UNDERSTANDING ATOPIC DERMATITIS IN THE US

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1 Key points: Resources for training general practitioners to treat atopic dermatitis (AD) remain sparse and inconsistent. A lack of comprehensive data makes it difficult to assess the prevalence of AD in the population. The has a high number of trained dermatologists proportionate to the population, but waiting times for appointments are high, and the structure of the healthcare system can make it difficult for patients to access specialists. The is unique among its industrialised country peers in that it has no universal health coverage, fragmented provision of care and a hybrid system in which most health care is delivered privately, even where it is publicly financed. Some 27.3m Americans were uninsured in the first quarter of 2016, equivalent to 8.6% of the population, down from 9.1% in The federal government accounted for 28% of spending while state and local governments accounted for 17%. 2 The Economist Intelligence Unit created an eight-country scorecard, which contains indicators of importance to the management of atopic dermatitis, a chronic skin disease that can have psychological impacts on patients. The Atopic Dermatitis (AD) Scorecard looked at 12 policy indicators, addressing a range of factors, including the provision of care and support for patients and caregivers (see below for the full scorecard results for the ). Indicator 3 Score Use of quality of life measures 2 out of 2 Availability of multidisciplinary care Number of dermatologists Patient advocacy and support groups Primary healthcare professional training and awareness programmes 1 out of per 100,000 population 2 out of 2 0 out of 2 Very high: 3 Exceeds on good practice criteria High: 2 Good practice criteria met Moderate: 1 Good practice criteria partially met Low: 0 Good practice criteria not met Source: Atopic Dermatitis Scorecard; full explanation of the scores are available at the end of the article. Sponsored by: 1

2 The was the only one of the countries surveyed for which statistics on lifetime prevalence of AD were unavailable (although other types of prevalence data are available). Estimates of lifetime prevalence of AD range from 3.2%, based on analysis of healthcare claims data from the public and private sectors, 4 to 4.9% in a study using web-based surveys. 5 Health providers have guidelines from the American Academy for Dermatology (AAD) for assessing the severity of AD, 6 but these have yet to be validated. There have been efforts to determine the economic impact of the disease on patients, with one recent study finding that the total mean annual per-patient direct medical costs were $9,782 higher for patients with AD than for those in a non-ad control group. 7 The study also found that AD patients had a significantly increased risk for arthritis, asthma and nasal allergies. AD patients can face a range of other burdens because of their condition, including increased rates of anxiety and depression, especially in those with severe AD. 4 These co-morbidities contribute to high cost burdens for emergency room visits, prescriptions and over-the-counter treatments, as well as the broader impact of reduced work productivity and health-related quality of life. According to the scorecard, the system lagged most sharply behind other countries in the provision of primary healthcare training and awareness programmes, and patient education programmes. By contrast, it performed better in the areas of quality of life measurement and in the number of dermatologists serving the population. As the scorecard shows, the does better in recommending the use of guidelines for measuring quality of life for AD patients, receiving the top score in this category. 6 Provision of care Although it has 3.6 dermatologists per 100,000 population, one of the higher proportions of the eight countries studied, the scores in the middle of the survey group with regards to multidisciplinary care, with AAD guidelines merely referring to the need for a multidisciplinary approach. This is despite the fact that studies have showed some improvement in both adult and child AD patients involved in multidisciplinary treatment programmes. 8 Despite the comparatively high number of dermatologists, however, the average wait times for a dermatology appointment is 32.3 days, according to one estimate, 9 with significant regional discrepancies. As the waiting times mentioned earlier reflect, making an appointment with a dermatology specialist can be challenging. Some have argued that the demand for cosmetic dermatology is filling many of the time slots for dermatology specialists, who prefer the procedures because they are generally not covered by insurers and require patients to pay up front. 9 Awareness and advocacy Primary healthcare professional training on AD has been identified as a key factor in boosting patient outcomes and quality of life. 10 Yet, in common with most of the other countries surveyed, the performs poorly in this category, receiving a score of zero. While medical schools require an average of ten hours of dermatology training, this accounts for less than 0.3 % of the total curriculum; the Accreditation Council of Graduate Medical Education requires exposure to dermatology as part of its Family Medicine residency curriculum, but no similar requirement exists for internal medicine residents, with only 14% of this group receiving at least a month of clinical dermatology training. 11 2

3 Although the AAD website contains a number of discussions and learning modules related to the basic dermatology curriculum, it wasn t immediately clear how much of this covers AD in particular, or is targeted towards primary care. 12 There have been some pilot projects aimed at providing training and other resources to primary care providers. 13 One group of researchers designed an algorithm to help primary care providers learn more about AD and manage the condition in paediatric patients; researchers concluded that the model helped to improve physician knowledge, although the study included only a small sample group. 14 Advocacy organisations also seem to devote few resources to educating health providers. The National Eczema Association provides medical professionals accessing its website with a series of brief fact sheets on the condition, with more of the information oriented primarily toward patients and carers. 15 The does substantially better in the area of AD patient advocacy and support, receiving the highest score in this category. 16 3

4 : results from the Atopic Dermatitis Scorecard Indicator Name The s score Scoring guideline Domain 1: Epidemiology 1.1 Lifetime prevalence Not Available % of people within the population who will have AD at some point in their life 1.2 Currency of prevalence data N/A 0=>15 years to 10 years; 1=<10 years to 5years; 2=<5 years old Domain 2: Monitoring and measuring 2.1 Use of validated disease severity measures 1 0=none recommended in guidelines; 1=non-validated measure recommended in guidelines; 2=validated measure recommended in guidelines 2.2 Use of quality of life measures 2 0=no; 1=yes, generic instrument recommended/used; 2=yes, AD-specific instrument recommended/used Domain 3: The provision of care 3.1 Presence of evidence-based treatment guidelines 2 0=no guidelines; 1=region-specific guidelines; 2=country-specific guidelines; +1= guidelines developed within past three years 3.2 Availability of multidisciplinary care 1 0=no recommendations about multidisciplinary care; 1=multidisciplinary care recommended; 2=multidisciplinary care and team make-up included in recommendations 3.3 Number of dermatologists 3.6 Reported as number of dermatologists per 100,000 population: figure does not distinguish between those in public and private practice Domain 4: Support for patients and carers 4.1 Assessment of wider impact of AD on families/carers 4.2 Availability of psychological and emotional support 1 0=no; 1=mentioned briefly in guidelines acknowledge that AD impacts on families/ carers; 2=guidelines recommend one or more specific interventions and a referral process 1 0=no; 1=mentioned briefly in guidelines; 2=guidelines recommend one or more specific interventions and a referral process Domain 5: Awareness and advocacy 5.1 Primary healthcare professional training and awareness programmes 5.2 Patient/carer education programmes 5.3 Patient advocacy and support groups 0 0=no; +1=nationwide primary healthcare professional awareness schemes; +1=nationwide primary healthcare professional training schemes 0 0=no; +1=nationwide patient self-care education schemes; +1=nationwide parent/ carer education schemes 2 0=no patient advocacy and/or support groups; +1=formal patient advocacy groups exist; +1=formal patient support groups exist 4

5 References 1 Available at: 2 Available at: 3 The Economist Intelligence Unit. A misunderstood skin disease: Mapping the policy response to atopic dermatitis, October 2018, the%20policy%20response%20to%20atopic%20dermatitis.pdf 4 Shrestha S et al. Burden of Atopic Dermatitis in the United States: Analysis of Healthcare Claims Data in the Commercial, Medicare, and Medi-Cal Databases. Advances in Therapy, 2017; 34(8): gov/pmc/articles/pmc / 5 Barbarot S et al. Epidemiology of atopic dermatitis in adults: Results from an international survey. Allergy June 2018; 73 (6) Eichenfield LF et al. Guidelines of Care for the Management of Atopic Dermatitis. Journal of the American Academy of Dermatology, February 2014, 70 (2) and aad.org/file%20library/main%20navigation/practice%20tools/quality%20care%20and%20guidelines/ad-part-2.pdf 7 Eckert L et al. The burden of atopic dermatitis in adults: Health care resource utilization data from the 2013 National Health and Wellness Survey, Vol. 78, Issue 1, January Spielman SC et al. A Review of Multidisciplinary Interventions in Atopic Dermatitis. Journal of Clinical Medicine. 2015;4: Available at: 10 This is in the key findings of the white paper and is referred to in Atopic Dermatitis: A Collective Global Voice for Improving Care, International Alliance of Dermatology Patient Organisations, February 2018, images/publications/atopicdermatitis.pdf 11 Beroukhim K et al. Primary Care Providers as Allies in Dermatology. Practical Dermatology, September These were 2009 guidelines. See pdf?ver= for 2018 guidelines. Page 20 of the guidelines says that medical residents must have experience in diagnosing and managing common dermatologic conditions, but provides no further specifics. 12 Available at: 13 Available at: 14 Miyar ME et al. An Atopic Dermatitis Management Algorithm for Primary Care Providers and Assessment of Its Usefulness as a Clinical Tool. Pediatric Dermatology. Vol. 34, Issue 4, July/August pdf/ /pde Available at: and quality/clinical-guidelines/atopic-dermatitis/disease-flares-and-adjunctive-therapy/recommendations-for-educationalinterventions 16 Ibid and 5