Findings

Coordinated and structured Multidisciplinary Team (MDT)

Coordinated and structured Multidisciplinary Team (MDT)

What is the challenge?
  • AD is a complex disease that is associated with multiple comorbidities/conditions, each of which may require specialist help to be diagnosed and managed effectively(a)
  • If not managed effectively these associated conditions can also in turn negatively impact AD (e.g. an asthma attack can worsen AD severity)(b)
  • Due to resource constraints and the expense associated with the provision of multidisciplinary care, it is important for HCPs to appropriately identify which patients require an MDT care approach(c)
Establishing a multidisciplinary team or network to manage complex patients, that follows a structured and coordinated approach to provide holistic patient care
What is the goal/s of the intervention?
  • Facilitate efficient identification and appropriate management of complex AD patients
  • Improve cross-specialty collaboration to further advance AD understanding/management and homogenise patient care and communication
  • Ensure efficient/quicker access to other specialists for comorbidities
Who is often involved in the intervention?
  • Dermatologist
  • Nurse/medical assistant/physician assistant
  • Clinical pharmacist
  • Comorbidity specialist:
    • Allergist
    • Pulmonologist/pneumologist
    • Ophthalmologist
    • ENT specialist
    • Gastroenterologist
    • Immunologist
  • Trainee dermatologist/trainee comorbidity specialist/medical student
  • Psychosocial professional:
    • Psychologist, psychiatrist, social worker
  • Paediatrician
  • Nutritionist/dietician
  • Occupational health physician
  • Physiotherapist
  • Primary care practitioner (PCP)
  • Laboratory staff (e.g. researcher, scientist)
  • Clinical trial members (e.g. study coordinator/recruiter, epidemiologist)
What are the potential outcomes?

Patients

  • Access to diagnostic tests to assess potential differential diagnoses (e.g. contact dermatitis) and/or associated comorbidities
  • Access to specialist multidisciplinary advice/education and faster initiation of required treatments, resulting in more effective management
  • Effective coordination between treating HCPs/specialists, therefore reducing travel time and cost burden (e.g. through joint consultations)

HCPs

  • Streamlined referral process between HCPs and specialists allowing for more efficient patient management
  • Increased communication between teams for education and knowledge sharing
  • Reduced burden on resources if patients are referred to correct department initially/jointly managed across departments

Healthcare system

  • Increased effectiveness of healthcare delivery if complex patient is better managed overtime by streamlined team and potential for removal of duplication across specialties/departments (e.g. test results)
(a)

Allergy UK and Sanofi Genzyme. Seeing Red: Getting under the skin of adult severe eczema. 2017. [Website] https://www.allergyuk.orghttps://live-secureportal.azurewebsites.net/000/ 001/411/Seeing_Red_Report_FINAL_25.04.17_ original.pdf?1508228476 Accessed 5 Nov 2019;

(b)

Simpson E, et al. Major Comorbidities of Atopic Dermatitis: Beyond Allergic Disorders. 2018;19(6):821-838. doi: 10.1007/s40257-018-0383-4;

(c)

LeBovidge J. Multidisciplinary interventions in the management of atopic dermatitis. The Journal of Allergy and Clinical Immunology. 2016;138(2):325-334. doi: 10.1016/j.jaci.2016.04.003

What is offered as part of the intervention?
  • Identification of AD triggers and comorbidities
  • Efficient access for patients to different specialists for the management of their comorbidities (which may be coordinated by a specific team member e.g. patient manager/care coordinator)
  • Co-management of patients, and/or input on patient management, from different specialties
  • Holistic patient education regarding disease understanding and management
  • Creation of cross-specialty research projects
  • Translation of research into clinical management and access to clinical trials for patients
  • Identification of when an MDT or referral to an MDT is needed
How has the intervention been implemented in different centres?

Note:    With input from the steering committee, we have categorised these activities by level of resource required to implement, however this may vary across centres/settings (e.g. depending on existing resources)

EASY
  • Assessing any relevant known comorbidities (via electronic health record or informal questioning) in consultations
  • Identifying appropriate specialists/department to refer patients for treatment and/or testing and diagnosis (internally or externally) and establishing communication channels
  • Identifying a primary point of contact within the team for AD patients to contact (e.g. via telephone) to triage questions to different team members
MEDIUM
  • Assessing symptoms of typical AD comorbidities (e.g. asthma, allergic rhinitis, food allergy)
  • Inviting internal or external specialists to team meetings (e.g. to discuss complex cases, or present on area of specialism)
  • Ensuring HCPs (especially new HCPs or trainee dermatologists) are familiar with which specialists are available to refer to within/outside the centre
  • Holding multidisciplinary team meetings across specialists within/across centres (e.g. to discuss complex patients, joint research ventures)
  • Collaborating in cross-specialty research (within centre)
  • Providing cross-specialty training for HCPs (e.g. specialism in dermatology and allergy)
  • Enabling shadowing of different atopic condition consultations/clinics across specialists (internally and externally)
  • Providing roles where HCPs work across atopic specialties (e.g. physician assistant part-time in allergy and dermatology) to share knowledge across
  • Developing cross-specialty assessments and treatment protocols (e.g. ophthalmology evaluation for AD patients)
  • Having a staff member who collects, collates and distils relevant information from across treating HCPs (e.g. case notes, test results) to share with treating HCPs
ADVANCED
  • Conducting joint HCP consultations/multidisciplinary clinics for patients with different specialists (from same or different departments)
  • Collaborating in cross-specialty research (across centres)
  • Forming cross-specialty units and/or co-location of specialties (e.g. joint dermatology and allergology department) to aid collaboration
  • Offering a teleconsultation service (between HCPs within or across centres) to discuss patient cases
  • Developing a dedicated ‘Case manager/patient coordinator’ role in the team to support coordination of patient care
  • Delivering cross-specialty Patient Group education events and meetings (from same centre or different centres) to provide cross-specialty education and support to patients
  • Integrating research (clinical trials and/or basic science research) teams into clinical management team
  • Using computer software that automatically collates and distills relevant information from across specialties/treating HCPs (e.g. case notes, test results)
Relevant centre case studies

Internal HCP networks

Nurse/medical assistants/physician assistants

Dermatology Advanced Nurse Practitioner (ANP), UMC Utrecht, Netherlands

Enhanced role of the nurse, UMC Groningen, Netherlands

Enhanced role of the nurse, Women’s College Hospital (Toronto), Canada

Extensive inpatient facilities and Collaboration with comorbidity specialists, University of São Paulo Hospital, Brazil

Healthcare assistant led consultations, CMSS (Selters), Germany

Joint Allergy-Dermatology Physician Assistant, Rady Children's Hospital (California), USA

Medical assistant led consultations, Dermatology Treatment and Research Centre (Texas), USA

Multidisciplinary approach to AD care, McGill University Health Centre (Montreal), Canada

Nurse led 1:1 education, CHRU Brest, France

Nurse led chronic disease clinic, Royal Devon & Exeter Hospital, UK

Nurse shared responsibilities, Aarhus Universitetshospital, Denmark

Nurse-led drug monitoring clinic, Harrogate District Hospital, UK

Nurse-led education consultations, Hiroshima University Hospital, Japan

Nurse-led patient education, Linkou Chang Gung Memorial Hospital, (Taipei), Taiwan

Prior authorisation nurse role, OHSU (Oregon), USA

Role of biologic coordinator, Dermatology Treatment and Research Center (Dallas), US

Role of the Advanced Nurse Practitioner (ANP), Inselspital (Bern), Switzerland

Specialist study nurses, UKSH (Kiel), Germany

Telephone consultations, Harrogate District Hospital, UK

Use of medical assistants, DermAssociates (Washington), USA

Medical assistant-led support, Dermatology Treatment and Research Center (Texas), USA

Co-location of key resources, KFMC, Saudi Arabia

Allergist/laboratory

24-hour allergy testing, Hospital La Paz (Madrid), Spain

Close dermatology-allergy collaboration, Hospital Italiano de Buenos Aires, Argentina

Collaboration with other specialities, UniCATT (Rome), Italy

Collaboration with specialist allergist, Hospital Sant Pau (Barcelona), Spain

Collaborative comorbidity specialist network, Mount Sinai & Ichan School of Medicine (New York), USA

Onsite allergy testing and pathology collection, CMSS (Selters), Germany

Onsite dermatology laboratory, Inselspital (Bern), Switzerland

Specialist dermatology-pathologist testing and diagnosis, Inselspital (Bern), Switzerland

Specialist laboratory testing and interpretation, UNIMORE (Modena), Italy

Comorbidity management, CH Lyon-Sud, France

Specialist in contact allergy, OHSU (Oregon), USA

Collaborative allergy relationships, OHSU (Oregon), USA

Centre’s own biobank, UKSH (Kiel), Germany

Psychosocial

Dedicated social worker, UMC Utrecht, Netherlands

Onsite psychologist, CHRU Brest, France

Onsite specialist in psychosomatic medicine and psychotherapy, UKSH (Kiel), Germany

Paediatric and adult psychological support, University of São Paulo Hospital, Brazil

Provision of psychological care, UNIMORE (Modena), Italy

Psycho-social care network, UMC Groningen, Netherlands

Ophthalmology

Collaboration with comorbidity specialists, Rabin Medical Centre (Petah Tikva), Israel

Ophthalmologist screening appointments, Hospital La Paz (Madrid), Spain

Specialised ophthalmology consultations, Hospital Sant Pau (Barcelona), Spain

Structured ophthalmology referral pathway, UMC Groningen, Netherlands

Established ophthalmologist working relationship, UMC Utrecht, Netherlands

Ophthalmology-dermatology collaboration, Inselspital (Bern), Switzerland

Collaboration with comorbidity specialists, University of São Paulo Hospital, Brazil

Established ophthalmologist working relationship, OHSU (Oregon), USA

Occupational health physician

AD occupational training and advice, UNIMORE (Modena), Italy

Role of occupational health physician, Aarhus Universitetshospital, Denmark

Role of occupational health physician, UMC Groningen, Netherlands

Pharmacist

Multidisciplinary approach to patient education, The Jikei University Hospital, Japan

Supportive role of the pharmacist, Hospital Sant Pau (Barcelona), Spain

Dietician

Role of the dietician, UMC Groningen, Netherlands

Conducting joint consultations/multidisciplinary clinics

Allergy centre comorbidity clinic, Aarhus Universitetshospital, Denmark

Joint paediatric dermatology-allergy clinic, Royal Devon & Exeter Hospital, UK

Joint psychiatry-dermatology clinics, CHRU Brest, France

Multidisciplinary Atopic Dermatitis Program (MADP), Rady Children's Hospital (California), USA

Onsite dermatology psychologist, Hospital Sant Pau (Barcelona), Spain

Psycho-derm clinic, Royal Devon & Exeter Hospital, UK

Forming cross-specialty units and/or co-location of specialties

Allergy Centre, Dokkyo Medical University Hospital, Japan

Allergy Centre, The Jikei University Hospital, Japan (Allergy Centre in development)

Chicago Integrative Eczema Centre, Medical Dermatology Associates of Chicago, USA

Coordination of AD care by allergologist, UNIMORE (Modena), Italy

Established dermo-allergy unit, Hospital La Paz (Madrid), Spain

Transitional processes into adult clinic, UMC Utrecht, Netherlands

Specialised atopic dermatitis outpatient clinic, The Jikei University Hospital, Japan

In-house contact dermatitis clinic, Mount Sinai & Ichan School of Medicine (New York), USA

Active clinical trials department, Mount Sinai & Ichan School of Medicine (New York), USA

External HCP networks

Centre Expert Eczema Network Auvergne Rhone Alpes, CH Lyon-Sud, France

Collaboration with other specialties, UniCATT (Rome), Italy

Comorbidity specialist network, DermAssociates (Washington), USA

Established specialist network, Medical Dermatology Associates of Chicago, USA

Referral to co-morbidity specialists, M.L.F. Knuckles Dermatology (Kentucky), USA

HCPs working across specialties

Integrated dermatology-allergology specialists, UMC Utrecht, Netherlands

Joint Allergy-Dermatology physician assistant, Rady Children's Hospital (California), USA

Multidisciplinary dermatology and allergy & immunology collaborative fellowship program, Rady Children's Hospital (California), USA

Offering a teleconsultation service (between specialties/departments within or across centre)

Improving Atopic Dermatitis Care by Paediatricians (IADCBP), Rady Children's Hospital (California), USA

MedPhone application, CH Lyon-Sud, France

Teledermatology service, Royal Devon & Exeter Hospital, UK

Teledermatology services, Rady Children's Hospital (California), USA

Delivering cross-specialty Patient Group education events and meetings

AD Patient education evenings, Inselspital (Bern), Switzerland

Multidisciplinary group based patient education programme, UKSH (Kiel), Germany

Cross-specialty research collaboration

Research expertise and integration, CH Lyon-Sud, France

Developing a dedicated ‘Case manager / patient coordinator

Role of clinical service coordinator, Hospital La Paz (Madrid), Spain