A multi-disciplinary group at the Children’s Hospital of Eastern Ontario (CHEO) in Ottawa is in the process of developing a written action plan for pediatric patients with atopic dermatitis (AD).
As part of the process, the investigators published a study evaluating the effectiveness of written action plans in AD, which was published in the journal Pediatric Dermatology (Mar. 2016; 33(2):e151–153).
Using Medline, Embase, and Cochrane Central databases, the researchers found and screened 419 article titles and abstracts, which yielded 18 full article reviews and abstracts, but only resulted in two studies that were eligible for their review. The authors concluded that their findings “highlight the need for more research on EAPs [eczema action plans].”
Plans improved asthma outcomes
The investigators noted that written action plans have been shown to improve outcomes in other chronic diseases that require a similar incremental approach—particularly asthma (Arch Pediatr Adolesc Med 2008;162:157–163).
“Our first step was to do the systematic literature review because wedid not want to reinvent the wheel and there is some great research out there,” said Dr. Maxwell Sauder, of the Division of Dermatology at The University of Ottawa.
The two studies included on EAPs were “The effectiveness of a written treatment plan in the management of children with atopic eczema” by Duhovic, et al (Br J Dermatol 2014; 171(1):115–130) and “Improving patient education with an eczema action plan: a randomized controlled trial” by Shi, et al (JAMA Dermatol 2013; 149:481–483).
The authors noted that in the Shi, et al study “the EAP group demonstrated statistically significant improvement in AD recognition, management and prevention. EAP elements perceived as most beneficial were stepwise treatment, visualization, and daily reminders.”
Testing tools with patients an important step The most important observation from “the research to date in the realm of eczema is that [the other investigators] have independently developed [their] tools and then tested them to see if they [were] clinically effective,” said Dr. Sauder. “What they have not done—and what we feel is a crucial intermediate step—is to test the tool first . . . with the patients to ensure that they understand the action plan and can use it appropriately.”
Dr. Sauder said they are in the process of validating an action plan with pictograms to make sure that it is being used in the manner intended. Once validated by the patients or caregivers, the researchers will conduct a randomized control trial to observe both qualitative and quantitative outcome measures. They want to evaluate if the AD action plan will improve quality of life measures, as well as show clinical improvements.
The group developing the AD action plan has been working closely with the team from CHEO who developed a self-management plan for patients with asthma (Can Respir J 2008;15(7):347–354). That tool incorporated three asthma control zones: the green zone is used when asthma is under control, the yellow zone is for when the patient’s asthma is not well controlled, and the red is the guiding zone for when the asthma is out of control.
“Ideally an action plan would be comprised of three different sections depending on severity. What we found is that a traffic light approach to these three areas is ideal for this patient population,” said Dr. Sauder.
“A green section would be that the patient is relatively well, minimal disease and that would [require] basic moisturization and/or maintenance therapy. A yellow section would be if a patient starts to flare [and the action plan would indicate] what type of prescriptions [to] use. A red section would be severe or out of control with associated prescriptions [to] use.”
Dr. Sauder said that language, which ideally a person with a Grade 5 to 8 level of education can understand, and validated pictograms will help the patient to identify which section of the traffic light they should adhere to.
“The main purpose of the EAP [is] to be very clear with the communication to the patients and/or caregivers and to give them something that they can keep at home [that will] always remind them exactly how they manage their condition or their child’s condition,” Dr. Sauder said.
More efficient process The action plan is also useful, he noted, because it reduces the amount of paperwork a patient is given. “While working in the pediatric dermatology clinic at CHEO, we find that [with] a new patient with eczema [it] takes usually anywhere from 10 to 20 minutes to go over the educational component and often in my personal experience they are left with a prescription with at least one topical treatment, an information sheet on their condition, a list of products that [are] generally safe for them to use, and then I also write out exactly how they use the prescription[s].
“So they are being left with at least four pieces of paper that can easily be lost. The idea is that [an action plan] actually streamlines all four of those components into a single sheet,” he said, adding that it also reduces the time needed with each new patient with AD because the stepwise approach is already outlined for the patient.
“I think [action plans] have shown promise,” concluded Dr. Sauder. “But, I think they can show even more promise if it is a tool that we know that patients understand and we know they are using them in the way that we are intending them to use it.”