Dr. David Stukus has had a busy year publishing research as well as bylined articles, and most of all his weekly “Bad Joke of the Week” as part of his active Twitter feed @AllergyKidsDoc. He has shared his thoughts with us about the role of Primary Care Providers and allergy treatment before, so it was particularly noteworthy the other day when he popped up as lead author of a study in Pediatrics called “Use of Food Allergy Panels by Pediatric Care Providers Compared With Allergists”. Employing data from Nationwide Children’s Hospital in Columbus, it revealed some eye-opening, but not quite surprising, statistics. The authors looked at all the NCH data for 2013. Notably, 45.1% of serum IgE (sIgE) tests ordered by primary care physicians (mostly pediatricians) and some nurse practitioners were panels of multiple allergens, compared to just 1.2% by allergists. Given our preoccupation with over diagnosis of food allergies and the consequences for personal, family, and public health, we decided to catch up with Dr. Stukus and ask what it all means. — Henry Ehrlich
AAC: Thanks Dave, and welcome back to our website. First, please tell us why you did this study. It’s a broad worry in the allergy community. You cite Dr. Andrew Bird who also did a piece for us. Is there some specific reason, a particular patient or group of patients that got you thinking? Did you see consequences in your own specialty practice?
Dave: Thank you, Henry, for the opportunity to return to your wonderful site and audience. The idea for this study originated from patients being seen in our office every day. We routinely receive referrals for evaluation of suspected food allergies in infants and young children, many of whom already had serum IgE testing performed. Sometimes they have foods taken out of their diet based upon these results. Many times, parents are told to withhold introduction of new foods based upon these tests. Rarely, we see patients develop a new allergy to a food they were eating regularly without problems but produced IgE towards; the food is removed based upon testing and then, when reintroduced weeks or months later, they develop a new allergic reaction to that same food they were previously eating without problems. So, yes – this felt like it was a big problem but had not previously been objectively assessed or characterized on a wide scale, which is what we sought to do.
AAC: You point out, “Compared with allergists, PCPs ordered significantly more sIgE tests for foods associated with a low prevalence of IgE-mediated food allergy, such as strawberry, beef, corn, and tomato.” Do you have any insight into why these tests are ordered? Do patients/parents ask for them? If so, do you get such requests in your practice and how do you handle them?
Dave: I think there are different reasons why testing for unlikely causes of food allergy occur. First, clinicians may have misunderstanding regarding the signs/symptoms of IgE mediated food allergy, the role of IgE testing, and common causes of IgE mediated food allergy reactions. Symptoms due to certain foods, such as heartburn from tomatoes, may be misattributed to IgE mediated allergy, thus prompting testing to be performed. Second, many parents/patients request testing for wide ranges of foods due to concern over symptoms they may be experiencing or “just to make sure I’m not allergic”.
I routinely have requests to perform food allergy testing for unlikely causes of food allergy or towards large numbers of allergens. In these cases, I spend a lot of time taking a detailed history, discuss the proper use and limitations of IgE testing, and offer suggestions for other causes of their symptoms. 99% of the time, I can avoid testing when it’s unnecessary. This takes a lot of time in digging out the details from the patient and also time to explain how testing works and doesn’t work. Rarely, I’ll still end up testing for limited foods, hoping that seeing a ‘negative’ result will provide enough reassurance to positively impact a parent/patient.
AAC: One element that your data raises is the role of the calendar in the life of an allergic child. Namely, that allergies develop after exposure, they aren’t there from the beginning. You mention “the Childhood Allergy Profile, which was only ordered 2 times during the study period by allergists, compared with 383 orders from PCPs. This profile contains 5 aeroallergens (cat, dog, dust mite, cockroach, and alternaria) that rarely cause clinical symptoms in infants (under) 12 months of age who may be suspected of having food allergies.” Don’t these tests come with “black box warnings” or something to discourage inappropriate use? Don’t doctors read them?
Dave: These tests not only lack any type of warning label or best practice alert, but are also aggressively marketed by laboratories to clinicians. IgE panels may be presented as a convenient way to find out all the things a patient may be allergic to, with one easy test. If a clinician lacks the understanding or expertise in the interpretation of IgE tests, then this may seem like a great idea. Unfortunately, when the results are reported with a big exclamation mark next to even the slightest elevation in level, or with pre-assigned arbitrary classes designating ‘severity’ (which is completely fabricated, by the way), then providers may be prone to overdiagnose food allergy based upon results.
AAC: You itemize the costs attached to the tests, and they can be pretty hefty. But where does the money go? Do doctors profit from ordering more tests or does it go to the laboratories and the manufacturers? Insurance companies are frequently demonized, rightly in my opinion, for denying testing and treatment, but isn’t there an algorithm for fishing expeditions?
Dave: The way our healthcare system is designed in the United States, the ordering clinician does not profit one penny from ordering these laboratory tests. Unless, of course, they also have equity in the laboratory used to process the sample. The money goes towards the laboratories that run the testing protocols and also to the companies that design and offer the assays. I’ve heard anecdotes of insurance companies refusing to pay for IgE testing if the same test was already performed within the past 12 months but I don’t actually know if this is true, from a patient perspective.
AAC: You mention the “Choosing Wisely” program, which seeks to discourage unnecessary tests. We also wrote about this a few years ago. Do you get the feeling that this campaign has had a tangible benefit in the intervening years? Is it actively promoted? Do you as a regional leader in this field exert special influence?
Dave: I think the Choosing Wisely program is fantastic but unfortunately, I do not believe it has reached it’s intended audience on an appreciable scale. It takes decades for clinical guidelines (see: NHLBI asthma guidelines) to actually change the behavior of practicing clinicians. Primary care physicians are fantastic due to their long-standing relationship with patients and ability to monitor/diagnose/treat literally hundreds of conditions. However, due to time constraints, it is impossible for a primary care doc to keep up with all the latest and greatest research or clinical guidelines from every subspecialty. For every allergist, such as myself, shouting from the mountain tops to stop the use of indiscriminate IgE panels/testing in the evaluation of food allergy, there is a gastroenterologist shouting about the risks of long term use of proton pump inhibitors, or a cardiologist shouting the latest advice regarding diet and exercise.
I think there are many ways to reach primary care providers and ultimately change behavior towards best practice and evidence-based management. One way is to publish research in widely read peer reviewed journals. I’ve received numerous positive messages from pediatricians and allergists alike since our study was published, which demonstrates at least some benefit from this approach. Social media is another avenue to utilize for spreading evidence-based information but this will be limited to the reach of the content originator and by size/involvement of the intending audience. Grand rounds, presentations at national meetings, and posts such as this one are other ways to help with dissemination.
As for your last question: Do I exert special influence? Unlikely, other than I may have access to platforms that others may not…such as your website. But, I’ll let others decide that…
AAC: My favorite factoid from the current study is the demarcation between older and younger PCPs in ordering the tests. To wit, those in practice for more than 15 years order more tests than those who have practice less. This is an encouraging trend. Do you think that the word is getting out to younger doctors? If so that bodes well for the future. It seems to me that older doctors are at a disadvantage here because they were trained in an era when food allergies particularly weren’t as well known as they are now and demand for testing is probably rising. Do you think a concerted effort at reaching older doctors might be in order? What can be done for them?
Dave: I agree that it is not an even playing field. We know that food allergy prevalence has increased relatively recently, over the past two decades. Physicians in practice for more than 15 years likely received little, if any, training to recognize or diagnose food allergies. The growth of allergy/immunology fellowship training programs, involvement of academic allergists in residency training programs, and newer manners of education, such as online learning may all improve the education and understanding of physicians with less experience.
Before we try to target physicians in practice for x number of years, we will need to better understand their preferred manner of ongoing adult learning, their receptiveness to new research and ideas, as well as their willingness to change their clinical practice.
AAC: The big problem here is the demographics of the allergy specialty. Consciousness of allergies is rising while training programs decline and the supply of new ones isn’t keeping up with the retirement of old ones. This dictates that more allergy treatment will be done by PCPs, and by the way they aren’t doing very well either in terms of replacement either. You practice in the middle of a state with lots of rural communities that must be struggling to maintain access to primary care. Any thoughts on how we can leverage the expertise of doctors such as yourself?
Dave: I think we evolve with the times! Telemedicine is the first thought that comes to mind. This is being implemented more and more, offers reimbursement from insurance companies, and is being refined and better understood on a continuous basis. Social media is another exciting avenue for dissemination of evidence-based information.
AAC: Thanks for your time, as ever.
Dave: It is my pleasure – any time. Thank you for all of your interest and help in spreading the word!
David Stukus, MD, is board certified in Allergy/Immunology and is an Assistant Professor of Pediatrics at Nationwide Children’s Hospital and The Ohio State University in Columbus, Ohio. His clinical and research interests focus on asthma and food allergies, especially improving education and adherence for patients and families. As part of his research, Dr. Stukus has created novel technology and educational tools using mobile health apps to improve the care of patients, for which he was recognized with the Nationwide Children’s Hospital Department of Pediatrics Junior Faculty Award in November 2013. Dr. Stukus has been an active member of the medical advisory team for Kids with Food Allergies since 2009 and was elected to the Board of Directors for the Asthma and Allergy Foundation of America in 2014. Lastly, Dr. Stukus actively engages with food allergy support groups and participates in social media on twitter through @AllergyKidsDoc.