Enhancing patient outcomes by strengthening allergy evaluation in primary care settings

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Nearly one in three U.S. adults and more than one in four U.S. children report having a respiratory allergy, eczema or food allergy. Not only this, but up to 80% of patients with a respiratory allergy are sensitized to more than one allergen, making it critical to identify the underlying causes of allergic symptoms so patients can effectively manage their allergies.

Not only do diagnosis and effective management, including allergen avoidance, help patients, but they can also save lives and reduce the burden of allergic diseases on the U.S. health care system. Each year in the U.S., 3.4 million patients, about the population of Oklahoma, have a food allergy-related emergency department visit. This means that every 10 seconds, a food allergy reaction sends a patient to the emergency department.

Niti Chokshi, MD
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Allergies have a substantial economic burden on the health care system, both in terms of direct financial costs like emergency department visits and primary care clinician visits and in indirect costs, such as efficiency losses due to potentially avoidable appointments and out-of-pocket expenses for individuals and families. Because of this, whether it’s a perennial or seasonal respiratory, food, insect or another type of allergy, getting to the root cause of a patient’s symptoms enables them to work with their health care team to create efficient management plans that minimize any unnecessary need for these health care services.

The importance of patient history in ordering the right tests

Blood testing and skin prick testing don’t necessarily indicate a clinical allergy but rather sensitization to an allergen. The most important factor in diagnosing allergies is a patient’s clinical history. It is critical to tie in a patient’s testing to their history of reactions or symptoms upon exposure to the allergen.

The proper gathering of a patient’s history should include an assessment of symptoms consistent with immunoglobulin E (IgE)-mediated allergy, which may involve the skin, gastrointestinal tract, cardiovascular system or respiratory tract, and these symptoms are typically exhibited within minutes to a couple of hours of exposure to the allergen, with the exception of specific delayed reactions like those associated with the mammalian meat allergy known as alpha-gal syndrome.

Clinicians should have an understanding of when symptoms occur, how often they happen and what seems to bring them on, including an understanding of work, home and eating habits to see whether these can provide clues to suggest an allergy. Additionally, a patient’s reactions should be consistently reproducible under similar circumstances.

It’s important to choose the right test to aid the diagnostic process. Allergy patients are often sensitized to many allergens but are only clinically allergic to one or more specific substances. Tests are chosen based on symptoms, environmental and occupational exposures, age and even hobbies, and all results are then interpreted in the context of the patient’s holistic medical history. Choosing the right allergy test in primary care is crucial for making an accurate diagnosis and effectively managing allergies. Ensuring that patients receive the right treatment, whether it’s medication, lifestyle changes or allergen-specific immunotherapy, can help lead to improved health outcomes and overall well-being.

Establishing medical necessity: The downstream importance of diagnosis codes

Establishing a patient’s medical necessity is critical because it ensures that diagnostic tests, treatments and referrals are both clinically justified and reimbursable by insurance. Since symptoms can overlap or be nonspecific, getting the patient’s detailed history helps clinicians ensure that they have clear documentation.

Inaccurate or nonspecific diagnostic coding may result in denied claims or requests for additional documentation, which can both delay patient care and add undue administrative burdens to primary care offices for appeals and claims resubmissions. Beyond reimbursement, receiving an accurate and timely allergy diagnosis shifts allergy management from reactive to proactive, ensuring better care and improved quality of life for patients.

Reducing the burden of allergies on the health care system

Allergic diseases, including allergic rhinitis (hay fever), atopic dermatitis (eczema), food allergies and allergic asthma, are highly prevalent, underdiagnosed and often inadequately managed, creating a significant strain on the health care system and contributing to adverse health outcomes. According to a seven-year retrospective analysis of insurance claims data of 355,520 individuals with food allergies continuously enrolled in a health insurance plan for at least 12 months pre- and post-index, 17% had a food allergy-related emergency department visit and 0.9% were hospitalized. The same study found that out-of-pocket cost per patient per year for outpatient visits, emergency department visits and hospitalizations had an estimated mean of $1,631 for patients with food allergy-related visits, which is approximately 11% of the total costs for these services ($14,395 per patient per year).

For food allergies in particular, emergency department visits are a significant cost driver, with one study estimating the overall cost of childhood food allergy in the United States at $24.8 billion annually, primarily due to inpatient, outpatient and ER visits. Evidence shows that if patients have an accurate picture of the triggers that cause their symptoms and take steps to avoid them, doing so can keep them out of the emergency department and hospital.

One study from Molina Healthcare found that for patients with asthma, the identification of environmental sensitization via specific IgE testing resulted in significant asthma-related health care utilization savings for patients. In the United States, skin prick testing is usually performed by allergy/immunology specialists, while serum IgE testing is a standard clinical laboratory test that can be and is ordered by both specialists and primary care clinicians. A majority of patients with asthma are managed by primary care physicians in the United States. According to the Centers for Disease Control and Prevention, about 40% of primary care visits are for chronic conditions, so with clinician shortages and increased wait times to see both allergists and primary care providers, IgE testing can be a cost-effective and efficient choice for primary care clinicians to improve control in patients with asthma and reduce asthma-related morbidity and costs, including clinicians’ time spent on potentially preventable appointments.

Overall, primary care’s role in determining the source of their patients’ allergy symptoms is critical both for the patient and for minimizing the burden of allergic diseases on the health care system. By ensuring that a complete patient history is recorded and diagnostic codes are accurately capturing the patient’s symptoms, patients and clinicians are then reimbursed and billed correctly. Getting to the root cause of patients’ symptoms also enables them to implement personalized care management plans that allow the patients and caregivers to improve their quality of life.

Niti Chokshi, MD, is a board-certified specialist in pediatrics and allergy/immunology care. She’s an integral part of the team at Complete Allergy & Asthma in Houston, Texas, providing personalized care to patients of all ages.