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Willingness to Pay and QOL in Alopecia Areata

      Abbreviations:

      AA (alopecia areata), AASIS (Alopecia Areata Symptom Impact Scale), WTP (willingness to pay)
      To the Editor
      Alopecia areata (AA) is an autoimmune disease that presents as nonscarring hair loss. In the United States, it is estimated that AA affects 0.1–0.2% of the population, with a lifetime risk of 2.1% (
      • Alkhalifah A.
      • Alsantali A.
      • Wang E.
      • McElwee K.J.
      • Shapiro J.
      Alopecia areata update: part I. Clinical picture, histopathology, and pathogenesis.
      ). Willingness to pay (WTP) is a monetary, preference-based measure designed to gauge patients’ WTP out of pocket (in US$) for a cure or control of their condition. To our knowledge, this is the first study measuring WTP in patients with AA.
      Patients indicated they were willing to pay a median of $500–1,000 or approximately 13–22% of their monthly income for a permanent cure for AA; 33% of patients (n = 13) were willing to pay $5,000 for a permanent cure and 15% (n = 6) were willing to pay $5,000 to control the disease.
      Patients with higher AA Symptom Impact Scale (AASIS) scores were more willing to pay > $1,000 (mean AASIS score 47.8 vs. 26.0, P = 0.012) and > $5,000 (mean AASIS score 53.2 vs. 25.8, P = 0.003) for a cure. Similarly, patients with higher AASIS scores were more willing to pay > $1,000 (mean AASIS score 53.7 vs. 30.4, P = 0.012) and > $5,000 (mean AASIS score 66.3 vs. 30.9, P = 0.003) to control disease (Table 2). Furthermore, patients with higher Severity of Alopecia Tool scores (≥ 25%) had significantly higher AASIS scores than those with lower Severity of Alopecia Tool scores (<25%) (mean AASIS 59.1 vs. 20.1, P < 0.0001). The average Severity of Alopecia Tool score for all 40 patients was 28.3%.
      Table 1Demographics of Patients with AA
      Patient CharacteristicsValue
      Values are n (%) except where indicated. Not all categories round to 100%.
      Age, y (range)40.5 (18–68)
      Disease duration, y
       <18 (20)
       1–512 (30)
       >519 (48)
      Male12 (30)
      Hispanic7 (18)
      Race
       Black3 (8)
       Asian14 (35)
       White15 (38)
       Multiple and/or other8 (20)
      Education completed
       High school4 (10)
       2-year college8 (20)
       4-year college15 (38)
       Graduate school8 (20)
       Professional school5 (13)
      Annual income, $
       <10,0009 (23)
       10,000–49,9994 (10)
       50,000–100,00014 (35)
       >100,00013 (33)
      Abbreviation: AA, alopecia areata.
      1 Values are n (%) except where indicated. Not all categories round to 100%.
      Table 2WTP for Cure or Treatment of AA
      Questionnaire ItemAASIS Score
      nValues, Mean (SD)P-Value
      Statistical test used is the Wilcoxon test.
      WTP for cure <$1,0002326.0 (21.5)0.012
      WTP for cure >$1,0001647.8 (30.0)
      WTP for cure <$5,0002625.8 (20.8)0.003
      WTP for cure >$5,0001353.2 (30.0)
      WTP for control <$1,0003030.4 (26.6)0.012
      WTP for control >$1,0001053.7 (25.8)
      WTP for control <$5,0003430.9 (25.6)0.003
      WTP for control >$5,000666.3 (22.4)
      Abbreviations: AA, alopecia areata; AASIS, Alopecia Areata Symptom Impact Scale; WTP, willingness to pay.
      1 Statistical test used is the Wilcoxon test.
      Our results indicate that 33% of patients with AA were willing to pay ≥ $5,000 for a permanent cure, comparable with the WTP of patients with vitiligo (32.9%) (
      • Radtke M.A.
      • Schäfer I.
      • Gajur A.
      • Langenbruch A.
      • Augustin M.
      Willingness-to-pay and quality of life in patients with vitiligo.
      ). For a permanent cure, our patients were willing to pay a median of $500–1,000, compared with patients with atopic dermatitis who were willing to pay a median of €1,000 (∼ US $1,132) and patients with rosacea who were willing to pay €500 (∼ US $566) (
      • Beikert F.C.
      • Langenbruch A.K.
      • Radtke M.A.
      • Kornek T.
      • Purwins S.
      • Augustin M.
      Willingness to pay and quality of life in patients with atopic dermatitis.
      ). The median WTP as a percentage of monthly income was 10–20%, which is comparable with the percentage found with patients with atopic dermatitis and psoriasis and slightly more than that found with patients with rosacea (
      • Beikert F.C.
      • Langenbruch A.K.
      • Radtke M.A.
      • Kornek T.
      • Purwins S.
      • Augustin M.
      Willingness to pay and quality of life in patients with atopic dermatitis.
      ).
      Severity of the disease was associated with QOL, a finding also noted in psoriasis. QOL was associated with WTP for both control and cure of the disease. Our patients reported a WTP at levels similar to patients with vitiligo, atopic dermatitis, and psoriasis, demonstrating the need for ongoing research toward a potential cure for AA. One limitation of our study was the small sample size; thus, further large-scale studies are warranted to validate our findings.
      A total of 40 patients with AA were recruited from the dermatology clinic at the University of California, Los Angeles (Table 1). Patients completed the AASIS and a WTP questionnaire and were assessed by a dermatologist to calculate the Severity of Alopecia Tool score (
      • Mendoza T.R.
      • Osei J.S.
      • Shi Q.
      • Duvic M.
      Development of the alopecia areata symptom impact scale.
      ,
      • Olsen E.A.
      • Hordinsky M.K.
      • Price V.H.
      • Roberts J.L.
      • Shapiro J.
      • Canfield D.
      • et al.
      Alopecia areata investigational assessment guidelines--part II. National Alopecia Areata Foundation.
      ). Our WTP questionnaire was a nonvalidated questionnaire that was based on those developed from previous WTP studies (
      • Beikert F.C.
      • Langenbruch A.K.
      • Radtke M.A.
      • Kornek T.
      • Purwins S.
      • Augustin M.
      Willingness to pay and quality of life in patients with atopic dermatitis.
      ,
      • Radtke M.A.
      • Schäfer I.
      • Gajur A.
      • Langenbruch A.
      • Augustin M.
      Willingness-to-pay and quality of life in patients with vitiligo.
      ). All patients provided written consent to participate, and study materials were approved by the University of California, Los Angeles Institutional Review Board.
      Statistical analyses were performed using the Fisher’s exact test (for categorical data) or Wilcoxon test (for continuous data) as appropriate using Statistical Package for the Social Sciences V23 (IBM, Armonk, NY).

      Conflict of Interest

      The authors state no conflict of interest.

      Acknowledgments

      This article is published as part of a supplement sponsored by the National Alopecia Areata Foundation .
      Funding for the Summit and publication of this supplement was provided by the National Alopecia Areata Foundation. This Summit was supported (in part) by the National Institute of Arthritis and Musculoskeletal and Skin Diseases under Award Number R13AR074890 . The opinions or views expressed in this professional supplement are those of the authors and do not necessarily reflect the official views, opinions, or recommendations of the National Institutes of Health or the National Alopecia Areata Foundation.
      We would like to thank Melvin Chiu for assistance and support with helping to develop the willingness to pay questionnaire. This article summarizes the work from a previous publication (
      • Okhovat J.P.
      • Grogan T.
      • Duan L.
      • Goh C.
      Willingness to pay and quality of life in alopecia areata.
      ) and has been reproduced with permission from the Journal of the American Academy of Dermatology. Statistical analyses for this research were supported by the National Institutes of Health, National Center for Advancing Translational Science, University of California, Los Angeles, Clinical and Translational Science Institute (grant number UL1TR000124).
      City, State, and County where work was done were Los, Angeles, California, USA.

      Author Contributions

      Conceptualization: JPO, TG, LD, CG; Data Curation: JPO, TG, LD, CG; Investigation: JPO, TG, LD, CG; Methodology: JPO, TG, LD, CG; Validation: JPO, TG, LD, CG; Writing - Original Draft Preparation: JPO, CG; Writing - Review and Editing: JPO, TG, LD, CG

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