https://orcid.org/0000-0002-0090-6289
Abstract
Background
The expanding number of potential treatment options for atopic dermatitis (AD) highlights the need to better understand the treatment preferences of individuals with AD.
Objective
This study identified attributes that most greatly influenced treatment preferences of adults/adolescents/caregivers of children with mild/moderate/severe AD.
Methods
Adults (≥18 years), adolescents (12–17 years), and caregivers of children (2–11 years) with mild, moderate, or severe AD in the United States (US) and United Kingdom (UK) participated in semistructured interviews. Thematic analysis was used to identify and generate themes across the interview results describing the treatment attributes of greatest importance to participants.
Results
Qualitative interviews were conducted with 35 adults, 35 caregivers, and 33 adolescent participants across both countries (n = 103; US = 51; UK = 52) and all severity groups (mild = 43; moderate = 47; severe = 13). The most important treatment attributes included efficacy (96.1%; speed and duration of symptom relief), mode of administration (66.0%; route of administration, frequency, and convenience), and side effects (55.3%, short-term, long-term, and general).
Conclusions
Efficacy, mode of administration, and side effects were the most important attributes that influenced AD treatment preferences for patients and caregivers across different countries, ages, and disease severity. These results may assist patients/caregivers/clinicians in shared decision-making discussions to improve treatment adherence and outcomes.
1. Introduction
Atopic dermatitis (AD) is a chronic, relapsing-remitting, inflammatory skin disease characterized by intense itching, dry skin, redness, and exudation (Citation1). Atopic dermatitis is one of the most common skin conditions and is more prevalent in children (15–38% across different age groups) than adults (2–10%), with onset often occurring in infancy (Citation2,Citation3). An estimated 70% of children with AD develop the condition before the age of 5 years (Citation2). Atopic dermatitis has been shown to impact the physical health (e.g. pain), emotional health (e.g. behavioral problems), physical functioning (e.g. activity restrictions), and social functioning (e.g. social isolation) of children (Citation4). Approximately, 40% of children with AD continue to have symptoms into adolescence and adulthood (Citation1,Citation2). Both children and adults with AD struggle with skin pain, sleep disruption, school or work disruption, and psychological distress (e.g. depression, anxiety) (Citation4–10). The economic impact of AD is substantial, with an annual estimated cost of $5.297 billion in the United States (US), including direct medical costs and indirect costs (e.g. lost work productivity and impacts on quality of life) (Citation4). The total annual indirect costs of moderate-to-severe AD for patients in France, Germany, Italy, Spain, and the United Kingdom (UK) has been estimated at €7277–€14,236 per patient, depending on the level of disease severity (Citation10).
The severity of AD is typically classified as mild, moderate, or severe based on clinical judgment or severity assessment scales (Citation11). Due to the chronic, relapsingremitting nature of AD, which includes symptoms flares, the severity of disease may fluctuate and require escalation of treatment (Citation12). Mild-to-moderate AD may be managed with topical medications, including emollients (e.g. creams, lotions, or ointments), topical corticosteroids (e.g. hydrocortisone or triamcinolone), and nonsteroidal topical anti-inflammatory agents (calcineurin inhibitors (tacrolimus and pimecrolimus) and phosphodiesterase 4 inhibitor (crisaborole)) (Citation1,Citation2,Citation13,Citation14). Phototherapy, systemic immunomodulatory or immunosuppressive agents, systemic corticosteroids, and subcutaneous-injected biologic therapy (i.e. the monoclonal antibody dupilumab that targets the interleukin (IL)-4 and IL-13 receptors) are treatment options for moderate-to-severe AD (Citation14). Adjunctive therapies, such as antibiotics and antihistamines, are often used as well (Citation15).
The drug development pipeline of topical, oral, and biologic therapies for mild, moderate, or severe AD has greatly expanded, with potential treatments focusing on Janus kinase (JAK) and IL inhibitors, including abrocitinib (JAK1), baricitinib (JAK1, JAK2), delgocitinib (JAK1, JAK3), ruxolitinib (JAK1, JAK2), upadacitinib (JAK1), fezakinumab (IL-22), lebrikizumab (IL-13), nemolizumab (IL-31), and tralokinumab (IL-13) (Citation16,Citation17). Low adherence to systemic immunosuppressants and systemic corticosteroids has been a challenge for treating AD (Citation18) and, combined with the multitude of new AD treatment options potentially becoming available, highlights the need to better understand the treatment preferences of individuals with AD. Incorporating shared decision making in clinical practice with discussions around treatment preferences may increase adherence to treatments (Citation19), including topical treatments. A recent study quantified the importance of AD treatment attributes (and the tradeoffs patients with moderate-to-severe AD are willing to take regarding to specific treatment attributes); however, these data are currently lacking in patients with mild-to-moderate disease (Citation20).
The objective of this study was to identify the treatment attributes that most greatly influence the stated treatment preference of patients with mild, moderate, or severe AD (adults, adolescents, and caregivers of children aged 2–11 years) in the US and UK. Additionally, we sought to gain a preliminary understanding of the relative importance of these attributes.
2. Patients and methods
This cross-sectional, observational study received approval from the RTI Institutional Review Board. Participants were recruited for semistructured interviews using qualitative research firms in Raleigh, NC, and Manchester, UK. Adolescents, adults, and adult caregivers of children with a self-reported clinical diagnosis of AD who met eligibility requirements provided written informed consent for study participation. Inclusion criteria included self-report of a clinical diagnosis of AD from a health care provider at least 3 months prior to screening and experience with prescription and/or over-the-counter treatment specifically for AD. Individuals were excluded for having any comorbid skin condition that would interfere with the diagnosis or treatment of AD or having any chronic medical or psychiatric condition, including cognitive impairment, that would prevent accurate assessment of AD symptoms. A purposeful sampling approach, where participants are enrolled who have experienced the key study concept (Citation21) (i.e. symptomatic AD), was taken to ensure a study population similar to those indicated for a range of AD therapeutics.
Adult participants included those aged ≥18 years, adolescent participants were aged between 12 and 17 years, and caregiver participants who were the primary caregiver (i.e. parent or guardian) to a child aged between 2 and 11 years with AD. The AD severity (i.e. mild, moderate, or severe) of each participant was determined at the time of screening based on scores on the self/proxy-completed Patient-Oriented Eczema Measure (POEM) (Citation11).
2.1. Interview process
Each interview lasted approximately 1 h and was audiorecorded. Interviews were conducted in person by two experienced qualitative interviewers using a standardized, semistructured interview guide. Interview guides were tailored to the different age groups and severity levels. To elicit a comprehensive list of treatment attributes that influence patient preference for AD treatments, participants were first asked about their experiences with AD and its treatment, specifically focusing on the type of treatments (i.e. topical, oral, and injectable). Participants were then asked what they liked and did not like about their current and previous treatments, as well as which factors would influence their decision to try a new treatment. Finally, participants were asked to choose and rank the five most important factors that influenced their preference for an AD treatment (‘top 5’ exercise). Participants were also asked to identify the attributes that were least important to them. Transcripts were prepared with all personal information de-identified and cross-checked against the audio recording for quality control.
2.2. Data analysis
Sociodemographic and clinical data were summarized using descriptive analyses. Interview notes were analyzed using thematic analysis methods. Specifically, dominant trends were identified from each interview and compared across the results of other interviews to generate themes or patterns in the way participants describe the treatment attributes of greatest import to them and what drives treatment preference. Representative participant quotes were directly extracted from the de-identified interview transcripts. Data were organized, analyzed, and stored using Excel (Redmond, WA).
3. Results
A total of 103 qualitative interviews were conducted with 35 adults, 35 caregivers, and 33 adolescent participants across both countries and all severity groups (). Adult participants had a mean age of 49.0 years (range: 26–72 years), adolescent participants had a mean age of 14.0 years (range: 12–17 years), and caregivers' children had a mean age of 7.7 years (range: 2–11 years). Several different ethnicities and races were included, with 60.2% of participants identifying as White, 25.2% Black, 6.8% Mixed/Other, and 5.8% Asian. Topical treatments had been used by 93.2% of participants within the previous 6 months compared with 10.7% and 0.9% usage for oral and injectable AD treatments, respectively.
Table 1. Clinical and demographic participant characteristics (N = 103).
3.1. Treatment attributes
Although differences were observed in the frequency with which specific treatment attributes were reported (across countries, populations, and severity levels), the importance of specific attributes remained consistent across the entire sample, with concept saturation achieved. Across the populations, over 50 potentially distinct attributes were reported. The most important attributes influencing treatment preference (i.e. most commonly included on participants’ top 5 lists () and least likely to be identified as an unimportant attribute) included those associated with efficacy, mode of administration, and side effects (). As such, the important attributes related to efficacy, mode of administration, and side effect/safety domains are further described in the following sections. Where applicable, participant quotes have been included to further support the study findings (bold text indicates interviewer text/probe).
Table 2. Attributes among the Top 5 most important reported by ≥3 participants (N = 103).
Table 3. Efficacy treatment attributes for atopic dermatitis reported by ≥3 participants: United Kingdom and United States sample (N = 103).
Table 4. Mode of administration treatment attributes for atopic dermatitis reported by ≥3 participants: United Kingdom and United States sample (N = 103).
Table 5. Side effects treatment attributes for atopic dermatitis reported by ≥3 participants: United Kingdom and United States sample (N = 103).
3.2. Most important treatment attributes
3.2.1. Efficacy
Efficacy attributes were the most frequently reported attributes across the different subgroups (). Specifically, the resolution (alone) and the rapid resolution of all symptoms (n = 78 (75.7%); n = 80 (77.7%), respectively) followed by the resolution of itch specifically (n = 57 (55.3%)) were the most frequently reported efficacy-related treatment attributes. The concept of ‘all symptoms’ depended on the participant, but these commonly included itching, redness, bumpy, cracking, bleeding, or dry skin. Other frequently reported efficacy attributes included how long the effects of the medication lasted (n = 48 (46.6%)), how well the treatment moisturized and/or soften skin (n = 42 (40.8%)), and flare reduction and/or prevention (n = 29 (28.2%)).
The concept of how long the effects of a medication lasts was intrinsically linked with frequency of administration given the perception that the less often patients have to take or apply their medication, the longer it seems to work. Of note, the majority of the interview population (90.3%) only had experience with topical treatments, and participants were, therefore, most familiar with treatments that were administered ‘on demand’ or ‘as needed.’ As such, participants wanted their medication to work longer so that their symptoms would be resolved or relieved for longer periods of time, thereby avoiding more frequent administration of topical ointments or creams. The concept of taking medication on a regular basis to prevent symptoms was unfamiliar to most participants.
Clearance of all symptoms within 1–3 days was most frequently included among participants’ top 5 treatment attributes (n = 52 (50.5%), ), and clearance of all symptoms (without the time constraint) was most commonly identified as the single most important attribute influencing treatment preference (n = 19 (18.4%)) (). The resolution of itching within minutes was the second most frequently reported single most important treatment attribute (n = 17 (16.5%)) and was among the three attributes most frequently included on participants’ list of top 5 treatment attributes (n = 37 (35.9%)). Participants across the severity spectrum described why the rapid resolution of symptoms, specifically itch, was so meaningful (bold text indicates interviewer probe):
Table 6. Attributes identified as the single most important attribute influencing preference reported by ≥3 participants (N = 103).
I would like it to work quicker because if I'm itching a lot and I need my medication, then I would like to just use it and then, like over a span of 30 minutes, it would stop, rather than having to wait, like, the day. [Adolescent, US]
I'd like for it to work in like as soon as I put it on. But you know, I know that might not be an option, so as long as it works in 5 to 10 minutes after I put it on, I'm fine with that. And what do you want it to do in 5 to 10 minutes? Stop the itching, burning, whatever the symptoms I'm having at that point. [Adult, US]
Clear it up very quickly… Not actually gone, but I definitely would want to, you know, at least the itchiness to be gone immediately. Because usually when I put the ointment on, the itchiness will stop immediately. But then like the redness and the swelling and, you know, all those symptoms to start improving within a day or two. [Adult, US]
It [stopping itch quickly] would be important because I'd like to get back to sleep. Again, it's [an] interfering with my activities kind of thing. [Adult, US]
We tried to do as much preventative stuff and keeping her skin moist, … beyond that it's just how can we get her, you know, as comfortable as possible and reduce the itching as quickly as possible. [Caregiver, US]
It works immediately…so she doesn’t have to suffer. [Caregiver, US]
Does it matter how quickly the medication works? The itching, yeah. If you can get an ointment or a treatment or anything that would stop the itching, um, quite quick, I mean that would be a really good treatment, yeah. What would be a time frame for… sort of how quick would you want it to have worked? Oh, about 10 minutes, 20 minutes tops, yeah. [Caregiver, UK]
Although the quick resolution of all symptoms was important to participants with AD and caregivers, caregivers did not report the quick resolution of itch, specifically, as among the top 5 most important treatment attributes (n = 5 (14.3%)) with the same frequency as adults (n = 19 (54.3%)) or adolescents (n = 13 (39.4%)). Participants’ importance rankings for how long the medication works and how often they had to administer/take their medication were very close (which further exemplifies the relationship between the two concepts). Specifically, how long the medication worked was included among participants’ top 5 attributes 35 times, and administration frequency appeared 36 times (both concepts were among the top 10 most frequently identified most important attributes). Participants described this relationship and the importance of these attributes:
…. Which I guess, if you're doing less of it [taking your medication less often] because it's made to last that long, so I guess it's the same thing. [Adult, US]
Probably [take the medication] less, yeah. Like I say, I prefer not to be having to squirt cream all over myself three times a day, so yeah. [Adult, UK]
I guess, um … kind of got used to applying it a couple times a day, too. But it would be nice to not have to. [Adult, US]
If there was a chance that my skin could be completely clear, I would definitely go for that [an oral treatment] because it's easier to just take something once a day for me than to have to wait for my skin to get bad, put on the steroid cream, and wait for it to get better. [Adolescent, US]
Yeah. I'd really like to just do it once a day because it's less to think about and if I'm doing something, like…if I'm late for school, or I have something…if I'm doing something during lunch, I don't have to stop and pull out my medicine and use it. [Adolescent, US]
I would say, for the most part, I want it to last longer. Like, if it's going to take away the itch, I want it to be something that I can apply, maybe, once or twice a day. But I don't want it to, you know, soak in after a while, and then, here we go having to re-apply within a couple of hours. I want it to be like after she's gotten dressed for the day and she's putting her clothes on, I can apply it. And then, she doesn't have to worry about it during the day. [Caregiver, US]
Does it matter to you the frequency [of administration]? Um, it does really. Anything more than three times a day, um, is a bit of a bind. It’s a bit like, "oh, here we are again," and the children get fed up with it, as well. If it could just be something you do once every evening after bath time and then once in the morning, that… if you can narrow it down to twice a day, it’s happy days really. [Caregiver, UK]
And what makes one medication easier to take than another one? Um, probably how often you do it. [Adolescent, US]
Would you like to apply your medication more or less often? Less. Why’s that? Cause it’s just a pain to put on every time I think about it. [Adolescent, UK]
Although less commonly reported among the top 5 most important treatment attributes that influence preference by patients with AD (n = 2 adults and 5 adolescents), symptom or flare prevention was more frequently reported by caregivers (n = 10) as among the op 5 most important treatment attributes and was identified by only 6 interview participants (5 caregivers; 1 adolescent) as the single most important treatment attribute. As one would anticipate, attributes related to efficacy were rarely included on participants’ list of least important attributes.
3.2.2. Mode of administration
Mode of administration referred to topical, oral, or injectable treatment administration; was inextricably linked with the attribute of administration frequency; and was directly associated with convenience/ease of administration (as described by interview participants) (). Mode of administration was among the most frequently reported treatment attributes (n = 83 (80.6%)) and was consistently reported among the top 5 most important treatment attributes that influenced preference across populations (n = 33 (32.0%)) ().
Participants also consistently described that the mode (topical, oral, or injectable) in which they took/administrated their medication was the key driver in how convenient and easy the treatment was to take/apply. The concept of convenience/ease of administration was reported by 72 (69.9%) participants, included on participants’ list of op 5 treatment attributes by 33 (32.0%) participants (making it among the top 10 most frequently identified most important attributes), and identified as the single most important attribute once (1.0%). Caregivers and participants with AD consistently reported that treating their AD (primarily with topical treatments) was burdensome or inconvenient. For example, topical treatments were often described as being greasy and/or messy, inconvenient to carry or travel with, and time-consuming to apply. Oral medications were commonly described as easy/fast to take. The only concerns participants expressed with the actual process of taking an oral medication were taste and whether the oral formulation was a pill/liquid or chewable medication. These considerations were most commonly reported by caregivers and adolescents, as some of these participants had concerns about swallowing a pill.
Although the process of administering an injectable treatment was commonly seen as something that could potentially be completed with relative ease, the general fear of needles/shots (due to pain) made this a less attractive option for most participants. Not surprisingly, ease of administration was reported more often by adolescents (45.5%) and caregivers (31.4%) as an important attribute, as compared with adults (20.0%). Participants described the importance of convenience/ease of administration and its relationship with mode of administration:
If you go somewhere for a period of time and you wouldn't have to bring it with you. You could put it on, like, before you go and then it would just be something you don't have to worry about. [Adolescent, US]
Because, like, uh, if it's a liquid, then you just have to pour the right amount and just drink it, and you're good to go. And if it's a pill, you just have to drink it down with something and swallow it. But if it's a cream, you have to rub every spot, and sometimes you might miss a couple of spots. [Adolescent, US]
If it worked faster or…probably like the storage, like the container, if it was like more convenient for me. Okay. What goes into that for you, convenience…what makes it more convenient? Um, well, the absorption because I don't like being sticky. [laughter] The speed, because then I don't have to worry about, like using it as much, as often. [Adolescent, US]
We had one that was once a day and, I mean, there were several times when it was just like getting him up at night, you know, I mean, after I've already put him to bed having to get him up to then give him his medicine. And, I mean, it's, again, that's just my world. And yeah. But if it's one more thing that I got to schedule, I'd rather it fit in with established routine. [Caregiver, US]
Something that's easier, you know, more convenient for her age group. Say, it was something like she can just spray on or something quick that she can do that she would like to do. Like, she doesn't want to pull out cream and that type of stuff when she was at school. [Caregiver, US]
The majority of participants and caregivers also noted that frequency of administration consistently influenced their preference (n = 91 (88.3%)), with most wanting to administer/take their medication less often. As with mode of administration, this attribute was highly linked to convenience where less frequent administration was commonly noted to be less intrusive or disruptive and, therefore, preferable. As such, the frequency in which participants had to take/administer their medication was identified as an important attribute (included on 35.0% (n = 36) of participants’ top 5 lists and identified as one person’s single most important treatment attribute).
Although the attributes related to treatment mode were frequently reported and commonly identified as important attributes influencing preference, they also represent the largest proportion of attributes identified as the least important (). Notably, the topical mode of administration attributes related to texture/consistency were the most frequently reported least important attributes. Similarly, some of the attributes related to convenience and moisturizing also were included among those least important attributes. This result indicates that these treatment attributes, while remaining important, are not key drivers of treatment preference.
Table 7. Least important attributes reported by ≥3 participants (N = 103).
3.2.3. Side effects
Side effects, including general/unspecified (n = 54 (52.4%)), short-term (n = 42 (40.8%)), and long-term (n = 32 (31.1%)), were consistently reported by adults and caregivers as important treatment attributes (). Participants reported that they considered both short-term side effects (e.g. burning, nausea, or skin sensitivity) and long-term side effects (e.g. change in skin pigmentation or organ functioning/damage) when determining treatment preference. Although adolescent participants did report considering side effects of treatment, they did so less frequently than adults and caregivers and commonly considered the short-term side effects associated with treatment (e.g. stinging or burning) ().
Side effects (general and long-term) were also frequently included on participants’ list of top 5 treatment attributes influencing preference (n = 29 (28.2%); n = 19 (18.4%)) (although not as often as some of the attributes related to efficacy and mode of administration). This frequency was largely driven by adult and caregiver reports (only nine reports from adolescents); 26 adults and 25 caregivers included one of these three safety attributes among their top 5 attributes influencing preference. Participants described the importance of side effects in influencing treatment preference:
Sometimes, like, some of them will just work, and then the other ones will kind of work. And then, they'll have, like, the side effects of pain and stuff. So, I, like, stop using those and then I move to a different one … [Adolescent, US]
Let's say I had to take it before I had sports later that day. If it was going to make my leg or my arm feel numb or something, then I might not want to take it … [Adolescent, US]
I want to know that when I do take [the treatment], whatever way I'm taking it, it's not going to make the situation worse. I want it to help. So side effects is really important to me, that it's not going to hurt me, but it's going to help me. [Adult, US]
You know, you read all the side effects, because I read everything. And you know, like okay, everything says can cause diarrhea but then you read can cause liver cancer, can cause this, you know…I don't want to take a chance on getting it back … So, you know, yeah, the side effects are scary. [Adult, US]
Obviously, my child's health and well-being is the number one priority. [Caregiver, US]
It really all boils down to side effects. Sorry. … As long as it's helping him, I want him to take it. But it all depends on what the side effects are. [Caregiver, US]
3.3. Willingness to change treatment modes
To gather some preliminary data regarding the tradeoffs interview participants were willing to make regarding mode of administration and efficacy, we probed interview participants regarding their willingness to change treatment modes (specifically from a topical treatment mode, understanding that all participants had some experience with topical administration) for specific treatment gains. Participants were probed regarding their willingness to switch from a topical treatment to an oral or injectable medication for total skin clearance or improved itch only. Results are described by country and subgroup. Although small differences were seen across severity groups (mild, moderate, and severe), percentages generally trended in the same direction.
More than 80% of participants said they would change from a topical treatment to an oral medication for a chance of achieving total clearance (responses ranged from 81.3% for US adult participants to 100% for US adolescent participants and UK caregivers). Small differences in percentages were seen across severity groups (mild, moderate, and severe), although percentages generally trended in the same direction. The percentage of participants willing to change from a topical treatment to an oral treatment that only targeted itch was generally lower and ranged from 50% in the US adult sample to 88.9% in the UK adult sample.
The willingness of participants with AD and caregivers to switch from a topical treatment to an injectable treatment was relatively low compared with stated willingness to switch to an oral treatment across both total clearance and improved itch only scenarios. For total clearance, the highest percentage of participants who indicated willingness to switch to an injectable treatment was in the UK adolescent population (81.3%). The lowest percentage was reported by US adolescents (46.7%). Even fewer participants said they would switch from a topical treatment to an injectable treatment if the medication improved itch only. These percentages ranged from 61.1% in UK adults to 17.6% in US caregivers. Reasons for a willingness to change treatment modes centered on improved efficacy coupled with increased convenience and/or a reduction in administration frequency:
But I'd be willing to do the oral thing…It would be easy thing to do. [Adult, US]
Um … Oral would be great. You know, you take a pill once a day or twice a day or something, and it did the same thing. The convenience factor is there…Well, you don't have the ointment, physical ointment, ointment, or cream getting all over the place. Get it all over your pajamas or the sheets or your coat, your shirt, your blouse, whatever. And assuming the pill did the same thing, there's a convenience factor. I can take a pill once in the morning with breakfast. I take one in the evening with dessert or something. [Adult, US]
The injectable twice a month actually sounds pretty good. If I only had to take it twice a month, I didn't have to worry about it. That would probably be a good option. [Adult, US]
They [topical medications] are still sticky and uncomfortable and because they take longer [to work] as well it is quite annoying…I think I would prefer it to be a pill because…Why’s that? Then it doesn’t get uncomfortable with clothes or sleeping or anything. [Adolescent, UK]
Um, obviously if there was an oral medication that did what a topical did, fabulous, give me the oral medication. Because it’s fast. It removes the mess. It would be easy. He could manage it himself basically at 10, you know, you could tell him to take one of his tablets, and it’s done, isn’t it? Um, that would be great. [Caregiver, UK]
4. Discussion
This is the first robust qualitative study to our knowledge that identified attributes that influence AD treatment preference and gathered evidence regarding the relative importance of these attributes from patients with AD and caregivers of children with AD. In this study, participants described the attributes that most greatly influenced their preference for AD treatments. The attributes related to treatment efficacy, mode of administration, and side effects were identified as the treatment attributes that most greatly influence treatment preference across adults, adolescents, and caregivers of children with mild, moderate, or severe AD.
The relative importance of specific attributes was somewhat different between subgroups. For example, caregivers and adults identified safety more commonly as being among the most important treatment attributes influencing preference as compared with adolescents. Similarly, the attributes related to mode of administration, administration frequency, and convenience were more commonly included among the top 5 most important treatment attributes for caregivers and adolescents as compared with adults. This is not surprising given the burden described by both adolescents and caregivers associated with frequent topical treatment administration.
Although the overwhelming majority of participants only had topical treatment experience, all participants had some kind of previous oral and injectable experience in general (e.g. analgesics, antibiotics, or vaccinations). As such, participants articulated their preferences for specific treatment modes and the associated attributes that would influence their preference for one mode over another. In addition, concept saturation was achieved with no new concepts/attributes of importance being reported during the final sets of interviews.
Understanding the attributes that influence treatment preference may be critical to improving treatment adherence and treatment outcomes. Additionally, preferred treatment attributes can offer guidance to clinicians for treatment planning and providing education to patients. These interviews yielded a clear set of treatment attributes that influence preference across each of the samples studied as well as preliminary evidence regarding the relative importance of these attributes across the severity spectrum as reported by participants with AD and caregivers. These data have informed one discrete choice experiment in patients with moderate-to-severe AD, the results of which confirmed the qualitative findings that for systemic treatments, respondents value probability of skin clearance, time to onset of itch relief, convenient dosing/administration schedule, and avoidance of safety risks (Citation20). Additional research in patients with mild-to-moderate disease will provide greater insight into the risk patients are willing to take to have greater treatment efficacy and will quantify the relative importance of specific AD treatment attributes.
Moreover, these preferred treatment attributes reflect the real-world burdens facing patients with AD. Long-term efficacy is especially important to patients with AD, and this preference is reinforced by the reported low 6-month adherence rates of systemic immunosuppressants and systemic corticosteroids of 32.3% and 1.1%, respectively (Citation18). Reducing itch is important to patients as a standalone treatment attribute without necessarily being associated with other sequelae. The primary importance of this attribute is further supported by The More Than Skin Deep Survey administered in coordination with the Eczema Patient-Focused Drug Development Meeting held in 2019. The survey found that 79% of respondents included itching within the three most problematic symptoms experienced, and when asked about the most important result that a treatment could provide patients with eczema, ‘immediate and sustained relief from itch’ received the greatest number of responses by polling during the meeting and was selected by 51% of survey respondents (Citation22). The risk profiles of AD treatments are dependent upon the specific treatments, many of which are not yet approved, so patients may not have experience or knowledge of certain safety events; as such, patient reporting of safety profiles for these medications is unlikely and could potentially be addressed in future, more targeted qualitative research.
One limitation of this study is that the stated preferences within the context of a study may not match exactly what participants are willing to do regarding their treatment choices; however, the attributes do correspond with treatment patterns in the literature (Citation18) and patient preferences stated in The More Than Skin Deep Survey (Citation22), as well as in the recent discrete choice experiment (Citation20). In addition, the study results may not be generalizable outside the US and UK as treatment preference could potentially differ across cultures.
5. Conclusions
Efficacy, mode of administration, and side effects were the three attribute domains that most greatly influenced the AD treatment preferences of participants with AD and caregivers across different countries, ages, and disease severities. These results may assist patients, caregivers, and providers in shared therapeutic decision-making discussions to improve treatment adherence and outcomes.
Acknowledgements
The authors thank Brian Samsell, of RTI Health Solutions, for medical writing assistance.
Disclosure statement
CE and RC are employees of RTI Health Solutions. EE was an employee of RTI Health Solutions at the time this study was conducted. MAZ, JCC, MD, LT, and DEM are employees and stockholders of Pfizer Inc. SRF and JZ are consultants for Pfizer but received no funding for contributions to this article. JZ is a consultant for AbbVie, Almirall, Cassiopea, EPI Health, Galderma, Johnson & Johnson, Journey, L’Oréal, Ortho Dermatologics, Procter and Gamble, Regeneron, Sanofi-Genzyme, Sun Pharma, Unilever, and Vyne. SRF has received research, speaking, and/or consulting support from Galderma, GSK/Stiefel, Almirall, Alvotech, Leo Pharma, BMS, Boehringer Ingelheim, Mylan, Celgene, Pfizer, Ortho Dermatology, AbbVie, Samsung, Janssen, Lilly, Menlo, Helsinn, Arena, Forte, Merck, Novartis, Regeneron, Sanofi, Novan, Qurient, National Biological Corporation, Caremark, Advance Medical, Sun Pharma, Suncare Research, Informa, UpToDate, and National Psoriasis Foundation. He consults for others through Guidepoint Global, Gerson Lehrman, and other consulting organizations. He is founder and majority owner of www.DrScore.com. He is also a founder and part owner of Causa Research, a company dedicated to enhancing patients’ adherence to treatment.
Data availability statement
Data are primarily in the form of transcripts and cannot be made available in order to protect participant privacy in accordance with the principles of the Belmont Report.
Additional information
Funding
References
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