Cholesterol treatment and changes in guidelines in an academic medical practice

Effects of time-restricted feeding (16/8) combined with a low-sugar diet on the management of non-alcoholic fatty liver disease: A randomized controlled trial

OBJECTIVES

Emerging studies have employed time-restricted feeding (TRF) and a low-sugar diet alone in the management of non-alcoholic fatty liver disease (NAFLD), but their combination has not been tested. The aim of this study was to investigate the effects of TRF combined with a low-sugar diet on NAFLD parameters, cardiometabolic and inflammatory biomarkers, and body composition in patients with NAFLD.

METHODS

A 12-wk randomized controlled trial was performed to compare the effects of TRF (16 h fasting/8 h feeding daily [16/8]) plus a low-sugar diet versus a control diet based on traditional meal distribution in patients with NAFLD. Changes in body composition, anthropometric indices, and liver and cardiometabolic markers were investigated.

RESULTS

TRF 16/8 with a low-sugar diet reduced body fat (26.7 ± 5.4 to 24.2 ± 4.9 kg), body weight (83.8 ± 12.7 to 80.5 ± 12.1 kg), waist circumference (104.59 ± 10.47 to 101.91 ± 7.42 cm), and body mass index (29.1 ± 2.6 to 28 ± 2.7 kg/m²), as well as circulating levels of fasting blood glucose and liver (alanine aminotransferase, 34 ± 13.9 to 21.2 ± 5.4 U/L; aspartate aminotransferase, 26.3 ± 6.2 to 20.50 ± 4 U/L; γ-glutamyl transpeptidase, 33 ± 15 to 23.2 ± 11.1 U/L; fibrosis score, 6.3 ± 1 to 5.2 ± 1.2 kPa; and controlled attenuation parameter, 322.9 ± 34.9 to 270.9 ± 36.2 dB/m), lipids (triacylglycerols, 201.5 ± 35.3 to 133.3 ± 48.7 mg/dL; total cholesterol, 190 ± 36.6 to 157.8 ± 33.6 mg/dL; and low-density lipoprotein cholesterol, 104.6 ± 27.3 to 84 ± 26.3 mg/dL), and inflammatory markers (high-sensitivity C-reactive protein, 3.1 ± 1.1 to 2 ± 0.9 mg/L; and cytokeratin-18, 1.35 ± 0.03 to 1.16 ± 0.03 ng/mL). These results were statistically significant (P < 0.05) compared with the control group.

CONCLUSIONS

TRF plus a low-sugar diet can reduce adiposity and improve liver, lipid, and inflammatory markers in patients with NAFLD.

Impact of cardiologist intervention on guideline-directed use of statin therapy

BACKGROUND

Statins have an important and well-established role in the prevention of atherosclerotic cardiovascular disease (ASCVD). However, several studies have reported widespread underuse of statins in various practice settings and populations. Review of relevant literature reveals opportunities for improvement in the implementation of guideline-directed statin therapy (GDST).

AIM

To examine the impact of cardiologist intervention on the use of GDST in the ambulatory setting.

METHODS

Patients with at least one encounter at the adult Internal Medicine Clinic (IMC) and/or Cardiology Clinic (CC), who had an available serum cholesterol test performed, were evaluated. The 2 comparison groups were defined as: (1) Patients only seen by IMC; and (2) Patients seen by both IMC and CC. Patients were excluded if variables needed for calculation of ASCVD risk scores were lacking, and if demographic information lacked guideline-directed treatment recommendations. Data were analyzed using student t-tests or χ², as appropriate. Analysis of Variance was used to compare rates of adherence to GDST.

RESULTS

A total of 268 patients met the inclusion criteria for this study; 211 in the IMC group and 57 in the IMC-CC group. Overall, 56% of patients were female, mean age 56 years (± 10.65, SD), 22% Black or African American, 56% Hispanic/Latino, 14% had clinical ASCVD, 13% current smokers, 66% diabetic and 63% hypertensive. Statin use was observed in 55% (n = 147/268) of the entire patient cohort. In the IMC-CC group, 73.6% (n = 42/57) of patients were prescribed statin therapy compared to 50.7% (n = 107/211) of patients in the IMC group (P = 0.002). In terms of appropriate statin use based on guidelines, there was no statistical difference between groups [IMC-CC group 61.4% (n = 35/57) vs IMC group, 55.5% (n = 117/211), P = 0.421]. Patients in the IMC-CC group were older, had more cardiac risk factors and had higher proportions of non-white patients compared to the IMC group (P < 0.02, all).

CONCLUSION

Although overall use of GDST was suboptimal, there was no statistical difference in appropriate statin use based on guidelines between groups managed by general internists alone or co-managed with a cardiologist. These findings highlight the need to design and implement strategies to improve adherence rates to GDST across all specialties.

Gender-Stratified Prevalence of Psychiatric and Pain Diagnoses in a Primary Care Patient Sample with Fibromyalgia

OBJECTIVE

Comorbid psychiatric and pain-related conditions are common in patients with fibromyalgia. Most studies in this area have used data from patients in specialty care and may not represent the characteristics of fibromyalgia in primary care patients. We sought to fill gaps in the literature by determining if the association between psychiatric diagnoses, conditions associated with chronic pain, and fibromyalgia differed by gender in a primary care patient population.

DESIGN

Retrospective cohort.

SETTING AND SUBJECTS

Medical record data obtained from 38,976 patients, ≥18 years of age with a primary care encounter between July 1, 2008, to June 30, 2016.

METHODS

International Classification of Diseases-9 codes were used to define fibromyalgia, psychiatric diagnoses, and conditions associated with chronic pain. Unadjusted associations between patient demographics, comorbid conditions, and fibromyalgia were computed using binary logistic regression for the entire cohort and separately by gender.

RESULTS

Overall, 4.6% of the sample had a fibromyalgia diagnosis, of whom 76.1% were women. Comorbid conditions were more prevalent among patients with vs without fibromyalgia. Depression and arthritis were more strongly related to fibromyalgia among women (odds ratio [OR] = 2.80, 95% confidence interval [CI] = 2.50-3.13; and OR = 5.19, 95% CI = 4.62-5.84) compared with men (OR = 2.16, 95% CI = 1.71-2.71; and (OR = 3.91, 95% CI = 3.22-4.75). The relationship of fibromyalgia and other diagnoses did not significantly differ by gender.

CONCLUSIONS

Except for depression and arthritis, the burden of comorbid conditions in patients with fibromyalgia is similar in women and men treated in primary care. Fibromyalgia comorbidities in primary care are similar to those found in specialty care.

Adoption of the 2013 American College of Cardiology/American Heart Association Cholesterol Management Guideline in Cardiology Practices Nationwide

Importance

The 2013 American College of Cardiology/American Heart Association (ACC/AHA) Cholesterol Management Guideline recommends moderate-intensity to high-intensity statin therapy in eligible patients.

Objective

To examine adoption of the 2013 ACC/AHA guideline in US cardiology practices.

Design, Setting, and Participants

Among 161 cardiology practices, trends in the use of moderate-intensity to high-intensity statin and nonstatin lipid-lowering therapy (LLT) were analyzed before (September 1, 2012, to November 1, 2013) and after (February 1, 2014, to April 1, 2015) publication of the 2013 ACC/AHA guideline among 4 mutually exclusive risk groups within the ACC Practice Innovation and Clinical Excellence Registry. Interrupted time series analysis was used to evaluate for differences in trend in use of moderate-intensity to high-intensity statin and nonstatin LLT use in hierarchical logistic regression models. Participants were a population-based sample of 1 105 356 preguideline patients (2 431 192 patient encounters) and 1 116 472 postguideline patients (2 377 219 patient encounters). Approximately 97% of patients had atherosclerotic cardiovascular disease (ASCVD).

Exposures

Moderate-intensity to high-intensity statin and nonstatin LLT use before and after publication of the 2013 ACC/AHA guideline.

Main Outcomes and Measures

Time trend in the use of moderate-intensity to high-intensity statin and nonstatin LLT.

Results

In the study cohort, the mean (SD) age was 69.6 (12.1) years among 1 105 356 patients (40.2% female) before publication of the guideline and 70.0 (11.9) years among 1 116 472 patients (39.8% female) after publication of the guideline. Although there was a trend toward increasing use of moderate-intensity to high-intensity statins overall and in the ASCVD cohort, such a trend was already present before publication of the guideline. No significant difference in trend in the use of moderate-intensity to high-intensity statins was observed in other groups. The use of moderate-intensity to high-intensity statin therapy was 62.1% (before publication of the guideline) and 66.6% (after publication of the guideline) in the overall cohort, 62.7% (before publication) and 67.0% (after publication) in the ASCVD cohort, 50.6% (before publication) and 52.3% (after publication) in the cohort with elevated low-density lipoprotein cholesterol levels (ie, ≥190 mg/dL), 52.4% (before publication) and 55.2% (after publication) in the diabetes cohort, and 41.9% (before publication) and 46.9% (after publication) in the remaining group with 10-year ASCVD risk of 7.5% or higher. In hierarchical logistic regression models, there was a significant increase in the use of moderate-intensity to high-intensity statins in the overall cohort (4.8%) and in the ASCVD cohort (4.3%) (P < .01 for slope for both). There was no significant change for other risk cohorts. Nonstatin LLT use remained unchanged in the preguideline and postguideline periods in the hierarchical logistic regression models for all of the risk groups.

Conclusions and Relevance

Adoption of the 2013 ACC/AHA Cholesterol Management Guideline in cardiology practices was modest. Timely interventions are needed to improve guideline-concordant practice to reduce the burden of ASCVD.

Statins for primary prevention of cardiovascular disease: modelling guidelines and patient preferences based on an Irish cohort

BACKGROUND

Changes in clinical guidelines for primary prevention of cardiovascular disease (CVD) have widened eligibility for statin therapy.

AIM

To illustrate the potential impacts of changes in clinical guidelines.

DESIGN AND SETTING

Modelling the impacts of seven consecutive European guidelines based on a cohort of people aged ≥50 years from the Irish Longitudinal Study on Ageing.

METHOD

The eligibility for statin therapy of a sample of people without a history of CVD was established, according to changing guideline recommendations and modelled associated potential costs. The authors calculated the numbers needed to treat (NNT) to prevent one major vascular event in patients at the lowest baseline risk for which each of the seven guidelines recommended treatment, and for those at low, medium, high, and very-high risk according to 2016 guidelines. These were compared with the NNT that patients reported as required to justify taking a daily medicine.

RESULTS

The proportion of patients eligible for statins increased from approximately 8% in 1987 to 61% in 2016; associated costs rose from €13.9 million to €107.1 million per annum. The NNT for those at the lowest risk for which each guideline recommended treatment rose from 40 to 400. By 2016, the NNT for low-risk patients was 400 compared to ≤25 very-high risk patients. The proportion of patients eligible for statins achieving NNT levels that patients regarded as justified to taking a daily medicine fell as guidelines changed over time.

CONCLUSION

Increased eligibility for statin therapy impacts large proportions of the present population and healthcare budgets. Decisions to take and reimburse statins should be considered on the basis of expected cost-effectiveness and acceptability to patients.

Pharmacist Statin Prescribing Initiative in Diabetic Patients at an Internal Medicine Resident Clinic

BACKGROUND

Despite general increases in statin use in the United States, statin therapy may be underutilized in diabetic patients and vulnerable populations.

OBJECTIVE

To determine the impact of a collaborative pharmacist initiative on statin prescribing for diabetic patients in an internal medicine residency clinic. The primary outcome was the change in prevalence of patients on statin therapy before and after intervention implementation. Secondary outcomes included recommendation acceptance rates and reported adverse effects.

METHODS

This was a single-center, quasi-experimental pre-post intervention study. The study site was a hospital-based primary care residency clinic serving patients regardless of financial or insurance status. Diabetic patients 40 to 75 years old who were not on a statin and had an upcoming primary care physician appointment were included. Over 3 months, a clinical pharmacist and pharmacy resident evaluated clinical appropriateness and cost of statin therapy, provided recommendations to physicians, facilitated statin prescribing, and provided patient education.

RESULTS

Of 454 patients, 343 were on statin therapy (75.6%) prior to the initiative. The mean age was 58 years, 59.7% were female, 76.4% were black, and 90% had hypertension. After implementation, 375 (82.6%) patients were on statins (P < .0001). Recommendations were well received (90.2% accepted) and no significant adverse effects were reported.

CONCLUSION

Pharmacist implementation of a collaborative, patient-centered initiative increased statin prescribing in diabetic patients, most of which were black and had hypertension, in an internal medicine resident clinic.

Does clinician-reported lipid guideline adoption translate to guideline-adherent care? An evaluation of the Patient and Provider Assessment of Lipid Management (PALM) registry

BACKGROUND

The 2013 American College of Cardiology (ACC)/American Heart Association (AHA) cholesterol guideline recommends statin treatment based on patients' predicted atherosclerotic cardiovascular disease (ASCVD) risk. Whether clinician-reported guideline adoption translates to implementation into practice is unknown.

OBJECTIVES

We aimed to compare clinician lipid management in hypothetical scenarios versus observed practice.

METHODS

The PALM Registry asked 774 clinicians how they would treat 4 hypothetical scenarios of primary prevention patients with: (1) diabetes; (2) high 10-year ASCVD risk (≥7.5%) with high low-density lipoprotein cholesterol (LDL-C; ≥130 mg/dL); (3) low 10-year ASCVD risk (<7.5%) with high LDL-C (130-189 mg/dL); or (4) primary and secondary prevention patients with persistently elevated LDL-C (≥130 mg/dL) despite high-intensity statin use. We assessed agreement between clinician survey responses and observed practice.

RESULTS

In primary prevention scenarios, 85% of clinicians reported they would prescribe a statin to a diabetic patient and 93% to a high-risk/high LDL-C patient (both indicated by guidelines), while 40% would prescribe statins to a low-risk/high LDL-C patient. In clinical practice, statin prescription rates were 68% for diabetic patients, 40% for high-risk/high LDL-C patients, and 50% for low-risk/high LDL-C patients. Agreement between hypothetical and observed practice was 64%, 39%, and 52% for patients with diabetes, high-risk/high LDL-C, and low-risk/high LDL-C, respectively. Among patients with persistently high LDL-C despite high-intensity statin treatment, 55% of providers reported they would add a non-statin lipid-lowering medication, while only 22% of patients were so treated.

CONCLUSIONS

While the majority of clinicians report adoption of the 2013 ACC/AHA guideline recommendations, observed lipid management decisions in practice are frequently discordant.

Chest Pain, Atherosclerotic Cardiovascular Disease Risk, and Cardiology Referral in Primary Care

Background: The atherosclerotic cardiovascular disease (ASCVD) 10-year risk estimate is recommended by cardiologists for determining risk of a cardiac event. However, the majority of patients presenting to primary care with chest pain have noncardiac etiologies. Therefore, we determined if high versus low ASCVD risk was associated with primary care physicians’ referral to cardiology in patients with and without chest pain. Methods: Deidentified electronic health record (EHR) data was obtained from 5795 patients treated in academic primary care clinics from 2008 to 2015. Referral to cardiology was defined by an EHR code, chest pain was defined by ICD-9-CM code (786.5) and ASCVD was modeled as high versus low risk. Separate logistic regression models were computed to estimate the association between chest pain and referral to cardiology, ASCVD risk and referral, and both chest pain and ASCVD risk and referral with adjustment for potential confounding factors. Results: More patients with (n = 95, 7.8%) versus without (n = 75, 2.0%) chest pain were referred to cardiology (P < .0001). Separate unadjusted models revealed chest pain and high versus low ASCVD risk were significantly associated with referral (odds ratio [OR] = 4.20; 95% confidence interval [CI] 3.07-5.73 and OR = 1.41; 95% CI 1.04-1.91, respectively). After adjusting for ASCVD risk and confounders, chest pain but not high ASCVD risk remained significantly associated with referral (OR = 1.75; 95% CI 1.24-2.47 and OR = 1.15; 95% CI 0.72-1.82, respectively). Conclusions: In primary care patients presenting with chest pain, ASCVD risk scores are not associated with referral to cardiology. Overall, less than 8% of patients with chest pain were referred. While there is no evidence to indicate excessive referral to cardiology, we posit that implementing ASCVD risk tools in decision aids could contribute to referring those most in need of cardiology care.

Comparison of Adherence to the 2013 ACC/AHA Cholesterol Guideline in a Teaching Versus Nonteaching Outpatient Clinic

BACKGROUND

Little information is available regarding prescribers' adherence rate to the 2013 American College of Cardiology (ACC)/American Heart Association (AHA) cholesterol guideline, especially that from a teaching versus a nonteaching setting.

OBJECTIVES

We aim to evaluate adherence rates to the 2013 ACC/AHA cholesterol guideline in a teaching versus a nonteaching practice site. In addition, the impact of a pharmacist-led seminar on adherence rate to the guideline was assessed.

METHODS

This study is a 2-part retrospective chart review. Part 1 consists of patients who were initiated on statin therapy between December 2013 and November 2014. Patients were analyzed to determine if they received concordant statin therapy as recommended by the guideline. For the second part, we evaluated the impact of a seminar on the adherence rate to the guideline.

RESULTS

Of the 325 patients who received a statin prescription, 233 were included in the study. Prescriber adherence to the guideline was 42.9%, which was significantly lower than the 65.8% observed in a study previously conducted at a teaching outpatient clinic ( P < 0.0001). For the second part of our study, prescriber adherence to the guideline 3 months before the pharmacist-led seminar was 53.5%, and this adherence rate remained virtually unchanged at 54.2% at 3 months after the educational session.

CONCLUSION

The overall adherence rate to the 2013 ACC/AHA cholesterol guideline from this nonteaching outpatient clinic was significantly lower than that previously observed in a teaching outpatient clinic. The single pharmacist-led seminar did not significantly affect prescribers' adherence rate to the guideline.

Monitoring Prevalence, Treatment, and Control of Metabolic Conditions in New York City Adults Using 2013 Primary Care Electronic Health Records: A Surveillance Validation Study

Introduction:

Electronic health records (EHRs) can potentially extend chronic disease surveillance, but few EHR-based initiatives tracking population-based metrics have been validated for accuracy. We designed a new EHR-based population health surveillance system for New York City (NYC) known as NYC Macroscope. This report is the third in a 3-part series describing the development and validation of that system. The first report describes governance and technical infrastructure underlying the NYC Macroscope. The second report describes validation methods and presents validation results for estimates of obesity, smoking, depression and influenza vaccination. In this third paper we present validation findings for metabolic indicators (hypertension, hyperlipidemia, diabetes).

Methods:

We compared EHR-based estimates to those from a gold standard surveillance source - the 2013–2014 NYC Health and Nutrition Examination Survey (NYC HANES) - overall and stratified by sex and age group, using the two one-sided test of equivalence and other validation criteria.

Results:

EHR-based hypertension prevalence estimates were highly concordant with NYC HANES estimates. Diabetes prevalence estimates were highly concordant when measuring diagnosed diabetes but less so when incorporating laboratory results. Hypercholesterolemia prevalence estimates were less concordant overall. Measures to assess treatment and control of the 3 metabolic conditions performed poorly.

Discussion:

While indicator performance was variable, findings here confirm that a carefully constructed EHR-based surveillance system can generate prevalence estimates comparable to those from gold-standard examination surveys for certain metabolic conditions such as hypertension and diabetes.

Conclusions:

Standardized EHR metrics have potential utility for surveillance at lower annual costs than surveys, especially as representativeness of contributing clinical practices to EHR-based surveillance systems increases.

Atorvastatin treatment and LDL cholesterol target attainment in patients at very high cardiovascular risk

The use of atorvastatin is rapidly increasing among statins since the introduction of generics. However, only limited data are available on its current use and the effectiveness outside of randomised trials. The aim of the study was to assess low-density lipoprotein (LDL-C) levels in ambulatory patients at very high cardiovascular risk on atorvastatin therapy in physician's offices. A total of 2625 high-risk patients on atorvastatin were included into this cross-sectional study by 539 office-based physicians between June and December 2014. 47.0 % of the patients had documented coronary heart disease (CHD), 25.1 % type 2 diabetes mellitus (DM), and 27.9 % CHD plus concomitant DM. The mean age was 66.1 ± 10.8 years, 62.1 % were male. Atorvastatin at the dose of 10, 20, 40 and 80 mg/day was administered in 15.6, 45.7, 33.9, and 4.8 % of the patients, respectively. The treatment duration was 92.6 ± 109.6 weeks. The mean atorvastatin dose at therapy start was 24.8 ± 15.2 mg/day and at time of documentation 27.9 ± 15.8 mg/day. Low-density lipoprotein cholesterol (LDL-C) <70 mg/dL was achieved by 10.5 % of the total cohort (7.5 % in DM, 9.3 % in CHD, and 15.2 % in CHD + DM). In contrast, according to physicians' subjective assessment, 62.7 % of patients (with small differences between groups) had reached their individual LDL-C target. In summary, higher doses of atorvastatin are not frequently used in clinical practice. The LDL-C target level <70 mg/dL as recommended by current guidelines is achieved only in a minority of atorvastatin treated patients at very high cardiovascular risk.

Adherence to the 2013 Blood Cholesterol Guidelines in Patients With Diabetes at a PCMH: Comparison of Physician Only and Combination Physician/Pharmacist Visits

PURPOSE

The purpose of this study is to assess adherence to the 2013 blood cholesterol guideline in a population with diabetes based on the atherosclerotic cardiovascular (ASCVD) risk.

METHODS

Patients with diabetes were assessed to see whether they received the appropriate intensity statin therapy via chart review. Patients seen by a physician or pharmacist at CommUnityCare, a PCMH, from December 2013 to October 2014 were included in this retrospective study. The ASCVD risks were calculated to determine if the patients received appropriate intensity statin.

RESULTS

A total of 583 patients met the inclusion criteria; there were 475 in the physician only group and 108 with additional pharmacist visits. Statin therapy was prescribed in 71% of patients in the physician group and 88% of patients in the pharmacist/physician group. The appropriate intensity statin was prescribed in 32% of patients in the physician group and 35% of patients in the pharmacist/physician group. The appropriate intensity statin in statin naïve patients was prescribed in 45% of the physician group and 50% of patients in the pharmacist/physician group.

CONCLUSION

The proportion of patients prescribed an appropriate intensity statin did not differ between patients managed by physicians alone compared to those managed by pharmacists and physicians. Overall adherence to the 2013 blood cholesterol guidelines was 33%, and this measure can be used as a baseline assessment of current adherence with the guidelines.

Comparison of Adherence to Guideline-Based Cholesterol Treatment Goals in Men Versus Women

Studies show women do not receive aggressive cardiovascular interventions and may not be given guideline-based treatment to reduce cardiac events. We describe cholesterol treatment in an academic practice of family and internal medicine physicians to understand factors associated with achievement of guideline-based treatment goals in women compared with men. Primary care patients aged 40 to 75 years were included if they were prescribed a statin, had a Framingham risk score of ≥ 10%, had diabetes, or had atherosclerotic cardiovascular disease. Patients were classified into Adult Treatment Panel III categories and assessed to whether they were in compliance with Adult Treatment Panel III guidelines. Odds ratios of goal adherence between women and men were calculated, and a multivariate model for goal achievement was created. In 2,747 patients, women were less likely to achieve cholesterol goals (odds ratio [OR] 0.82; 95% confidence interval [CI] 0.70 to 0.95) despite having more prescriptions for statins (48% vs 39%, p <0.001). More women than men failed to reach low-density lipoprotein goals because they were not prescribed a statin (OR 0.69; 95% CI 0.56 to 0.85) and women on high-intensity statins were less likely than men to achieve goals (OR 0.51; 95% CI 0.27 to 0.96). In all patients, diabetes was associated with nonattainment of cholesterol goals, but in high-risk women, the presence of diabetes improved goal achievement. In conclusion, women achieved guideline-based cholesterol recommendations at a lower rate than men, even when individual goals are considered.

Deficits in allergy knowledge among physicians at academic medical centers

BACKGROUND

Allergic conditions have high prevalence in the general population. Misconceptions regarding the diagnosis and management of allergic disease among physicians can lead to suboptimal clinical care.

OBJECTIVE

To determine the extent of allergy-related knowledge deficits among physicians.

METHODS

Pediatric and internal medicine resident and attending physicians from 2 separate academic medical centers were asked to answer an anonymous electronic survey. Survey questions addressed 7 different allergy content areas.

RESULTS

Four hundred eight physicians completed surveys (23.9% response rate). Respondents had few correct answers (mean ± SD 1.91 ± 1.43). Pediatric respondents had a larger number of correct answers compared with medicine-trained physicians (P < .001). No individual answered every survey question correctly, and 50 respondents (12.3%) had no correct answer. Three hundred seventy-eight respondents (92.6%) were unable to provide correct answers for at least 50% of survey questions. Level of residency training and prior rotation through an allergy and immunology elective correlated with a larger number of correct responses (P < .01). Only 1 survey question had an overall correct response rate higher than 50% (n = 261, 64%). Correct response rate was lower than 30% for 7 of the 9 possible questions.

CONCLUSION

There are significant knowledge deficits in many areas of allergy-related content among pediatric and internal medicine physicians and across all levels of training and specialty. Given the prevalence of allergic conditions, the potential implications of a negative impact on clinical care are staggering.