The Role of Food Challenges in Clinical Practice

Geographical discrepancy in oral food challenge utilization based on Canadian billing data

BACKGROUND

Oral food challenges (OFC) confer the highest sensitivity and specificity in diagnosis; however, uptake has been variable across clinical settings. Numerous barriers were identified in literature from inadequate training to resource access. OFC utilization patterns using billing data have not been previously studied.

OBJECTIVE

The objective of this study is to explore the geographic differences in utilization of OFCs across Ontario and Québec using anonymized billing data from 2013 to 2017.

METHODS

Anonymized OFC billing data were obtained between 2013 and 2017 from Ontario Health Insurance Plan (OHIP) and Régie de l'Assurance Maladie du Québec (RAMQ). The number of OFCs was extracted by location, billings, and physician demographics for clinic and hospital-based challenges.

RESULTS

Over the period studied, the number of OFCs increased by 92% and 85% in Ontario clinics and Québec hospitals, respectively. For Ontario hospitals, the number of OFCs increased by 194%. While Québec performed exclusively hospital-based OFCs, after controlling for the population, the number of OFCs per 100,000 residents annually were similar to Ontario at 50 and 49 OFCs, respectively. The number of OFCs varied across the regions studied with an annual rate reaching up to 156 OFCs per 100,000 residents in urban regions and as low as 0.1 in regions furthest from city centers.

CONCLUSION

OFC utilization has steadily increased over the last decade. There has been marked geographical discrepancies in OFC utilization which could be driven by the location of allergists and heterogeneity in their practices. More research is needed to identify barriers and propose solutions to them.

AAAAI Work Group Report: Trends in Oral Food Challenge Practices Among Allergists in the United States

The oral food challenge (OFC) is the criterion standard for diagnosing food allergy, but prior studies indicate many allergists may not be using OFCs for various reasons. To better understand current OFC trends, practices, and barriers, the American Academy of Allergy Asthma and Immunology (AAAAI) Adverse Reactions to Foods Committee subcommittee updated a 19-item survey (previously administered in 2009) and sent it to AAAAI and American College of Allergy, Asthma, and Immunology (ACAAI) membership. There were a total of 546 respondents who represented approximately a 10% response rate. Among the 546 respondents, compared with 2009, significantly more providers offer OFCs (95% vs 84.5%), offer >10 OFCs per month (17% vs 5.6%), obtain informed consent (82.2% vs 53.6%), and performed OFCs in fellowship (71% vs 45%) (all P < .001). Fellowship OFC training was limited, with 56% performing <10 OFCs in fellowship and 29% performing none. Although 94% see patients <12 months of age, 35.5% do not offer OFCs for early peanut introduction. Although 79% dedicate a supervising medical provider (MD, NP, PA) and 86% have a written OFC protocol, only 60% had a standardized reaction treatment protocol and 56% prepared emergency medications before OFC. Compared with 2009, there was significant worsening of perceived barriers to performing OFCs, including time (65.6% vs 55%), space (55.3% vs 27.1%), staffing (59.6% vs 44.3%), experience (16.9% vs 11.5%), and hospital proximity (10.9% vs 7.9%), though reimbursement as a barrier improved (45.9% vs 53.7%) (all P < .01). Compared with 2009, although more providers offer OFCs, multiple perceived barriers to performing OFCs have worsened. Hesitancy to challenge infants and emergency preparedness issues are emerging potential concerns.

Practical challenges in oral immunotherapy resolved through patient-centered care

Oral immunotherapy (OIT) is now widely recognized as a valid option for the management of IgE-mediated food allergies. However, in real-life practice, OIT can lead to a variety of unique situations where the best course of action is undetermined. In patient-centered care, individual patient preferences, needs and values, should guide all clinical decisions. This can be achieved by using shared-decision making and treatment customization to navigate areas of uncertainty in a way that is responsive to patient’s needs and preferences. However, in the context of OIT, lack of awareness of potential protocol adaptability or alternatives can become a barrier to treatment personalization. The purpose of this article is to review the theoretical bases of patient-centered care and shared decision-making and their practical implication for the patient-centered delivery of OIT. Clinical cases highlighting common challenges in real-life OIT practice are presented along with a discussion of potential personalized management options to be considered. While the practice of OIT is bound to evolve as additional scientific and experiential knowledge is gained, it should always remain rooted in the general principles of patient-centered care.

Does Provider Specialty Matter?

OBJECTIVES

Multiple practice guidelines discourage indiscriminate use of broad panels of allergen-specific IgE (sIgE) tests due to increased risk of false positives and misinterpretation of results. We provide an analytical framework to identify specialty-specific differences in ordering patterns and effectiveness, which can be used to improve test utilization.

METHODS

Test results from a tertiary pediatric hospital were analyzed by ordering specialty to evaluate size of allergen workups. Positivity rates were analyzed to determine effectiveness in selecting tests with high positive pretest probabilities. Laboratory test menu components were also evaluated.

RESULTS

Our findings demonstrate 29% of sIgE tests are ordered as part of broad workups (>20 sIgE tests/date of service) contrary to the recommended testing approach. Detailed descriptions of ordering patterns and positivity rates are provided.

CONCLUSIONS

This study provides a framework for using a cross-sectional analytical approach to assess test utilization patterns and evaluate components of laboratory testing menus.

The role of incurred materials in method development and validation to account for food processing effects in food allergen analysis

The issue of undeclared allergens represents a matter of great concern, being the subject of many alert notifications by the Rapid Alert System for Food and Feed portal of the European Commission, often leading to food recalls. The availability of reliable analytical approaches able to detect and quantify hidden allergens in processed foods is increasingly requested by the food industry, food safety authorities and regulatory bodies to protect sensitive consumers' health. The present review discusses the fundamental role of incurred materials for method development and analytical performance assessment in a metrology perspective on testing for undeclared allergens in processed foodstuffs. Due to the nature of the analytes and their susceptibility to various processing effects, reliability and comparability of results have posed a great challenge. In this context, the use of incurred samples as reference materials permits simulation of the effects of food processing on target analyte structure affecting analyte extractability and detectability. Graphical abstract ᅟ.

Food-dependent, exercise-induced anaphylaxis in a patient allergic to peach

Determining the single factor that triggered anaphylactic shock can be challenging. We present an interesting case of a 25-year-old female patient with recurrent anaphylactic reactions developing after eating various foods, particularly in presence of co-factors of allergic reactions. Symptoms occurred after consumption of various kinds of foods - peach, pancakes with cottage cheese and fruit, a meal from a Chinese restaurant - all eaten on other occasions without symptoms. During diagnosis, skin prick tests were negative for all tested allergen extracts (both inhalatory and food) from Allergopharma. Prick by prick tests were positive for the peach - wheal diameter - 6 mm, nectarine - 4 mm (histamine 4 mm, negative control 0 mm). Increased levels of asIgE were found for allergens of peach (0.55 kU/L).Open challenge test with one mid-size peach combined with the physical exercise challenge test was positive. ImmunoCAP ISAC test indicated increased levels of IgE specific for the lipid transfer protein (LTP) for walnut (nJug r 3), peach (Pru p 3), wheat (rTri a 14) and plane tree (rPla a 3). The patient was diagnosed with food-dependent, exercise-induced anaphylaxis associated with an allergy to lipid transport proteins (LTPs).