AAAAI Issues New Round of 'Don'ts Designed to Improve Patient Care

The American Academy of Allergy, Asthma & Immunology (AAAAI) on March 3, 2014, released its second list of overused tests and procedures that allergists, primary care physicians, and patients should question before they occur. The list represents the fruits of the Academy’s second year of participation in the “Choosing Wisely” initiative, and was presented at a press conference during the Academy’s annual meeting in San Diego, California.

“Choosing Wisely,” a project of the ABIM Foundation, asks leading professional associations across medicine to scrutinize those actions within each specialty that may be overused at the expense of quality care. “The intent is that the evidence shows that much of the care that is delivered in America is unnecessary,” said Linda Cox, MD, who was completing her term as AAAAI president. “It’s really about starting a conversation between the patients and their physicians.”

While issuing the list and curtailing the excess may save healthcare dollars, Cox and the other AAAAI leaders who spoke at the press conference emphasized that the priority of “Choosing Wisely” is providing better care and outcomes for patients. “We didn’t look at money. That’s not what ‘Choosing Wisely’ is about,” said Theodore M. Freeman, MD, who chaired the “Choosing Wisely” committee for AAAAI. The other presenters, David M. Lang, MD, and John Oppenheimer, MD, agreed with Freeman that quality of care is what is at issue, as some downstream effects of improper tests are hard to measure—such as not eating a favorite food because of a misdiagnosed “allergy.”

AAAAI’s “Choosing Wisely” list for 2014 includes:

• Don’t rely on antihistamines as first-line treatment for severe allergic reactions. Allergic reactions of anaphylaxis may present initially as cutaneous reactions, but they involve organ systems and require epinephrine. Overuse of antihistamines, which do not treat cardiovascular or respiratory manifestations of anaphylaxis, can delay the effective first-line treatment with epinephrine. Deaths have occurred in children with insect stings who did not receive epinephrine for anaphylaxis.

• Don’t perform food immunoglobin E (IgE) testing without a history consistent with potential IgE-mediated foodallergy. False-positive or clinically irrelevant positive allergy tests for foods are frequent. When this happens, patients who are not bothered by foods may avoid them for no reason, which wastes resources and limits patient dietary choices. IgE testing for specific foods should only occur when there are signs or symptoms consistent with an IgE-mediated reaction after eating a particular food.

• Don’t routinely order low- or iso-osmolar radiocontrast media or pretreat with corticosteroids and antihistamines for patients with a history of seafood allergy, who require radiocontrast media. The precise reason for contrast media reactions is unknown, but it is known that there is no cause-and-effect connection with seafood allergy—even though many patients believe there is. Using more expensive agents or premedication before using contrast media in patients with a history of seafood allergy should not be automatic; what matters is a prior history of anaphylaxis to contrast media. This is an indication to use low- or iso-osmolar agents and pretreat with corticosteroids and antihistamines.

• Don’t routinely avoid influenza vaccination in egg-allergic patients. While some vaccines have egg protein, the flu vaccine has not produced reactions. Freeman in particular was emphatic on this point: Evidence in the literature is very clear that egg-allergic patients can safely have flu vaccines. By contrast, he said, more than 40,000 people have suffered the flu this season, and 61 children have died from it.

• Don’t overuse non—beta-lactam antibiotics in patients with a history of penicillin allergy, without an appropriate evaluation. Self-reported penicillin allergies should be investigated and confirmed, as studies show that while 10% of the population reports such an allergy, about 90% of these patients turn out to be not allergic to this common antibiotic.

Other antibiotics are may be more expensive and less effective, resulting in hospital stays. With plenty of discussion at this year’s AAAAI meeting surrounding the use of electronic health records (EHRs), including to improve adherence to asthma medications, the 4 physicians agreed that EHRs would possibly help implement many of the 2014 recommendations, as well as those put in place a year ago. The doctors offered examples, such as a record asking whether a patient’s reported pencillin allergy has been clinically confirmed, or whether a patient who is told he has an asthma diagnosis has had spirometry—a common pulmonary test to measure lung function—which was included in the 2013 “Choosing Wisely” campaign from AAAAI