Psoriasis is a chronic skin disorder, that is mostly treated with creams and ointments. When topical treatment fails, narrowband ultraviolet B (UVB) light becomes the primary treatment option. UVB treatment is nearly always carried out in an outpatient clinic, requiring patients to attend the clinic during working hours several times a week. To overcome this drawback, home UVB treatment was introduced in the 1970s. Ever since, however, the effectiveness and safety of this therapy have been debated. The results of chapter 2 demonstrate that very little research on home UVB treatment has been conducted. Literature is scarce and personal, non-evidence based opinions are widespread, while the official opinion suggests being cautious. Only a randomised study can settle the ongoing discussions concerning the advisability of home UVB phototherapy for psoriasis. Chapter 3 presents the protocol of a randomised clinical trial comparing home UVB treatment with outpatient UVB treatment. Both treatments were performed in a setting reflecting daily practice, a so-called ‘pragmatic’ design. In chapter 4 the methodological particulars of pragmatic and non-inferiority designs are explained. The results of the clinical trial (chapter 5) demonstrate that home and outpatient UVB treatment are equally effective and equally safe. Quality of life was also similar. Patients treated at home, however, experienced a lower burden of treatment, were more satisfied, while the waiting time for home treatment was mostly found acceptable or not a problem. Most patients said to prefer home UVB treatment over outpatient treatment in the future. In chapter 6 the relation between an improved patient assessed psoriasis severity and a better quality of life is specified. Also gender, age and employment status turned out to be important predictors of quality of life. The impact of psoriasis on quality adjusted life years (QALYs) was considerable and comparable to the impact of other chronic diseases. In chapter 7 the EQ-5D and SF-6D utility scores (both used to calculate QALYs) were compared for their agreement and usefulness in psoriasis studies. Agreement between individual measurements of both instruments was poor, but the mean scores displayed a similar sensitivity to change and hence a similar course during the study. In this population the use of either instrument may yield equal incremental costs-QALY ratios. The results of the economic evaluation (chapter 8) show very small and not significant differences in costs and effects (QALYs) between both groups, yielding home UVB phototherapy a cost-effective intervention. From a more clinical perspective, the number of days with a so-called ‘relevant treatment effect’ was taken into account. Overall, home UVB treatment appeared cost-effective, but cost-effectiveness may be improved by reducing waiting times for home UVB treatment. In chapter 9, the main findings are summarised and discussed. Home UVB treatment was proven to be an effective, safe and cost-effective treatment that it is preferred by most patients. Therefore the positioning of home UVB treatment should be reconsidered and agreed upon, and guidelines should be adapted to reflect this view. In addition, home UVB treatment should be routinely reimbursed and provision should be improved
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