Economic burden of eczema in a middle-income country: A public hospital-based retrospective study in 2016-2017 in Vietnam.

OBJECTIVES: Eczema, which is synonymous with atopic eczema, is classified as a complex, chronic, and relapsing inflammatory skin condition, affecting both adults and children. However, there has not been any research into health-care expenditure to evaluate the medical cost of eczema from patients' perspective in Vietnam. This retrospective study aimed to fill in the gap concerning the medical cost of eczema treatment from patients' perspective. METHODS: Data from Ho Chi Minh City Hospital of Dermato Venereology's electronic medical database on demographics and drug therapy from June 2016 to May 2017 were collected. The patients who met the study's criteria were included in the study and were then categorized as mild, moderate, and severe according to received treatment level. Bootstrapping methods were used to evaluate average and emphasized the difference of cost burden adjusted by factors. RESULTS: A total of 6,212 patients (52.1% women and 85% urban residents) participated in the study; they were divided into three groups according to treatment stage: mild (n = 3,159, 50.9%), moderate (n = 599, 9.6%), and severe (n = 2,454, 39.5%). The evaluated total cost for the three groups was 5,255.82, 1,064.03, and 5,8154.60 US dollars, respectively; the average expenditure per patient per year was around $12.11 ($11.63-12.59). CONCLUSIONS: The results suggested that the estimated direct medical cost of eczema treatment was much lower than that in the Western countries, mostly because of insurance coverage. The findings provide useful insights into health economic evaluations and treatment costs of eczema in Vietnam.

Individuals with filaggrin-related eczema and asthma have increased long-term medication and hospital admission costs.

BACKGROUND: Eczema and asthma are chronic diseases with onset usually before the age of 5 years. More than 50% of individuals with eczema will develop asthma and/or other allergic diseases. Several loss-of-function mutations in filaggrin (FLG) have been identified in patients with eczema. However, the association of FLG with healthcare use is unknown. OBJECTIVES: To determine whether FLG mutations are associated with increased prescribing for eczema and asthma and whether increased prescribing is associated with increased healthcare costs. METHODS: A secondary analysis of BREATHE, a cross-sectional study of gene-environment associations with asthma severity, was undertaken. BREATHE data was collected for 1100 participants with asthma, in Tayside and Fife, Scotland during the period 2003-2005. Through collaboration with the Health Informatics Centre in Dundee, BREATHE was linked to accident and emergency, community prescribing and Scottish morbidity records. The data linkage allowed longitudinal exploration of associations between genetic variation and prescribing. RESULTS: An association was found between FLG mutations and increased prescribing for mild and moderate eczema, asthma-reliever medicine and asthma exacerbations. A strong association was found between FLG mutations and prescribing of emollients [incidence rate ratio (IRR) 2·19, 95% confidence interval (CI) 1·36-3·52], treatment for severe eczema (IRR 2·18, 95% CI 1·22-3·91) and a combination of a long-acting ß2 -agonist and corticosteroids (IRR 3·29, 95% CI 1·68-6·43). CONCLUSIONS: The presence of FLG mutations in this cohort is associated with increased prescribing for eczema and asthma. Randomized controlled trials are required to determine if these individuals could benefit from management strategies to reduce morbidity and treatment costs.

Improving Value for Patients with Eczema.

OBJECTIVE: Chronic diseases now represent a cost majority in the United States health care system. Contributing factors to rising costs include expensive novel and emerging therapies, under-treatment of disease, under-management of comorbidities, and patient dissatisfaction with care results. Critical to identifying replicable improvement methods is a reliable model to measure value. STUDY DESIGN: If we understand value within healthcare consumerism to be equal to a patient's health outcome improvement over costs associated with care (Value=Outcomes/Costs), we can use this equation to measure the improvement of value. METHODS: Research and literature show that patient activation-the skills and confidence that equip patients to become actively engaged in their health care-impact health outcomes, costs, and patient experience. Reaching patient activation through engagement methods including shared decision-making (SDM) lead to improved value of care received. The National Eczema Association (NEA) Shared Decision-Making Resource Center can be a transformative strategy to measure and evaluate value of health care interventions for eczema patients to advance a value-driven health care system in the United States. RESULTS: Through this Resource Center, NEA will measure patient value through their own perceptions using validated PRO instruments and other patient-generated health data. CONCLUSIONS: Assessment of this data will reveal findings that can assist researchers in evaluating the impact this care framework on patient-perceived value across other chronic diseases.

Financial burden of emergency department visits for atopic dermatitis in the United States.

BACKGROUND: Little is known about the usage and financial burden of emergency care visits for atopic dermatitis (AD) or eczema (AD-E) in the United States. OBJECTIVE: To determine the prevalence, risk factors, and cost of emergency care for AD-E in the United States. METHODS: Cross-sectional study of the 2006-2012 National Emergency Department Sample, including a 20% sample of emergency department (ED) visits throughout the United States (n = 198,102,435). RESULTS: The mean annual incidence of ED visits with a primary diagnosis of AD-E was 3368.4-3553.0 cases/1 million persons. The prevalence of ED visits for AD-E increased significantly during 2006-2012 (survey logistic regression, P < .05). ED visits with a primary diagnosis of AD-E versus ED visits without were associated with younger patient age, Medicaid or no insurance, and lower household income quartile and more likely to occur during weekends and summer months. The geometric mean and total costs of ED visits for AD-E significantly increased from $369.07 and $127,275,080, respectively, in 2006 to $642.10 and $265,541,084, respectively, in 2012. LIMITATIONS: The National Emergency Department Sample did not include data on AD severity, recurrent ED visits, race/ethnicity, or treatments provided. CONCLUSION: There is a substantial and increasing financial burden of ED visits for AD-E in the United States. Interventions are needed to decrease ED visits for AD.

The burden of atopic dermatitis in US adults: Health care resource utilization data from the 2013 National Health and Wellness Survey.

BACKGROUND: There is a lack of data on the burden of atopic dermatitis (AD) in adults relative to the general population. OBJECTIVE: To characterize the AD burden in adult patients relative to both matched non-AD controls and matched patients with psoriasis in terms of comorbidities, health care resource utilization (HCRU), and costs. METHODS: Adults (≥18 years) who self-reported a diagnosis of AD or psoriasis and adult non-AD controls were identified from the 2013 US National Health and Wellness Survey. Patients with AD were propensity score-matched with non-AD controls and patients with psoriasis on demographic variables. Patient-reported outcomes were analyzed between matched cohorts. RESULTS: Patients with AD had a significantly greater risk for atopic comorbidities, as well as significantly greater HCRU and total cost compared with non-AD controls. The burden of AD was generally comparable to that of psoriasis, although patients with AD reported increased use of emergency room visits compared with patients with psoriasis. LIMITATIONS: Patient-reported data are susceptible to recall bias and erroneous classification. CONCLUSIONS: Adult patients with AD reported a substantial disease burden, suggesting an unmet need for more effective AD treatment options.

Health utilities for controlled and uncontrolled chronic hand eczema in healthcare employees.

BACKGROUND: Health utilities provide a universally applicable method for measuring the relative preferences or values of specific health states. Health economic studies use health utilities to estimate disease burden and the cost-effectiveness of interventions. Chronic hand eczema (CHE) affects many individuals and adversely affects work productivity. Health utilities for CHE from the perspective of healthcare professionals are lacking. OBJECTIVES: To assess health utilities for CHE from the perspectives of employees in the healthcare sector and affected patients. METHODS: A cross-sectional study with volunteers from the healthcare sector (n = 126) and patients (n = 32) was conducted to establish health utilities (ranging from 1 = perfect health to 0 = death) for mild and severe CHE. RESULTS: The median health utilities of the healthy volunteers derived with the time trade-off method were 0.97 (mean: 0.92) for mild CHE and 0.77 (mean: 0.75) for severe CHE. The median health utilities for mild and severe CHE from the perspective of affected patients were 0.98 (mean: 0.91) and 0.82 (mean: 0.77), respectively. Differences in health utilities between the two study groups were not significant. CONCLUSION: CHE constitutes a considerable burden from the perspective of healthcare employees. Effective control of CHE constitutes an important public health goal.

Systematic review of self-management interventions for people with eczema.

Eczema is a common long-term condition, but inadequate support and information can lead to poor adherence and treatment failure. We have reviewed the international literature of interventions designed to promote self-management in adults and children with eczema. MEDLINE, MEDLINE in process, Embase, CINAHL and the Global Resource for EczemA Trials database were searched from their inception to August 2016, for randomized controlled trials. Two authors independently applied eligibility criteria, assessed risk of bias for all included studies and extracted data. Twenty studies (3028 participants) conducted in 11 different countries were included. The majority (n = 18) were based in secondary care and most (n = 16) targeted children with eczema. Reporting of studies, including descriptions of the interventions and the outcomes themselves, was generally poor. Thirteen studies were face-to-face educational interventions, five were delivered online and two were studies of written action plans. Follow-up in most studies (n = 12) was short term (up to 12 weeks). Only six trials specified a single primary outcome. There was limited evidence of effectiveness. Only three studies collected and reported outcomes related to cost and just one study undertook any formal cost-effectiveness analysis. In summary, we have identified a general absence of well-conducted and well-reported randomized controlled trials with a strong theoretical basis. Therefore, there is still uncertainty about how best to support self-management of eczema in a clinically effective and cost-effective way. Recommendations on design and conduct of future trials are presented.

Disability Pensions due to Skin Diseases: A Cohort Study in Swedish Construction Workers.

Disability pensions due to skin diseases in Swedish male construction workers were studied by linking data from pension registers and an occupational health service. Incidence rates of disability pensions for cement workers, painters and plumbers were compared with 2 control groups. A total of 623 disability pensions were granted during 4 decades of follow-up. The main diagnoses were eczema (36%) and psoriasis (49%). Pensions were mostly granted in the age range 55-64 years. Among painters, cement workers and plumbers the incidence rates for disability pensions were 33.3, 24.5 and 20.4 cases/100,000 person-years, respectively, compared with 13.7 and 9.2 cases/100,000 person-years in control groups. Relative risks were highest for eczema, and were notable for psoriasis. Attributable fractions for eczema were 90% in cement workers and painters and 75% in plumbers compared with control groups. Attributable fractions for psoriasis in the occupational groups studied were in the range 54-67%. In conclusion, eczema and psoriasis have a high impact on loss of work ability, as reflected by disability pensions.

Economic Evaluation of a Multifaceted Implementation Strategy for the Prevention of Hand Eczema Among Healthcare Workers in Comparison with a Control Group: The Hands4U Study.

The aim of this study was to evaluate the cost-effectiveness of a multifaceted implementation strategy for the prevention of hand eczema in comparison with a control group among healthcare workers. A total of 48 departments (n=1,649) were randomly allocated to the implementation strategy or the control group. Data on hand eczema and costs were collected at baseline and every 3 months. Cost-effectiveness analyses were performed using linear multilevel analyses. The probability of the implementation strategy being cost-effective gradually increased with an increasing willingness-to-pay, to 0.84 at a ceiling ratio of €590,000 per person with hand eczema prevented (societal perspective). The implementation strategy appeared to be not cost-effective in comparison with the control group (societal perspective), nor was it cost-beneficial to the employer. However, this study had some methodological problems which should be taken into account when interpreting the results.

Systematic review of cost-of-illness studies in hand eczema.

The individual burden of disease in hand eczema patients is considerable. However, little is known about the socio-economic impact of this disease. The aims of this review were to evaluate the literature on cost-of-illness in hand eczema, and to compose a checklist for future use. The literature was retrieved from the MEDLINE and EMBASE databases up to October 2015. Quality evaluation was based on seven relevant items in cost-of-illness studies. Cost data (direct and indirect) were extracted and converted into euros (2014 price level) by use of the Dutch Consumer Price Index. Six articles were included. The mean annual total cost per patient ranged from €1311 [corrected] to €9792 (direct cost per patient, €521 to €3722; [corrected] and indirect cost per patient, €100 to €6846). Occupational hand eczema patients showed indirect costs up to 70% of total costs, mainly because of absenteeism. A large diversity in hand eczema severity was found between studies. The socio-economic burden of hand eczema is considerable, especially for more severe and/or occupational hand eczema. Absenteeism from paid work leads to a high total cost-of-illness, although disregard of presenteeism often leads to underestimation of indirect costs. Differences in included cost components, the occupational status of patients and hand eczema severity make international comparison difficult. A checklist was added to standardize the approach to cost-of-illness studies in hand eczema.

Cost and quality of life in patients with severe chronic hand eczema refractory to standard therapy with topical potent corticosteroids.

BACKGROUND: Little is known about the socio-economic burden of severe chronic hand eczema in patients refractory to treatment with potent corticosteroids. OBJECTIVES: To estimate the socio-economic burden of severe chronic hand eczema refractory to potent topical corticosteroids, and to establish an algorithm for the estimation of the health-related quality of life EuroQol five-dimensional (EQ-5D) utility index from the Dermatology Life Quality Index (DLQI) summary score. METHODS: A multicentre cost of illness study was conducted, adopting the societal perspective. Adult patients with severe and refractory chronic hand eczema were enrolled. Direct (e.g. drug treatment and travel) and indirect (i.e. loss of productivity) mean costs/patient-month were estimated. Health-related quality of life was assessed with the EQ-5D and DLQI questionnaires. An ordinary least square regression model was used to investigate relationships between health-related quality of life scores. RESULTS: One hundred and four valid patients (mean age 44.5 years, 39.4% male) participated. Overall mean costs were €418.3/patient-month: loss of productivity contributed 43.7%, followed by hospitalization (16.1%) and travel (10.3%). Health-related quality of life scores were, on average, 0.50 (EQ-5D utility) and 11.3 (DLQI). Utility and DLQI summary were significantly related to each other. CONCLUSIONS: Wellbeing and loss of productivity are the most important consequences in these patients. Appropriate treatment is necessary to improve patient health and productivity, which will contribute to reducing societal costs.

[Hand eczema : disability and impact]. / Eczéma des mains : handicap et impact.

INTRODUCTION: Hand eczema is a dermatological condition that may lead to physical and psychological disability, with psychological impact on social relationships, daily life activities and work. OBJECTIVES: Review of the literature on the impact of eczema of the hands and resulting disabilities. METHODS: Medline and Embase search from 1990 to 2013. RESULTS: Hand eczema is a disabling disease because of its poor prognosis. It has an impact on quality of life, which has been assessed using generic scales (MOS-SF36 and EQ-5D) and generic dermatological scales (DLQI and the Skindex). There are no quality-of-life scales specific to hand eczema. This dermatosis may also have repercussions on work, resulting in absenteeism and at times requiring occupational retraining. Hand eczema has economic repercussions with several factors to be taken into account such as medical consultations, medical expenses, loss of productivity, work leave, changes in job position, compensation, and the need for occupational retraining. CONCLUSION: Management of hand eczema by a dermatologist requires taking into account the importance of the physical and psychological disability and the consequences on social relations, activities of daily life, and work. In this context, measuring quality of life is important in assessing patients'perception of the disease and their experience.

Cost-effectiveness of two online interventions supporting self-care for eczema for parents/carers and young people.

OBJECTIVE: To estimate the cost-effectiveness of online behavioral interventions (EczemaCareOnline.org.uk) designed to support eczema self-care management for parents/carers and young people from an NHS perspective. METHODS: Two within-trial economic evaluations, using regression-based approaches, adjusting for baseline and pre-specified confounder variables, were undertaken alongside two independent, pragmatic, parallel group, unmasked randomized controlled trials, recruiting through primary care. Trial 1 recruited 340 parents/carers of children aged 0-12 years and Trial 2 337 young people aged 13-25 years with eczema scored ≥ 5 on Patient-Oriented Eczema Measure (POEM). Participants were randomized (1:1) to online intervention plus usual care or usual care alone. Resource use, collected via medical notes review, was valued using published unit costs in UK £Sterling 2021. Quality-of-life was elicited using proxy CHU-9D in Trial 1 and self-report EQ-5D-5L in Trial 2. RESULTS: The intervention was dominant (cost saving and more effective) with a high probability of cost-effectiveness (> 68%) in most analyses. The exception was the complete case cost-utility analysis for Trial 1 (omitting participants with children aged < 2), with adjusted incremental cost savings of -£34.15 (95% CI - 104.54 to 36.24) and incremental QALYs of - 0.003 (95% CI - 0.021 to 0.015) producing an incremental cost per QALY of £12,466. In the secondary combined (Trials 1 and 2) cost-effectiveness analysis, the adjusted incremental cost was -£20.35 (95% CI - 55.41 to 14.70) with incremental success (≥ 2-point change on POEM) of 10.3% (95% CI 2.3-18.1%). CONCLUSION: The free at point of use online eczema self-management intervention was low cost to run and cost-effective. TRIAL REGISTRATION: This trial was registered prospectively with the ISRCTN registry (ISRCTN79282252). URL www.EczemaCareOnline.org.uk .

Pediatric access to dermatologists: Medicaid versus private insurance.

BACKGROUND: There is disparity in access to outpatient care for Medicaid beneficiaries. This inequity disproportionately impacts children. Access for children with skin disease may be especially limited. OBJECTIVE: We sought to compare access to dermatologists for new pediatric patients insured by Medicaid versus a private plan. METHODS: We surveyed 13 metropolitan markets by conducting secret-shopper scripted telephone calls to dermatology providers listed by Medicaid health plans. Paired calls, differing by insurance type, were made to each office on the same day, portraying a parent requesting a new appointment for a child with eczema. RESULTS: We called the offices of 723 Medicaid-listed providers. Final analysis included 471 dermatologists practicing general dermatology. Of these, an average of 44% refused a new Medicaid-insured pediatric patient. The average wait time for an appointment did not significantly vary between insurance types. Assuming that dermatologists not listed as Medicaid providers do not see Medicaid-insured children, our data indicate that pediatric Medicaid acceptance rates ranged from 6% to 64% by market, with an overall market size-weighted average acceptance rate of 19%. Relative reimbursement levels for Medicaid-insured patients did not correlate with acceptance rates. LIMITATIONS: Although the most current health plan directories were used to create calling lists, these are dynamic. The sample sizes of confirmed appointments were in part limited by a lack of referral letters and/or health plan identification numbers. Only confirmed appointments were used to calculate average wait times. CONCLUSIONS: Access to dermatologists is limited for Medicaid-insured children with eczema.

Cost of illness from occupational hand eczema in Germany.

BACKGROUND: There is little knowledge about the costs of occupational hand eczema. OBJECTIVES: To estimate the societal costs of patients with occupational hand eczema in Germany. METHODS: Resource use during the past year, disease severity and quality of life [Dermatology Life Quality Index (DLQI)] were gathered for patients with occupational hand eczema before they entered a special rehabilitation programme. Costs were calculated from the societal perspective. The analysis focused on all patients and the severity groups no signs/mild (group A) and moderate to severe (group B). RESULTS: One hundred and fifty-one patients were analysed, with a mean age of 44.9~years and a mean DLQI score of 10.9; 64.9% were male. Sickness absence was recorded for 62.9% of all patients (76.4~days on average in the last 12~months). Annual societal costs were €8799 per patient. Indirect costs represented 70% of total costs. Quality of life (DLQI) was statistically different across both severity groups (group A, 7.9; group B, 12.9), but direct treatment costs were not (€2705 versus €2610, respectively). There was a trend towards higher indirect costs in patients in severity group B (group A, €5120; group B, €6796). CONCLUSION: The annual societal costs of patients with occupational hand eczema in this study are high, and similar to those for severe psoriasis and atopic dermatitis.

Cost-of-illness of patients with chronic hand eczema in routine care: results from a multicentre study in Germany.

BACKGROUND: It is broadly assumed that costs caused by chronic hand eczema (CHE) are significant. However, there is a lack of cost-of-illness studies on CHE. OBJECTIVES: To determine the direct and indirect costs of CHE under routine conditions in Germany from the societal perspective. METHODS: A cross-sectional survey was conducted in 24 outpatient practices and clinics across Germany. Patients with CHE refractory to potent topical steroids and insured by statutory health insurance were eligible. Clinical and cost data were collected using standardized questionnaires. Severity classes were defined according to a photographic guide and physician global assessment (PGA). Four treatment stages were defined based on the German CHE guidelines: topical treatments only (stage I), additionally ultraviolet (UV) radiation therapy (II), systemic therapy (III) and inpatient treatment (IV). Bivariate associations between costs and severity as well as treatment stage were assessed. RESULTS: Two hundred and twenty-three patients with CHE (mean age 45·7years, 56% women) enrolled in the study, of whom 63·2% were treated only with topical treatments, 15·7% additionally with UV radiation and 11·7% with systemic treatments. Of all patients, 9·4% had been admitted to hospital. Total costs per year and patient were €2128, including €1742 direct costs and €386 indirect costs. The total costs increased with treatment stages I-IV (P<0·001): €1044, €2307, €2697 and €8407, respectively. Accordingly, costs also correlated with clinical severity. CONCLUSIONS: Patients with CHE refractory to topical steroids incur marked costs to society. The costs increase disproportionately with escalating treatment stages, especially in patients admitted to hospital. Hence, new treatments may help to reduce the societal costs of CHE.

Hands4U: a multifaceted strategy to implement guideline-based recommendations to prevent hand eczema in health care workers: design of a randomised controlled trial and (cost) effectiveness evaluation.

BACKGROUND: Workers in wet work occupations have a risk for developing hand eczema. Prevention strategies exist, but compliance to the proposed recommendations is poor. Therefore, a multifaceted implementation strategy (MIS) is developed to implement these recommendations to reduce hand eczema among health care workers performing wet work. METHODS/DESIGN: This study is a randomised controlled trial in three university hospitals in the Netherlands. Randomisation to the control or intervention group is performed at department level. The control group receives a leaflet containing the recommendations only. The intervention group receives the MIS which consists of five parts: 1) within a department, a participatory working group is formed to identify problems with the implementation of the recommendations, to find solutions for it and implement these solutions; 2) role models will help their colleagues in performing the desired behaviour; 3) education to all workers will enhance knowledge about (the prevention of) hand eczema; 4) reminders will be placed at the department reminding workers to use the recommendations; 5) workers receive the same leaflet as the control group containing the recommendations. Data are collected by questionnaires at baseline and after 3, 6, 9 and 12 months. The primary outcome measure is self-reported hand eczema. The most important secondary outcome measures are symptoms of hand eczema; actual use of the recommendations; sick leave; work productivity; and health care costs.Analyses will be performed according to the intention to treat principle. Cost-effectiveness of the MIS will be evaluated from both the societal and the employer's perspective. DISCUSSION: The prevention of hand eczema is important for the hospital environment. If the MIS has proven to be effective, a major improvement in the health of health care workers can be obtained. Results are expected in 2014. TRIAL REGISTRATION NUMBER: NTR2812.

[Health services research: the example of hand eczema]. / Versorgungsforschung am Beispiel des Handekzems.

Hand eczema is one of the most frequent skin diseases with a lifetime prevalence of up to 15% and a median incidence rate of 6 cases per 1000 person-years. Female gender, contact allergy, atopic eczema and wet work have been identified as the most important associated risk factors. Hand eczema has a high public health and socio-economic significance, since the vast majority of occupational skin disease is hand eczema. Hand eczema is often chronic, chronically relapsing or persisting. It entails substantial impairment of health-related quality of life for the affected individual. The cost-of-illness of hand eczema is estimated to be in the range of moderate to severe psoriasis and even higher than that of atopic eczema. Although various therapeutic options to treat hand eczema exist, an assessment of these options in randomized, controlled clinical trials to build up an evidence base is mostly lacking. The investigation of the treatment of chronic hand eczema under everyday conditions in dermatological clinics and private practices has only just begun. The first register of patients with chronic hand eczema (acronym: carpe) is expected to yield substantial insights in the effectiveness and safety of different therapeutic measures. A related task is the assessment of the quality of care in the light of the guidelines for the management of chronic hand eczema.