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Frequency of US emergency department visits for food-related acute allergic reactions

2010; Elsevier BV; Volume: 127; Issue: 3 Linguagem: Inglês

10.1016/j.jaci.2010.10.040

1097-6825

Sunday Clark, Janice A. Espinola, Susan A. Rudders, Aleena Banerji, Carlos A. Camargo,

Occupational exposure and asthma

To the Editor: Estimates of the burden of food-related acute allergic reactions have been reported across various health care settings, including ambulatory care,1Branum A.M. Lukacs S.L. Food allergy among children in the United States.Pediatrics. 2009; 124: 1549-1555Crossref PubMed Scopus (583) Google Scholar hospitalizations,1Branum A.M. Lukacs S.L. Food allergy among children in the United States.Pediatrics. 2009; 124: 1549-1555Crossref PubMed Scopus (583) Google Scholar and the emergency department (ED).1Branum A.M. Lukacs S.L. Food allergy among children in the United States.Pediatrics. 2009; 124: 1549-1555Crossref PubMed Scopus (583) Google Scholar, 2Ross M.P. Ferguson M. Street D. Klontz K. Schroeder T. Luccioli S. Analysis of food-allergic and anaphylactic events in the National Electronic Injury Surveillance System.J Allergy Clin Immunol. 2008; 121: 166-171Abstract Full Text Full Text PDF PubMed Scopus (193) Google Scholar, 3Sampson H.A. Food anapylaxis.Br Med Bull. 2000; 56: 925-935Crossref PubMed Scopus (101) Google Scholar Food-related anaphylaxis has been cited as the most frequent cause of anaphylaxis treated in the ED.3Sampson H.A. Food anapylaxis.Br Med Bull. 2000; 56: 925-935Crossref PubMed Scopus (101) Google Scholar Treatment delays are associated with poor outcomes and suggest the need for additional training and resources for patients and providers. To that end, we describe the national burden of food-related acute allergic reactions treated in the ED by using data from 2 large ED-based cohort studies and the National Hospital Ambulatory Medical Care Survey (NHAMCS). Data from 2 ED-based studies were used to identify the proportion of patients assigned to each International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code that was later determined to be a food-related acute allergic reaction4Rudders 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 (105) Google Scholar and the proportion of these patients who had food-induced anaphylaxis.4Rudders 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 (105) Google Scholar, 5Clark S. Bock S.A. Gaeta T.J. Brenner B.E. Cydulka R.K. Camargo Jr., C.A. Multicenter study of emergency department visits for food allergies.J Allergy Clin Immunol. 2004; 113: 347-352Abstract Full Text Full Text PDF PubMed Scopus (232) Google Scholar We multiplied these 2 proportions against counts from the 2001 to 2005 NHAMCS to estimate the national number of ED visits for each ICD-9-CM code with food-related acute allergic reaction and with food-induced anaphylaxis. Table I lists the ICD-9-CM codes.Table IICD-9-CM codes used to identify food-related acute allergic reactions, including anaphylaxisICD-9-CM codeDescription477.1Allergic rhinitis due to food558.3Allergic gastroenteritis and colitis692.5Contact dermatitis due to food in contact with skin693.1Dermatitis due to food taken internally708.xUrticaria988.0Toxic effect of fish and shellfish989.0Toxic effect of hydrocyanic acid and cyanides989.9Toxic effect of unspecified substance995.0Other anaphylactic shock995.1Angioneurotic edema995.2Unspecified adverse effect of drug, etc995.3Allergy unspecified995.4Shock due to anesthesia995.60-995.69Anaphylactic shock due to adverse food reaction with specific codes for unspecified food, peanuts, crustaceans, fruits and vegetables, tree nuts and seeds, fish, food additives, milk products, eggs, other specified food995.7Other adverse food reactions not elsewhere classified999.4Anaphylactic shock to serum Open table in a new tab The first ED-based study was a multicenter retrospective cohort study performed at 21 North American EDs to examine ED visits for food allergy; ICD-9-CM codes 693.1, 995.60, 995.61 to 995.69, 995.0, and 995.3 were used to identify cases of food allergy.5Clark S. Bock S.A. Gaeta T.J. Brenner B.E. Cydulka R.K. Camargo Jr., C.A. Multicenter study of emergency department visits for food allergies.J Allergy Clin Immunol. 2004; 113: 347-352Abstract Full Text Full Text PDF PubMed Scopus (232) Google Scholar Physician investigators at each of the participating sites determined whether the ED visit was a result of food allergy. The second ED-based study was a multicenter retrospective cohort study performed at 3 Boston EDs to describe the management of food-related acute allergic reactions.4Rudders 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 (105) Google Scholar In the second study, all ED visits identified by ICD-9-CM codes 995.60, 995.61 to 995.69, 995.0, 693.1, 995.7, 558.3, and 692.5, and a random sample of the codes 995.3, 995.1, and 708.x, were reviewed by 2 physicians to determine whether the ED visit was a result of food allergy. In both studies, a food-related acute allergic reaction was defined as an acute episode of IgE-mediated symptoms in which the onset was immediately related to a known or suspected food allergen. The working definition of anaphylaxis resembled national criteria.6Sampson H.A. Muñoz-Furlong A. Campbell R.L. Adkinson Jr., N.F. Bock S.A. Branum A. et al.Second symposium on the definition and management of anaphylaxis: summary report—Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network Symposium.J Allergy Clin Immunol. 2006; 117: 391-397Abstract Full Text Full Text PDF PubMed Scopus (1764) Google Scholar Specifically, we defined anaphylaxis as an acute allergic reaction involving 2 or more organ systems or hypotension alone. Hypotension was defined as a systolic blood pressure <100 mmHg for adults and <90 mmHg for children between ages 10 and 17 years. For children younger than 10 years, hypotension was defined as a systolic blood pressure less than 70 mmHg + (age multiplied by 2).6Sampson H.A. Muñoz-Furlong A. Campbell R.L. Adkinson Jr., N.F. Bock S.A. Branum A. et al.Second symposium on the definition and management of anaphylaxis: summary report—Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network Symposium.J Allergy Clin Immunol. 2006; 117: 391-397Abstract Full Text Full Text PDF PubMed Scopus (1764) Google Scholar NHAMCS, the third study, is a 4-stage probability sample of visits to noninstitutional general and short-stay hospitals, excluding federal, military, and Veterans Affairs hospitals, in the United States. NHAMCS is conducted annually and covers geographic primary sampling units located in all 50 states and the District of Columbia. At each sampled hospital, trained hospital staff collect data during a randomly assigned 4-week data period, and a US Census Bureau field supervisor reviews the data collection. The nonresponse rate for most items was <5%, and error rates were <2% for items that required medical coding. Completed data collection forms are sent for coding using the ICD-9-CM. National estimates are obtained through use of a multistage estimation procedure and patient visit weights. A detailed description of NHAMCS procedures is available in the technical notes section of each year's NHAMCS Emergency Department Survey.7Nawar E.W. Niska R.W. Xu J. National Hospital Ambulatory Medical Care Survey: 2005 emergency department summary.Adv Data. 2007; 386: 1-32PubMed Google Scholar Descriptive analyses were performed using STATA 10.1 (StataCorp, College Station, Tex). Overall, from 2001 to 2005, a total of 7,075,000 ED visits were identified by using the specified ICD-9-CM codes,7Nawar E.W. Niska R.W. Xu J. National Hospital Ambulatory Medical Care Survey: 2005 emergency department summary.Adv Data. 2007; 386: 1-32PubMed Google Scholar of which an estimated 1,015,000 visits (14%) were considered to be true food-related acute allergic reactions.4Rudders 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 (105) Google Scholar, 5Clark S. Bock S.A. Gaeta T.J. Brenner B.E. Cydulka R.K. Camargo Jr., C.A. Multicenter study of emergency department visits for food allergies.J Allergy Clin Immunol. 2004; 113: 347-352Abstract Full Text Full Text PDF PubMed Scopus (232) Google Scholar This accounts for approximately 203,000 ED visits for food-related acute allergic reactions each year (final line of Table II). With a total of 525,600 minutes per year, this suggests—on average—an ED visit for food-related acute allergic reaction somewhere in the United States every 3 minutes. Among the 1,015,000 ED visits for food-related allergic reactions from 2001 to 2005, an estimated 448,000 visits (44%), or 90,000 visits each year, would be classified as probable anaphylaxis.4Rudders 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 (105) Google Scholar, 5Clark S. Bock S.A. Gaeta T.J. Brenner B.E. Cydulka R.K. Camargo Jr., C.A. Multicenter study of emergency department visits for food allergies.J Allergy Clin Immunol. 2004; 113: 347-352Abstract Full Text Full Text PDF PubMed Scopus (232) Google Scholar On average, an ED visit caused by food-related anaphylaxis occurred somewhere in the US every 6 minutes. These estimates are for number of ED visits and include repeat visits; they are not numbers of unique (individual) patients with food allergy.Table IIEstimated number of ED visits for food-related acute allergic reactions and anaphylaxisAcute allergic reactionSubset with anaphylaxisStudyYearsMethod of case identificationED visits/yMinutes∗On average, there was an ED visit for the specified condition every __ minutes.ED visits/yMinutes∗On average, there was an ED visit for the specified condition every __ minutes.Yocum et al,8Yocum M.W. Butterfield J.H. Klein J.S. Volcheck G.W. Schroeder D.R. Silverstein M.D. Epidemiology of anaphylaxis in Olmsted County: a population-based study.J Allergy Clin Immunol. 1999; 104: 452-456Abstract Full Text Full Text PDF PubMed Scopus (423) Google Scholar Sampson3Sampson H.A. Food anapylaxis.Br Med Bull. 2000; 56: 925-935Crossref PubMed Scopus (101) Google Scholar1983-1987Medical records——29,00018Branum and Lukacs1Branum A.M. Lukacs S.L. Food allergy among children in the United States.Pediatrics. 2009; 124: 1549-1555Crossref PubMed Scopus (583) Google Scholar1993-2006ICD-9-CM codes25,000†Among children age <18 years.‡Includes visits to EDs, hospital outpatient departments, and physician office.21†Among children age <18 years.‡Includes visits to EDs, hospital outpatient departments, and physician office.——Ross et al2Ross M.P. Ferguson M. Street D. Klontz K. Schroeder T. Luccioli S. Analysis of food-allergic and anaphylactic events in the National Electronic Injury Surveillance System.J Allergy Clin Immunol. 2008; 121: 166-171Abstract Full Text Full Text PDF PubMed Scopus (193) Google Scholar2003Symptom codes125,000414,00038Current study2001-2005ICD-9-CM codes203,000390,0006—, Not reported.∗ On average, there was an ED visit for the specified condition every __ minutes.† Among children age <18 years.‡ Includes visits to EDs, hospital outpatient departments, and physician office. Open table in a new tab —, Not reported. These results suggest that the number of US ED visits for food-related acute allergic reactions may be significantly higher than estimated in previous reports.1Branum A.M. Lukacs S.L. Food allergy among children in the United States.Pediatrics. 2009; 124: 1549-1555Crossref PubMed Scopus (583) Google Scholar, 2Ross M.P. Ferguson M. Street D. Klontz K. Schroeder T. Luccioli S. Analysis of food-allergic and anaphylactic events in the National Electronic Injury Surveillance System.J Allergy Clin Immunol. 2008; 121: 166-171Abstract Full Text Full Text PDF PubMed Scopus (193) Google Scholar, 3Sampson H.A. Food anapylaxis.Br Med Bull. 2000; 56: 925-935Crossref PubMed Scopus (101) Google Scholar Based on the work of Yocum et al8Yocum M.W. Butterfield J.H. Klein J.S. Volcheck G.W. Schroeder D.R. Silverstein M.D. Epidemiology of anaphylaxis in Olmsted County: a population-based study.J Allergy Clin Immunol. 1999; 104: 452-456Abstract Full Text Full Text PDF PubMed Scopus (423) Google Scholar in the late 1990s, an early estimate was ∼29,000 ED visits for food-induced anaphylaxis annually.3Sampson H.A. Food anapylaxis.Br Med Bull. 2000; 56: 925-935Crossref PubMed Scopus (101) Google Scholar Ross et al2Ross M.P. Ferguson M. Street D. Klontz K. Schroeder T. Luccioli S. Analysis of food-allergic and anaphylactic events in the National Electronic Injury Surveillance System.J Allergy Clin Immunol. 2008; 121: 166-171Abstract Full Text Full Text PDF PubMed Scopus (193) Google Scholar used symptom codes in the National Electronic Injury Surveillance System during August and September 2003 to estimate 2,333 ED visits for food-induced anaphylaxis, or 14,000 ED visits annually. Our results show nearly 90,000 ED visits for anaphylaxis annually (Table II). In a recent study, Branum and Lukacs1Branum A.M. Lukacs S.L. Food allergy among children in the United States.Pediatrics. 2009; 124: 1549-1555Crossref PubMed Scopus (583) Google Scholar reported aggregate visits for food allergy to EDs, hospital outpatient departments, and physician offices by using NHAMCS and the National Ambulatory Medical Care Survey between 1993 and 2006. In total, they found 353,300 visits among children 75,000 additional ED visits each year. Future work should more closely evaluate differences in the frequency of ED visits for food-related acute allergic reactions between children and adults, and also evaluate the appropriateness of commonly used ICD-9-CM codes to identify cases of food-related allergic reactions. Recent concerns about the increasing prevalence of food allergy support further research on time trends in ED use for food-related acute allergic reactions.9Rudders S.A. Banerji A. Vassallo M.F. Clark S. Camargo Jr, C.A. Trends in pediatric emergency department visits for food-induced anaphylaxis.J Allergy Clin Immunol. 2010; 126: 385-388Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar Well designed surveillance programs are needed to improve our understanding of the incidence and prevalence of food-related allergic reactions. Together, such work will improve public awareness about food allergy and assist efforts to ensure that appropriate resources are allocated for this potentially life-threatening condition.