Physician attitudes, opinions, and referral patterns: comparisons of those who have and have not taken an allergy/immunology rotation

Allergy and immunology interest and exposure among US medical students and residents

Background

Despite the immense burden of allergic disease, the allergy and immunology (AI) workforce in the United States continues to shrink. Fellowship applications for AI have declined sharply in contrast to those in more popular specialties.

Objectives

Here we have sought to evaluate the current level of AI interest and exposure among early trainees in the United States, as well as their perspective on how to improve interest in the field.

Methods

An 18-item questionnaire was sent via e-mail list-serve to 2 groups: (1) mostly residents in the American Academy of Allergy, Asthma & Immunology (AAAAI) with interest in AI and (2) medical students in the American Medical Student Association (AMSA) whose specialty interests were not known.

Results

In the AAAAI group, 412 members were surveyed and 70 responses were received. In the AMSA group, 4778 members were surveyed and 47 responses were received. More individuals in the AAAAI group interacted with their AI division than in the AMSA group (73% vs 19% [P < .001]). On average, the AAAAI group would "probably" pursue AI whereas the AMSA group who would "definitely not" do so (P < .001). Almost all of the AMSA group (94%) had heard of AI before, but only 19% of them interacted with AI at their program. Regarding ways to increase interest in AI, the top responses for both groups were clinical exposure via electives and shadowing (a score of 4.69 on a 5-point scale) and didactic exposure via lectures and presentations (a score of 4.29).

Conclusions

Our study suggests that increasing AI opportunities for didactics and clinical exposure may lead medical students to develop more interest in pursuing the field. Some strategies are also discussed.

Practices and attitudes of doctors and patients to downward referral in Shanghai, China

OBJECTIVES

In China, the rate of downward referral is relatively low, as most people are unwilling to be referred from hospitals to community health systems (CHSs). The aim of this study was to explore the effect of doctors' and patients' practices and attitudes on their willingness for downward referral and the relationship between downward referral and sociodemographic characteristics.

METHODS

Doctors and patients of 13 tertiary hospitals in Shanghai were stratified through random sampling. The questionnaire surveyed their sociodemographic characteristics, attitudes towards CHSs and hospitals, understanding of downward referral, recognition of the community first treatment system, and downward referral practices and willingness. Descriptive statistics, χ2 test and stepwise logistic regression analysis were employed for statistical analysis.

RESULTS

Only 20.8% (161/773) of doctors were willing to accept downward referrals, although this proportion was higher among patients (37.6%, 326/866). Doctors' willingness was influenced by education, understanding of downward referral, and perception of health resources in hospitals. Patients' willingness was influenced by marital status, economic factors and recognition of the community first treatment system. Well-educated doctors who do not consider downward referral would increase their workloads and those with a more comprehensive understanding of hospitals and downward referral process were more likely to make a downward referral decision. Single-injury patients fully recognising the community first treatment system were more willing to accept downward referral. Patients' willingness was significantly increased if downward referral was cost-saving. A better medical insurance system was another key factor for patients to accept downward referral decisions, especially for the floating population.

CONCLUSIONS

To increase the rate of downward referral, the Chinese government should optimise the current referral system and conduct universal publicity for downward referral. Doctors and patients should promote understandings of downward referral. Hospitals should realise the necessity of downward referral, effectively reduce workloads and provide continuing education for doctors. Increasing monetary reimbursement is urgent, as is improving the medical insurance system.

Physician's recommendation and explanation is important in the initiation and maintenance of allergen immunotherapy

BACKGROUND

Allergen immunotherapy (AIT) is currently the only immune-modifying treatment for allergic disease. The clinical efficacy of AIT for the treatment of allergic rhinitis and bronchial asthma is well documented. However, many factors including inconvenience, cost, side effects, and adherence influence the initiation and persistence of AIT, and patients lack knowledge and have misconceptions about the treatment.

OBJECTIVE

We evaluated the knowledge, attitude, and satisfaction of patients who received AIT.

METHODS

We conducted a retrospective analysis of medical records of 167 patients who received AIT, and compared the clinical characteristics between conventional immunotherapy (CIT) and rush immunotherapy (RIT). Ninety-nine patients completed a questionnaire survey.

RESULTS

Of the total 167 patients, 65.9% (n=110) were treated with CIT and 34.1% (n=57) with RIT. More than half of the patients (68.7%) initiated AIT according to their physician's recommendation. Frequent hospital visits were the main barrier for persistence of AIT. RIT patients were younger and started AIT earlier than CIT patients. The majority (77%) of patients who received AIT were satisfied, with no significant difference between CIT and RIT groups. RIT and fewer allergens used in AIT were related with preference for AIT to pharmacotherapy. The longer duration of AIT was associated with higher treatment satisfaction.

CONCLUSION

A majority of patients initiated AIT by the physician's recommendation and were satisfied with treatment regardless of CIT or RIT schedule. Adequate patient education and a strict patient-physician relationship in early AIT period could improve the effectiveness and compliance of AIT.

Attitudes toward allergy: what do the pediatricians think?

BACKGROUND

In 1971, we published a survey regarding pediatricians' attitudes toward the field of allergy/immunology (A/I). Results indicated general attitudes and practices fell short of what most allergist-immunologists would hope. We revisited this in 1998 to determine how pediatricians' attitudes toward A/I had changed nearly 3 decades later. Despite some advances, results from 1998 revealed that A/I remained a misunderstood specialty. With the increasing incidence of atopic disorders and improving awareness of primary immunodeficiency, it is more important today than ever before that pediatricians and general practitioners have a strong appreciation for the scope of disorders the subspecialty of A/I encompasses.

OBJECTIVE

To reevaluate attitudes and practices of pediatricians toward A/I 40 years after the initial study and 13 years after this topic was last addressed.

METHODS

A 25-question survey was mailed to 293 pediatricians in the St Louis area. Surveys were completed confidentially. Pearson correlation and χ(2) analyses were performed.

RESULTS

Of 293 pediatricians polled, 135 (46%) responded. Referrals to allergist-immunologists for urticaria have increased. Fewer pediatricians are referring asthma and atopic dermatitis patients to allergist-immunologists. Personal experience referring to an allergist-immunologist remains the greatest influence on current attitudes toward A/I. Prior exposure to A/I during medical education continues to have the least influence on pediatricians' attitudes toward A/I.

CONCLUSION

Increased appropriate referrals and improved patient outcomes could result from efforts to enhance A/I education during medical school and residency, maintain effective communication with referring physicians, and break down referral barriers to improve physicians' attitudes toward A/I.

Sublingual immunotherapy: World Allergy Organization position paper 2013 update

We have prepared this document, "Sublingual Immunotherapy: World Allergy Organization Position Paper 2013 Update", according to the evidence-based criteria, revising and updating chapters of the originally published paper, "Sublingual Immunotherapy: World Allergy Organization Position Paper 2009", available at http://www.waojournal.org. Namely, these comprise: "Mechanisms of sublingual immunotherapy;" "Clinical efficacy of sublingual immunotherapy" - reporting all the data of all controlled trials published after 2009; "Safety of sublingual immunotherapy" - with the recently published Grading System for adverse reactions; "Impact of sublingual immunotherapy on the natural history of respiratory allergy" - with the relevant evidences published since 2009; "Efficacy of SLIT in children" - with detailed analysis of all the studies; "Definition of SLIT patient selection" - reporting the criteria for eligibility to sublingual immunotherapy; "The future of immunotherapy in the community care setting"; "Methodology of clinical trials according to the current scientific and regulatory standards"; and "Guideline development: from evidence-based medicine to patients' views" - including the evolution of the methods to make clinical recommendations.Additionally, we have added new chapters to cover a few emerging crucial topics: "Practical aspects of schedules and dosages and counseling for adherence" - which is crucial in clinical practice for all treatments; "Perspectives and new approaches" - including recombinant allergens, adjuvants, modified allergens, and the concept of validity of the single products. Furthermore, "Raising public awareness about sublingual immunotherapy", as a need for our patients, and strategies to increase awareness of allergen immunotherapy (AIT) among patients, the medical community, all healthcare stakeholders, and public opinion, are also reported in detail.

Allergen immunotherapy and health care cost benefits for children with allergic rhinitis: a large-scale, retrospective, matched cohort study

BACKGROUND

Children with allergic rhinitis (AR) often experience significant impairment in quality of life and health, which increases health care utilization.

OBJECTIVE

To determine whether allergen immunotherapy reduces health care utilization and costs in children newly diagnosed as having AR using a retrospective matched cohort design.

METHODS

Among children (age <18 years) with a Florida Medicaid paid claim between 1997 and 2007, immunotherapy-treated patients were selected who had newly diagnosed AR, who had not received immunotherapy before their first (index) AR diagnosis, who had received at least 2 immunotherapy administrations after their index AR diagnosis, and who had at least 18 months of data after their first immunotherapy administration. A control group of patients with newly diagnosed AR who had not received immunotherapy either before or subsequent to their index AR diagnosis also were identified, and up to 5 were matched with each immunotherapy-treated patient by age at first AR diagnosis, sex, race/ethnicity, and diagnosis of asthma, conjunctivitis, or atopic dermatitis.

RESULTS

Immunotherapy-treated patients had significantly lower 18-month median per-patient total health care costs ($3,247 vs $4,872), outpatient costs exclusive of immunotherapy-related care ($1,107 vs $2,626), and pharmacy costs ($1,108 vs $1,316) compared with matched controls (P < .001 for all). The significant difference in total health care costs was evident 3 months after initiating immunotherapy and increased through study end.

CONCLUSIONS

This study demonstrates the potential for early and significant cost savings in children with AR treated with immunotherapy. Greater use of this treatment in children could significantly reduce AR-related morbidity and its economic burden.

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.

Management of stinging insect hypersensitivity: a 5-year retrospective medical record review

BACKGROUND

The Joint Task Force on Practice Parameters for Allergy and Immunology recommends that patients with a history of a systemic reaction to an insect sting be educated on ways to avoid insect stings, carry injectable epinephrine for emergency self-treatment, undergo specific IgE testing for stinging insect sensitivity, and be considered for immunotherapy.

OBJECTIVE

To review frontline providers' documented care and recommendations for imported fire ant and flying insect hypersensitivity reactions.

METHODS

A retrospective medical record review was performed of emergency department and primary care clinic visits between November 1, 1999, and November 30, 2004. Using International Classification of Diseases, Ninth Revision, codes, medical records were selected for review to identify patients with potential insect hypersensitivity.

RESULTS

A total of 769 medical records from patients who experienced an insect sting were reviewed. Of 120 patients with a systemic reaction, 66 (55.0%) received a prescription for injectable epinephrine, and 14 (11.7%) were given information regarding avoidance of the offending insect. Forty-seven patients with systemic reactions (39.2%) were referred to an allergist. Of 28 patients who kept their appointments and underwent skin testing, 3 had negative results and 25 (89%) had positive results and were advised to start immunotherapy.

CONCLUSION

Adherence to the stinging insect hypersensitivity practice parameter recommendations is poor. Many patients who have experienced a systemic reaction after an insect sting and have sought medical care are not afforded an opportunity for potentially lifesaving therapy.

Diagnosis and management of food-induced anaphylaxis: a national survey of pediatricians

BACKGROUND

Food allergy is a common pediatric problem, affecting as many as 6% of young children, yet it is unclear whether pediatricians are well prepared to manage food-induced anaphylaxis.

OBJECTIVE

The purpose of this work was to assess pediatricians' knowledge of diagnosis and management of children with food-induced anaphylaxis.

METHODS

A survey designed to assess food allergy diagnosis and management was mailed to a US national random sample of 1130 pediatricians. Survey questions were based on a clinical scenario involving a child having an anaphylactic reaction after ingesting peanut. Primary outcome measures included correct responses to the 11 questions about anaphylaxis.

RESULTS

A total of 468 pediatricians (41%) responded to the survey. The majority of the respondents were women (58%), spent > 50% of their time in a clinical setting (78%), and reported providing care for food allergy patients (86%). Overall, 70% of the pediatricians agreed that the clinical scenario was consistent with anaphylaxis, and 72% chose to administer epinephrine. However, only 56% of respondents agreed with both the diagnosis of anaphylaxis and treating with epinephrine. Most pediatricians (70%) did not recognize that a 30-minute observation period after anaphylaxis was too short. Pediatricians who reported providing care for food allergy patients were more likely to agree with the diagnosis of anaphylaxis (73% vs 59%), with treating the reaction with epinephrine (73% vs 64%), and with prescribing self-injectable epinephrine (83% vs 66%) than pediatricians who did not care for food allergy patients. The more certain that pediatricians were that the child was having an anaphylactic reaction, the more likely they were to agree with treating the reaction with epinephrine. In general, recent continuing medical education was not predictive of improved knowledge.

CONCLUSION

Although the majority of pediatricians seem to have some knowledge of food-induced anaphylaxis, a substantial proportion has knowledge deficits that may hinder their ability to provide optimal care to children with food-induced anaphylaxis. Pediatricians who provide health care for patients with food allergy may be better equipped to manage food-induced anaphylaxis than those who do not. Because continuing medical education was not a significant predictor of increased knowledge, ensuring that pediatric residents develop experience managing patients with food allergies may be a better strategy to educate primary care pediatricians about food allergy.

Elective rotations and their impact on resident and faculty decision making

BACKGROUND

Restrictions on resident-duty work hours have led to fewer opportunities to participate in elective rotations.

PURPOSE

To investigate the potential impact of elective rotations on resident and faculty physicians using allergy/immunology (A/I) as a model.

METHODS

A questionnaire was sent to 375 primary care physicians. It assessed demographic information, training background, A/I-referral history and intentions, and perceived knowledge of A/I-specific issues.

RESULTS

A total of 228 surveys were returned. Resident physicians who were more senior in their training or who had taken an A/I rotation were more likely to have referred a patient to A/I in the past, more likely to refer a patient to A/I for chronic sinusitis, and more likely to report a greater knowledge of A/I topics. Faculty physicians with a history of an A/I rotation were more likely to feel knowledgeable about A/I topics.

CONCLUSION

Elective rotations are positively correlated with perceived knowledge, referral intentions, and past history of referrals.