Patient-Reported Outcomes to Support AD Care

Raj Chovatiya, MD, PhD, shares what dermatologists need to know about using patient-reported outcome data to evaluate and support an atopic dermatitis care plan. Dr Chovatiya is an assistant professor of dermatology at the Northwestern University Feinberg School of Medicine in Chicago, IL, where he also directs the Eczema and Itch Clinic.

Transcript
Dr Chovatiya: When you think about atopic dermatitis, it's associated with a whole bunch of heterogeneity across a number of different clinical domains. As dermatologists, our forte is describing the skin findings, what exactly the physical exam looks like. While that's interesting and it can be helpful, it doesn't capture every one of these domains.

For instance, not everyone has a large body surface area or inflamed, oozing lesions, things that are easy to spot as a dermatologist. But they might have really severe disease measured by other metrics, let's say the number of comorbidities they have, or their symptomatic burden, really bad itch and bad skin pain, sleep issues, and things like that, those patient-centered symptoms like itch, skin pain, sleep, mental health symptoms like depression, anxiety, quality of life burden. Patients can have impairment in any of these areas, and that's not something that's easily evidenced to your eyes just by doing a physical exam. Unless you ask these in some way, you're not going to find out about them, but they're a really important part of the actual disease process itself.

Patient-reported outcome measures are standardized measures you can use to get information about these patient-reported symptoms in a systematic, formal way. It allows you to better characterize the disease state, you can make comparisons over time, you can track changes and responses to therapy. I like to explain them to patients or colleagues like it's another version of vital signs. When we think about vital signs that have been largely unchanged for a large number of years, blood pressure, things like that. Some of that's relevant to some of the stuff we do in dermatology, but these are different ways of tracking symptoms or traits that are almost like the vital signs associated with the disease process. I'm a big proponent of these tools. I think that, at the end of the day, they actually save you time and allow you to direct your conversation to what's important to the patient.

As far as implementation goes, that's a whole project in itself. We're beginning to understand what's the best way to go about putting these into routine clinical care. Each clinic is a different setting and has different abilities to administer these measures, time it takes to do these things. What I like to tell people is, "Start small, on things that are easy, almost simple, one-question measures, to get information that's important for you." I recommend doing them at every visit. With atopic dermatitis patients, oftentimes if it's pretty active disease, you're seeing them every few months. If it's less active disease, more like half a year, even a year later. Those are all reasonable interviews. 

Important questions that you want to ask? Very simply a patient-reported global severity. Essentially, "How bad do you think your disease is? Mild, moderate, severe?" Studies have shown that this correlates well to what you see and what else is going on. This is a really important question, just to ask and track how the patient feels. Simple, one-question, numerical rating scale question. If you have the ability to implement more specific measures where you can delve deeper, that's great, but even just getting that one number to guide what you want to discuss in terms of your care.

Other things to ask about, a patient global impression of change. Essentially, once you've made a treatment, do people feel like they're totally cleared? Do they think they've had a major improvement, a minor improvement, they're exactly the same, no improvement, or things are getting worse? Oftentimes, that information can be really helpful when you want to assess how a treatment been going. Just asking that and getting an answer takes only seconds from your patient.

Then, depending on how much time you have and what you're able to get, there are slightly longer questionnaires that have a few questions. The Dermatology Life Quality Index is a general dermatologic quality of life measure. It's 10 questions. It may work in some clinic settings and not others, but it is one of the preferred measures for quality of life in atopic dermatitis, or even the POEM, the Patient-Oriented Eczema Measure, that's another one that's commonly used. This one is less than 10 questions. It can be administered pretty quickly in a couple minutes, and tells you about the frequency of atopic dermatitis symptoms, and can be something helpful to compare between visits.

Aside from those classic atopic dermatitis-oriented measures, there's other things that still fall in the patient-reported outcome measure category, but aren't necessarily things you think about specifically with atopic dermatitis. It can be a little more general.

Let's start with general measures of quality of life. We know that a lot of our patients oftentimes have other comorbid conditions. They've got a bunch of things going on. It's not just atopic dermatitis that's impacting their life. These are formalized measures. The short form is one of them, the PROMIS, the Patient-Reported Outcomes Measurement Information System, is a global health tool as well. All these are freely available. These can track general mental and physical health. They can be important to just generally see how things are going with your patient, and extend beyond just very specific symptoms for atopic dermatitis.

Something that gets lost sometimes is having a more formalized approach to asking about comorbidities, or a very specifically in-depth review system, can also reveal a lot about your patients with atopic dermatitis, not specifically a patient-reported outcome measure, but simply asking people about any difficulty swallowing. That could lead you to understanding that this person is at risk for eosinophilic esophagitis, which we know is increased in patients with atopic dermatitis. Additionally, trying to better understand the long-term course with atopic dermatitis is important. There's development of some tools that oftentimes very simple questions to ask are about how people are flaring, what their disease course looks like over time, periods of remission, quiescence. This can help you understand the long-term course of the atopic dermatitis.

Finally, to your point about wearables, I think we're making big headway there. This is an area we're going to explore more deeply in the future to understand how does this data, something that we can be getting continuously, coincide with some of those patient-reported outcome measures, and how we can use both of these together.

There's been a lot of interesting work in trying to better develop sensors related to sleep, potentially related to scratching. It remains to be seen exactly how these will be implemented into routine care, but I think you're going to start to see that stuff play a part in how we take care of our atopic dermatitis patients over the next decade.