Allergists' self-reported adherence to anaphylaxis practice parameters and perceived barriers to care: an American College of Allergy, Asthma, and Immunology member survey

Abstract

Background

Anaphylaxis is life-threatening and requires rapid medical intervention. Knowledge of treatment guidelines and addressing barriers to care are essential for appropriate management.

Objective

To investigate allergists' self-reported practices in managing patients at risk for anaphylaxis, specifically in following practice parameters for diagnosis, treatment, and appropriate use of epinephrine, and to identify perceived barriers to care.

Methods

Online questionnaires were distributed to members of the American College of Allergy, Asthma, and Immunology. The US physicians who self-identified as “allergist/immunologist” were eligible to participate. The first 500 completed questionnaires were analyzed.

Results

Nearly all (≥95%) reported adherence to practice parameters in prescribing an epinephrine auto-injector and instructing patients on its use, taking a detailed allergy history, counseling patients on avoidance measures, and educating patients on the signs and symptoms of anaphylaxis. More than 90% stated they determined the best diagnostic procedures to identify triggers and coordinated laboratory and allergy testing. Adherence to practice parameters was less robust for providing patients with written action plans and in-office anaphylaxis preparedness. Perceived barriers to care included a significant proportion of patients who were uncomfortable using epinephrine auto-injectors and inadequate knowledge of anaphylaxis among referral physicians.

Conclusion

Allergists overwhelmingly adhere to practice parameter recommendations for the treatment and management of anaphylaxis, including appropriate use of epinephrine as first-line treatment, educating patients, and testing to diagnose anaphylaxis and identify its triggers. Opportunities for improvement include preparing staff and patients for anaphylactic events, providing written action plans, and improving knowledge of referring physicians.

Introduction

Evidence-based clinical practice guidelines play an ever-increasing role in clinical decision making. By describing widely accepted practices for the diagnosis and management of specific diseases or conditions, practice guidelines are an important tool for physicians in treatment planning. Because of the severe, potentially fatal consequences of anaphylaxis and its often rapid onset requiring immediate medical intervention, knowledge of best practices in anaphylaxis management is essential to improving care and preventing fatalities.

Anaphylaxis is likely underdiagnosed owing to uncertainty by patients and lack of a universal clinical definition.[1], [2], [3] Worldwide, 0.05% to 2% of people are estimated to have anaphylaxis at some point in their lives,⁴ and data based on the number of prescriptions for self-administered epinephrine injectors suggest that prevalence may be as high as 2%[5], [6] overall and higher in the northern US states.[6], [7], [8] There also are studies indicating that prevalence may be increasing, especially in the young,⁹ and other data suggest an increase in fatalities[9], [10] and hospitalizations.¹¹

The Diagnosis and Management of Anaphylaxis: A Practice Parameter was first developed in 1999 and updated in 2005 and 2010.¹² The parameter was developed by the Joint Task Force on Practice Parameters, comprised of members from the American Academy of Allergy, Asthma, and Immunology; the American College of Allergy, Asthma, and Immunology (ACAAI); and the Joint Council on Allergy, Asthma, and Immunology. The document contains guidelines and recommendations based on a systematic review and synthesis of the best available scientific evidence and clinical consensus. The parameter presents 2 algorithms: (1) the evaluation of the patient who presents to the physician's office with a previous episode of anaphylaxis or a condition simulating an anaphylactic event and (2) the recommended management of an episode occurring in the office.

Although adherence to anaphylaxis practice parameters by allergists has not been studied previously, there is evidence that in general the dissemination of practice guidelines alone does not significantly affect physician or patient behavior.[13], [14] The authors conducted a survey among members of the ACAAI to assess their self-reported practices and procedures in the management of anaphylaxis. The survey focused on comparing physician practices with those recommended in the parameters regarding diagnosis, treatment, and patient education, including the appropriate use of epinephrine. The study also sought to identify perceived barriers to care and areas for improvement. This included looking at factors such as whether patients carry their epinephrine auto-injectors and are comfortable using them and the knowledge and skills of emergency department (ED) and other referring physicians in diagnosing and managing anaphylaxis.