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Food Allergy Diagnosis and Management Practices Among Pediatricians Ruchi S. Gupta, Claudia H. Lau, Ashley A. Dyer, Min-Woong Sohn, Barry A. Altshuler, Bennett A. Kaye and Jonathan Necheles CLIN PEDIATR published online 13 January 2014 DOI: 10.1177/0009922813518425 The online version of this article can be found at: http://cpj.sagepub.com/content/early/2014/01/10/0009922813518425 A more recent version of this article was published on - May 8, 2014

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CPJXXX10.1177/0009922813518425Clinical PediatricsGupta et al

Original Article

Food Allergy Diagnosis and Management Practices Among Pediatricians

Clinical Pediatrics 1­–7 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922813518425 cpj.sagepub.com

Ruchi S. Gupta, MD, MPH1,2, Claudia H. Lau1, Ashley A. Dyer, MPH2, Min-Woong Sohn, PhD2,3, Barry A. Altshuler, MD1,2,4,5, Bennett A. Kaye, MD1,2,4,6, and Jonathan Necheles, MD, MPH, FAAP1,2,4,6

Abstract Our goals were to (1) estimate the rates of parent-reported versus physician-diagnosed food allergy, (2) determine pediatrician adherence to national guidelines, and (3) obtain pediatricians’ perspectives on guideline nonadherence. A mixed method approach was used, including survey, chart review, and qualitative methods. Overall, 10.9% of parents reported having a child with food allergy and two thirds of these cases were detected by the pediatrician. Chart reviews revealed high rates of guideline adherence with respect to allergist referral (67.3%), but less consistent adherence regarding documentation of reaction history (38.8%), appropriate use of diagnostic tests (34.7%), prescription of epinephrine autoinjectors (44.9%), and counseling families in food allergy management (24.5%). Pediatricians suggested that poor adherence was due to lack of documentation, familiarity with guidelines, and clarity regarding the pediatrician’s role in managing food allergy. Findings emphasize the need to better establish the role of the pediatrician and to improve awareness and adherence to guidelines. Keywords food allergy, management, guidelines, primary care, pediatrics

Introduction Childhood food allergy affects 8% or an estimated 1 in 13 children in the United States.1 Appropriate diagnosis and management by a physician is essential to keep affected children safe while preventing unnecessary avoidance.2 As pediatricians are often the first and sometimes only physician these children see, it is critical that they provide caregivers with potentially life-saving medications and education on how to recognize and respond to allergic reactions.2 Currently, few data exist that describe practices in the diagnosis and management of food allergy among primary care physicians in the United States. Previous studies suggest that many misconceptions regarding food allergy exist among physicians.3-5 Physicians themselves often report little training in the care of children with food allergy and, as such, have expressed concern regarding their ability to care for these patients.5 Indeed, surveys have shown that many primary care physicians in the United States are not providing patients with the means to appropriately manage foodinduced reactions.6-9

Guidelines for the diagnosis and management of food allergy were released by the National Institute of Allergy and Infectious Diseases (NIAID) in 2010 in an attempt to standardize best clinical practices.2 A better understanding of current practices with respect to these guidelines is critical to standardize care and identify opportunities for improvement. To this end, the goals of this study were to (1) estimate the rates of parentreported versus physician-diagnosed food allergy, (2) determine pediatrician adherence to NIAID guidelines, 1

Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA 2 Northwestern University Feinberg School of Medicine, Chicago, IL, USA 3 Center for Management of Complex Chronic Care, Edward Hines Jr. VA Hospital, Hines, IL, USA 4 Pediatric Practice Research Group, Chicago, IL, USA 5 Pediatric Specialists of the Northwest, Crystal Lake, IL, USA 6 Children’s Healthcare Associates, Chicago, IL, USA Corresponding Author: Ruchi S. Gupta, Ann & Robert H. Lurie Children’s Hospital of Chicago, 225 E. Chicago Avenue, Box 157, Chicago IL 60611, USA. Email: [email protected]

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and (3) obtain pediatricians’ perspectives on rates of guideline nonadherence.

Methods A mixed method approach was used to study management practices in three pediatric clinics in the Chicago area. Study protocol was approved by the institutional review board of the Ann & Robert H. Lurie Children’s Hospital of Chicago.

Parent-Reported Versus Physician-Diagnosed Prevalence A food allergy screening survey was administered to caregivers in waiting rooms between October 2011 and January 2012 to estimate the rate of parent-reported food allergy (n = 459). Eligible participants included caregivers of children with a scheduled appointment able to complete the survey in English. All eligible caregivers were invited to participate during check-in by a research assistant. Participants were instructed to complete the survey for the child with the scheduled appointment. The survey was developed by modifying a validated childhood food allergy screening survey1 and is available on request. The original survey included items assessing caregiver report of a child’s food allergy. Items assessing clinical management of the child’s food allergy were added. The survey was administered either on paper or using a tablet personal computer based on participant preference. A random subset of children of parents participating in the screening survey were selected for a brief chart review to estimate the rate of physician-diagnosed food allergy (n = 41). Randomization was performed using a random number generator (GraphPad Software, La Jolla, CA).

Clinical Practice With Respect to NIAID Guidelines Medical records of patients with a diagnosis of food allergy between August 2009 and 2011 were reviewed to evaluate current practices (n = 49). Office managers from each clinic screened and pulled records containing appropriate International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Codes included 692.5 (contact dermatitis and other eczema due to food), 693.1 (dermatitis due to food taken internally), 995.60-995.69 (anaphylactic shock due to adverse food reaction), or 995.7 (other adverse food reactions not elsewhere classified). Additional charts of children reported by their physician to have

food allergy were included if documentation of food allergy was made during the study period. Structured chart reviews were conducted by 2 research assistants using a standardized data abstraction form developed by an allergist and a pediatrician. The form was designed to document degree of adherence to NIAID guidelines based on 5 key areas of recommendation: (1) documentation of a diagnosis based on reaction history, (2) use of appropriate diagnostic tests (ie, allergenspecific serum IgE test) when indicated by reaction history, (3) prescription of epinephrine autoinjectors as first-line treatment and antihistamines as adjunctive treatment, (4) counseling and education of patient families, and (5) referral to an allergist (Figure 1).2

Pediatricians’ Perspectives on Guideline Nonadherence Survey and chart review findings were presented to the pediatricians at two of the three clinics, and perspectives on guideline nonadherence were solicited. Sessions were transcribed and are summarized below.

Statistical Analysis Descriptive statistics were used to characterize survey participants. Food allergy prevalence was estimated based on parent report in survey data and based on physician report in brief chart reviews. To assess adherence to guidelines, we computed percentage of reviewed medical charts that had documentation of recommended practices in the 5 key areas. All analyses were performed using Stata/SE 10.0 (Stata Corp LP, College Station, TX).

Results Parent-Reported Versus Physician-Diagnosed Prevalence Food allergy prevalence based on parent report was 10.9%; two thirds of parent-reported food allergy had a physician diagnosis. Demographic characteristics of surveyed children are presented in Table 1. Seventy-four percent of parents reported discussing their child’s food allergy with their pediatrician. Parents who did not discuss a perceived food allergy with their pediatrician most often reported that they (1) had already discussed the food allergy with another physician, (2) believed the food allergy was not severe enough to warrant a discussion with the pediatrician, (3) believed the child could avoid the food without consulting a physician, and/or (4) had more serious health problems to address.

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Figure 1.  Adaption of National Institute of Allergy and Infectious Diseases (NIAID) guidelines for primary care physicians, categorized into 5 areas for the purposes of this study: (1) History, (2) Testing, (3) Medications, (4) Counseling, and (5) Referrals.

Clinical Practice With Respect to NIAID Guidelines Medical records were adherent with NIAID guidelines in 2 of 5 areas on average (Figure 2). There was some documentation of an appropriate reason to suspect food allergy (ie, reaction history and/or allergen-specific IgE testing) in 59.2% of medical records. Some form of appropriate management (ie, epinephrine autoinjector prescription, counseling, and/or an allergist referral) was documented in 81.6% of records. Detailed documentation of history, testing, medications, counseling, and referrals are presented in Table 2. All pediatricians who prescribed an epinephrine autoinjector prescribed the correct type according to the weight of the child. The mean wait time between referral and first allergist consultation was 125 days (SD = 198; median = 34; range = 0-658).

Pediatricians’ Perspectives on Guideline Nonadherence Discrepancies in parent-reported versus physician-diagnosed food allergy were discussed. Several pediatricians

stated that their patients with Preferred Provider Organizations (PPOs) were able to seek allergist care directly, bypassing their primary care provider and accounting for undocumented cases of food allergy. Other patients with Medicaid or Health Maintenance Organizations (HMOs) were required to notify the pediatrician of a food allergy in order to receive an allergy referral, and therefore should always be documented in the chart. Pediatricians offered three reasons for guideline nonadherence. Several pediatricians suggested that the high rates of nonadherence were due to lack of documentation rather than true nonadherence. Physicians also stated that time constraints prevented complete documentation in the patient’s chart. Others were not familiar with recommended practices or were unsure of the pediatrician’s role in the management of food allergy. History. Most pediatricians felt that infrequent documentation of reaction history was the result of poor documentation and did not represent nonadherence to guidelines.

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Table 1.  Demographic Characteristics of Surveyed Children (n = 459). Frequency, % (n)   Race/ethnicitya  Asian  Black  Hispanic  White  Other Gender  Female  Male Age (years)  0-2  3-5  6-10  11-13  14-18 Household income ($)   four months) from referral to first visit for over half of all patients. It is therefore critical that the pediatrician provides patient families with the means and guidance to appropriately manage food-induced reactions in the interim. Current NIAID guidelines are the first to provide standardized food allergy diagnosis and management practices based on evidence report and expert clinical opinion. However, guideline adoption has been slow because they are not tailored to meet the needs of the busy primary care provider. This pattern of guideline adoption is consistent with that of other chronic diseases such as asthma.20 Asthma guideline adherence has been improved in the past through disseminating concise summaries and decision trees.20 Thus, we simplified recommended practices for the diagnosis and management of food allergy into five easy-to-follow steps (Figure 1). Additional educational information, including a copy of a food allergy anaphylaxis action plan, can be found on the Food Allergy Research and Education website (http://www.foodallergy.org). Several limitations to this study should be highlighted. In evaluating the accuracy of parent-reported food allergies, we did not collect biologic samples. Use of medical records assumed their accuracy and completeness, which may not always be the case. Detection of nonadherence may have also been limited by the inclusion medical records identified by providers in the clinic. Finally, our small sample size limited to the Chicago area may limit generalizability of findings to other populations.

Conclusion Childhood food allergy may be underdocumented in the pediatric clinic. Among documented cases of food allergy, areas in need of improvement with respect to national guidelines were identified. Guideline adherence was high with respect to specialty referral but was limited regarding documentation of reaction history, appropriate use of diagnostic tests, prescription of epinephrine autoinjectors, and counseling patient families in food allergy management. Appropriate management by the pediatrician is critical, as they are often the only health care providers for these children; even if children are referred to an allergist, the wait time is on average four months. Findings emphasize the need to better establish the role of the pediatrician in the care of foodallergic children, and the need to provide additional clinical support to improve awareness and adherence to established practice guidelines.

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Gupta et al Acknowledgments We thank the following Pediatric Practice Research Group practices for their participation: Children’s Healthcare Associates, Chicago, IL; Pediatric Specialists of the Northwest, Crystal Lake, IL; Pediatric Associates of Barrington, Barrington, IL. We would especially like to thank Dr Judith A. Brown of the Pediatric Associates of Barrington for her support and collaboration. We also thank Sonya Dave, Vishal Kumar, Andrew Ta, and Aadi Tolappa for their assistance in data collection. Additionally, special thanks to Drs Helen Binns and Adolfo Ariza for their valuable guidance in the conception of the study, and Ms Elizabeth Springston for her critical revisions of the article.

Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was supported by institutional funding from the Northwestern University Clinical and Translational Sciences Institute (Principal Investigator: Ruchi S. Gupta).

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and manifestations. Ann Allergy Asthma Immunol. 2007;99:325-333. 8. Sicherer SH, Forman JA, Noone SA. Use assessment of self-administered epinephrine among food-allergic children and pediatricians. Pediatrics. 2000;105:359-362. 9. Gupta RS, Springston EE, Smith B, Pongracic J, Holl JL, Warrier MR. Parent report of physician diagnosis in pediatric food allergy. J Allergy Clin Immunol. 2013;131:150156. 10. Luccioli S, Ross M, Labiner-Wolfe J, Fein SB. Maternally reported food allergies and other food-related health problems in infants: characteristics and associated factors. Pediatrics. 2008;122(suppl 2):S105-S112. 11. Custovic A, Nicolaou N. Peanut allergy: overestimated in epidemiology or underdiagnosed in primary care? J Allergy Clin Immunol. 2011;127:631-632. 12. Kotz D, Simpson CR, Sheikh A. Incidence, prevalence, and trends of general practitioner-recorded diagnosis of peanut allergy in England, 2001 to 2005. J Allergy Clin Immunol. 2011;127:623.e1-630.e1. 13. Hughes JL, Stewart M. Self-administration of epinephrine in children: a survey of current prescription practice and recommendations for improvement. Ulster Med J. 2003;72:80-85. 14. Portnoy JM. Appropriate allergy testing and interpretation. Mo Med. 2011;108:339-343. 15. Rudders SA, Banerji A, Corel B, Clark S, Camargo CA Jr. Multicenter study of repeat epinephrine treatments for food-related anaphylaxis. Pediatrics. 2010;125:e711-e718. 16. Clark S, Bock SA, Gaeta TJ, Brenner BE, Cydulka RK, Camargo CA. Multicenter study of emergency department visits for food allergies. J Allergy Clin Immunol. 2004;113:347-352. 17. Klein JS, Yocum MW. Underreporting of anaphylaxis in a community emergency room. J Allergy Clin Immunol. 1995;95:637-638. 18. Banerji A, Rudders SA, Corel B, Garth AM, Clark S, Camargo CA Jr. Repeat epinephrine treatments for foodrelated allergic reactions that present to the emergency department. Allergy Asthma Proc. 2010;31:308-316. 19. Campbell RL, Luke A, Weaver AL, et al. Prescriptions for self-injectable epinephrine and follow-up referral in emergency department patients presenting with anaphylaxis. Ann Allergy Asthma Immunol. 2008;101: 631-636. 20. Gupta RS, Weiss KB. The 2007 National Asthma Education and Prevention Program asthma guidelines: accelerating their implementation and facilitating their impact on children with asthma. Pediatrics. 2009;123(suppl 3):S193-S198.

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Food allergy diagnosis and management practices among pediatricians.

Our goals were to (1) estimate the rates of parent-reported versus physician-diagnosed food allergy, (2) determine pediatrician adherence to national ...
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