Eczema tops reasons why pediatricians order food allergy IgE panels
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LOUISVILLE, Ky. — Eczema was the top non-IgE mediated indication pediatricians at a health care network used for food allergy IgE panel testing, according to study results.
Quality improvement interventions can reduce the number of IgE panel tests ordered by pediatricians, according to the researchers, who presented their results at the American College of Allergy, Asthma & Immunology Annual Scientific Meeting.
“Food allergy IgE panels are often inappropriately ordered by generalists who evaluate eczema and other non-IgE mediated conditions,” Rachna R. Dave, MD, MS, a second-year resident with Children’s Healthcare of Atlanta, said during her presentation.
These tests then result in inaccurate diagnosis of food allergy, increased health care costs and potentially increased food allergy development because of delayed introduction to allergenic foods, Dave continued.
“To address this problem, we implemented a quality improvement (QI) project that aims to reduce food allergy panel utilization among pediatricians of The Children’s Care Network (TCCN), a clinically integrated network of over 120 practices,” Dave said.
The researchers conducted a literature review and listening sessions with pediatricians as well as surveys to ascertain the reasons why food allergen IgE panels were opened and to identify the barriers to change.
Also, the researchers analyzed 2020 to 2021 Anthem Payor data from TCCN pediatricians to identify practices that regularly used food allergy panel testing, defined as serum IgE levels ordered for more than three food allergens simultaneously.
Study findings
“We found that eczema and other non-IgE mediated conditions were the most common reasons why food allergen IgE panels were ordered,” Dave said.
Specifically, the most common reasons included immediate reactions after meals (27%), atopic dermatitis or eczema (17%), hives or swelling with an unclear cause not related to the meal (15%), parental request but no medical indication (10%) and hay fever or asthma (6%). Also, 9% of pediatricians had not ordered a food allergen IgE test.
When asked to rate their comfort level in educating parents about the early introduction of food allergens such as peanut to infants, 40% of clinicians said they were somewhat comfortable and another 40% said they were very comfortable, with 12% reporting they were somewhat uncomfortable, 4% saying they were very uncomfortable and 4% who were neutral.
Similarly, when asked to rate their comfort level in educating parents about the pathophysiology or causes of eczema, 49% said they were somewhat comfortable and 31% said they were very comfortable. Next, 10% were somewhat uncomfortable, 5% were very uncomfortable and 5% were neutral.
The pressure that caregivers placed on clinicians for testing, the misinformation that they received about food allergen testing, a lack of patient education materials and a lack of time for face-to-face education all were barriers in reducing food allergy IgE testing.
“We did find that among TCCN pediatricians, on average between 2020 to 2021, a practice would order three food allergen IgE panels. TCCN pediatricians often order food allergen IgE panels,” Dave said.
According to the study, 157 of the practices ordered between one and five tests. Also, 14 ordered between 6 and 10 tests, four ordered between 11 and 15 tests, and one ordered more than 15 tests. Eczema was the most common non-IgE mediated indication for food allergen IgE panel testing.
“However, pediatricians lack self-efficacy in explaining the pathophysiology of eczema to caregivers and educating about the importance of early introduction of food allergens, rather than testing and avoidance,” Dave said.
In addition to how much caregivers pressure these clinicians to conduct these tests, Dave continued, there is a lack of resources for combatting misinformation about food allergen testing.
Proposed interventions
The researchers believe that their interventions can help address these barriers, including didactics, handouts, newsletters, videos, posters, academic detailing and online modules.
For example, lectures will incorporate interactive teaching methods and adult learning theory to address knowledge gaps and barriers among clinicians.
Patient handouts will provide information about what causes eczema, how to manage it, and the early introduction of food allergens.
Newsletters will feature regular reports to TCCN practices that grade their adherence to quality metrics as well as answers to frequently asked questions.
To improve patient education, videos will feature caregiver attestations and interviews with food allergy experts to address knowledge gaps about food allergies and eczema.
Patient examination rooms will feature posters designed to prime caregivers with knowledge before they discuss treatment with the pediatrician.
The researchers additionally plan on face-to-face educational outreach with TCCN practices that are low performers in this project to help address their practice gaps.
Finally, e-learning modules will offer interactive elements that address knowledge gaps and barriers that emerge during this project.
“Pediatricians lack self-efficacy in addressing caregiver concerns about food allergies in children with eczema,” Dave said. “Multiple QI interventions will be utilized to address barriers to change and reduce the frequency of food allergen IgE panel testing.”