Journal Club: Atopic Dermatitis Control Tool

Dr. Peter A. Lio:
Hello everyone, and welcome. I'm very excited to be here tonight with my friend and colleague, Dr. Lisa Swanson.

Lisa, will you introduce yourself for the group?

Dr. Lisa Swanson:
Yes, of course. Peter Lio. Yes, I'm Lisa Swanson. I'm a dermatologist in pediatric dermatology in Boise, Idaho. Thrilled to be here with one of the greatest people in the whole world, Dr. Peter Lio.

Dr. Peter A. Lio:
Well, I feel the same way. I'm Peter Lio. I'm a dermatologist based in Chicago. I am lucky because I get to be involved in a couple of different things. I'm a board member for the National Eczema Association, and I run this kind of interesting integrative eczema center where I get to look at some alternative traditions as well as our conventional dermatology. So I get to see the world from some different perspectives.

And tonight I'm excited to talk to you about I think some big questions. The first thing I want to ask you about is when we think about patient reported outcomes versus clinician reported outcomes, this comes up a lot. I think historically we've seen mostly objective measures. The clinician sort of says, yes, they're better. No, they're not. But now we're seeing this move towards patient reported outcomes. How do you think about that? And could you talk to us about where things have gone and where you think they're going?

Dr. Lisa Swanson:
Yes, yes. I think it's so important. I think we all strive in our busy clinics to get an accurate assessment of how the patient is doing, but sometimes that's difficult because you're only seeing them this one snippet of time. We don't really know how it's been going the other moments of the other days. All we have to really judge is that 10 to 15 minute visit right in front of you.

And also sometimes some patients are really good communicators and then other patients might not be as good communicators. For example, the teenagers. Teenagers don't commonly want to talk about their feelings and how things are going. And sometimes I feel with my questions, I'm just pulling teeth to get them to talk about how things are going. And then sometimes you have the patients where you come in and you're like, "How are you doing?" And they're like, "I'm doing great." And then you look at their skin and you're like, "You're not doing great. You're not doing great. Things still look pretty bad."

And so we need to kind of mesh the patient experience with the clinician experience that one moment in time visit with the general experience that the patient has been having in the preceding weeks to try to come up with a good treatment plan for them so that we know where we stand and where we want to go.

Dr. Peter A. Lio:
I think you make a great case for the importance of both. Because we definitely have patients who are not very forthcoming and who maybe are just, I often say they're so inured to their disease they don't really tell us how they're feeling or they think they're feeling pretty good. On the other hand, I think we also know there's the limitations of having just a clinical score or something. And I always say there's a couple of major issues. One is it's just at that moment, and we always run into this mechanics problem where the patient's, "I know I look good today, but I've been really miserable." And then you feel kind of bad for them, "I believe you. I do." Just if the car's making a funny noise, you bring it to the mechanic and now it won't make the funny noise. Usually the mechanics are more dismissive. They're like, "Yeah, we believe you. Bring it when it makes that noise."

Dr. Lisa Swanson:
Right. Yeah, yeah, yeah. And so many of them are like, "Trust me, it's been worse. I have pictures." And they bring out their phone and then they take you through about 18 pictures.

Dr. Peter A. Lio:
It's so true. That's a good one. The hard ones when they're having to look through the pictures and they're digging through or you're like, oh my goodness. But, you're right. So we have both of these pieces of the puzzle, and I think we're seeing an increased focus and emphasis, particularly in trials on patient reported outcomes. So I think that's good because capturing the rest.

It makes me think of one of the things that's been, for me, a career changing tool, and it's this Atopic Dermatitis Control Tool, or ADCT, and I love the way you put it. I feel the same way. I'll start the visit, "Hey, how are you? How have you been?" They're like, "I'm good." They're smiling. Maybe they look pretty good. So maybe my IGA score, Investigator Global Assessment, maybe it would only be like a one or a two that day. But then I start asking them the AD control tool questions, these structured questions, it's only six, and all of a sudden they start crying because it's like, ugh, it's actually not that good. And even though you look pretty good today, the last week has been rough.

So could you talk to me a little bit about that and your experience with the tool and what you think of it, and even its validity?

Dr. Lisa Swanson:
Yes. Yes. I think the tool is excellent because it's super easy. It's just six questions. They're easy to answer. You rate your score between zero and four. Yes.

Dr. Peter A. Lio:
Yeah, I think that's right. Yeah. Because, yeah, zero, one, two, three or four. Exactly. And your total score could be up to 24. Perfect.

Dr. Lisa Swanson:
Up to 24. So the most poorly controlled atopic dermatitis would have a score of 24. So this is like golf, you want a low score. And the uncontrolled disease is considered to be a number greater than or equal to seven. So if you fill out that scoring tool and you're greater than or equal to seven, the tool would say that you're poorly controlled and that more should be done to try to make things better.

And so I love it because it's easy. My patients can do it in the waiting room while they're waiting to be brought back to the exam room. It's easy to understand. The choices are easy. It's easy to calculate your score. And then I get a good sense for how things have been going at least over the past week very quickly in a snapshot, which is also very helpful in a busy clinic because sometimes it can be hard to really dive into all those details in a busy clinic.

Dr. Peter A. Lio:
100%. And one of the things I am trying to do, which may be for better or for worse, I might get in trouble with our colleagues, but I've been even encouraging some of my patients to just have one filled out and just bring it into a visit. It's so short. And to me, it's really answering that important question is it's not just how severe you are. That's interesting and somewhat academic. But the real question, as you say, it's are you under control? And no matter how mild you look, if you're not under control it means we need to do something different. And no matter how severe you might've been, if you're under control, that's great. We don't have to go any further. So I love it. It's such a clinical tool that even the patients can do and bring.

Dr. Lisa Swanson:
And I think it's so useful these days because we have so many options now and coming to treat and adequately control atopic dermatitis. I think there was a reason this tool was not being distributed 7, 8, 10 years ago because people could be poorly controlled, but it was hard to find another option for them. And so I think we potentially asked fewer questions back then, but now we have all of these options, all of these tools in our toolbox. We can enact positive change for our patients if we know that we need to.

Dr. Peter A. Lio:
It's such a great point, and I'd love to kind of tie it to something you said a little bit earlier on. When you have those adolescent patients who maybe are not very forthcoming, there's sort of tacitly sitting there. Do you find that this can also be helpful for that group?

Dr. Lisa Swanson:
Yes, I really do because it's just six questions, it's easy to score. And so I think it's even useful for the teenagers that don't really want to talk to me.

Dr. Peter A. Lio:
I always say it's multiple choice, you don't have to say anything, just circle the right answer.

Dr. Lisa Swanson:
Yes. Yes, yes.

Dr. Peter A. Lio:
And then in your practice, do you feel that it has been something that has actually helped steer you in different directions and has been useful clinically as a tool?

Dr. Lisa Swanson:
I think, honestly, it's been the most helpful in terms of saving a little time during the patient discussion and evaluation, because typically they fill it out in the waiting room and then I have a chance to review it right before I walk into the room, so I kind of know where things stand before I've even started that discussion. So I can start from this point instead of from down here building up to that point. And so I can hit the ground running and say, "I see here we're still struggling with sleep. We're still struggling with just itchiness. We're still struggling with being worried about and thinking about our atopic dermatitis all the time. Let's talk about some options to improve things." And so I think that's been the greatest part of it for me. It cuts to the meat of the conversation.

Dr. Peter A. Lio:
I love it. And I think one of the things that has come up before with some of my colleagues when I'm evangelizing about it is that they don't maybe want something so rigorous. They don't want to really do a score. But what I've often said is you can just then use them as guidance questions, right? I mean, there's six really important questions.

Dr. Lisa Swanson:
Yes, 100%. 100%. And we know from this journal article that we reviewed that it's very valid. The validity has been well established in adults, and we see in this article that it's been validated in teenagers, which is wonderful. So we have a good solid tool that's easy for our patients to understand. And we have this objective science that tells us it's a valid tool to assess disease control in our patients.

Dr. Peter A. Lio:
It's pretty amazing to have an article like this that takes something very simple, and again, almost kind of obvious in a way, I mean, I think good clinicians are getting at these questions, but standardize them, put it in a simple, easy to use tool, then validate that, go through the trouble of actually saying, hey, this really does correlate with the real world and such that I think it could be useful for further research. But I love the fact that we have this as a clinical tool.

And then my next question is, what about for the younger kids? It seems like we have it down to a certain age. But from what I understand, they're looking at it in even younger kids being able to talk to the caregivers. Would that be useful to you?

Dr. Lisa Swanson:
It would be so useful. I think it does pose some unique challenges, but I mean, they were able to do it with the Children's DLQI, so I think adjustments can be made in order to have it apply to that younger patient population. And so I look forward to that. I think that'd be awesome.

Dr. Peter A. Lio:
Amazing. Thank you so much. I'm so glad we got to discuss this and hopefully this will be useful to patients and other clinicians out there. It's been useful to us, and I look very much forward to seeing you very soon.