Techniques for Improving Outcomes

Anna Fishbein, MD, MS, discusses novel techniques for improving patient adherence and outcomes when treating atopic dermatitis.

Dr Fishbein is an associate professor of pediatrics (allergy and immunology) at Ann & Robert H. Lurie Children's Hospital of Chicago in Illinois.

Transcript

Dr Fishbein: I like to get know my patients and their hobbies. Some of these questions are queried on Patient-Oriented Eczema Measure, the Children's Dermatology Life Quality Index, or the DLQI, the Dermatology Life Quality Index For Adults.

I try to get to know my patients, so I can better understand how AD actually affects their life. I have a patient, for example, who's an avid hockey player, and you can imagine, with all that hockey equipment, it gets pretty sweaty. The focus of our conversations are about something that's important to him, like the hockey, and how his eczema might be impacting that. He'll say, "Oh, hockey's been really difficult lately, Dr Fishbein. I really need to update my medications in these areas where the equipment's been making it flares."

That feedback really helps me with the care plan and to make it personalized to him. Sometimes, the conversation will center around patients' other interests, times that they might be embarrassed, a big event they have coming up that might actually direct the treatments.

Sometimes, the conversation's really focused on shortfalls or complications related to the treatment that is bothersome to them. Some of that might actually even be steroid myths. I frequently get the question about, "Doctor, these steroids are making my skin get more pale."

Actually, that lightening is related to scarring from eczema. I find myself counseling a lot about things that like, that might be perceived as side effects, but are not actually side effects. Particularly in pediatrics, where that might be something I'm discussing not only with the patient, but really, with the parent. If the child's really young, that'll be a conversation directly with the parent.

Our group has also started a multidisciplinary atopic dermatitis clinic that incorporates physicians in sleep medicine, allergy, dermatology, and psychology to try to treat the whole person and address some of the concerns or the complications related to atopic dermatitis.

We recently developed a manual with a therapist and a psychologist that I work with called Mastering Your Itch. We've actually developed several modules that were based off qualitative research we did to ask patients with eczema about what really bothers them and how can we develop something to help you in a non-medication way address your itch?

That's been really fun, and we've found that mindfulness and medication adherence are things that often come up, and we're trying to meet those needs. One interesting thing we learned is, a lot of times, the feeling, especially in kids, of the ointment can be very bothersome to them. We've actually done this desensitization, which one of our brilliant therapists thought of, where she put on the medication, and she did this over Zoom at the same time as the patient. They put on the medication together and described the feeling. It actually tremendously helped this patient learn how to actually use her therapies and get comfortable with the feeling of it.

We're also working, speaking about personalizing therapy, on shared decision-making, which is an extension of what the American College of Allergy and National Eczema Association have to started to work on, to help patients coming to the appointment, ready to think about what they might want to consider in their therapy. What are something important to them?

There's not very good assessments about adherence, and as you may know, patients tend to be pretty good about remembering to take their medications right before their visits and right after. It can be really hard. It's hard to have a chronic condition and remember to take your medications on a daily or twice-daily basis.

I usually ask patients about the last time that they took their medication. That's usually something they remember, like, "Oh, when did you last take it?" or, "How many times this week did you use it?" Patients, I have found, are pretty responsive to that question and usually pretty honest, particularly parents. Sometimes, the kids will call them out if they're not, or vice-versa. Usually, the older teenagers, the parents remind them that they haven't taken it in a while, and it's a nice starting point into the conversation about, "OK, so this week, maybe you were busy, or what were some of the aspects that made it challenging for you to use your medication?" I find that's a good way to broach the conversation without being judgmental.

We also have other methodologies in the electronic medical record, using patient-reported outcome measures, such as the Promise, which is the NIH-funded tool that helps patients to self-monitor. It's something that we have written a grant for and are hoping to incorporate more into real clinical care. Our multidisciplinary team approach also uses debriefing sessions. We discuss complicated cases and talk about each of our patients, really to come up with a personalized strategy.

The therapist might bring up something like, "Oh, they really didn't like the feeling of that ointment. Can you try a cream?" That really helps us to improve adherence and meet the patients where they're at, giving them what they need, and benefiting everybody.