Survey of physicians' approach to food allergy, Part 1: Prevalence and manifestations

Use of Food Allergy Panels by Pediatric Care Providers Compared With Allergists

BACKGROUND AND OBJECTIVE

Immunoglobullin E (IgE)-mediated food allergies affect 5% to 8% of children. Serum IgE levels assist in diagnosing food allergies but have low positive predictive value. This can lead to misinterpretation, overdiagnosis, and unnecessary dietary elimination. Use of IgE food allergen panels has been associated with increased cost and burden. The scale of use of these panels has not been reported in the medical literature.

METHODS

We conducted a retrospective review of a commercial laboratory database associated with a tertiary care pediatric academic medical center for food IgE tests ordered by all provider types during 2013.

RESULTS

A total of 10 794 single-food IgE tests and 3065 allergen panels were ordered. Allergists ordered the majority of single-food IgE tests (58.2%) whereas 78.8% of food allergen panels were ordered by primary care providers (PCPs) (P < .001). Of all IgE tests ordered by PCPs, 45.1% were panels compared with 1.2% of orders placed by allergists (P < .001). PCPs in practice for >15 years ordered a higher number of food allergen panels (P < .05) compared with PCPs with less experience. Compared with allergists, PCPs ordered more tests for unlikely causes of food allergies (P < .001). Total cost of IgE testing and cost per patient were higher for PCPs compared with allergists.

CONCLUSIONS

Review of food allergen IgE testing through a high volume outpatient laboratory revealed PCPs order significantly more food allergen panels, tests for uncommon causes of food allergy, and generate higher cost per patient compared with allergists. These results suggest a need for increased education of PCPs regarding proper use of food IgE tests.

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 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.

Anaphylaxis knowledge and practice preferences of pediatric emergency medicine physicians: a national survey

OBJECTIVES

To assess the knowledge and practice preferences of anaphylaxis in pediatric emergency medicine (PEM) physicians by practice setting, and to identify factors associated with intramuscular (IM) epinephrine administration and admission of patients with anaphylaxis.

STUDY DESIGN

The cohort was a cross-sectional convenience sample; potential participants were recruited using contact information obtained from the American Board of Pediatrics and American Board of Medical Specialties membership databases and were asked to complete a 12 item survey. Board-certified PEM physicians were categorized by practice setting: university hospital, non-university hospital with a residency training program, or community hospital with no residency training program. Management practices based on practice setting are presented as proportions. Multivariate logistic regression identified factors associated with IM epinephrine administration and admission of patients with anaphylaxis for observation.

RESULTS

Of the 1114 PEM physicians solicited, 620 (56%) completed the survey. The majority (93.5%) correctly identified epinephrine as the treatment of choice for anaphylaxis, yet only 66.9% used the IM route of administration, and only 37.4% admitted affected patients for observation. Factors associated with the use of IM epinephrine included the presence of a residency program at the site of care (OR, 2.28, 95% CI, 1.3-4.04) and higher volume of anaphylaxis cases (OR, 1.21; 95% CI, 1.06-1.38). Increasing anaphylaxis case volume was associated with decreased likelihood of admission of patients with anaphylaxis (OR, 0.81; 95% CI, 0.72-0.92).

CONCLUSION

Even though the majority of PEM physicians correctly report using epinephrine in pediatric anaphylaxis, not all use the preferred administration route, and many discharge patients home after an abbreviated period.

Food allergy knowledge, attitudes, and beliefs of primary care physicians

OBJECTIVE

To provide insight into food allergy knowledge and perceptions among pediatricians and family physicians in the United States.

METHODS

A national sample of pediatricians and family physicians was recruited between April and July 2008 to complete the validated, Web-based Chicago Food Allergy Research Survey for Primary Care Physicians. Findings were analyzed to provide composite/itemized knowledge scores, describe attitudes and beliefs, and examine the effects of participant characteristics on response.

RESULTS

The sample included 407 primary care physicians; 99% of the respondents reported providing care for food-allergic patients. Participants answered 61% of knowledge-based items correctly. Strengths and weaknesses were identified in each content domain evaluated by the survey. For example, 80% of physicians surveyed knew that the flu vaccine is unsafe for egg-allergic children, 90% recognized that the number of food-allergic children is increasing in the United States, and 80% were aware that there is no cure for food allergy. However, only 24% knew that oral food challenges may be used in the diagnosis of food allergy, 12% correctly rejected that chronic nasal problems are not symptom of food allergy, and 23% recognized that yogurts/cheeses from milk are unsafe for children with immunoglobulin E-mediated milk allergies. Fewer than 30% of the participants felt comfortable interpreting laboratory tests to diagnose food allergy or felt adequately prepared by their medical training to care for food-allergic children.

CONCLUSIONS

Knowledge of food allergy among primary care physicians was fair. Opportunities for improvement exist, as acknowledged by participants' own perceptions of their clinical abilities in the management of food allergy.