Good Practice Interventions for Assessment, Diagnosis of AD Published

A global Atopic Dermatitis (AD) Quality of Care (ADQoC) Initiative has identified benchmarks and several high-priority good practice implementations clinics can use for ensuring quality assessment and diagnosis of AD. Recommendations made by the Initiative were published online in a December issue of Dermatologic Therapy.

Inconsistencies and Gaps in Care: The Plight of Patients With AD

According to the international team of researchers who contributed to the ADQoC Initiative, AD is often misdiagnosed and consequently undertreated. Given these gaps in care, the researchers noted that patients with AD undoubtedly experience significant morbidity associated with their disorder.

Initially, patients with AD are typically treated by primary care physicians (PCPs) who have a limited understanding of the disease, the researchers added. Although many countries have guidelines covering the diagnosis and treatment of AD, the researchers involved in the ADQoC Initiative wrote that not “all practitioners who may treat AD” may be familiar with available guideline recommendations.

To improve awareness of AD diagnosis and management and to further understand challenges in AD care, the ADQoC Initiative working group conducted a comprehensive literature review. In addition, the investigators also surveyed 32 centers to identify high-priority good practice interventions for assessment and diagnosis of AD.

Common Challenges in AD Care

A review of peer-reviewed journals, guidelines, and site surveys by the ADQoC Initiative identified several shortcomings in AD clinical assessments and diagnosis. Some of the most common gaps were related to differentiating AD from disorders that mimic the disease as well as diagnosing atypical AD and staging AD severity/activity.

According to site surveys, most patients receive an initial diagnosis by their PCP, yet these clinicians tended to possess suboptimal AD knowledge and experience. The mean interval between initial assessment with the PCP and referral to an AD center was 1.9 months. Also, the most rapid clinical assessments were 1 day after presentation to emergency departments affiliated with specialist AD centers. In contrast, the most extended delay in referral lag was 6 months.

High-Priority Good Practice Implementations

Based on the published literature, the researchers found that the overarching goal of good practice interventions for the assessment and diagnosis of AD was to reduce delays to care access. A patient-centered goal consisted of avoiding any unnecessary deterioration in a patient’s condition while ensuring patient autonomy within a shared decision-making pathway. A complementary goal included the “effective and efficient use of limited medical resources” in assessment and diagnosis.

The majority of the identified good practice implementations reduced misdiagnoses and standardized AD care. The care teams that were involved in the good practice implementations consisted of dermatologists, nurses, medical assistants, physician assistants, PCPs, and comorbidity specialists.

High-priority good practice implementations for AD assessment and diagnosis of AD were classified as “easy resource-sparing implementations,” “moderately complex,” and “advanced.” These classifications were used to accommodate the different clinical settings where these implementations might be applied.

Easy, Resource-Sparing Implementations

These good practice implementations consisted of taking a clinical history and performing an examination “to rule out other complications on the differential diagnosis,” the researchers wrote. Another important element of easy, resource-sparing implementations included clinical assessment of disease severity as well as the assessment of intensity of inflammation.

In this category, another implementation included identifying patients who might be unresponsive to therapies and who likewise require step-up treatments. The researchers also suggest that another important implementation in this category is the assessment of the impact of AD on patients. The disease impact could be assessed with either informal questioning or patient-reported outcome (PRO) measures. The most frequently used PRO measure used at 20 centers in the review was the Dermatology Quality of Life Index.

Moderately Advanced Implementations

Use of validated diagnostic tools, including the Hanifin and Rajka criteria or the American Academy of Dermatology Diagnosis and Assessment consensus criteria, was identified as moderately advanced implementations. The researchers noted that these tools include specific criteria that allow dermatologists and allergists to develop a differential diagnosis and assess severity of AD.

Despite the benefits of these diagnostic tools, however, the researchers explained that they may not be easily integrated into busy PCP offices, given that the tools “are not sufficiently straightforward and streamlined” for use in the primary setting.

The review found that half of centers followed EADV guidelines and 8 followed the AAD guidelines and/or American Academy of Allergy, Asthma & Immunology/American College of Allergy, Asthma & Immunology Joint Task Force 2012 AD Practice Parameters for ensuring accurate assessment of AD severity. A total of 17 centers followed local guidelines either with or without considering international guideline recommendations.

Advanced Implementations

Several approaches were included within this category, including the use of outcome assessments with validated instruments. The most frequently used physician instruments among centers to assess severity of AD included the Eczema Area and Severity Index (EASI) and Scoring of Atopic Dermatitis (SCORAD).

Other tools used among centers to assess AD included tools included the Investigator Global Assessment (IGA), Numerical Rating Score (NRS), Validated Investigator Global Assessment for Atopic Dermatitis (vIGA-AD), Hand Eczema Severity Index (HECSI), Physician Global Assessment (PhGA), and Body Surface Area (BSA).

All centers included in the review used 1 or more objective disease assessment measures to expedite diagnosis and improve accuracy of AD assessment. A total of 17 centers administered both the EASI and SCORAD on a regular basis, while 3 centers did not use the EASI or SCORAD.

Disclosure: This clinical trial was supported by Sanofi Genzyme & Regeneron. Several authors declared affiliations with the pharmaceutical industry. Please refer to the original article for a full list of disclosures.

Reference

Weidinger S, Nosbaum A, Simpson E, Guttman E. Good practice intervention for clinical assessment and diagnosis of atopic dermatitis: Findings from the atopic dermatitis quality of care initiative. Dermatol Ther. Published online Dec 11, 2021. doi:10.1111/dth.15259