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Unnecessary food allergy testing by primary care providers

2018; Elsevier BV; Volume: 121; Issue: 6 Linguagem: Inglês

10.1016/j.anai.2018.07.009

1534-4436

David E. Tapke, Rebecca Scherzer, Mitchell H. Grayson,

Contact Dermatitis and Allergies

Key Messages •Serum specific immunoglobulin (Ig)E tests can be useful in the diagnosis of IgE-mediated food allergy by demonstrating the presence of sensitization; however, they should not be considered diagnostic of food allergy without clinical correlation, given their poor positive predictive value and inability to reliably predict clinical reactivity.•The use of multiple food allergen panels has been associated with the misdiagnosis of food allergy, leading to unnecessary dietary avoidance and higher health care costs.•Most food allergen panels are ordered by primary care providers, who may be unaware of the added costs and potential harms associated with panel testing.•Specialists have an ethical responsibility to provide education and expertise to other providers, and they should use all opportunities to exercise this responsibility.•Clinical practices that are thought to be unethical or incompetent should be reported to the appropriate state medical board. •Serum specific immunoglobulin (Ig)E tests can be useful in the diagnosis of IgE-mediated food allergy by demonstrating the presence of sensitization; however, they should not be considered diagnostic of food allergy without clinical correlation, given their poor positive predictive value and inability to reliably predict clinical reactivity.•The use of multiple food allergen panels has been associated with the misdiagnosis of food allergy, leading to unnecessary dietary avoidance and higher health care costs.•Most food allergen panels are ordered by primary care providers, who may be unaware of the added costs and potential harms associated with panel testing.•Specialists have an ethical responsibility to provide education and expertise to other providers, and they should use all opportunities to exercise this responsibility.•Clinical practices that are thought to be unethical or incompetent should be reported to the appropriate state medical board. InstructionsCredit can now be obtained, free for a limited time, by reading the review article in this issue and completing all activity components. Please note the instructions listed below:•Review the target audience, learning objectives and all disclosures.•Complete the pre-test.•Read the article and reflect on all content as to how it may be applicable to your practice.•Complete the post-test/evaluation and claim credit earned. At this time, physicians will have earned up to 1.0 AMA PRA Category 1 CreditTM. Minimum passing score on the post-test is 70%.•Approximately 4-6 weeks later you will receive an online outcomes assessment regarding your application of this article to your practice. Once you have completed this assessment, you will be eligible to receive MOC Part II credit from the American Board of Allergy and Immunology.Overall PurposeParticipants will be able to demonstrate increased knowledge of the clinical treatment of allergy/asthma/immunology and how new information can be applied to their own practices.Learning ObjectivesAt the conclusion of this activity, participants should be able to:•Discuss the ethical responsibilities of a specialist when dealing with inappropriate test utilization•Define the importance of beneficence and nonmaleficence in medical practiceRelease Date: December 1, 2018Expiration Date: November 30, 2020Target AudiencePhysicians involved in providing patient care in the field of allergy/asthma/immunologyAccreditationThe American College of Allergy, Asthma & Immunology (ACAAI) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.DesignationThe American College of Allergy, Asthma & Immunology (ACAAI) designates this journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.Disclosure PolicyAs required by the Accreditation Council for Continuing Medical Education (ACCME) and in accordance with the American College of Allergy, Asthma and Immunology (ACAAI) policy, all CME planners, presenters, moderators, authors, reviewers, and other individuals in a position to control and/or influence the content of an activity must disclose all relevant financial relationships with any commercial interest that have occurred within the past 12 months. All identified conflicts of interest must be resolved and the educational content thoroughly vetted for fair balance, scientific objectivity, and appropriateness of patient care recommendations. It is required that disclosure be provided to the learners prior to the start of the activity. Individuals with no relevant financial relationships must also inform the learners that no relevant financial relationships exist. Learners must also be informed when off-label, experimental/investigational uses of drugs or devices are discussed in an educational activity or included in related materials. Disclosure in no way implies that the information presented is biased or of lesser quality. It is incumbent upon course participants to be aware of these factors in interpreting the program contents and evaluating recommendations. Moreover, expressed views do not necessarily reflect the opinions of ACAAI.Disclosure of Relevant Financial RelationshipsAll identified conflicts of interest have been resolved. Any unapproved/investigative uses of therapeutic agents/devices discussed are appropriately noted.Planning Committee•Jonathan A. Bernstein, MD (Annals CME Subcommittee): Consultant, Fees: Imedics; Consultant/Principal Investigator, Grants/Fees: Boehringer Ingelheim, GlaxoSmithKline; Consultant/Principal Investigator/Speaker, Grants/Fees: AstraZeneca, CSL Behring, Novartis/Genentech, Shire; Speaker, Fees: Baxalta•Guha Krishnaswamy, MD (Annals CME Subcommittee): Clinical Research, Grant: CSL Behring•Gailen D. Marshall, Jr, MD, PhD (Editor-in-Chief): Clinical Research, Grants: Sanofi, Stallergenes•Anna Nowak-Wegrzyn, MD (CME Series Editor, Deputy Editor): Clinical Research, Grant: Nutricia, Nestle, ITN NIH, DBV, Astellas; Speaker, Fees: Nutricia, Nestle, Thermofisher; Contributor, Royalties: UpToDate: Clinical Trial DMC Member: Merck; Board Member: Gerber, IFPIES•John J. Oppenheimer, MD (Annals CME Subcommittee, Associate Editor): Consultant, Other financial gains: DBV Technologies, GlaxoSmithKline, Kaleo; Clinical Research, Grants: AstraZeneca, Boehringer Ingelheim, NovartisAuthorsThe following individuals have no relevant financial relationships to disclose:• David E. Tapke, MD, MPH• Rebecca Scherzer, MD• Mitchell H. Grayson, MDRecognition of Commercial Support: This activity has not received external commercial support.Copyright Statement: © 2015–2018 ACAAI. All rights reserved.CME Inquiries: Contact the American College of Allergy, Asthma & Immunology at [email protected]or 847-427-1200. Credit can now be obtained, free for a limited time, by reading the review article in this issue and completing all activity components. Please note the instructions listed below:•Review the target audience, learning objectives and all disclosures.•Complete the pre-test.•Read the article and reflect on all content as to how it may be applicable to your practice.•Complete the post-test/evaluation and claim credit earned. At this time, physicians will have earned up to 1.0 AMA PRA Category 1 CreditTM. Minimum passing score on the post-test is 70%.•Approximately 4-6 weeks later you will receive an online outcomes assessment regarding your application of this article to your practice. Once you have completed this assessment, you will be eligible to receive MOC Part II credit from the American Board of Allergy and Immunology. Participants will be able to demonstrate increased knowledge of the clinical treatment of allergy/asthma/immunology and how new information can be applied to their own practices. At the conclusion of this activity, participants should be able to:•Discuss the ethical responsibilities of a specialist when dealing with inappropriate test utilization•Define the importance of beneficence and nonmaleficence in medical practice Release Date: December 1, 2018 Expiration Date: November 30, 2020 Physicians involved in providing patient care in the field of allergy/asthma/immunology The American College of Allergy, Asthma & Immunology (ACAAI) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The American College of Allergy, Asthma & Immunology (ACAAI) designates this journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity. As required by the Accreditation Council for Continuing Medical Education (ACCME) and in accordance with the American College of Allergy, Asthma and Immunology (ACAAI) policy, all CME planners, presenters, moderators, authors, reviewers, and other individuals in a position to control and/or influence the content of an activity must disclose all relevant financial relationships with any commercial interest that have occurred within the past 12 months. All identified conflicts of interest must be resolved and the educational content thoroughly vetted for fair balance, scientific objectivity, and appropriateness of patient care recommendations. It is required that disclosure be provided to the learners prior to the start of the activity. Individuals with no relevant financial relationships must also inform the learners that no relevant financial relationships exist. Learners must also be informed when off-label, experimental/investigational uses of drugs or devices are discussed in an educational activity or included in related materials. Disclosure in no way implies that the information presented is biased or of lesser quality. It is incumbent upon course participants to be aware of these factors in interpreting the program contents and evaluating recommendations. Moreover, expressed views do not necessarily reflect the opinions of ACAAI. All identified conflicts of interest have been resolved. Any unapproved/investigative uses of therapeutic agents/devices discussed are appropriately noted. •Jonathan A. Bernstein, MD (Annals CME Subcommittee): Consultant, Fees: Imedics; Consultant/Principal Investigator, Grants/Fees: Boehringer Ingelheim, GlaxoSmithKline; Consultant/Principal Investigator/Speaker, Grants/Fees: AstraZeneca, CSL Behring, Novartis/Genentech, Shire; Speaker, Fees: Baxalta•Guha Krishnaswamy, MD (Annals CME Subcommittee): Clinical Research, Grant: CSL Behring•Gailen D. Marshall, Jr, MD, PhD (Editor-in-Chief): Clinical Research, Grants: Sanofi, Stallergenes•Anna Nowak-Wegrzyn, MD (CME Series Editor, Deputy Editor): Clinical Research, Grant: Nutricia, Nestle, ITN NIH, DBV, Astellas; Speaker, Fees: Nutricia, Nestle, Thermofisher; Contributor, Royalties: UpToDate: Clinical Trial DMC Member: Merck; Board Member: Gerber, IFPIES•John J. Oppenheimer, MD (Annals CME Subcommittee, Associate Editor): Consultant, Other financial gains: DBV Technologies, GlaxoSmithKline, Kaleo; Clinical Research, Grants: AstraZeneca, Boehringer Ingelheim, Novartis The following individuals have no relevant financial relationships to disclose: • David E. Tapke, MD, MPH • Rebecca Scherzer, MD • Mitchell H. Grayson, MD Recognition of Commercial Support: This activity has not received external commercial support. Copyright Statement: © 2015–2018 ACAAI. All rights reserved. CME Inquiries: Contact the American College of Allergy, Asthma & Immunology at [email protected] or 847-427-1200. After completing her fellowship in allergy and immunology, Dr. X accepted an appointment in an academic position at a tertiary care pediatric hospital. Many of the patients Dr. X sees for evaluation of food allergy have undergone serum specific IgE testing before their allergy consultation. As time goes on, Dr. X begins to notice a concerning trend in patients referred from Dr. Y, a primary care provider who has been practicing in the community for over 20 years. Dr. X is worried that many of Dr. Y's patients have undergone clinically unwarranted extensive serum specific IgE testing with panels of multiple food allergens. In many instances, families were instructed to avoid all foods against which the patient was found to have detectable serum specific IgE, even if these were foods that were previously tolerated in their diet. Although Dr. X has included comments in her communications to Dr. Y recommending against ordering panel testing for the assessment of possible food allergy, Dr. Y continues to regularly order them and uses the results to direct dietary avoidance. Dr. X is concerned that Dr. Y may cause patient harm through management decisions that are inconsistent with currently accepted clinical practices and published guidelines. What should Dr. X do?