient acantholytic dermatosis (L11.1), inflammatory (L43.0), planus lichen hypertrophic (L98.1), dermatitis fungoides (C84.0), nummular dermatitis (L30.0), factitial herpeticum (B00.1), erythema nodosum (L52), mycosis eczema (L30.9), dermatitis unspecified (L80), vitiligo (M33), dermatomyositis with diagnosed each patient In our analysis, more than one-third of all patients all of one-third than more analysis, our In PN accounted for just 3.7 inpatient visits per 100,000 n = 4), encounter for observation for other sus other for observation for encounter 4), n = 2), and a single n = 3), - - - - the basis for analyses of disease prevalence (8). More (8). prevalence disease of analyses for basis the as coding clinical of use the for and databases, national visits (10). Such findings have implications for the use of be higher for diagnoses made at secondary (vs. primary) a range of diseases (12, 13). Coding omissions may also diseases (11), and with coding accuracy differing across certain recording for unsuitable being codes available being selected (8–10). There can also be issues with the tation of case notes, with the incorrect code subsequently is potential for coding errors to occur due to misinterpre physician who makes the initial diagnosis, meaning there population. Clinical codes are often not assigned by the patient true the of underestimation and bias coding to lead can this coding, clinical simplifying while coding; land, only the primary diagnosis is reported for medical Po In purposes. billing and reimbursement for as well as here, reported type the of analyses for essential thus is reporting database Accurate purpose. secondary a is reimbursement purposes; analyses of disease prevalence to a patient’s case notes primarily for billing and hospital coding isusedtoassignstandardizeddiagnosticcodes Clinical approach. this with associated limitations are disease for which the burden is not well understood, there opportunity to estimate the prevalence of an uncommon prevalence ofPN(5). the of underestimation an to contribute might overall physicians among awareness disease of lack general a that conceivable is it voivodships, 5 those in accurate more is PN for ascertainment case that suggest to tive Celgene, Chema Elektromet, Eli Lilly, Galderma, Janssen, Leo Janssen, Galderma, Lilly, Eli Elektromet, Chema Celgene, AR: declare. to interest funding: of and Conflicts peutics. Thera Trevi from support with Medica, Excerpta of Rouwette by Tomauthors the of direction the under provided was sistance as Editorial Therapeutics. Trevi by sponsored was study This ACKNOWLEDGEMENT among physiciansingeneral. disease the of awareness raise to needed are efforts ongoing initially,suggesting misdiagnosed be may PN sed as outpatients. More than one-third of patients with setting, patients with PN were more likely to be diagno inpatient the in occurred predominantly which prurigo, burden of PN in the Polish population. In contrast to other coding listtothedepartment. simplified the passed surgeons when billing increased accuracy with a coding proforma, which also resulted in improved reported (9) al. et Conversely,Clement (14). reimbursement increase to order in “up-coding” to or to record only diagnoses that lead to reimbursement (12), ment, the system is also open to potential misuse in order reimburse for used is coding where countries in over, prurigo in 5 further voivodships. Although it is specula Although use of the NHF database provided a unique In conclusion, the present findings characterize the characterize findings present the conclusion, In Consultant or Speaker for AbbVie, Bioderma, AbbVie, for Speaker or Consultant Prurigo nodularisinPoland AR has no conflicts of interest of conflicts no has AR Acta DermVenereol 2020 3/4 ------Advances in dermatology and venereology ActaDV Acta Dermato-Venereologica ActaDV www.medicaljournals.se/acta REFERENCES Pfizer and Trevi Therapeutics. 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