Anaphylaxis in America: A national physician survey
2015; Elsevier BV; Volume: 135; Issue: 3 Linguagem: Inglês
10.1016/j.jaci.2014.10.049
ISSN1097-6825
AutoresAshley Altman, Carlos A. Camargo, F. Estelle R. Simons, Philip Lieberman, Hugh A. Sampson, Lawrence B. Schwartz, F. Myron Zitt, Charlotte Collins, Michael Tringale, Marilyn Wilkinson, Robert A. Wood,
Tópico(s)Drug-Induced Adverse Reactions
ResumoAnaphylaxis is an acute, life-threatening reaction with various triggers, presentations, and severities.1Russell W. Farrar J. Evaluating the management of anaphylaxis in US emergency departments: guidelines vs. practice.World J Emerg Med. 2013; 4: 98-106Crossref Google Scholar, 2Simons F.E.R. Ardusso L.R. Bilò M.B. Cardona V. Ebisawa M. El-Gamal Y.M. et al.International consensus on (ICON) anaphylaxis.World Allergy Organ J. 2014; 7: 9Crossref PubMed Scopus (312) Google Scholar Although prevalence estimates vary, our recent national survey estimated a lifetime prevalence of 1.6% to 5.1% in adults.3Wood R.A. Camargo C.A. Lieberman P. Sampson H.A. Schwartz L.B. Zitt M. et al.Anaphylaxis in America: the prevalence and characteristics of anaphylaxis in the United States.J Allergy Clin Immunol. 2013; 133: 461-467Abstract Full Text Full Text PDF PubMed Scopus (243) Google Scholar This is therefore a common entity that most physicians are likely to encounter. Several previous publications examining the care of patients with anaphylaxis have demonstrated potential deficiencies among primary care and emergency physicians, as well as allergy/immunology (A/I) specialists.4Fineman S. Dowling P. O'Rourke D. Allergists' self-reported adherence to anaphylaxis practice parameters and perceived barriers to care: an American College of Allergy, Asthma and Immunology member survey.Ann Allergy Asthma Immunol. 2013; 111: 529-536Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar, 5Krugman S.D. Chiaramonte D.R. Matsui E.C. Diagnosis and management of food-induced anaphylaxis: a national survey of pediatricians.Pediatrics. 2006; 118: e554-e560Crossref PubMed Scopus (77) Google Scholar, 6Wang J. Sicherer S.H. Nowak-Wegrzyn A. Primary care physicians' approach to food-induced anaphylaxis: a survey.J Allergy Clin Immunol. 2004; 114: 689-691Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar, 7Grossman S.L. Baumann B.M. Garica Pena B.M. Linares M.Y.R. Greenberg B. Hernandez-Trujillo V.P. Anaphylaxis knowledge and practice preferences of pediatric emergency medicine physicians: a national survey.J Pediatr. 2013; 163: 841-846Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar Consistent with this, we found in our recent survey that although most of those reporting anaphylaxis had experienced at least 2 previous episodes, most had not received an emergency action plan, only 32% intended to use their epinephrine autoinjector (EAI) for future reactions, 52% reported never receiving an EAI prescription, and 60% did not have an EAI available.3Wood R.A. Camargo C.A. Lieberman P. Sampson H.A. Schwartz L.B. Zitt M. et al.Anaphylaxis in America: the prevalence and characteristics of anaphylaxis in the United States.J Allergy Clin Immunol. 2013; 133: 461-467Abstract Full Text Full Text PDF PubMed Scopus (243) Google Scholar In this report, we summarize results from an additional survey in which we gathered data on experience, knowledge, and attitudes regarding anaphylaxis among A/I specialists, primary care physicians, and emergency physicians.We conducted a telephone interview of physicians comprising A/I specialists (50% with pediatric and 50% with internal medicine training), emergency physicians, family practitioners, and pediatricians. Four thousand advance letters were sent to a sample derived randomly from the American Medical Association/American Osteopathic Association, from which 330 were screened and 318 interviewed. The final cohort included 114 A/I specialists (including 58 with pediatric and 56 with internal medicine training), 102 emergency physicians, 50 family practitioners, and 50 pediatricians. The interview consisted of 47 questions and lasted on average 19.1 minutes. Responses among the 5 physician groups were compared using ANOVA, with P < .05 considered statistically significant.The survey revealed that most physicians reported being very familiar with the term anaphylaxis (range, 89% to 100%; see Table I for all results). Most had witnessed an anaphylactic reaction, ranging from 82% (family practitioners) to 99% (emergency physicians) (P = .01). Not surprisingly, A/I specialists and emergency physicians were more likely to see those patients at least once a month who reported a history of anaphylaxis (overall range, 17% family practitioners to 67% to 75% of A/I specialists; P < .001).Table ISummary of survey resultsQuestionnaire itemA/I (pediatric) (n = 58)A/I (internal medicine) (n = 56)Emergency medicine (n = 102)Family/general practice (n = 50)Pediatrics (n = 52)P valueFamiliarity with "anaphylaxis".03 Very10098959089 Somewhat0251012 Have witnessed anaphylaxis9589998285.01Frequency of witnessing anaphylaxis ≥Once a month4028211025<.001Frequency of seeing patients reporting anaphylaxis ≥Once a month6775561722<.001Symptoms of anaphylaxis Dizziness/fainting5768555052.37 Breathing problems7277717477.86 Coughing3155373044.02 Swelling3841414454.42 Skin reactions5354412656.003 Sudden behavioral change24884.41 Anxiety99748.87 Loss of bladder control54004.14 Throat itching141315610.59 Hoarse voice74526.78 Cramps, abdominal pain314610629<.001Foods most likely to cause a severe allergic reaction Strawberries0013144.001 Soy14160010<.001 Wheat1214186.01 Fish283010819.001 Milk473261637<.001 Eggs573292037<.001 Tree nuts7271343042<.001 Shellfish7679634846<.001 Peanuts9589767089<.001Medications most likely to cause a severe allergic reaction Blood pressure medications9918162.04 Aspirin, Advil, Motrin33419640<.001 Sulfa drugs2825293439.57 Penicillin7663354462<.001 Other antibiotics4059605840.05Treatment for anaphylaxis Administer epinephrine9398918189.28 Administer something else407102 Send patient to hospital22055 Other20152Treatment for patients reporting previous anaphylaxis Nothing001822<.001 Send patient to specialist305619<.001 Discuss preventative measures7971012.83 Prescribe steroids372144<.001 Prescribe antihistamines1225171612.34 Prescribe EAI10093638885<.001 Awareness of professional guidelines on anaphylaxis9796604667<.001Patients carry epinephrine as directed All56275.007 Most6054375162 Some2938422623 Few3218143 None00020Patients use epinephrine as directed All914393.24 Most5550395462 Some2830452128 Few9411145 Believe there are absolute contraindications to prescribing EIA1632383821.03Agreement with statements about allergic reactions Restaurants are required to have epinephrine2230182633<.053 All ambulances are required to carry epinephrine8577849487.08 Teenagers are at a higher risk for fatal allergic reactions9173353662<.001 Asthma is an important risk factor for severe allergic reaction (anaphylaxis)9896799085.009 Think there are more life-threatening reactions today (compared with 10 y ago)7857594048.03Daily life impact of patients with severe allergies A lot5338251031<.001 Moderate3334303439 Some1420282615 A little09163012 Not at all00104All values are in % except P values. Open table in a new tab When asked which symptoms may be indicative of anaphylaxis, there were significant differences among the groups regarding cough (range, 30% to 55%; P = .02), skin reactions (26% to 54%; P = .003), and abdominal pain (6% to 46%; P < .001). Responses were similar regarding breathing problems (71% to 77%), dizziness/fainting (50% to 68%), and swelling (38% to 54%). Fewer than 20% of each group considered sudden behavioral change, anxiety, loss of bladder control, or hoarse voice to be indicative of anaphylaxis.With regard to the foods that are most likely to cause severe allergic reactions, significant differences were found among the groups for each of the 9 foods queried. Peanut was recognized most consistently, although it was not recognized as a common trigger by 24% of emergency physicians and 30% of family practitioners. In addition, most non-A/I specialists did not identify tree nuts as a common cause of severe allergic reactions and shellfish was noted by less than half of family practitioners and pediatricians. With regard to medications as a cause of severe allergic reactions, there were significant differences among the groups for all medication classes except sulfa drugs. Possibly most surprising, nonsteroidal anti-inflammatory drugs were not recognized as a trigger by the vast majority of family practitioners and emergency physicians.When queried regarding treatment of witnessed anaphylaxis, there were no significant differences among the groups, with 81% of family practitioners to 98% of A/I specialists reporting epinephrine as the first-line treatment. Significantly fewer emergency physicians (63%; P < .001) indicated that they prescribe an EAI for patients reporting a history of anaphylaxis, while they were also more likely to prescribe oral corticosteroids (21%; P < .001). Differences were also seen in those reporting subspecialty referral, ranging among non-A/I specialists from 5% of emergency physicians to 19% of pediatricians (P < .001).A series of questions also focused on awareness and attitudes regarding anaphylaxis. Although almost all A/I specialists were aware of professional anaphylaxis guidelines, this was true for only 60%, 46%, and 67% of emergency physicians, family practitioners, and pediatricians, respectively (P < .001). Most of the A/I specialists, family practitioners, and pediatricians believed that patients carry their EAI most/all of the time compared with only 39% of emergency physicians (P = .007). There were no differences regarding the opinion that patients will use their EAI appropriately (range, 42% to 65%). In addition, 16% to 38% believed that there are absolute contraindications to the use of epinephrine in treating anaphylaxis. Although most physicians recognized asthma as a risk factor for severe anaphylaxis, most emergency and family physicians did not recognize that teenagers are at an increased risk of fatal anaphylaxis.In addition, 19% to 33% of the physicians mistakenly reported that restaurants are required to have EAIs available and 77% to 94% wrongly indicated that all ambulances are required to carry epinephrine. Finally, when asked about the impact of severe allergies on daily life, only 10% of the family practitioners responded "a lot" compared with 53% of pediatric A/I specialists.Given that anaphylaxis is common and can have potentially deadly consequences, the findings from this survey raise concern about overall physician knowledge of this condition. Although it is reassuring that almost all physicians were very familiar with the term anaphylaxis and recognized that epinephrine is the recommended first-line treatment, it is concerning that many physicians did not identify breathing problems, fainting, swelling, and abdominal pain as symptoms that might indicate anaphylaxis. It is also of potential concern that very few physicians advise subspecialty referral for patients with anaphylaxis.Fortunately, most physicians did state that they would provide an EAI prescription for patients reporting a history of anaphylaxis. Although emergency physicians were less likely to do so at 63%, this is not surprising given the fact that most patients in the emergency department are there for reasons unrelated to anaphylaxis. These results, however, are somewhat inconsistent with our previous public and patient surveys,3Wood R.A. Camargo C.A. Lieberman P. Sampson H.A. Schwartz L.B. Zitt M. et al.Anaphylaxis in America: the prevalence and characteristics of anaphylaxis in the United States.J Allergy Clin Immunol. 2013; 133: 461-467Abstract Full Text Full Text PDF PubMed Scopus (243) Google Scholar in which we found that although most respondents reported 2 or more previous anaphylactic episodes, and 19% reported 5 or more, 60% did not have EAI available. They are also inconsistent with published reports of emergency treatment of anaphylaxis, in which epinephrine is actually used in only a minority of patients, even in those with cardiovascular symptoms.8Aun M.V. Blanca M. Garro L.S. Ribeiro M.R. Kalil J. Motta A.A. et al.Nonsteroidal anti-inflammatory drugs are major causes of drug-induced anaphylaxis.J Allergy Clin Immunol Pract. 2014; 2: 414-420Abstract Full Text Full Text PDF PubMed Scopus (90) Google Scholar, 9Rudders S.A. Banerji A. Corel B. Clark S. Camargo Jr., C.A. Multicenter study of repeat epinephrine treatments for food-related anaphylaxis.Pediatrics. 2010; 125: e711-e718Crossref PubMed Scopus (101) Google Scholar These discrepancies may be due at least in part to a limitation in the design of the questionnaire, which did not capture data about which specific symptoms would trigger administration of epinephrine, recognizing that respondents may have different interpretations of anaphylaxis and thresholds for the use of epinephrine. Finally, many doctors responded that there are absolute contraindications to epinephrine, although most experts agree that this is not the case for patients presenting with anaphylaxis. All these issues raise significant concern that physicians may be less likely to both prescribe and use epinephrine in actual practice than they reported in the survey.In addition to survey responses about the recognition and treatment of anaphylaxis, a number of interesting findings emerged regarding other day-to-day issues. Physicians were overall misinformed about the availability of epinephrine in both restaurants and ambulances. When questioned regarding quality of life, only 10% of family practitioners and 31% of pediatricians believed that "severe allergies" have a major impact on quality of life. This differs markedly from results of previous studies about patients' perceptions regarding the effects of food allergy on quality of life.10Sicherer S.H. Noone S.A. Munoz-Furlong A. The impact of childhood food allergy on quality of life.J Allergy Clin Immunol. 2001; 81: 461-464Google Scholar More pediatric A/I specialists (78%) than others (P = .03) believed that life-threatening allergic reactions today are more common than 10 years ago, consistent with published data,11Simons F.E.R. Anaphylaxis.J Allergy Clin Immunol. 2010; 125: S161-S181Abstract Full Text Full Text PDF PubMed Scopus (338) Google Scholar and most physicians in all groups recognized that asthma is a risk factor for severe reactions.Similar to our surveys of patients and the general public, this study clearly demonstrates the need for ongoing education regarding anaphylaxis. As with previous studies, knowledge gaps are especially apparent for primary care and emergency physicians, who are most often the physicians on the front line in the treatment of this common and life-threatening condition. Anaphylaxis is an acute, life-threatening reaction with various triggers, presentations, and severities.1Russell W. Farrar J. Evaluating the management of anaphylaxis in US emergency departments: guidelines vs. practice.World J Emerg Med. 2013; 4: 98-106Crossref Google Scholar, 2Simons F.E.R. Ardusso L.R. Bilò M.B. Cardona V. Ebisawa M. El-Gamal Y.M. et al.International consensus on (ICON) anaphylaxis.World Allergy Organ J. 2014; 7: 9Crossref PubMed Scopus (312) Google Scholar Although prevalence estimates vary, our recent national survey estimated a lifetime prevalence of 1.6% to 5.1% in adults.3Wood R.A. Camargo C.A. Lieberman P. Sampson H.A. Schwartz L.B. Zitt M. et al.Anaphylaxis in America: the prevalence and characteristics of anaphylaxis in the United States.J Allergy Clin Immunol. 2013; 133: 461-467Abstract Full Text Full Text PDF PubMed Scopus (243) Google Scholar This is therefore a common entity that most physicians are likely to encounter. Several previous publications examining the care of patients with anaphylaxis have demonstrated potential deficiencies among primary care and emergency physicians, as well as allergy/immunology (A/I) specialists.4Fineman S. Dowling P. O'Rourke D. Allergists' self-reported adherence to anaphylaxis practice parameters and perceived barriers to care: an American College of Allergy, Asthma and Immunology member survey.Ann Allergy Asthma Immunol. 2013; 111: 529-536Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar, 5Krugman S.D. Chiaramonte D.R. Matsui E.C. Diagnosis and management of food-induced anaphylaxis: a national survey of pediatricians.Pediatrics. 2006; 118: e554-e560Crossref PubMed Scopus (77) Google Scholar, 6Wang J. Sicherer S.H. Nowak-Wegrzyn A. Primary care physicians' approach to food-induced anaphylaxis: a survey.J Allergy Clin Immunol. 2004; 114: 689-691Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar, 7Grossman S.L. Baumann B.M. Garica Pena B.M. Linares M.Y.R. Greenberg B. Hernandez-Trujillo V.P. Anaphylaxis knowledge and practice preferences of pediatric emergency medicine physicians: a national survey.J Pediatr. 2013; 163: 841-846Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar Consistent with this, we found in our recent survey that although most of those reporting anaphylaxis had experienced at least 2 previous episodes, most had not received an emergency action plan, only 32% intended to use their epinephrine autoinjector (EAI) for future reactions, 52% reported never receiving an EAI prescription, and 60% did not have an EAI available.3Wood R.A. Camargo C.A. Lieberman P. Sampson H.A. Schwartz L.B. Zitt M. et al.Anaphylaxis in America: the prevalence and characteristics of anaphylaxis in the United States.J Allergy Clin Immunol. 2013; 133: 461-467Abstract Full Text Full Text PDF PubMed Scopus (243) Google Scholar In this report, we summarize results from an additional survey in which we gathered data on experience, knowledge, and attitudes regarding anaphylaxis among A/I specialists, primary care physicians, and emergency physicians. We conducted a telephone interview of physicians comprising A/I specialists (50% with pediatric and 50% with internal medicine training), emergency physicians, family practitioners, and pediatricians. Four thousand advance letters were sent to a sample derived randomly from the American Medical Association/American Osteopathic Association, from which 330 were screened and 318 interviewed. The final cohort included 114 A/I specialists (including 58 with pediatric and 56 with internal medicine training), 102 emergency physicians, 50 family practitioners, and 50 pediatricians. The interview consisted of 47 questions and lasted on average 19.1 minutes. Responses among the 5 physician groups were compared using ANOVA, with P < .05 considered statistically significant. The survey revealed that most physicians reported being very familiar with the term anaphylaxis (range, 89% to 100%; see Table I for all results). Most had witnessed an anaphylactic reaction, ranging from 82% (family practitioners) to 99% (emergency physicians) (P = .01). Not surprisingly, A/I specialists and emergency physicians were more likely to see those patients at least once a month who reported a history of anaphylaxis (overall range, 17% family practitioners to 67% to 75% of A/I specialists; P < .001). All values are in % except P values. When asked which symptoms may be indicative of anaphylaxis, there were significant differences among the groups regarding cough (range, 30% to 55%; P = .02), skin reactions (26% to 54%; P = .003), and abdominal pain (6% to 46%; P < .001). Responses were similar regarding breathing problems (71% to 77%), dizziness/fainting (50% to 68%), and swelling (38% to 54%). Fewer than 20% of each group considered sudden behavioral change, anxiety, loss of bladder control, or hoarse voice to be indicative of anaphylaxis. With regard to the foods that are most likely to cause severe allergic reactions, significant differences were found among the groups for each of the 9 foods queried. Peanut was recognized most consistently, although it was not recognized as a common trigger by 24% of emergency physicians and 30% of family practitioners. In addition, most non-A/I specialists did not identify tree nuts as a common cause of severe allergic reactions and shellfish was noted by less than half of family practitioners and pediatricians. With regard to medications as a cause of severe allergic reactions, there were significant differences among the groups for all medication classes except sulfa drugs. Possibly most surprising, nonsteroidal anti-inflammatory drugs were not recognized as a trigger by the vast majority of family practitioners and emergency physicians. When queried regarding treatment of witnessed anaphylaxis, there were no significant differences among the groups, with 81% of family practitioners to 98% of A/I specialists reporting epinephrine as the first-line treatment. Significantly fewer emergency physicians (63%; P < .001) indicated that they prescribe an EAI for patients reporting a history of anaphylaxis, while they were also more likely to prescribe oral corticosteroids (21%; P < .001). Differences were also seen in those reporting subspecialty referral, ranging among non-A/I specialists from 5% of emergency physicians to 19% of pediatricians (P < .001). A series of questions also focused on awareness and attitudes regarding anaphylaxis. Although almost all A/I specialists were aware of professional anaphylaxis guidelines, this was true for only 60%, 46%, and 67% of emergency physicians, family practitioners, and pediatricians, respectively (P < .001). Most of the A/I specialists, family practitioners, and pediatricians believed that patients carry their EAI most/all of the time compared with only 39% of emergency physicians (P = .007). There were no differences regarding the opinion that patients will use their EAI appropriately (range, 42% to 65%). In addition, 16% to 38% believed that there are absolute contraindications to the use of epinephrine in treating anaphylaxis. Although most physicians recognized asthma as a risk factor for severe anaphylaxis, most emergency and family physicians did not recognize that teenagers are at an increased risk of fatal anaphylaxis. In addition, 19% to 33% of the physicians mistakenly reported that restaurants are required to have EAIs available and 77% to 94% wrongly indicated that all ambulances are required to carry epinephrine. Finally, when asked about the impact of severe allergies on daily life, only 10% of the family practitioners responded "a lot" compared with 53% of pediatric A/I specialists. Given that anaphylaxis is common and can have potentially deadly consequences, the findings from this survey raise concern about overall physician knowledge of this condition. Although it is reassuring that almost all physicians were very familiar with the term anaphylaxis and recognized that epinephrine is the recommended first-line treatment, it is concerning that many physicians did not identify breathing problems, fainting, swelling, and abdominal pain as symptoms that might indicate anaphylaxis. It is also of potential concern that very few physicians advise subspecialty referral for patients with anaphylaxis. Fortunately, most physicians did state that they would provide an EAI prescription for patients reporting a history of anaphylaxis. Although emergency physicians were less likely to do so at 63%, this is not surprising given the fact that most patients in the emergency department are there for reasons unrelated to anaphylaxis. These results, however, are somewhat inconsistent with our previous public and patient surveys,3Wood R.A. Camargo C.A. Lieberman P. Sampson H.A. Schwartz L.B. Zitt M. et al.Anaphylaxis in America: the prevalence and characteristics of anaphylaxis in the United States.J Allergy Clin Immunol. 2013; 133: 461-467Abstract Full Text Full Text PDF PubMed Scopus (243) Google Scholar in which we found that although most respondents reported 2 or more previous anaphylactic episodes, and 19% reported 5 or more, 60% did not have EAI available. They are also inconsistent with published reports of emergency treatment of anaphylaxis, in which epinephrine is actually used in only a minority of patients, even in those with cardiovascular symptoms.8Aun M.V. Blanca M. Garro L.S. Ribeiro M.R. Kalil J. Motta A.A. et al.Nonsteroidal anti-inflammatory drugs are major causes of drug-induced anaphylaxis.J Allergy Clin Immunol Pract. 2014; 2: 414-420Abstract Full Text Full Text PDF PubMed Scopus (90) Google Scholar, 9Rudders S.A. Banerji A. Corel B. Clark S. Camargo Jr., C.A. Multicenter study of repeat epinephrine treatments for food-related anaphylaxis.Pediatrics. 2010; 125: e711-e718Crossref PubMed Scopus (101) Google Scholar These discrepancies may be due at least in part to a limitation in the design of the questionnaire, which did not capture data about which specific symptoms would trigger administration of epinephrine, recognizing that respondents may have different interpretations of anaphylaxis and thresholds for the use of epinephrine. Finally, many doctors responded that there are absolute contraindications to epinephrine, although most experts agree that this is not the case for patients presenting with anaphylaxis. All these issues raise significant concern that physicians may be less likely to both prescribe and use epinephrine in actual practice than they reported in the survey. In addition to survey responses about the recognition and treatment of anaphylaxis, a number of interesting findings emerged regarding other day-to-day issues. Physicians were overall misinformed about the availability of epinephrine in both restaurants and ambulances. When questioned regarding quality of life, only 10% of family practitioners and 31% of pediatricians believed that "severe allergies" have a major impact on quality of life. This differs markedly from results of previous studies about patients' perceptions regarding the effects of food allergy on quality of life.10Sicherer S.H. Noone S.A. Munoz-Furlong A. The impact of childhood food allergy on quality of life.J Allergy Clin Immunol. 2001; 81: 461-464Google Scholar More pediatric A/I specialists (78%) than others (P = .03) believed that life-threatening allergic reactions today are more common than 10 years ago, consistent with published data,11Simons F.E.R. Anaphylaxis.J Allergy Clin Immunol. 2010; 125: S161-S181Abstract Full Text Full Text PDF PubMed Scopus (338) Google Scholar and most physicians in all groups recognized that asthma is a risk factor for severe reactions. Similar to our surveys of patients and the general public, this study clearly demonstrates the need for ongoing education regarding anaphylaxis. As with previous studies, knowledge gaps are especially apparent for primary care and emergency physicians, who are most often the physicians on the front line in the treatment of this common and life-threatening condition. Supplementary data Download .doc (.12 MB) Help with doc files Anaphylaxis Physician Survey Download .doc (.12 MB) Help with doc files Anaphylaxis Physician Survey
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