Boothby-Shoemaker, Wyatt

Hamzavi, Iltefat

Huggins, Richard H

Mohammad, Tasneem F

Rehman, Rafey

English

Henry Ford Health System Scholarly Commons

Henry Ford Health Henry Ford Health Scholarly Commons Dermatology Articles Dermatology 6-10-2022 Recommendations to Optimize Patient Care in Hidradenitis Suppurativa Clinics: Our Experience Wyatt Boothby-Shoemaker Henry Ford Health, wboothb1@hfhs.org Rafey Rehman Henry Ford Health, rrehman1@hfhs.org Iltefat Hamzavi Henry Ford Health, ihamzav1@hfhs.org Richard H. Huggins Henry Ford Health, RHUGGIN1@hfhs.org Tasneem F. Mohammad Henry Ford Health, TMOHAMM2@hfhs.org Follow this and additional works at: https://scholarlycommons.henryford.com/dermatology_articles Recommended Citation Boothby-Shoemaker W, Rehman R, Hamzavi I, Huggins RH, and Mohammad TF. Recommendations to Optimize Patient Care in Hidradenitis Suppurativa Clinics: Our Experience. Dermatology 2022; 1-4. This Article is brought to you for free and open access by the Dermatology at Henry Ford Health Scholarly Commons. It has been accepted for inclusion in Dermatology Articles by an authorized administrator of Henry Ford Health Scholarly Commons. LetterDermatologyRecommendations to Optimize Patient Care in Hidradenitis Suppurativa Clinics: Our ExperienceWyatt Boothby-Shoemaker a, b    Rafey Rehman a, c    Iltefat Hamzavi a     Richard H. Huggins a    Tasneem F. Mohammad aaDepartment of Dermatology, Henry Ford Hospital, Detroit, MI, USA; bMichigan State University College of Human Medicine, East Lansing, MI, USA; cOakland University William Beaumont School of Medicine, Rochester, MI, USAReceived: November 7, 2021Accepted: March 19, 2022Published online: June 10, 2022Correspondence to: Tasneem F. Mohammad, tmohamm2 @ hfhs.org© 2022 S. Karger AG, BaselKarger@karger.comwww.karger.com/drmDOI: 10.1159/000524226Dear Editor,Hidradenitis suppurativa (HS) is a systemic inflamma-tory disease that has genetic heterogeneity and often re-quires a multimodal approach [1–3]. Given the recent in-crease in HS awareness, more providers are recognizing this entity and referring patients to dermatologists. As a result, the number of HS specialty clinics has been in-creasing in the USA during recent years [4]. Information about existing HS specialty clinics can be found at www.hs-foundation.org/hs-specialty-clinics. Currently, there is a gap in academic literature regarding recommenda-tions to efficiently manage HS patients. One method is to start or improve existing HS specialty clinics via quality improvement (QI) initiatives that expand organizational capabilities. After implementing multiple QI initiatives over a 2-year period, we now serve approximately 750 pa-tients annually across five clinic sites more efficiently and effectively than before. Here, we describe our experience with three QI initiatives focused on shortening appoint-ment lead-time delays, improving clinical documenta-tion via patient intake forms and note templates, and cre-ating educational videos explaining HS-specific proce-dures.Our first initiative focused on shortening lead-time delays, or the time to when new and returning HS patients are seen in clinic. To improve lead-time delay, most HS patients were first seen in the general dermatology clinics. Patients with mild to moderate HS were managed here over time, while patients with severe, refractory HS were referred to our HS clinic. However, patients referred from outside dermatologists or traveling a distance greater than 50 miles were immediately seen in our HS clinic. We created an internal set of HS treatment guidelines to be available at our institution’s general dermatology clinics to assist providers and residents in managing mild or moderate HS cases and to route severe cases to our HS clinic. These guidelines were based upon the North American HS guidelines, and Henry Ford clinicians ex-perienced in HS management [5]. The QI team coordi-nated Grand Rounds lectures to ensure all faculty and residents were educated on the internal guidelines, acute HS management, and the referral process. For example, patients with multiple comorbidities, disease recalcitrant Wyatt Boothby-Shoemaker and Rafey Rehman contributed equally to the work.Boothby-Shoemaker/Rehman/Hamzavi/Huggins/MohammadDermatology2DOI: 10.1159/000524226to conventional therapies, or Hurley Stage III HS requir-ing CO2 laser excision – a procedure that focuses on tissue debulking through vaporization and excision of affected HS lesions – are immediately referred to our HS clinic and are managed in-house over time [6]. For less emergent referrals, we created a treatment plan that the referring provider can follow. We also increased the number of providers in our HS clinic as patient demand increased and a single provider clinic became inefficient. Now, two providers alternate between seeing patients, with one provider performing a CO2 excision toward the end of clinic. Clinic appointments are double to triple booked, with resident and nurse/medical assistant support being instrumental in maintaining clinic flow. By instituting these measures over 2 years, lead-time delays decreased by 30%, from 52.7 days to 36.5 days for new patients, and decreased by 26% from 54.8 days to 40.6 days for return-ing patients. The overall clinic workflow and staff well-ness improved significantly as providers could spend an adequate amount of time with patients without running behind in clinic.Another recommendation to improve HS clinic effi-ciency focused on using patient intake forms and elec-tronic medical record (EMR) templates to facilitate histo-ry-taking and documentation. At our institution, patients complete intake forms describing their recent HS history and treatment, which decrease time spent taking histories and allow providers to spend more time counseling pa-tients. Specifically, our intake form asks questions related to severity and frequency of pain; location of current and previous flares; topical, oral, and IV medications used and side effects; surgical or laser treatment; associated medi-cal symptoms, quality of life impact, and lifestyle factors. Given that patients may struggle to complete the forms due to inadequate time or health literacy, our support staff help patients complete these forms prior to being roomed. Our providers also use dedicated note templates to assist with EMR documentation. Note templates have the added benefit of helping providers determine wheth-er CO2 laser excision and other HS procedures are indi-cated in more severe or recalcitrant HS cases. While insti-tutional guidelines for CO2 laser procedures may vary, we promoted our internal guidelines for direct CO2 laser pa-tient referrals through sharing a referral criteria docu-mentation template in the EMR to all providers to assist with this process.Lastly, we created educational videos on specific HS procedures and postsurgical wound care to assist in an-swering commonly asked questions. Patients are provided with access to informational videos on CO2 laser excision performed under tumescent anesthesia and the deroofing procedure. Previously, residents would sit with patients and go through PowerPoint presentations, which took a significant amount of time. With the development of edu-cational videos, residents can complete patient orders and discharge paperwork, while patients  watch the videos and 40%0%10%20%Residents (%)30%1-2a2-4Time Needed to Educate Patients (min)5-7 7-10 >10Video PowerPoint80%0%20%40%Residents (%)60%Not helpful enough –I don‘t think it iscomprehensive enoughVery helpful –I can‘t imagine abetter waySomewhat helpful –It gets the job doneb Residents‘ perceptionsVideo PowerPointFig. 1. Resident survey results on the utility of different educational modalities. a Time needed by residents to counsel patients on the HS CO2 laser procedure. b Resident perceptions on the utility of different presentation methods to educate patients.Hidradenitis Suppurativa Clinic Recommendations3DermatologyDOI: 10.1159/000524226ask  any questions afterward. We conducted a survey to assess residents’ perceptions of using the CO2 laser exci-sion video compared to the traditional PowerPoint pre-sentation method. The survey was administered to 31 res-idents after an approximately 3-month implementation period. Our analysis revealed that 82% of residents were able to educate patients on the procedure in less than 7 min using the video, while 67% of residents needed more than 7 min to educate patients using the PowerPoint (Fig. 1). Furthermore, 75% of residents thought the video was an extremely helpful tool and could not think of a bet-ter way to educate patients, while only 20% of residents felt the same way about the PowerPoint (Fig. 1). We also sur-veyed 20 patients at the end of their visit to assess percep-tions of their level of preparedness for the HS CO2 proce-dure and perceived effectiveness in explaining the HS CO2 procedure (Fig. 2). All of the video group patients (10/10) reported feeling extremely or very prepared for the proce-dure compared to 9/10 patients feeling extremely or very prepared in the PowerPoint group, with 1 patient from the PowerPoint group reporting feeling slightly prepared. When asked perceived efficacy in learning about the CO2 procedure, all of the PowerPoint group patients (10/10) reported this modality to be extremely or very effective, compared to 9/10 patients in the video group providing ratings of extremely or very effective, with 1 patient rating the video as slightly effective. Given these comparable findings, video presentations may be another useful tool to help save providers’ time in their HS clinic. An overview of the recommendations to improve HS clinic efficiency can be found in Table 1.50%0%10%20%30%Patients (%)40%Extremely Effective Very Effective Slightly Effective Not Effectivea Perception of Educational Modality EfficacyVideo PowerPoint50%0%10%20%30%Patients (%)40%Extremely prepared Very prepared Slightly prepared Not preparedb Perception of Preparedness after Educational ModalitiesVideo PowerPointFig. 2. Patient survey results on the utility of different educational modalities. a Patient perceptions of educa-tional modality efficacy in learning about an HS CO2 laser procedure. b Patient perceptions of their preparedness for the HS CO2 laser procedure after different educational modalities.Table 1. Overview of recommendations to improve efficiency in HS clinicsRecommendationsBuild a QI team composed of both general dermatologists and dermatologists focused in HS care, residents, nurses, medical assistants, and research staffStaff multiple providers in the HS clinic to improve clinic workflow and personnel wellnessCreate an HS management ladder to educate non-HS clinic faculty on how to manage milder HS cases in general dermatology clinics and refer more severe HS patients to the HS clinicUse intake forms to improve the accuracy and thoroughness of patient histories and decrease the time spent on history-taking in the clinicProvide adequate time for patients to complete the intake forms prior to being roomedHave nursing staff and medical assistants help patients complete the intake form if needed to improve completion ratesUse note templates to ensure the complete history is documented, decrease charting time, and assist decision-making for CO2 laser excision and other HS procedures in moderately complex patientsProvide patients with educational videos to help save time in answering frequently asked questions about HS-specific procedures and necessary wound careBoothby-Shoemaker/Rehman/Hamzavi/Huggins/MohammadDermatology4DOI: 10.1159/000524226We have provided some recommendations to assist in-stitutions in serving HS patients more efficiently in HS clinics. By sharing our experiences, we hope to encourage other HS clinics to share their best practices in order to foster a culture that ultimately promotes higher quality, accessible healthcare for HS patients.Key MessageQuality improvement initiatives for hidradenitis suppurativa clinics can improve time to evaluation for patients.Conflict of Interest StatementIH serves on the advisory board for AbbVie; is a principal in-vestigator for Pfizer, LENICURA, Jansen, and Incyte; is a consul-tant for Incyte, Pfizer, UCB, and Boehringer Ingelheim; and serves as the president of the Hidradenitis Suppurativa Foundation. Ilte-fat Hamzavi is an investigator for PCORI, Incyte Corporation, L’Oréal, Beiersdorf, Estee Lauder, Unigen Inc., Ferndale Health-care Inc., Pfizer, Allergan, and Johnson & Johnson and has served as a consultant for Pfizer, Johnson & Johnson, and Beiersdorf. None of the remaining authors have any conflict of interest to dis-close. Richard H. Huggins is an investigator for Pfizer, Incyte, Ar-cutis, and the Immune Tolerance Network. Tasneem Mohammad is an investigator for Clinuvel, Incyte Corporation, Pfizer, Avita, Arcutis, Pierre Fabre, Estee Lauder, Unigen Inc., Ferndale Health-care Inc., and Allergan.Funding SourcesNone.Author ContributionsWyatt Boothby-Shoemaker, Rafey Rehman, Iltefat Hamzavi, Richard Huggins, and Tasneem Mohammad all contributed to the generation of the manuscript.References 1 Damiani G, Della Valle V, Iannone M, Dini V, Marzano AV. Autoinflammatory Disease Damage Index (ADDI): a possible newborn also in hidradenitis suppurativa daily prac-tice. Ann Rheum Dis. 2017 [cited 2022 Jan 12]; 76(8). 2 Zouboulis CC, Hansen H, Caposiena Caro RD, Damiani G, Delorme I, Pascual JC, et al. Adalimumab dose intensification in recalci-trant hidradenitis suppurativa/acne inversa. Dermatology. 2020 Feb 1 [cited 2022 Jan 12]; 236(1): 25–30. Available from: https: //www.karger.com/Article/FullText/503606. 3 Duchatelet S, Miskinyte S, Delage M, Unge-heuer MN, Lam T, Benhadou F, et al. Low prevalence of GSC gene mutations in a large cohort of predominantly caucasian patients with hidradenitis suppurativa. J Invest Der-matol. 2020 Oct 1 [cited 2022 Jan 12]; 140(10): 2085–8.e14. 4 Seivright JR, Thompson A, Hamzavi I, Lowes MA, Porter M, Shi VY, et al. Hidradenitis sup-purativa specialty clinics in the USA. Skin Ap-pendage Disord. 2021 Aug 1 [cited 2022 Jan 12]; 7(5): 359–62. 5 Alikhan A, Sayed C, Alavi A, Alhusayen R, Brassard A, Burkhart C, et al. North American clinical management guidelines for hidradeni-tis suppurativa: a publication from the United States and Canadian Hidradenitis Suppura-tiva Foundations – part II: topical, intralesion-al, and systemic medical management. J Am Acad Dermatol. 2019 Jul 1 [cited 2022 Jan 12]; 81(1): 91–101. Available from: http: //www.jaad.org/art ic le/S0190962219303688/ fulltext. 6 Hamzavi IH, Griffith JL, Riyaz F, Hessam S, Bechara FG. Laser and light-based treatment options for hidradenitis suppurativa. J Am Acad Dermatol. 2015 Nov 1 [cited 2022 Jan 12]; 73(5 Suppl 1): S78–81.

Recommendations to Optimize Patient Care in Hidradenitis Suppurativa Clinics: Our Experience

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Recommendations to Optimize Patient Care in Hidradenitis Suppurativa Clinics: Our Experience

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