Faculty Bibliography

BACKGROUND:Little is known about the predictors of healthcare utilization among US adults with atopic dermatitis (AD). OBJECTIVES/OBJECTIVE:To determine the proportion and predictors of utilization in outpatient, urgent care, emergency department (ED) and hospital settings in US adults with AD. METHODS:A cross-sectional, population-based study of 3,495 adults was performed. AD was determined using modified United Kingdom Working Party (UKWP) Criteria. AD severity was assessed using Patient-Oriented Eczema Measure (POEM), Patient-Oriented Scoring AD (PO-SCORAD) and Numeric rating scale (NRS)-itch. Weighted frequency and prevalence (95% confidence intervals [CI]) of utilization were determined. RESULTS:Overall, 10.42% (95% CI: 8.55-12.28%; weighted frequency: 25,844,871) reported a diagnosis of AD or eczema, 7.39% (5.81-8.97%; 18,324,869) met UKWP criteria, and 3.56% (2.40-4.72%; 8,830,095) met both. 31.8% (2,711,690) had a severe score for POEM, PO-SCORAD and/or NRS-itch, with 4.0% (337,586) having severe scores for all three. Outpatient utilization for AD was low for mild disease (29.3-34.7%) and increased by severity (moderate: 36.2-49.8%; severe: 50.6-86.6%). Timeliness of appointments, expenses and insurance coverage were also predictors of outpatient utilization. Severe POEM, PO-SCORAD and/or NRS-itch were associated with being uninsured, not having full prescription coverage, AD prescriptions being denied by insurers, and costs of AD medications being problematic. One in 10 adults with AD had ≥1 urgent care, ED or hospital visit in the past year. Urgent care or ED visits were significantly more common among blacks and Hispanics, lower household income, lower education level, and AD prescriptions being denied by their insurance company. CONCLUSION/CONCLUSIONS:Adults with AD had low rates of outpatient and high rates of urgent care, ED and hospital visits. The major predictor of outpatient utilization for AD care was AD severity. Racial/ethnic, socio-economic and/or healthcare disparities reduce outpatient utilization and increase urgent, ED and hospital utilization.

Few studies examine the experience of AD in adults and AD-treating physicians. Our objective was to compare the perspectives on AD among adults with, and AD-treating physicians. A cross-sectional sample of 602 adults who met AD UK Working Party criteria. Severity was assessed using POEM. A national sample of AD-treating physicians in outpatient settings wwere surveyed (N=401). Based on POEM score, 40% patients had moderate/severe AD (MSAD). Itch was reported as the most bothersome symptom for patients (57.5%) and AD-treating physicians. 15% of MSAD patients reported daily sleep disturbance, compared to 7% of physicians who reported that their MSAD patients experience this everyday. 41.4% of MSAD patients reported an average pain level of 7 or greater during the past week compared to 14.0% of physicians who rated their patient's pain. With respect to treatment experience, 29.6% of MSAD patients felt both physician and patient were equally in charge of treatment decisions vs 60.9% of physicians. 67.7% of physicians think their patients are very/somewhat satisfied with treatment vs 72.2% of patients with MSAD. Among those who reported treatment dissatisfaction, the primary reason was that these do not appear to work. Lastly, 1/3 of patients reported not being well informed about the cause of AD, similar to physicians who reported 34.0% of patients were not well informed. Recognition of itch burden, need for improved therapies, and disease education were similar between patients and physicians. Differences were observed in perception of pain and treatment experience. Our findings can help inform strategies to improve the care of adults with AD.

BACKGROUND:The impact of atopic dermatitis (AD) on health-related quality of life and health utility in the US adult population is not well established. OBJECTIVE:To determine the health utilities and quality-adjusted life-years (QALYs) lost in adults with AD versus without AD in the US population. METHODS:A cross-sectional, population-based study of 3495 adults was performed. AD was determined using modified UK diagnostic criteria for AD. AD severity was assessed using self-reported global AD severity, the Patient-Oriented Eczema Measure, the Patient-Oriented Scoring AD, and the Patient-Oriented Scoring AD itch and sleep. Six-dimensional health state short form (SF-6D) health utility scores and total QALY loss were assessed. RESULTS:The mean SF-6D score was lower in adults with AD compared with healthy adults (0.69 [95% CI, 0.68-0.70] versus 0.79 [95% CI, 0.77-0.79]). In particular, those with moderate-to-severe AD (mean, 0.53-0.66) had similar or lower SF-6D scores compared with those with all other self-reported disorders examined, except autoimmune disorders. Adults with AD and atopic comorbidities had significantly lower SF-6D scores compared with those without atopic comorbidities. Among the 7 disorders examined, AD was associated with higher total QALY loss than autoimmune disorders, diabetes, food allergy, and heart disease in both males and females. The largest QALY loss was for moderate AD in females and mild AD in males. CONCLUSIONS:Moderate-to-severe AD is associated with significant decrements of health utility in the US population. These data illustrate the heavy societal burden of moderate and severe AD and provide important insight for prioritization of resource allocation and cost-effectiveness research.

Population-based estimates on the prevalence of atopic dermatitis in adults vary widely. The objectives of the present study were to determine the prevalence of atopic dermatitis in the population of the United States, distribution of disease severity, and assess its impact on health-related quality of life. Among 1,278 participating adults, the prevalence (95%CI) of atopic dermatitis was 7.3% (5.9-8.8). 60.1% (56.1-64.1%) of participants were classified as mild 28.9% (25.3-32.7%) as moderate and 11% as severe (8.6-13.7%). Patients with atopic dermatitis and those with more severe disease had higher scores in the dermatology life quality index (mean [SD] AD: 4.71 [6.44] vs. controls: 0.97 [2.12] (<0.001), and the hospital anxiety (mean [SD] AD: 7.03 [4.80] vs. controls: 4.73 [4.8], and depression (mean (SD) AD: 5.83 [4.54] vs. controls: 3.62 [3.61]) scale indicating a worse impact on quality of life and an increased likelihood of anxiety or depression. Based on our prevalence estimates 16.5 million adults would have a diagnosis of atopic dermatitis with 6.6 million meeting criteria for moderate-to-severe disease. Our study confirms the high prevalence and disease burden of atopic dermatitis in this population.

Atopic dermatitis (AD) is a chronic inflammatory skin disease that affects around 13% of children and 7% of adults in the US. It can have a significant impact on the quality of life (QoL) of affected individuals due to pruritus and the visibility of lesions on the skin. AD is increasingly recognized as a systemic disease, since dysregulation of the adaptive and innate immune systems plays a key role in the underlying disease pathogenesis, which has important implications for how the condition is treated. Patients with moderate-to-severe disease who have failed to achieve disease control may benefit from systemic immunomodulatory treatments. Recently published expert perspectives outlined recommendations for the diagnosis and treatment of moderate-to-severe AD in adults, reflecting evidence-based, practical recommendations to support allergists and dermatologists in selecting appropriate treatment in the era of biologic therapies. To help clinicians understand how these practical recommendations can be implemented into clinical practice, we describe two real life case studies of adult patients with AD. In these case studies, we demonstrate how AD severity, treatment response, and treatment failure can be assessed, and the role of emerging systemic treatments in the management of moderate-to-severe AD.

Rationale: Mandatory influenza vaccination for all hospital employees is increasingly common, and was a policy at NYU Langone Health System (NYC, Winthrop, Lutheran) in 2017. Employees applying for exemption based on prior allergic reaction underwent evaluation by an allergist. We assessed the success of mandating the vaccine and whether allergic evaluation increased vaccination rates. Method(s): Prior reaction history, skin testing, and outcomes of evaluation were reviewed from charts. Primary outcomes were total vaccination rate and outcomes of those that applied for exemption. Result(s): A total of 39,146 of 39,558 employees (98.9%) received vaccination without evaluation. Of 39,558 employees, 419 (0.01%) applied for exemption; 73 sought exemption based on prior allergic reaction. Exemption was granted to 303 employees for other reasons. Egg-free vaccine was administered to 38/73 (52%) who reported egg allergy. The remaining 35 underwent allergy evaluation; 15 were granted exemption while 20 (57%) were vaccinated. At Winthrop, 46 employees applied for medical exemption due to allergy; 45 (97%) were ultimately vaccinated. Eight employees with reported vaccine allergy were evaluated. Four received the vaccine without testing, while four were skin tested. One patient developed a generalized rash with skin testing and was granted exemption. The other three successfully received influenza vaccine via graded challenge. Institution-wide, 99.04% (39,182 of 39,558) of employees received the vaccine. Conclusion(s): Mandating flu vaccination is by itself an effective method to ensure compliance (98.9%). Allergy evaluation increased the vaccination rate in those applying for an exemption due to allergy, with only 15/73 (20%) granted exemption.

Contact dermatitis accounts for 95% of occupational skin disorders. Irritant contact dermatitis (ICD) is often caused by cumulative exposure to weak irritants, accounting for 80% of all cases of contact dermatitis. ICD can co-exist with atopic dermatitis (AD) and allergic contact dermatitis (ACD). Patients with AD and ACD may have a lower inflammatory threshold for developing ICD. Therefore, it needs to be distinguished from lesions of AD and ACD. ICD Patients report stinging and burning in excess of pruritus. Pruritus is classically reported by patients with AD and ACD. ICD lesions are typically well-demarcated unlike AD and ACD. ICD is diagnosed by exclusion. Patients undergo testing to rule out type I and type IV hypersensitivity. Negative results suggest a diagnosis of ICD. Management consists of irritant identification and avoidance with regular emollient use. Although ICD is more common in certain occupations, genetics and environment play significant roles in its development.