Food-Allergic Kids Need Current Epi Script

November 18, 2013

BALTIMORE — Just 30% of food-allergic children presenting to a pediatric outpatient clinic have a current prescription for an epinephrine autoinjector, with far fewer having chart documentation of how to administer it, according to a new study.

"It was a surprise," lead investigator Christopher Couch, MD, told Medscape Medical News before presenting the findings here at the American College of Allergy, Asthma & Immunology (ACAAI) 2013 Annual Scientific Meeting.

"This study started as a quality-improvement project. There's room for much improvement ― and some of those quality-improvement measures include physician education," said Dr. Couch, a pediatric resident at the University of Nevada School of Medicine in Las Vegas.

The retrospective chart review of outpatient visits at 2 pediatric resident clinics included 57 patients (mean age, 6 years).

Most of the patients, 53%, were allergic to peanut, with 30% allergic to egg, 26% to shellfish, 18% to tree nut, 5% to milk, and 4% to wheat.

Although 67% of the charts documented the prescription of an epinephrine autoinjector at some time, only 30% of patients had a current prescription, with just 18% having documentation of administration instructions, and 14% having documentation of a food allergy action plan.

The study also found that 58% had received a referral to an allergist and that 58% had undergone laboratory testing for allergy-specific serum IgE levels.

Three quarters of the patients had Medicaid insurance, and 21% were Spanish speaking.

There's room for much improvement ― and some of those quality-improvement measures include physician education. Dr. Christopher Couch

Current guidelines from the National Institute of Allergy and Infectious Diseases on the management of food allergies recommend that patients be prescribed epinephrine autoinjectors on a yearly basis, that instructions be given regarding use and administration of the medication, and that an emergency action plan be discussed with the patient and written down, said Dr. Couch. A plan for monitoring expiration dates should also be outlined with the family, he said.

"Many residents aren't aware that the prescription does expire," he added. "We have paper charts, but with electronic records, it's a great opportunity to have pop-up reminders 1 year after the prescription is written."

Dr. Couch pointed out that the results may reflect physician oversight "or could simply be a lack of documentation in the chart. We cannot conclude that the prescriptions were not filled by the patient."

Asked by Medscape Medical News to comment on the findings, Ronna Campbell, MD, from the Mayo Clinic Department of Emergency Medicine, in Rochester, Minnesota, said, "Food allergy in children is frequently a lifelong condition that requires ongoing reassessment and management. I agree with the authors' conclusions that development of quality-improvement strategies would be helpful in ensuring consistent and appropriate long-term management so that patients are adequately prepared to manage anaphylaxis should it occur."

Dr. Campbell's recent review on this topic pointed to evidence that many clinicians do not know how to properly demonstrate autoinjector use (Pediatr Emerg Care 2012;28:938-942).

"In a study of junior and senior medical staff demonstrating the use of the EpiPen, Mehr et al revealed that, in 37% of cases, the physician's demonstration would have failed to deliver epinephrine to a patient," Dr. Campbell wrote in the review. "Furthermore, 16% of the physicians would have self-injected their thumb had they been using an actual EpiPen."

Asked whether failure to prescribe autoinjectors might be related to physician lack of confidence or knowledge in this area, she said, "One could speculate that that is a possible cause, but it is more likely that it just gets overlooked because there are no systematic ways of ensuring that the prescription is renewed."

Dr. Couch and Dr. Campbell report no relevant financial relationships.

American College of Allergy, Asthma & Immunology (ACAAI) 2013 Annual Scientific Meeting: Abstract 5. Presented November 10, 2013.


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