Nurse-led allergy clinics expand access to care, improve patient satisfaction
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Key takeaways:
- Nurse-led allergy clinics can successfully recruit, deliver and retain patients with in-person and remote care.
- Patients and health care providers both expressed satisfaction with the quality of care that these clinics provided.
- Patients particularly reported satisfaction with the longer consultation times where they felt like their individual concerns were personally addressed by an expert professional.
Allergy clinics led by nurses successfully recruited, delivered and retained patients while providing successful care in person and through remote consultations, according to a study published in Clinical and Translational Allergy.
Patients and professionals alike said the care that was provided was acceptable as well, Vicky Hammersley, PhD, research fellow with the Usher Institute at The University of Edinburgh, and colleagues wrote in the study.
According to the researchers, current demand for specialist allergy service far outweighs its supply, prompting a need to provide allergy care in community settings, particularly considering the growing numbers of people with allergic conditions.
Nurse, patient populations
Thirty-five out of the invited 37 general practices in Edinburgh referred patients with allergic problems to nurse-led allergy clinics located in three hub practices. These clinics provided care in person between July 2017 and March 2020 (phase 1) and then via secure remote technology from September 2020 to February 2021 (phase 2). Local specialist services in pediatric and adult allergy, dermatology, ENT and respiratory medicine supported these clinics as well.
The nurses leading these clinics — both of whom had postgraduate allergy qualifications and extensive secondary care experience — took allergy-focused histories during patient visits and they conducted clinical exams and clinically appropriate investigations. They provided diagnoses, management advice and relevant education to the patient and communicated with the referring health care provider (HCP) as well.
The study involved 426 patients seen during phase 1 and 40 patients seen during phase 2, focusing on suspected food allergy (phase 1, 34%; phase 2, 35%) and moderate to severe atopic eczema (phase 1, 12%; phase 2, 30%) in children aged younger than 36 months, allergic rhinitis in children and young people up to age 16 years (phase 1, 2%), and suspected anaphylaxis in adults (phase 1, 52%; phase 2, 35%). Eighty-three percent of referrals were for possible food allergy or anaphylaxis.
Also, 49% of the patients in phase 1 and 53% of the patients in phase 2 were classified as quintile 5 on the Scottish Index of Multiple Deprivation 2020, indicating that they came from the 20% least deprived areas of Scotland.
Patient, professional opinions
Patients were surveyed about their quality of life at baseline and between 6 and 12 weeks after their visit, with reduced or unchanged scores in all measures, the researchers found, indicating improved or unchanged quality of life for almost all measures.
Researchers surveyed patients and professionals about their satisfaction with care as well, with 64% to 91% of respondents saying they were very happy with individual aspects of the service. Patients gave the highest scores to the general information provided by the nurses.
Also, 155 (42%) of the patients said their allergy had gotten much better since visiting the clinic, 148 (40%) said they were slightly better, 59 (16%) said they felt no change and less than 2% said they were worse or slightly worse. Nearly all the patients (92%) said they were able to stick to the personal management or treatment plan their nurse provided.
The researchers additionally surveyed 12 general practitioners, six health visitors, one practice nurse, one community nursery nurse and one other professional who referred patients to the clinic.
Most of the HCPs had referred between one and 10 patients, two had referred between 11 and 20 patients, and two had referred between 21 and 30 patients. Although most of these HCPs said the referral process was easy, they suggested adding the clinic to the Scottish Care Information (SCI) Gateway, which integrates primary and secondary care systems.
Further, the HCPs had mean scores of 4.3 to 4.7 on a satisfaction scale of 1 (not happy) to 5 (very happy) when rating all aspects of their patients’ care at these clinics.
The HCPs called the ease of access, quick appointment times, reduced waiting times, the ability to see an experienced HCP and the time allowed for discussion as the best aspects of these clinics.
The worst aspects included requests for the use of the SCI Gateway for referrals, discharge summaries including prescribing information, and shorter waiting times for clinic appointments.
The researchers also conducted structured interviews with 16 patients and/or patient caregivers, who all were impressed by the clinic and pleased with their experience there.
These patients and caregivers said the time they spent with an experienced specialist nurse improved their knowledge about their allergies, gave them a greater feeling of control over their allergies and improved their quality of life as a result.
As consultations focused on practical ways to minimize the impact of these allergies on daily lives and cope with the anxieties raised by allergic symptoms, these patients also said they felt more supported and that they appreciated the convenience of the local clinic.
The local and familiar location of these clinics additionally made attendance easy, eliminating transportation problems. In fact, the researchers wrote, some patients indicated that they might not have attended the clinic if it would have been based in a hospital.
Further, patients were impressed by the short time that elapsed between the referral and their visit with the nurse, particularly because of the anxieties they felt about their allergies.
Patients said these consultations were helpful as well, considering the nurses’ expertise in allergies and in living with them, in addition to tests that were performed in the clinic with some results provided immediately.
These consultations, which patients said were longer than they had expected, enabled discussions that covered all the patients’ concerns, unlike consultations with general practitioners during which patients said they felt rushed.
Patients reported feeling happy with and confident in the care these nurses provided and felt as if they left these visits with a clear plan on how to manage their allergies daily, including autoinjector training and other practical tips in addition to their emotional needs.
The researchers also interviewed nine HCPs, all of whom were positive about the service and said these clinics addressed an existing gap. The referral process was straightforward, these respondents said, as communication with the nurses and post-discharge care were easy. The respondents also appreciated how the clinics were led by nurses with specialist knowledge.
These clinics did not reduce the workload for HCPs, the researchers continued, but they particularly met a need for young adults who lacked transition or adult allergy services in Edinburgh while providing accessibility due to their local presence.
Overall, the researchers concluded that the in-person and remote models of these nurse-led allergy clinics were acceptable, feasible and effective in providing care for patients with suspected or confirmed food allergy, eczema, allergic rhinitis and anaphylaxis, although their effectiveness should be confirmed with a formal randomized controlled trial.
Perspective
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There are a lot of similarities between Scotland and what we see in the U.S. We have similar capacity constraints for specialists, often resulting in waits of several months to see an allergist. And if one doesn’t live near a major metropolitan area, it can require traveling long distances.
After anaphylaxis or a food allergy diagnosis, those long waiting times can be incredibly stressful and induce anxiety among parents. Parents are often left with many questions and few resources after such a life-changing diagnosis.
Relatedly, when it comes to moderate to severe eczema, we know those kids are at a high risk for developing food allergies. Being able to intervene at an early stage can help inform parents of what they can potentially do to prevent food allergies from developing.
We also see similar challenges to those in Scotland, with pediatricians often lacking the skills to correctly diagnose food allergies, determine the appropriate diagnostic tests to use and accurately interpret results. One of the most common refrains we hear from allergists is that they routinely have to set right a misdiagnosis made by the primary care provider.
I believe nurses can deliver high-quality specialty care when properly trained. They can be a great avenue to expand access to care, especially in underserved communities. Our challenge in implementing something like this in the U.S. ultimately comes down to how it fits into the current system — and overcoming political and financial barriers.
There are limitations on how much practice independence nurses have in the U.S. There’s an increasing number of states where nurses can practice independently without physician oversight, as the American Association of Nurse Practitioners reports. However, they tend to focus more on primary care than specialty care.
Because each state has regulations, implementing this nationwide would be a significant challenge. In addition, there is pushback from many physician organizations on expanding the scope of practice for nurses.
I also would expect similar positive responses from patients and providers participating in a program like this, but I suspect there would be hesitation on the part of PCPs to refer to a nurse-led team vs. a physician specialist.
There is definitely a gap between primary care and specialty allergy care, and a lot of it relates to education. Physicians often run out of time in a visit before they can cover all the pertinent info and answer all the questions a patient or parent has, not to mention all the ones they have in the days and weeks following diagnosis. Parents and patients are often left to their own Google searches after that.
I see a path for creating allergy educators similar to diabetes educators. Rather than creating a new workflow, it would essentially piggyback on the existing one that has been built up over many years in the diabetes space. The next step would be opening up reimbursement avenues.
Reference:
State practice environment. https://www.aanp.org/advocacy/state/state-practice-environment. Updated April 15, 2022. Accessed Aug. 16, 2022.
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