Patterns and trends in eczema management in UK primary care (2009-2018): A population-based cohort study

Simon de Lusignan, Helen Alexander, Conor Broderick, John Dennis, Andrew McGovern, Clarie Feeney, Carsten Flohr, Simon de Lusignan, Helen Alexander, Conor Broderick, John Dennis, Andrew McGovern, Clarie Feeney, Carsten Flohr

Abstract

Background: Despite the high disease burden of eczema, a contemporary overview of the patterns and trends in primary care healthcare utilization and treatment is lacking.

Objective: To quantify primary care consultations, specialist referrals, prescribing, and treatment escalation, in children and adults with eczema in England.

Methods: A large primary care research database was used to examine healthcare and treatment utilization in people with active eczema (n = 411,931). Management trends and variations by age, sex, socioeconomic status, and ethnicity were described from 2009 to 2018 inclusive.

Results: Primary care consultation rates increased from 87.8 (95% confidence interval [95% CI] 87.3-88.3) to 112.0 (95% CI 111.5-112.6) per 100 person-years over 2009 to 2018. Specialist referral rates also increased from 3.8 (95% CI 3.7-3.9) to 5.0 (95% CI 4.9-5.1) per 100 person-years over the same period. Consultation rates were highest in infants. Specialist referrals were greatest in the over 50s and lowest in people of lower socioeconomic status, despite a higher rate of primary care consultations. There were small changes in prescribing over time; emollients increased (prescribed to 48.5% of people with active eczema in 2009 compared to 51.4% in 2018) and topical corticosteroids decreased (57.3%-52.0%). Prescribing disparities were observed, including less prescribing of potent and very potent topical corticosteroids in non-white ethnicities and people of lower socioeconomic status. Treatment escalation was more common with increasing age and in children of non-white ethnicity.

Conclusion and clinical relevance: The management of eczema varies by sociodemographic status in England, with lower rates of specialist referral in people from more-deprived backgrounds. There are different patterns of healthcare utilization, treatment, and treatment escalation in people of non-white ethnicity and of more-deprived backgrounds.

Trial registration: ClinicalTrials.gov NCT03823794.

Keywords: atopic dermatitis; atopic eczema; dermatology; eczema; epidemiology; primary care; treatment.

Conflict of interest statement

S. de Lusignan is Director of the Royal College of General Practitioners Research and Surveillance Centre as part of his academic post; he has also received funding for projects from Eli Lilly, AstraZeneca, GSK, Seqirus, and Takeda, all through his universities and none related to this study. C. Feeney is an employee of Pfizer. J. Dennis and A. McGovern are employees of Momentum Data who were paid consultants to Pfizer in connection with the development of this manuscript. C. Flohr is chief investigator of the UK National Institute for Health Research–funded TREAT (ISRCTN15837754) and SOFTER (ClinicalTrials.gov: NCT03270566) trials and the UK‐Irish Atopic Eczema Systemic Therapy Register (A‐STAR; ISRCTN11210918) and is a principal investigator in the European Union Horizon 2020–funded BIOMAP Consortium (http://www.biomap‐imi.eu/). His department has also received funding from Sanofi‐Genzyme. All other authors have no competing interests to declare.

© 2020 The Authors. Clinical & Experimental Allergy published by John Wiley & Sons Ltd.

Figures

FIGURE 1
FIGURE 1
The annual rates of eczema primary care consultations and specialist referrals for eczema between 2009 and 2018 (n = 411,931). A, Primary care consultations. B, Specialist referrals for eczema
FIGURE 2
FIGURE 2
The annual prevalence of prescribing for eczema by therapy class between 2009 and 2018 (n = 411,931)
FIGURE 3
FIGURE 3
The prevalence of prescribing for eczema by age group and by therapy class for people with active eczema in 2018 (n = 148,166)
FIGURE 4
FIGURE 4
Cumulative incidence of treatment escalation by age at diagnosis category in people with incident eczema over 2009–2018. A, Cumulative incidence of the prescription of a second potent topical corticosteroid treatment within 1 year or a first topical calcineurin inhibitor (TCI) (moderate eczema) in 140,236 people without moderate or severe eczema at diagnosis. B, Cumulative incidence of the first of systemic immuno‐modulatory therapy or a dermatology referral (severe eczema) in 140,236 people without moderate or severe eczema at diagnosis. C, Cumulative incidence of initiation of systemic immuno‐modulatory therapy (Ciclosporin, Azathioprine, Methotrexate & Mycophenolate mofetil) in 167,311 people with incident eczema

References

    1. Williams H, Stewart A, von Mutius E, Cookson W, Anderson HR. Is eczema really on the increase worldwide? J Allergy Clin Immunol. 2008;121(4):947‐954.e15.
    1. Garmhausen D, Hagemann T, Bieber T, et al. Characterization of different courses of atopic dermatitis in adolescent and adult patients. Allergy. 2013;68(4):498‐506.
    1. Peters AS, Kellberger J, Vogelberg C, et al. Prediction of the incidence, recurrence, and persistence of atopic dermatitis in adolescence: a prospective cohort study. J Allergy Clin Immunol. 2010;126(3):590‐5.e1‐3.
    1. Howlett S. Emotional dysfunction, child‐family relationships and childhood atopic dermatitis. Br J Dermatol. 1999;140(3):381‐384.
    1. Yaghmaie P, Koudelka CW, Simpson EL. Mental health comorbidity in patients with atopic dermatitis. J Allergy Clin Immunol. 2013;131(2):428‐433.
    1. Dalgard FJ, Gieler U, Tomas‐Aragones L, et al. The psychological burden of skin diseases: a cross‐sectional multicenter study among dermatological out‐patients in 13 European countries. J Invest Dermatol. 2015;135(4):984‐991.
    1. Emerson RM, Williams HC, Allen BR. Severity distribution of atopic dermatitis in the community and its relationship to secondary referral. Br J Dermatol. 1998;139(1):73‐76.
    1. Jacquet L, Gaunt DM, Garfield K, Ridd MJ. Diagnosis, assessment, and treatment of childhood eczema in primary care: cross‐sectional study. BJGP Open. 2017;1(2):bjgpopen17X100821.
    1. Santer M, Ridd MJ, Francis NA, et al. Emollient bath additives for the treatment of childhood eczema (BATHE): multicentre pragmatic parallel group randomised controlled trial of clinical and cost effectiveness. BMJ. 2018;361:k1332.
    1. Silverberg J, Simpson E. Associations of childhood eczema severity: a US population based study. Dermatitis. 2014;25(3):107‐114.
    1. Chiesa Fuxench ZC, Block JK, Boguniewicz M, et al. Atopic dermatitis in America Study: A cross‐sectional study examining the prevalence and disease burden of atopic dermatitis in the US Adult Population. J Invest Dermatol. 2019;139(3):583‐590.
    1. Verboom P, Hakkaart‐Van L, Sturkenboom M, De Zeeuw R, Menke H, Rutten F. The cost of atopic dermatitis in the Netherlands: an international comparison. Br J Dermatol. 2002;147(4):716‐724.
    1. McAleer MA, Flohr C, Irvine AD. Management of difficult and severe eczema in childhood. BMJ. 2012;345:e4770.
    1. The National Institute for Health and Care Excellence . Atopic eczema in under 12s: diagnosis and management 2007.
    1. Matterne U, Böhmer MM, Weisshaar E, Jupiter A, Carter B, Apfelbacher CJ. Oral H1 antihistamines as 'add‐on' therapy to topical treatment for eczema. Cochrane Database Syst Rev. 2019;1(1):CD012167.
    1. Proudfoot LE, Powell AM, Ayis S, et al. The European TREatment of severe Atopic eczema in children Taskforce (TREAT) survey. Br J Dermatol. 2013;169(4):901‐909.
    1. Flohr C, Irvine AD. Systemic therapies for severe atopic dermatitis in children and adults. J Allergy Clin Immunol. 2013;132(3):774.e6.
    1. National Institute for Health and Care Excellence . Dupilumab for treating moderate to severe atopic dermatitis. Technology appraisal guidance [TA534]. 2018.
    1. Silverwood RJ, Forbes HJ, Abuabara K, et al. Severe and predominantly active atopic eczema in adulthood and long term risk of cardiovascular disease: population based cohort study. BMJ. 2018;361:k1786.
    1. Correa A, Hinton W, McGovern A, et al. Royal College of General Practitioners Research and Surveillance Centre (RCGP RSC) sentinel network: a cohort profile. BMJ Open. 2016;6(4):e011092.
    1. de Lusignan S, Liaw ST, Michalakidis G, Jones S. Defining datasets and creating data dictionaries for quality improvement and research in chronic disease using routinely collected data: an ontology‐driven approach. Informatics in primary care. 2011;19(3):127‐134.
    1. de Lusignan S, van Weel C. The use of routinely collected computer data for research in primary care: opportunities and challenges. Fam Pract. 2006;23(2):253‐263.
    1. de Lusignan S, Metsemakers JF, Houwink P, Gunnarsdottir V, van der Lei J. Routinely collected general practice data: goldmines for research? A report of the European Federation for Medical Informatics Primary Care Informatics Working Group (EFMI PCIWG) from MIE2006, Maastricht, The Netherlands. Inform Prim Care. 2006;14(3):203‐209.
    1. Pathirannehelage S, Kumarapeli P, Byford R, Yonova I, Ferreira F, de Lusignan S. Uptake of a dashboard designed to give realtime feedback to a sentinel network about key data required for influenza vaccine effectiveness studies. Stud Health Technol Inform. 2018;247:161‐165.
    1. de Lusignan S, Alexander H, Broderick C, et al. Epidemiology and management of atopic dermatitis in England: an observational cohort study protocol. BMJ Open. 2020;10(9):e037518.
    1. Ban L, Langan SM, Abuabara K, et al. Incidence and sociodemographic characteristics of eczema diagnosis in children: a cohort study. J Allergy Clin Immunol. 2018;141(5):1927‐1929.e8.
    1. Abuabara K, Magyari AM, Hoffstad O, et al. Development and validation of an algorithm to accurately identify atopic eczema patients in primary care electronic health records from the UK. J Invest Dermatol. 2017;137(8):1655‐1662.
    1. Stapley SA, Rubin GP, Alsina D, Shephard EA, Rutter MD, Hamilton WT. Clinical features of bowel disease in patients aged <50 years in primary care: a large case‐control study. Br J Gen Pract. 2017;67(658):e336‐e344.
    1. Abrahami D, Douros A, Yin H, et al. Dipeptidyl peptidase‐4 inhibitors and incidence of inflammatory bowel disease among patients with type 2 diabetes: population based cohort study. BMJ. 2018;360:k872.
    1. Muller S, Hider SL, Raza K, Stack RJ, Hayward RA, Mallen CD. An algorithm to identify rheumatoid arthritis in primary care: a Clinical Practice Research Datalink study. BMJ open. 2015;5(12):e009309.
    1. Davé S, Petersen I. Creating medical and drug code lists to identify cases in primary care databases. Pharmacoepidemiol Drug Saf. 2009;18(8):704‐707.
    1. Department for Communities and Local Government . The English indices of deprivation. 2015.2015 5/11/19.
    1. Benchimol EI, Smeeth L, Guttmann A, et al. The REporting of studies Conducted using Observational Routinely‐collected health Data (RECORD) Statement. PLoS Med. 2015;12(10):e1001885.
    1. Langan SM, Thomas KS, Williams HC. What is meant by a “Flare” in atopic dermatitis?: A systematic review and proposal. Arch Dermatol. 2006;142(9):1190‐1196.
    1. Hobbs FDR, Bankhead C, Mukhtar T, et al. Clinical workload in UK primary care: a retrospective analysis of 100 million consultations in England, 2007–14. Lancet (London, England). 2016;387(10035):2323‐2330.
    1. Barker I, Steventon A, Williamson R, Deeny SR. Self‐management capability in patients with long‐term conditions is associated with reduced healthcare utilisation across a whole health economy: cross‐sectional analysis of electronic health records. BMJ Qual Saf. 2018;27(12):989‐999.
    1. Shi VY, Nanda S, Lee K, Armstrong AW, Lio PA. Improving patient education with an eczema action plan: a randomized controlled trial. JAMA Dermatol. 2013;149(4):481‐483.
    1. Le Roux E, Powell K, Banks JP, Ridd MJ. GPs' experiences of diagnosing and managing childhood eczema: a qualitative study in primary care. Br J Gen Pract. 2018;68(667):e73‐e80.
    1. Tanei R, Hasegawa Y. Atopic dermatitis in older adults: a viewpoint from geriatric dermatology. Geriatr Gerontol Int. 2016;16(Suppl 1):75‐86.
    1. Tudor HJ. The inverse care law. Lancet. 1971;297(7696):405‐412.
    1. McBride D, Hardoon S, Walters K, Gilmour S, Raine R. Explaining variation in referral from primary to secondary care: cohort study. BMJ. 2010;341:c6267.
    1. Mercer SW, Watt GC. The inverse care law: clinical primary care encounters in deprived and affluent areas of Scotland. Ann Fam Med. 2007;5(6):503‐510.
    1. Wilkinson S, Douglas I, Stirnadel‐Farrant H, et al. Changing use of antidiabetic drugs in the UK: trends in prescribing 2000–2017. BMJ open. 2018;8(7):e022768.
    1. Chen L, Lin DY, Zeng D. Attributable fraction functions for censored event times. Biometrika. 2010;97(3):713‐726.
    1. NHS England . Conditions for which over the counter items should not routinely be prescribed in primary care: guidance for CCGs. . Accessed February 2, 2020.
    1. National Institute for Heath and Care Excellence . Eczema – atopic. 2018. .
    1. Fjær EL, Balaj M, Stornes P, Todd A, McNamara CL, Eikemo TA. Exploring the differences in general practitioner and health care specialist utilization according to education, occupation, income and social networks across Europe: findings from the European social survey (2014) special module on the social determinants of health. Eur J Public Health. 2017;27(suppl_1):73–81.
    1. Kaufman BP, Guttman‐Yassky E, Alexis AF. Atopic dermatitis in diverse racial and ethnic groups‐Variations in epidemiology, genetics, clinical presentation and treatment. Exp Dermatol. 2018;27(4):340‐357.
    1. Brunner PM, Guttman‐Yassky E. Racial differences in atopic dermatitis. Ann Allergy Asthma Immunol. 2019;122(5):449‐455.
    1. Liyanage H, Akinyemi O, Pathirannahelage S, Joy M, de Lusignan S. Near real time feedback of seasonal influenza vaccination and virological sampling: dashboard utilisation in a primary care sentinel network. Stud Health Technol Inform. 2020;270:1339‐1340.

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