Health care access in allergy and immunology: Problems and potential solutions

Nonallergist Delabeling-Should Penicillin Allergy Delabeling Only Be Performed by Allergists?

Penicillin allergy labels (PAL) are common but rarely correspond with a patient's likelihood to tolerate penicillin. This results in unnecessary penicillin avoidance in many patients, driving numerous negative health outcomes. Evaluation strategies for a PAL are driven by risk stratification and include a spectrum of modalities such as delabeling without any testing, direct oral challenge, and skin testing followed by challenge testing. Historically, PAL delabeling has primarily been the domain of the allergist, but this has resulted in significant limitations in access to testing for many patients globally and in the United States. Novel strategies to increase access to penicillin allergy evaluations are urgently needed, and nonallergist delabeling has been proposed as one strategy to help address this. Using a pro/con format, we review the evidence for nonallergist PAL delabeling in children and adults, focusing on direct challenge testing and highlighting considerations to guide nonallergist implementation of penicillin allergy evaluations.

Diagnostic disparities in inborn errors of immunity: From clinical suspicion to diagnosis

Background

Emerging evidence suggests that inborn errors of immunity (IEI) are underdiagnosed among underserved populations. However, there remains a lack of national studies evaluating diagnostic disparities in IEI.

Objective

We examined disparities in the timely IEI diagnosis and related health outcomes.

Methods

A retrospective analysis was performed of a US national claims database (years 2007 to 2021). Participants included patients diagnosed with an "unspecified immune deficiency" (uID) and presented with IEI-related symptoms, who later received an IEI diagnosis (n = 1429). We quantified the diagnostic interval from clinical suspicion (uID) to IEI diagnosis and examined its association with sociodemographic factors and related health outcomes.

Results

The median (interquartile range) diagnostic interval was 369 (126-808) days. Diagnostic interval was 14% longer among patients residing in predominantly non-White neighborhoods, compared with those in predominantly White neighborhoods (P = .04), despite having more severe IEI-related symptoms at uID diagnosis and significantly more health care encounters for pneumonia (incidence rate ratio, 2.24; 95% confidence interval, 1.40-3.70) and sepsis (incidence rate ratio, 2.15; 95% confidence interval, 1.21-3.99) in the year after uID diagnosis. Residence in neighborhoods with greater deprivation was also associated with more severe IEI-related symptoms and greater health care utilization in the year after uID diagnosis. Older age was associated with longer diagnostic interval (P < .001). Longer diagnostic interval was associated with a longer interval to receiving IgR therapy (hazard ratio, 0.64; 95% confidence interval, 0.49-0.83).

Conclusion

We observed significant racial and socioeconomic disparities in the timeliness of IEI diagnosis and IEI-related outcomes. Further studies are needed to address the underlying factors contributing to diagnostic inequity.

Inequalities in Access to Specialist Allergy Services in the United Kingdom: A Report From the BSACI Registry for Immunotherapy (BRIT)

BACKGROUND

There is an unmet need for specialist allergy treatment in the United Kingdom. Allergen immunotherapy and treatment with omalizumab for chronic spontaneous urticaria (CSU) are key markers for these services. The British Society for Allergy and Clinical Immunology (BSACI) Registry for Immunotherapy (BRIT) is a national project to record the real-world effectiveness, safety and access to treatment for aero-allergen, venom and peanut immunotherapy as well as omalizumab for CSU.

METHODS

We described participant demographics, the index of multiple deprivation (IMD) and access to treatment from the registry launch. Data for 1835 participants were available for analysis from 63 centres enrolled between 1st October 2018 and 24th August 2023.

RESULTS

96.5% (1771/1835) were living in England, with only 3.5% (64) being from the devolved nations. 14.4% (251/1748) were in the most affluent IMD decile compared to 4.5% (78/1748) in the most deprived IMD decile. White participants were 1.74 times more likely to be referred directly from primary care compared to people of Asian, black, mixed or other minority ethnic groups. Instead, these groups were referred more frequently from secondary or tertiary hospital services. The median distance travelled from home to the treatment centre was 15.2 miles, with evidence of clustering around specialist centres.

CONCLUSIONS

We have described disparities and unwarranted variation in the provision of treatment around the UK. The data suggest that there is limited access to immunotherapy in the devolved nations. Access is also reduced by socioeconomic deprivation. White participants were more likely to receive a direct referral from primary care than those from other ethnic groups whose referral pathways were more complex. Registry data are limited by participant enrolment and may have selection bias. Nevertheless, BRIT has highlighted inequity in access to specialist allergy services in the UK.

Factors Affecting Adherence in Allergic Disorders and Strategies for Improvement

Addressing patient adherence is a key element in ensuring positive health outcomes and improving health-related quality of life for patients with atopic and immunologic disorders. Understanding the complex etiologies of patient nonadherence and identifying real-world solutions is important for clinicians, patients, and systems to design and effect change. This review serves as an important resource for defining key issues related to patient nonadherence and outlines solutions, resources, knowledge gaps, and advocacy areas across five domains: health care access, financial considerations, socioenvironmental factors, health literacy, and psychosocial factors. To allow for more easily digestible and usable content, we describe solutions based on three macrolevels of focus: patient, clinician, and system. This review and interactive tool kit serve as an educational resource and call to action to improve equitable distribution of resources, institutional policies, patient-centered care, and practice guidelines for improving health outcomes for all patients with atopic and immunologic disorders.

Asthma management in the digital age

Asthma affects 25 million people in the United States, and its prevalence is increasing. Access to care and adherence to prescribed asthma-treatment programs remain the principal formidable challenges for asthma management. Telemedicine offers substantial opportunities for improved asthma care of patients across the full range of socioeconomic strata. Ever-improving digital tools for asthma assessment and treatment are key components of telemedicine platforms for asthma management. These include a variety of remote patient-monitoring devices, digital inhaler systems, and mobile-health applications that facilitate ongoing assessment and adherence to treatment protocols. Digital tools for monitoring treatment focus on tracking medication use, inhalation technique, and physiological markers such as peak-flow rate and pulse-oximetry. Telemedicine visits allow for elements of assessment via video, approximating or duplicating many aspects of in-person visits, such as evaluating a patient's general appearance, breathing effort, and cough. Challenges remain in ensuring equitable access to these technologies, especially in rural and low-income areas, and in maintaining patient privacy and data security in digital platforms.