Physicians’ perspectives and practice in atopic dermatitis management: a cross-sectional online survey in Japan

Abstract

Data on the problems physicians face when providing care for atopic dermatitis (AD) is limited. To understand the current status of AD management in Japan and identify the difficulties physicians are having and their support requirements, a cross-sectional online survey was conducted using the AD task force of the Japanese Society for Cutaneous Immunology and Allergy. Society members were sent an online questionnaire on demographic information, daily clinical practice, and perceptions of AD management. Using responses to 17 items listed as barriers to the treatment of atopic dermatitis (Question 12) and questions about the treatment difficulty of those items, 284 respondents were divided into three groups using unstratified cluster analysis. These three groups were classified as high-difficulty, medium-difficulty, and low-difficulty groups, and the relationship between physicians’ cognition and daily practice was examined for each group. There were no significant differences in affiliations or specializations among the three clusters. The low-difficulty group had a significantly higher proportion of participants believing that it was possible to achieve long-term remission, satisfaction, and motivation in AD management while carrying out precise assessments of skin lesions as part of their daily practice. Some physicians experience problems in their practice. This results indicate that AD management can be improved if satisfaction and motivation can be increased by providing appropriate support.

Introduction

Atopic dermatitis (AD) is a common skin disease seen in 9.98% of all dermatology outpatients [1]. The history of AD treatment in Japan during the 1990 s was very problematic, causing serious distress for both patients and physicians. Distrust of the approach used in regular medicine originated with concerns about the use of topical corticosteroids and was exacerbated by mass media misinformation (steroid bashing). This has led to confusion regarding the management of AD, resulting in an increasing number of patients with severe AD, which adversely affects their quality of life and social activities [2–4].

To address this situation, the first AD clinical practice guidelines were developed by the Japanese Dermatological Association in 2000 and have subsequently been revised to improve treatment outcomes and respond to advances in understanding the pathophysiology and treatment options [5, 6]. This has led to the popularization of standard treatments and improved therapies for AD over the past two decades. However, there are still many cases in which long-term control is not achieved due to a lack of appropriate treatment. In such cases, dermatologists should be responsible for providing more specialized management, considering individual characteristics, and going beyond guidelines. Variations in treatment outcomes may depend on differences in the skills, abilities, or attitudes of dermatologists.

Expensive novel therapeutic agents have recently been developed for severe AD, including molecularly targeted drugs [7–9]. Appropriate selection of patients for these new drugs is necessary to improve both patients’ quality of life and the sustainability of healthcare finances. Therefore, dermatologists must maximize the effectiveness of conventional drugs by improving and standardizing AD management attitudes and skills.

The Task Force on Atopic Dermatitis of the Japanese Society for Cutaneous Immunology and Allergy (JSCIA) is currently preparing continuing professional education for dermatologists to improve the management of atopic dermatitis. We conducted a questionnaire survey to understand the current clinical practices related to AD, how it is being treated, and what information or support is required by dermatologists. This study also aimed to identify barriers to AD treatment that could be addressed by providing information to healthcare professionals and patients. The questionnaire items were chosen based on the hypothesis that the issues and problems in AD management perceived by physicians in daily clinical practice may influence their perspective on the disease and treatment plan. No previous studies have examined physicians’ perspectives on AD management, including their motivation or perceived difficulty in treating this condition.

Materials and methods

Development of a questionnaire to investigate AD practice among healthcare professionals

We prepared a draft questionnaire to investigate physicians’ performance, difficulties, and treatment strategies for managing AD. Questionnaire items were prepared based on the knowledge of JSCIA task force members. A first draft questionnaire was prepared with 42 questions related to demographic information, practices related to patients with AD in the outpatient setting, implementation of proactive treatment, implementation of patient education, and perceptions of AD practice. This was piloted with five dermatologists to verify the accuracy of the text, the validity of the questions, and the time required to answer the questionnaire. The questionnaire was revised following feedback to obtain the final version (Table 1).

Online survey of dermatologists in Japan

From October 2019 to January 2020, a web-based survey questionnaire was administered to 1,259 dermatologists affiliated with the JSCIA using the Questant system from MACROMILL, Inc. (Tokyo, Japan). This study was reviewed and approved by the Ethics Approval Committee of the JSCIA (approval date: 31 July 2019). The survey questions were presented after each respondent had read the purpose of the study and provided consent to use their data.

Cluster analysis

Respondents were grouped by non-stratified cluster analysis using a question on their perception of the difficulty of treating AD (Question [Q] 12) to examine the relationship between each physician’s perception of AD as a condition, treatment strategy, and their usual practice. The appropriate number of clusters was set to three, and the physicians were grouped into three clusters: high, moderate, and low difficulty. Cluster analyses were performed using the NbClust packages and k-means methods.

Statistical analysis

R 4.0.3 (The R Foundation for Statistical Computing, Vienna, Austria) was used for statistical analysis. Cronbach’s alpha was used to examine the internal validity. The following variables were compared among the clusters: attributes (age and whether the respondent was an authorized dermatologist or allergist), the degree to which the physician had read or referred to the atopic dermatitis guidelines, and actual performance in outpatient clinics, including proactive therapy. Multiple comparisons were performed using the Kruskal–Wallis and Steel–Dwass tests for continuous variables and the chi-square test and residual analysis for nominal variables.

Results

Participants

We received 284 responses (response rate: 22.5%) from 1,259 JSCIA members whose e-mail addresses were registered on the list of JSCIA members. After excluding incorrect information, 243 responses (an effective response rate of 85.6%) were considered valid. The alpha coefficient of the questionnaire was 0.78, confirming its internal validity.

Outpatient clinic performance

The median age of the responding physicians was 50 years (interquartile range [IQR] 42–59 years), the median level of dermatology experience was 22 years (IQR 14.5–31.5 years), 137 (56.4%) were men and 106 (43.6%) were women. The place of work (Q5), authorized specialisms (Q6), and outpatient medical care performance (Q8) are summarized in Table 2. The question regarding the degree to which the physician read the AD clinical practice guidelines [6] (Q7) was based on an 11-point scale. Physicians who scored five or more points were considered highly aware. The percentage of physicians with high awareness was 86.4% for “have read” and 87.6% for ‘have been referred to. Therefore, respondents often read and used these guidelines as references.

Many physicians felt that AD consultations were rewarding (Q10: five-level evaluation), with 30% thinking they were very rewarding and 57.2% thinking they were somewhat rewarding. In assessing satisfaction with and motivation to provide AD care using a 10-point scale (Q11), 90.5% of the respondents scored at least five for satisfaction and 95.6% for motivation. In response to “Do you think it is possible to achieve good long-term AD control?” (Q40), 82% of respondents gave a score of ≥ 5, and 55.4% gave a score of ≥ 8 on an 11-point scale (0, not good long-term control; 10, good long-term control).

For the question about the required amount of topical corticosteroid for use on the entire adult body per week (Q15), the median was 50 g (IQR, 30–100 g). Figure 1 summarizes the physicians’ approach during the patient’s initial visit. More than 60% replied that they “always” or “usually” assessed severity, made a rash distribution record, and explained the etiology, current condition, and treatment goals at each patient’s first visit (Q13). Figure 2 summarizes the differences in the severity assessments between the initial and second visits. At the first visit, 90% “always” or “usually” assessed their patient’s severity by an entire body undressed inspection with palpation and discussion about the patient’s level of itching.

FIGURE 1

FIGURE 2

However, 25% always examined only the exposed skin lesions, and this ratio increased to 40% during revisits. Most physicians also assess severity by patient-reported degree of itching, and the number of respondents saying that they “generally” did this increased to 70% for revisits. Half (50%) of the patients were assessed for blood biomarkers, including serum Thymus and Activation-Regulated Chemokine (TARC), at the initial visit, falling to 40% on revisiting. Of the respondents, 95.1% said that they “always” or “often” gave directions for the next visit when the patient required ongoing treatment (Q16).

Proactive therapy

More than 90% of the physicians implemented proactive therapy; a fixed tendency was not observed in the standard for proactive therapy. A total of 97 physicians (43%) met the criteria for withdrawal from proactive therapy; these physicians were significantly older than physicians who did not meet the criteria for withdrawal (mean ± standard deviation: 51.0 ± 10.4 vs. 48.9 ± 10.4; p < 0.001 [Welch’s t-test]) and were significantly more likely to have an allergist (p = 0.04858; Pearson’s chi-squared test). The median time to discontinuation of proactive therapy after induction of remission was 6 months, but there was no consistent trend, nor was there a consistent trend in the criteria for the symptoms and tests that should be used to decide on discontinuation.

Educational tools

When asked about the tools they used to support their explanations of treatment details or how to manage daily activities, such as bathing (Q35: multiple answers possible), the most common were brochures (66.3%) and nurses’ education (44.9%). Overall, 42.8% thought that video education materials were necessary (Q36) “for physicians” and 59.3% “for patients,” and a range of content was sought. Over 80% wanted video materials for treatment practice (Q37: multiple answers allowed), 52.3% wanted these materials delivered over the internet (Q38), and 5.8% preferred a DVD. The proposed targets of the materials were patients, their families, physicians, nurses, pharmacists, and other medical partners. More than 50% wanted materials available to all these groups (Q39).

Assessment of AD disease burden

More than 50% of respondents “always” or “usually” asked AD patients about their burden of disease (Q41, Figure 3).

FIGURE 3

Cluster analysis according to the perception of treatment difficulty

Cluster analysis of the responses to the question on the difficulty of treating AD (Q12) provided three clusters. Cluster 1 (53 respondents) had a high overall score (low-difficulty group), Cluster 2 (99 respondents) had an intermediate score (moderate-difficulty group), and Cluster 3 (91 respondents) had a low overall score (high-difficulty group) (Figure 4). Significant differences were observed between the three clusters in the responses to several questions, particularly “Do you think it is possible to achieve good long-term control of AD?,” “Satisfied with AD treatment,” and “Motivation to provide AD treatment” (Q11). However, no significant differences were found in age (Q2), work style (Q5), specialty (Q6), number of outpatients (Q8), or the number of patients treated with cyclosporine or dupilumab (Q8) (Table 3). Cluster 1 also answered “yes” significantly more often than Cluster 3 (p = 0.026, Pearson’s chi-square test) to “Do you assess the severity of the patient during the first examination?” (Q13 and Q14). Similarly, for evaluation of the effectiveness of treatment at revisit (Q17), those in Cluster 1 were significantly more likely to say that they “rarely” or “not at all” used a visual inspection only of the exposed skin (with clothes on). Those in Cluster 3 were significantly less likely to say they did this “rarely” or “not at all” (p = 0.027, Pearson’s chi-square test). Significantly fewer respondents in Cluster 1 said they wanted training via video streaming (Q36), and significantly more selected “not required” (Table 3; p = 0.031, Pearson’s chi-squared test).

FIGURE 4

Discussion

AD is a chronic disease requiring long-term management [10]. Both the practical skills of healthcare professionals and patient adherence to treatment plans are essential for successful treatment [11]. Many studies have evaluated the burden of disease on patients [12–14], but few have reported on the actual state of clinical practice, including satisfaction and difficulties experienced by physicians treating chronic diseases such as AD [15].

This survey was a landmark investigation that clarified the problems faced by physicians providing care for patients with AD. This investigation aimed to examine the current status of AD management and identify physicians who have difficulty managing this condition to improve the overall care provision.

Guidelines have been developed in Japan to resolve the confusion in AD practice [2], and these are continuously revised [5, 6]. A notable feature of the Japanese guidelines is that they describe the goal of treatment [6]. In this survey, many physicians reported reading the guideline (86.4%; >5 points), using it as a reference (87.6%; >5 points), and feeling that medical care of AD was rewarding (very rewarding 30% and somewhat rewarding 57.2%). This indicates that these guidelines play an important role in the management of AD.

However, the precise method for proactive therapy, an important remission maintenance therapy described in the guidelines, varies widely among physicians. These results indicate that proactive therapy is not an established method in clinical practice. To support its development, it may be necessary to develop and disseminate guidelines on the scope of application required, the timing of the transition from daily to intermittent application, and timing of completion.

The challenges identified in AD management included “low patient willingness to receive treatment,” “repeated deterioration and remission over time,” “increased consultation time per patient,” “low medical remission, exploration of deteriorating factors,” “management of mental aspects” and “understanding of patient’s adherence.”(10–13) These problems need to be resolved.

The respondents were divided into three clusters based on their perceived difficulty in managing AD patients. There were no differences in age, work location, specialty, and whether they read or used the guidelines. Although many physicians read and used the guidelines as a reference, there were also physicians who did so who often experienced problems in their practice (Cluster 3 [high-difficulty group]). Other support methods are required for these physicians.

When the three clusters were compared, the physicians in each cluster described similar problems, although the degree of difficulty varied. Therefore, we believe that providing support for items many physicians perceive as problematic will improve practices across all dermatologists. Therefore, we need to provide general problem-solving support for physicians who find it difficult to treat AD and support them in addressing items that many physicians perceive as problems, regardless of how difficult they find treating AD.

Significant differences were found between clusters in the responses to the question “Do you think it is possible to achieve good long-term control of AD?” (Q40) and “Please indicate your satisfaction and motivation for treating with atopic dermatitis on a scale of 10” (Q11). Physicians in the low-difficulty cluster believed that it was possible to achieve good long-term control of AD and showed higher satisfaction with and greater motivation to treat AD. These physicians were also significantly more likely to evaluate severity during the initial diagnosis and inspect the entire skin with the patient undressed at a return visit. This suggests that careful evaluation of the skin rash may affect the prognosis of patients and, in turn, improve ease of treatment and satisfaction with the management of AD.

The interpretation of the ‘curing of AD, a chronic disease, may differ among physicians. However, the results of this study suggest that physicians who experience less difficulty treating AD have more positive practice attitudes and treatment satisfaction. When physicians consider that “it is possible to achieve good long-term control of AD,” they achieve better treatment outcomes. In other words, differences in treatment goals affect physicians’ practice and patient outcomes. There is no international definition of “cured” for AD, but the final goal of treatment described in the Japanese clinical practice guidelines is to maintain a state of minimal to mild symptoms and avoid sudden deterioration that may interfere with daily life [6]. This may be one definition of a cure.

Many physicians in the high-difficulty cluster said they would like to use video educational materials, which may be useful for providing general problem-solving support. The content might include “evaluation of the severity as part of the initial diagnosis,” “inspecting whole skin of an undressed patient on a return visit” and “encouraging treatment with the goal of “long-term remission.”

Questions 12 and 14 suggest that solutions to the challenges that many physicians experience, irrespective of the cluster, would require greater awareness of specific methods used in proactive therapy. Further investigation is needed on balancing labor and medical service charges for an ideal AD practice. However, developing materials and patient guidance tools to reduce the workload may be useful. If patients express excessive anxiety about the use of topical corticosteroids and molecularly targeted drugs, materials that address these issues may be useful.

In the future, it is expected that patients’ problems will be understood before consultations using multiple patient-reported outcomes. Therefore, developing a system that provides patients with suitable guidance is possible. This system should encourage and motivate patients and healthcare workers.

Providing additional support may be costly; therefore, it is necessary to prove whether it reduces the overall cost of AD care. Other factors that may improve care provision include educating dermatologists on the psychosomatic approach to dermatology (Q12-10), developing a questionnaire on steroid anxiety (Q12-14), and developing a questionnaire on adherence (Q12-17).

Good communication between physicians and patients may improve patient satisfaction and lead to improved treatment adherence [16, 17]. One way to improve adherence is shared decision-making about treatment [18]. Among the items of guidance considered important by physicians for AD, the two top items are explanations of how to use topical ointments and knowledge about the disease [19, 20]. Therefore, it is important to determine patients’ preferences for treatment among the evidence-based therapies recommended in clinical practice guidelines. In the future, we will have access to materials and artificial intelligence to improve the efficiency of this process.

Limitations

Most survey respondents were dermatologists with an interest in skin allergies, and 70% were hospital physicians. Very few responses were received from the physicians or clinics responsible for dermatology in primary care settings. Future studies should repeat the same survey in a larger number and a wider variety of clinics.

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