Interest in urticarial skin disease has risen in the last 10 years. A simple search of the US National Library of Medicine databases reveals that the number of publications indexed under the keyword urticaria in just the last year easily exceeds 600. The reasons behind the growing interest were well summarized in a recent opinion article in this journal, in which authors Gimenez-Arnau et al.1 remarked on the following developments:

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  the recent publication of European clinical practice guidelines,

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  our improved understanding of the pathogenesis of the disease,

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  the emergence of patient associations and the participation of a variety of professionals in World Urticaria Day, and most importantly,

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  the development of new biologic therapies available to treat the condition.

A disease with a prevalence of nearly 1% in the United States2 and similar rates in other Western countries like Spain,3 naturally draws attention. Chronic urticaria affects middle-aged populations and has a resulting economic impact on employed persons as well as the use of hospital resources. The patient with urticaria is a high user of health care services through visits to the emergency department, primary care clinics, and specialists—mainly dermatologists, allergy specialists, or internists.

The clinical practice guidelines updated in 20094 and revised again in 20145 were based on a systematic review of the literature applying the GRADE scale (Grading of Recommendations Assessment, Development and Evaluation). The members of 21 Spanish and international associations involved in the management of urticaria participated in the effort, which established an easy-to-use treatment algorithm incorporating indications that are implicitly or explicitly in accordance with each drug's summary of product characteristics. (An example is cyclosporin, whose use in the treatment of urticaria refractory to conventional treatment with antihistamines is regulated in Andalusia by resolution SA352/2012 of November 15, 2012.) However, the guidelines have not yet been analyzed and filled out with revisions specific to each participating country.6

While our main objective in managing the diagnosis and treatment of urticaria is to achieve rapid and complete control over signs and symptoms by prescribing appropriate medications according to the best available evidence of safety and efficacy, meeting that goal requires individualized case management. However, tailored care is not incompatible with planning the pathway our patients should follow in the health care system so that duplicated effort and unnecessary interventions are avoided.

Here is where systematizing care through process planning becomes essential. A clinical pathway, or care plan, specifies the who, when, where and how that govern the delivery of care for a condition or a set of related ones.

Our aim in this paper is to present the consensus reached by dermatologists of the national health service (NHS) of Andalusia regarding the care process for patients with urticaria. We describe the clinical pathway, the necessary steps and interventions, and the characteristics of quality of care for each act.

The need to define and develop a framework for providing quality care efficiently in the Andalusian NHS led the working group to map the care processes that have been in place since 2000. This strategy has a single fundamental aim: to guarantee the quality of NHS services.7

The care process plan encompasses an overview of the actual path a patient will follow through the system. Work flows have been reordered and interventions that are of no use have been eliminated.

Elements intrinsic to the plan are

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  interventions designed to be patient-, or user-, centered,

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  the active involvement of health care professionals organized into multidisciplinary working groups,

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  clinical practice that is appropriate according to guidelines and care plans,

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  integrated recording of information, and finally,

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  continuity of care to ensure cooperation between the various levels of the health care system.

The only care process plan currently in use in clinical management units (CMUs) in dermatology in the autonomous community of Andalusia is the one for the integrated care of skin cancer.8 Therefore, the Andalusian Regional Section of the Spanish Academy of Dermatology and Venereology (AEDV) took the portfolio of medical and surgical services in dermatology and the treatment of sexually transmitted infections of 20149 as its starting point and developed pathways for prioritized conditions and those for which no documentary support was currently in place. The conditions chosen were atopic dermatitis, sexually transmitted infections, benign cysts or tumors, and urticaria.

The patient interacts with both primary care physicians and specialists after referral along the clinical pathway described in Tables 1 and 2, which define the who, what, where, when, and how of steps in the sequential phases of a process that guarantees continuity of care. (See Appendix A for the drafting process.)

Table 1 (primary care) and Table 2 (specialized care) list the activities of multidisciplinary teams of health care and other professionals who attend the patient with urticaria as part of a coordinated process. The organization of the tables follows the patient's pathway through a system that includes both health care and related services. Aspects and dimensions of quality of care, clinical effectiveness, critical safety points (CSPs), nursing care, information-oriented CSPs, nonclinical interventions, and the recommendations of experts have been incorporated into the tables. The flow chart (Fig. 1) shows how specialist follow-up is carried out and offers a summary of a therapeutic approach rooted in the recently updated European guidelines.5

Figure 1.

Flow chart of the urticaria patient's pathway through the different parts of the health care system. CMU refers to clinical management unit; UAS7, Urticaria Activity Score 7; DQLI, Dermatology Quality of Life Index.

(0.66MB).

The Metaplan approach10 that was used to draft this paper is a qualitative focus-group method for generating ideas and solutions, exploring opinions and reaching consensus; the focus groups also formulate objectives, make recommendations, and draft action plans. The method gathers information on cards that can be posted on a board to add a visual component to discussions. A moderator leads the group and structures the analysis and discussion in keeping with the context for the activity.

The intention is to foster the full participation of all members equally without the moderator exercising influence over individuals’ opinions. The method seeks to facilitate focus and foster understanding of ideas, using visual aids (posted cards) to expand on the spoken word. Gaps are left so that participants can fill them by suggesting new ideas to add to the board in an orderly way. Experts agree that these techniques break complex statements down into simpler ones, making them easier for participants to grasp. Complex ideas may even be condensed visually to only a single word or two, clarifying them and bridging gaps created during spoken communication.

The dermatologists who drafted the present paper came from all the provinces and health centers in the autonomous community of Andalusia. Support in applying the method was given by professionals from the Spanish Society for Quality in Health Care (SECA).

Finally, we note that the recommendations based on the consensus of experts with a wide range of clinical and management experience correspond to evidence level IV; this limitation applies to this paper.

In conclusion, we propose a clinical pathway for urticaria, a condition that is commonly seen in dermatology practices. The dermatologist is clearly the best qualified specialist to manage patients with urticaria in an integrated way, in collaboration with allergy specialists, family practitioners, and other professionals. The dermatologist can confirm the diagnosis, ruling out possible alternative diagnoses such as other inflammatory or reactive skin conditions. The specialist can also assess severity and manage an exhaustive therapeutic plan that is well informed by appropriate clinical practice guidelines. The actions involved in clinical management, however, must be undertaken in an orderly way and in concert with other specialists and professionals. The patient, for whom continuity of care must be guaranteed, is at the center of this process. We believe the proposed clinical pathway is a dynamic starting point that will facilitate the approach we describe here.