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Nochaiwong S, Chuamanochan M, Ruengorn C, Awiphan R, Bernstein JA, Thavorn K. Cost and Cost-Effectiveness of the Management Strategies of Chronic Urticaria: A Systematic Review. JAMA Dermatol 2024:2823063. [PMID: 39196583 DOI: 10.1001/jamadermatol.2024.2863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2024]
Abstract
Importance Although treatment for chronic urticaria (CU) has improved over the past decades, evidence regarding costs and net benefits associated with these treatment strategies have yet to be comprehensively characterized and synthesized. Objective To summarize the cost and cost-effectiveness of CU management strategies. Evidence Review An extensive systematic literature search of 6 databases (MEDLINE, Embase, PubMed Cochrane, Scopus, and CINAHL) and gray literature sources, without language restriction, was conducted and updated to March 23, 2024. Articles that performed cost analysis or full economic evaluation among patients with CU were included. Two reviewers independently extracted data, such as annual costs of health care services or incremental cost-effectiveness ratio (ICER) per quality-adjusted life-year (QALY). All monetary values were converted and inflated to 2023 US dollars. Evidence-based synthesis for health benefit was judged using the Evidence Rating Matrix by the Institute for Clinical and Economic Review. Findings Seventeen unique studies (11 cost analysis studies and 6 full economic evaluations) were included. With the wide variation in health care resources, services that included biologic omalizumab utilization had higher annual health care cost estimations for CU management than services that did not include omalizumab prescription (median [IQR] cost, $6933 [$5988-$8717] vs $5621 [$2488-$8754]). The biologic omalizumab, 300 mg, for H1 antihistamine-refractory chronic spontaneous urticaria (CSU) (3 studies) was found to have a median (IQR) ICER of $89 005 ($36 058-$145 694) per QALY (evidence rating as incremental or better; moderate certainty with substantial net health benefit). Routine laboratory testing among patients with CSU with otherwise normal histories and physical examination findings (1 study) had ICERs ranging from $1 427 928 to $1 950 524 per QALY (evidence rating as comparable or inferior; moderate certainty that the net health benefit is inferior). Conclusions and Relevance With limited evidence of cost-effectiveness, biologic omalizumab, 300 mg, for H1 antihistamine-refractory CSU was found to be cost-effective in US health care services at the willingness to pay threshold of $150 000 per QALY. Meanwhile, routine laboratory testing among patients with CSU without compelling indication was not cost-effective. Future studies in more diverse CU populations and resource settings are needed to fill evidence gaps.
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Affiliation(s)
- Surapon Nochaiwong
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
- Pharmacoepidemiology and Statistics Research Center (PESRC), Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
| | - Mati Chuamanochan
- Pharmacoepidemiology and Statistics Research Center (PESRC), Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
- Division of Dermatology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Chidchanok Ruengorn
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
- Pharmacoepidemiology and Statistics Research Center (PESRC), Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
| | - Ratanaporn Awiphan
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
- Pharmacoepidemiology and Statistics Research Center (PESRC), Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
| | - Jonathan A Bernstein
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Kednapa Thavorn
- Pharmacoepidemiology and Statistics Research Center (PESRC), Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
- Ottawa Hospital Research Institute, Ottawa Hospital, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
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2
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Joshi SR, Anstey KM, Khan DA. Chronic Spontaneous Urticaria: An Update on the Evaluation and Management. Immunol Allergy Clin North Am 2024; 44:503-515. [PMID: 38937012 DOI: 10.1016/j.iac.2024.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Abstract
Chronic spontaneous urticaria (CSU) affects 0.5% to 1% of the general population and is often managed by allergy and immunology specialists. Guidelines have evolved over the past several decades with an emphasis on decreasing extensive screening laboratory testing as they are of low-yield and cost-ineffective. The utility of biomarkers remains under investigation but total immunoglobulin E may be helpful in determining specific endotypes and response to omalizumab. Antihistamines and omalizumab remain the primary therapeutic options for CSU, but an expanding body of evidence supports the use of immunosuppressants and anti-inflammatory medications in refractory cases.
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Affiliation(s)
- Shyam R Joshi
- Department of Medicine, Section of Allergy and Immunology, Oregon Health and Science University, 3181 Southwest Sam Jackson Park Road, PPV320, Portland, OR 97239, USA
| | - Karen M Anstey
- Department of Medicine, Section of Allergy and Immunology, Oregon Health and Science University, 3181 Southwest Sam Jackson Park Road, PPV320, Portland, OR 97239, USA
| | - David A Khan
- Department of Internal Medicine, Division of Allergy & Immunology, University of Texas Southwestern Medical Center, 5939 Harry Hines Boulevard, HQ9.935, Dallas, TX 75390-8503, USA.
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3
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Keller L, Stitt J. Chronic Spontaneous Urticaria: Quality of Life and Economic Impacts. Immunol Allergy Clin North Am 2024; 44:453-467. [PMID: 38937009 DOI: 10.1016/j.iac.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Abstract
This study focuses on quality of life (QoL) assessment in chronic urticaria, delving into tools, disease-specific measures, and its profound impact. With expanding therapeutic options, understanding QoL becomes crucial. QoL measures often involve comparisons of patient-reported outcomes in addition to quantitative measures of disease control. Emerging tools include the Urticaria Activity and Impact Measure, which may provide a balanced evaluation. In addition to discussions of the various QoL measures, the psychological impact of chronic urticaria are highlighted, covering emotional burden, stress, and psychiatric comorbidities. Finally, the economic impacts reveal escalating health care costs and cost-effectiveness considerations of therapies like omalizumab.
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Affiliation(s)
- Levi Keller
- Division of Allergy and Clinical Immunology, University of Colorado School of Medicine, 12700 East 19th Avenue 10C03, Aurora, CO 80045, USA.
| | - Jenny Stitt
- Division of Allergy and Clinical Immunology, University of Colorado School of Medicine, 12700 East 19th Avenue 10C03, Aurora, CO 80045, USA
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Maurer M, Albuquerque M, Boursiquot JN, Dery E, Giménez-Arnau A, Godse K, Guitiérrez G, Kanani A, Lacuesta G, McCarthy J, Nigen S, Winders T. A Patient Charter for Chronic Urticaria. Adv Ther 2024; 41:14-33. [PMID: 37991694 PMCID: PMC10796664 DOI: 10.1007/s12325-023-02724-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 10/30/2023] [Indexed: 11/23/2023]
Abstract
Chronic urticaria (CU) is the recurring development of wheals (aka "hives" or "welts"), angioedema, or both for more than 6 weeks. Wheals and angioedema occur with no definite triggers in chronic spontaneous urticaria, and in response to known and definite physical triggers in chronic inducible urticaria. Approximately 1.4% of individuals globally will have CU during their lifetime. The itching and physical discomfort associated with CU have a profound impact on daily activities, sexual function, work or school performance, and sleep, causing significant impairment in a patient's physical and mental quality of life. CU also places a financial burden on patients and healthcare systems. Patients should feel empowered to self-advocate to receive the best care. The voice of the patient in navigating the journey of CU diagnosis and management may improve patient-provider communication, thereby improving diagnosis and outcomes. A collaboration of patients, providers, advocacy organizations, and pharmaceutical representatives have created a patient charter to define the realistic and achievable principles of care that patients with CU should expect to receive. Principle (1): I deserve an accurate and timely diagnosis of my CU; Principle (2): I deserve access to specialty care for my CU; Principle (3): I deserve access to innovative treatments that reduce the burden of CU on my daily life; Principle (4): I deserve to be free of unnecessary treatment-related side-effects during the management of my CU; and Principle (5): I expect a holistic treatment approach to address all the components of my life impacted by CU. The stated principles may serve as a guide for healthcare providers who care for patients with CU and translate into better patient-physician communication. In addition, we urge policymakers and authors of CU treatment guidelines to consider these principles in their decision-making to ensure the goals of the patient are achievable.
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Affiliation(s)
- Marcus Maurer
- Institute of Allergology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany
| | | | | | - Elaine Dery
- Canadian Chronic Urticaria Society, Quebec City, Canada
| | - Ana Giménez-Arnau
- Hospital del Mar Research Institute, Universitat Pompeu Fabra, Barcelona, Spain
| | | | | | - Amin Kanani
- University of British Columbia, Vancouver, Canada
| | | | | | - Simon Nigen
- Montreal General Hospital, McGill University, Montreal, Canada
| | - Tonya Winders
- Global Allergy & Airways Patient Platform, Vienna, Austria.
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5
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Shaker M, Mauger D, Fuhlbrigge AL. Value-Based, Cost-Effective Care: The Role of the Allergist-Immunologist. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:132-139. [PMID: 35944893 DOI: 10.1016/j.jaip.2022.07.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 07/19/2022] [Accepted: 07/21/2022] [Indexed: 01/11/2023]
Abstract
Asthma and allergic disease impact millions of patients and are associated with high costs. Up to 30% of all medical care involves wasted spending. Across the spectrum of care provided by the allergist-immunologist, there are opportunities to improve value and reduce medical waste. Several examples highlight this reality. Evidence suggests that most patients may receive cost-effective care in the management of chronic spontaneous urticaria without the need for laboratory testing. For patients with asthma, although a single maintenance and reliever therapy approach may be cost-effective, insurance-mandated therapy changes are not, and may harm patients. Biologics may be very effective in improving asthma control but are too expensive for this indication-as demonstrated by cost-effectiveness analyses and highlighted by the Institute of Clinical and Economic Review, which concluded that the value-based price for asthma biologics ranges between $6500 and 14,3000 per year. Early introduction may prevent food allergy, but screening before first introduction is neither necessary nor cost-effective, although early salvage food oral immunotherapy may result in improved quality of life and cost savings. Evidence does not support the presence of allergic disease as a risk factor for anaphylaxis to coronavirus disease 2019 vaccination, and risk-stratified vaccination approaches do not appear cost-effective. Allergen immunotherapy is a very cost-effective treatment option. The practice of allergy-immunology has continued to evolve in recent years and can provide a leading example of high-value practice.
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Affiliation(s)
- Marcus Shaker
- Section of Allergy and Immunology, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Department of Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, NH; Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH.
| | - David Mauger
- Department of Public Health Sciences, Division of Biostatistics and Bioinformatics, The Pennsylvania State University, State College, Pa
| | - Anne L Fuhlbrigge
- Pulmonary Science and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colo
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6
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Do regional geography and race influence management of chronic spontaneous urticaria? J Allergy Clin Immunol 2022; 150:1260-1264.e7. [PMID: 36481046 DOI: 10.1016/j.jaci.2022.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 09/21/2022] [Accepted: 10/18/2022] [Indexed: 12/07/2022]
Abstract
Chronic spontaneous urticaria is defined as migratory evanescent pruritic blanching wheals that occur with variable frequency for 6 weeks or more, with or without accompanying angioedema. This condition affects approximately 0.1% to 1.4% of persons worldwide. Second-generation H1 antihistamines are the mainstay of management, with refractory cases often managed with an array of options, including H2 antihistamines, leukotriene receptor antagonists, glucocorticosteroids, immunosuppressive agents, and omalizumab. However, the degree of practice variation as to what treatments are prescribed is poorly understood, given that clinical care could be driven by patient preferences or lack of clarity as to best practices for refractory cases. We conducted a small, exploratory study of the role of race, ethnicity, and regional geographic distance to specialist care on chronic spontaneous urticaria prescribing practices. A small-area geographic variation in chronic spontaneous urticaria management in a large Chicago-area health care system was identified. Rates of omalizumab use varied by patient zip code, with more omalizumab prescriptions being associated with zip codes closer to the main office of an academic medical center-affiliated allergist-immunologist practice. Higher rates of omalizumab use were associated with White race in regional and patient-level analyses, though the reasons for this race-based finding are not clear.
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Affiliation(s)
- David M Lang
- From the Cleveland Clinic, Respiratory Institute, Department of Allergy and Clinical Immunology, Cleveland
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8
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Waters AM, Park HJ, Weskamp AL, Mateja A, Kachur ME, Lyons JJ, Rosen BJ, Boggs NA. Elevated Basal Serum Tryptase: Disease Distribution and Variability in a Regional Health System. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:2424-2435.e5. [PMID: 35032694 PMCID: PMC9273808 DOI: 10.1016/j.jaip.2021.12.031] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 12/29/2021] [Accepted: 12/30/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Hereditary-alpha tryptasemia (HαT) is the most common etiology for elevated basal serum tryptase (BST). However, the utility of tryptase genotyping of individuals with elevated BST in general clinical practice remains undefined. Moreover, studies showing associations between elevated BST and chronic kidney disease (CKD), myelodysplastic syndrome (MDS), rheumatoid arthritis, or eosinophilic esophagitis did not include tryptase genotyping. OBJECTIVE To determine the utility of tryptase genotyping among individuals with moderate elevations in BST at a regional health system. METHODS Clinical and laboratory data from 109 subjects with basal tryptase values of 7.5 ng/mL or greater who were tested for HαT or had a disorder previously linked to elevated BST were collected retrospectively by chart review. RESULTS Fifty-eight subjects had elevated BST defined as 11.5 ng/mL or greater. HαT was found in 63.8% (n = 37), 12.1% (n = 7) had CKD, and 20.7% (n = 12) had clonal myeloid disorders. A total of 6.9% (n = 4) with elevated BST had negative testing for HαT, CKD, and myeloid neoplasms. Two subjects with CKD, 1 subject with MDS, and 1 with myeloid hypereosinophilic syndrome had negative testing for HαT. Among subjects with elevated BST and more than 1 tryptase measurement, 41.5% (n = 22) had BST variability that exceeded the 20% plus 2 formula. Increased BST variability was found in subjects with HαT, all forms of mastocytosis, CKD, MDS, and those with no associated diagnosis. CONCLUSIONS HαT, CKD, and clonal myeloid disorders or a combination of the 3 constitute approximately 90% of individuals with elevated BST in clinical practice. Myeloid neoplasms were over-represented in this cohort relative to population prevalence data suggesting tryptase measurement selection bias by clinicians or higher prevalence. Elevated BST is associated with increased tryptase variability, regardless of etiology.
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Affiliation(s)
- Aubri M Waters
- Allergy and Immunology Service, Walter Reed National Military Medical Center, Bethesda, Md
| | - Hyun J Park
- Allergy and Immunology Service, Walter Reed National Military Medical Center, Bethesda, Md
| | - Andrew L Weskamp
- Internal Medicine Service, Walter Reed National Military Medical Center, Bethesda, Md
| | - Allyson Mateja
- Clinical Monitoring Research Program Directorate, Frederick National Laboratory for Cancer Research, Frederick, Md
| | - Megan E Kachur
- Department of Pathology, Walter Reed National Military Medical Center, Bethesda, Md
| | - Jonathan J Lyons
- Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Benjamin J Rosen
- Hematopathology Service, Walter Reed National Military Medical Center, Bethesda, Md
| | - Nathan A Boggs
- Allergy and Immunology Service, Walter Reed National Military Medical Center, Bethesda, Md; Department of Medicine, Uniformed Services University, Bethesda, Md.
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9
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Vassilopoulou E, Skypala I, Feketea G, Gawlik R, Dunn Galvin A, Meyer R, Pitsios C, Maria Pop R, Ryan D, Said M, Schiere S, Vlieg-Boerstra B, Kull I. A multi-disciplinary approach to the diagnosis and management of allergic diseases: An EAACI Task Force. Pediatr Allergy Immunol 2022; 33:e13692. [PMID: 34724234 DOI: 10.1111/pai.13692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 10/19/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Guidelines for management of patients with allergic conditions are available, but the added value of nurses, allied healthcare professionals (AHPs), and general practitioners (GPs), in the management of allergic disease, has not been fully clarified. The European Academy of Allergy and Clinical Immunology (EAACI) appointed a task force to explore this issue. AIM To investigate the added value of nurses, AHPs, and GPs in management of allergic diseases, in an integrated model of care. METHODS A search was made of peer-reviewed literature published between 2010 and December 2020 (Cochrane Library, PubMed, and CINAHL) on the involvement of the various specific healthcare providers (HCPs) in the management of allergic diseases. RESULTS Facilitative models of care for patients with allergies can be achieved if HCP collaborates in the diagnosis and management. Working in multi-disciplinary teams (MDT) can increase patients' understanding of the disease, adherence to treatment, self-care capabilities, and ultimately improve quality of life. The MDT competencies and procedures can be improved and enhanced in a climate of mutual respect and shared values, and with inclusion of patients in the planning of care. Patient-centered communication among HCPs and emphasis on the added value of each profession can create an effective integrated model of care for patients with allergic diseases. CONCLUSION Nurses, AHPs, and GPs, both individually and in collaboration, can contribute to the improvement of the management of patients with allergic disease. The interaction between the HCPs and the patients themselves can ensure maximum support for people with allergies.
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Affiliation(s)
- Emilia Vassilopoulou
- Department of Nutritional Sciences and Dietetics, International Hellenic University, Thessaloniki, Greece
| | - Isabel Skypala
- Department of Allergy & Clinical Immunology, Royal Brompton & Harefield NHS Foundation Trust, London, and Imperial College, London, UK
| | - Gavriela Feketea
- Iuliu Hatieganu, University of Medicine and Pharmacy, Cluj-Napoca, Romania.,Department of Pediatrics, Pediatric Allergy Outpatient Clinic, "Karamandaneio", Children Hospital, Patras, Greece
| | | | | | - Rosan Meyer
- Department of Paediatrics, Imperial College London, London, UK
| | | | - Raluca Maria Pop
- Department of Pharmacology, Toxicology and Clinical Pharmacology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Dermot Ryan
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Maria Said
- Allergy & Anaphylaxis Australia, Sydney, Australia.,EAACI Patient Organisation Committee, Zurich, Switzerland
| | - Sophie Schiere
- Department of Pharmacology, Gent University, Gent, Belgium
| | | | - Inger Kull
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.,Sachs' Children and Youth Hospital, Stockholm, Sweden
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10
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Cassano N, Genovese G, Asero R, Crimi N, Cristaudo A, Dapavo P, DE Pità O, Ferrucci SM, Fierro MT, Foti C, Girolomoni G, Nettis E, Offidani A, Patrizi A, Pepe P, Pigatto P, Stingeni L, Marzano AV, Vena GA. Chronic spontaneous urticaria in clinical practice: a pilot survey about attitudes and perceptions on assessment, diagnostic work-up and dietary management. Ital J Dermatol Venerol 2020; 156:659-664. [PMID: 33228337 DOI: 10.23736/s2784-8671.20.06760-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Chronic spontaneous urticaria (CSU) is a heterogeneous condition whose management can be complex and challenging. The aim of this study is to evaluate physicians' attitudes regarding practical aspects of CSU management, including adherence to international guidelines, criteria and instruments for CSU assessment, prescription of laboratory investigations and role of dietary measures. METHODS A cross-sectional survey was conducted using a study-specific questionnaire. It was administered to a group of physicians with a specialist interest in CSU from different areas of Italy definable as "CSU experts" (group A; N.=21) and subsequently to other physicians who managed CSU only occasionally in their clinical activity (group B; N.=25). RESULTS The EAACI/GA2LEN/EDF/WAO guidelines were considered very or moderately useful by the majority of participants. Significantly more physicians in group A reported that such guidelines were always followed in clinical practice (P=0.0008). Instruments for the assessment of CSU severity/activity and quality of life were used in clinical practice significantly more often by CSU experts as compared to group B. Dietary measures were frequently suggested for CSU patients by nearly three quarters of group B members and by only 5% of CSU experts (P<0.00001). When physicians were asked to indicate the type of laboratory examinations that were commonly performed in patients with longstanding and/or uncontrolled CSU, regardless of history, the investigations most frequently reported were full blood count and thyroid autoantibodies, followed by erythrocyte sedimentation rate and/or C-reactive protein and thyroid function tests. CONCLUSIONS The results of the present pilot survey seem to suggest the heterogeneity of the approaches used for CSU management in clinical practice.
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Affiliation(s)
| | - Giovanni Genovese
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Riccardo Asero
- Outpatient Service of Allergology, San Carlo Clinic, Paderno Dugnano, Milan, Italy
| | - Nunzio Crimi
- Department of Clinical and Experimental Medicine-Respiratory Medicine and Allergy, University of Catania, Catania, Italy
| | - Antonio Cristaudo
- Service of Occupational and Environmental Allergic Dermatology, San Gallicano Dermatology Institute for Research and Care, Rome, Italy
| | - Paolo Dapavo
- Section of Dermatology, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Ornella DE Pità
- Department of Dermatology and Allergy, Cristo Re Hospital, Rome, Italy
| | - Silvia M Ferrucci
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maria T Fierro
- Section of Dermatology, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Caterina Foti
- Section of Dermatology, Department of Biomedical Science and Human Oncology, University of Bari, Bari, Italy
| | - Giampiero Girolomoni
- Section of Dermatology, Department of Medicine, University of Verona, Verona, Italy
| | - Eustachio Nettis
- Department of Emergency and Organ Transplantation, School of Allergology and Clinical Immunology, Aldo Moro University, Bari, Italy
| | - Annamaria Offidani
- Dermatology Unit, Department of Clinical and Molecular Sciences, Polytechnic Marche University, Ancona, Italy
| | - Annalisa Patrizi
- Division of Dermatology, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Patrizia Pepe
- Dermatology Unit, Surgical, Medical and Dental Department of Morphological Sciences Related to Transplant, Oncology and Regenerative Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Paolo Pigatto
- Clinical Dermatology, Department of Biomedical, Surgical and Dental Sciences, IRCCS Galeazzi Orthopedic Institute, University of Milan, Milan, Italy
| | - Luca Stingeni
- Section of Clinical, Allergological and Venereological Dermatology, Department of Medicine, University of Perugia, Perugia, Italy
| | - Angelo V Marzano
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy - .,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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11
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Oliver ET, Hogan MB. Eliminating Low-Value Medical Care in Chronic Spontaneous Urticaria. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:2370-2371. [PMID: 32620436 DOI: 10.1016/j.jaip.2020.04.065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 04/28/2020] [Accepted: 04/28/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Eric T Oliver
- Division of Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, Md.
| | - Mary Beth Hogan
- Section of Allergy/Immunology, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV
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12
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Iglesia EGA, Greenhawt M, Shaker MS. Achieving the Quadruple Aim to deliver value-based allergy care in an ever-evolving health care system. Ann Allergy Asthma Immunol 2020; 125:126-136. [PMID: 32289524 DOI: 10.1016/j.anai.2020.04.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Revised: 04/04/2020] [Accepted: 04/07/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To define the concept of value-based care in allergy, and to review challenges and opportunities in value-based health care delivery for allergists and immunologists. DATA SOURCES Articles describing practice variation, health care financing and reimbursement, shared decision-making, cost-effective health care delivery, patient-reported outcome measures, social determinants of health, and screening. STUDY SELECTIONS A narrative review detailing concepts and approaches to improve value-based health care in the context of the Quadruple Aim to address the patient and physician experience, cost, and population health. RESULTS Efforts to improve cost-effective care can be informed by understanding unwarranted geographic practice variation and benchmarking best practices. Although evidence suggests that shared decision-making and addressing social determinants of health have critical roles in high-quality care, some practices such as routine laboratory screening for urticaria, premedication to prevent recurrent low- or iso-osmolar contrast reactions, extended observation of resolved anaphylaxis, food allergy screening, and penicillin allergy overdiagnosis have high costs in relation to overall societal benefit. Food allergy prevention, newborn screening for severe combined immune deficiency, and penicillin delabeling are examples of population-based opportunities in which allergists and immunologists can assist in creating health care value. Although efforts to incentivize value-based care have emerged in recent years, the degree to which process measures improve patient-important outcomes remain uncertain. Clinician wellness must be made a priority for continued effective practice. CONCLUSION As health care systems continue to evolve, allergists and immunologists will play a key role in optimizing value by translating emerging evidence into practice and communicating novel approaches to prevent and treat allergic diseases.
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Affiliation(s)
- Edward G A Iglesia
- Division of Pediatric Allergy, Immunology, and Rheumatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Matthew Greenhawt
- Section of Allergy and Immunology, Food Challenge and Research Unit, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Marcus S Shaker
- Section of Allergy and Immunology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; Departments of Pediatrics, Medicine, and Community and Family Medicine, Dartmouth Geisel School of Medicine, Hanover, New Hampshire.
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Shaker MS, Oppenheimer J, Grayson M, Stukus D, Hartog N, Hsieh EWY, Rider N, Dutmer CM, Vander Leek TK, Kim H, Chan ES, Mack D, Ellis AK, Lang D, Lieberman J, Fleischer D, Golden DBK, Wallace D, Portnoy J, Mosnaim G, Greenhawt M. COVID-19: Pandemic Contingency Planning for the Allergy and Immunology Clinic. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:1477-1488.e5. [PMID: 32224232 PMCID: PMC7195089 DOI: 10.1016/j.jaip.2020.03.012] [Citation(s) in RCA: 210] [Impact Index Per Article: 52.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 03/18/2020] [Indexed: 01/15/2023]
Abstract
In the event of a global infectious pandemic, drastic measures may be needed that limit or require adjustment of ambulatory allergy services. However, no rationale for how to prioritize service shut down and patient care exists. A consensus-based ad-hoc expert panel of allergy/immunology specialists from the United States and Canada developed a service and patient prioritization schematic to temporarily triage allergy/immunology services. Recommendations and feedback were developed iteratively, using an adapted modified Delphi methodology to achieve consensus. During the ongoing pandemic while social distancing is being encouraged, most allergy/immunology care could be postponed/delayed or handled through virtual care. With the exception of many patients with primary immunodeficiency, patients on venom immunotherapy, and patients with asthma of a certain severity, there is limited need for face-to-face visits under such conditions. These suggestions are intended to help provide a logical approach to quickly adjust service to mitigate risk to both medical staff and patients. Importantly, individual community circumstances may be unique and require contextual consideration. The decision to enact any of these measures rests with the judgment of each clinician and individual health care system. Pandemics are unanticipated, and enforced social distancing/quarantining is highly unusual. This expert panel consensus document offers a prioritization rational to help guide decision making when such situations arise and an allergist/immunologist is forced to reduce services or makes the decision on his or her own to do so.
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Affiliation(s)
- Marcus S Shaker
- Dartmouth-Hitchcock Medical Center, Section of Allergy and Immunology, Lebanon, NH; Dartmouth Geisel School of Medicine, Hanover, NH
| | | | - Mitchell Grayson
- Nationwide Children's Hospital, The Ohio State University School of Medicine, Columbus, Ohio
| | - David Stukus
- Nationwide Children's Hospital, The Ohio State University School of Medicine, Columbus, Ohio
| | - Nicholas Hartog
- Spectrum Health Helen DeVos Children's Hospital, Grand Rapids, Mich
| | - Elena W Y Hsieh
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - Nicholas Rider
- The Texas Children's Hospital, Section of Immunology, Allergy, and Retrovirology and the Baylor College of Medicine, Houston, Texas
| | - Cullen M Dutmer
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - Timothy K Vander Leek
- Pediatric Allergy and Asthma, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Harold Kim
- Western University and McMaster University, London, ON, Canada
| | - Edmond S Chan
- BC Children's Hospital, The University of British Columbia, Vancouver, BC, Canada
| | - Doug Mack
- McMaster University, Hamilton, ON, Canada; Halton Pediatric Allergy, Burlington, ON, Canada
| | - Anne K Ellis
- Division of Allergy and Immunology, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - David Lang
- Department of Medicine, Section of Allergy and Immunology, Cleveland Clinic, Cleveland, Ohio
| | - Jay Lieberman
- Division of Allergy and Immunology, The University of Tennessee, Memphis, Tenn
| | - David Fleischer
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - David B K Golden
- Division of Allergy and Clinical Immunology, John Hopkins University School of Medicine, Baltimore, Md
| | - Dana Wallace
- Nova Southeastern University College of Allopathic Medicine, Fort Lauderdale, Fla
| | - Jay Portnoy
- Children's Mercy, University of Missouri-Kansas City School of Medicine, Kansas City, Mo
| | - Giselle Mosnaim
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, NorthShore University Health System, Evanston, Ill
| | - Matthew Greenhawt
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo.
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