Abstract
This study assesses the adherence to guidelines on peanut allergy assessment in infants aged 4 to 6 months in a clinic supplied with clinical decision support tools vs a comparator clinic.
Peanut allergy (PA) affects 2.2% of children in the United States.1 The Learning Early About Peanut Allergy (LEAP) study2 prompted the National Institute for Allergy and Infectious Disease to create the 2017 Addendum Guidelines for the Prevention of Peanut Allergy. The guidelines recommend that clinicians screen infants aged 4 to 6 months for PA risk. Infants at high risk (those with severe eczema and/or egg allergy) should receive a specific IgE (sIgE) or an allergy referral for assessment prior to peanut product introduction, while infants with low or moderate risk (with mild-moderate or no eczema) can have peanut products introduced and maintained in their diet.3 The possible prevention of PA in infants depends on pediatricians incorporating guidelines in well-child visits for infants aged 4 to 6 months. Clinical decision support (CDS) tools are an effective way to facilitate physician adherence to clinical guidelines.4 This study examines the effectiveness of a pediatrician-designed CDS tool and training on pediatrician adherence to the guidelines.
Methods
The Intervention to Reduce Early (Peanut) Allergy in Children (iREACH) included pediatrician training and CDS tools implemented in the electronic medical record (EMR) for well-child visits for infants aged 4 to 6 months. Tools included (1) an order set for peanut sIgE or allergy referral for infants at high risk of PA, (2) a prompt to evaluate PA risk, (3) a prompt indicating peanut product–introduction counseling, (4) an instructional handout for caregivers, and (5) a best-practice advisory for infants with known eczema or egg allergy. The Ann & Robert H. Lurie Children’s Hospital of Chicago’s institutional review board ruled this study exempt from review and informed consent.
In June 2017, a pediatric clinic received the iREACH training module and CDS tool. A second, comparison clinic had no EMR modification or training. Data from visits from infants aged 4 to 6 months between June 2017 and March 2018 were collected for 151 infants from the iREACH clinic and a random sample of 312 infants from the comparison clinic. For infants at low-moderate risk, full pediatrician adherence was achieved if the pediatrician noted peanut product introduction was recommended in the infant’s EMR. Partial adherence was observed among infants at low-moderate risk in the iREACH clinic if the instructional handout was given to families and/or peanut introduction was recommended, as noted in the EMR. For infants at high risk, full pediatrician adherence was achieved if the pediatrician ordered a peanut sIgE or referred the infant to an allergist.
Descriptive statistics and Pearson χ2 or Fisher exact test statistics are reported to identify associations between clinics. Two-sided P values <.05 were considered statistically significant. Analyses were conducted using SAS version 9.4 (SAS Institute).
Results
Among 463 infants, 92 (19.9%) had an eczema diagnosis and 9 (1.9%) had a diagnosis of severe eczema. There were significant differences in demographic factors between the clinics. In the iREACH clinic, there were more male infants (96 of 151 [63.6%] vs 157 of 312 [50.3%]; P = .007), more infants identified as black (45 of 151 [29.8%] vs 2 of 312 [0.6%]) or of multiple/other races (74 of 151 [49.0%] vs 26 of 312 [8.3%]; both comparisons, P < .001), and more Hispanic infants (69 of 151 [45.7%] vs 9 of 312 [2.9%]; P < .001) (Table 1).
Table 1. Characteristics of Infants Seen for Well-Child Visits at Age 4 to 6 Months by Practice From June 2017 to March 2018.
| Variable | Infants, No. (%) | P Valuea | |
|---|---|---|---|
| iREACH Clinic | Non-iREACH Clinic | ||
| Total | 151 (100.0) | 312 (100.0) | NA |
| Sex | |||
| Male | 96 (63.6) | 157 (50.3) | .007 |
| Female | 55 (36.4) | 155 (49.7) | |
| Age at first visit, mo | |||
| 4 | 96 (63.6) | 221 (70.8) | .12 |
| 6 | 55 (36.4) | 91 (29.2) | |
| Race | |||
| White | 18 (11.9) | 164 (52.6) | <.001 |
| Black/African American | 45 (29.8) | 2 (0.6) | |
| Asian | 12 (7.9) | 11 (3.5) | |
| Multiple/other | 74 (49.0) | 26 (8.3) | |
| Unknown | 2 (1.3) | 109 (34.9) | |
| Hispanic ethnicity | |||
| Yes | 69 (45.7) | 9 (2.9) | <.001 |
| No | 80 (53.0) | 195 (62.5) | |
| Unknown | 2 (1.3) | 108 (34.6) | |
| Payer type | |||
| Commercial | 31 (20.5) | 311 (99.7) | <.001 |
| Public | 117 (77.5) | 0 | |
| Missing | 3 (2.0) | 1 (0.3) | |
| Comorbidities | |||
| Any eczema | 42 (27.8) | 50 (14.4) | .03 |
| Any egg allergy | 1 (0.01) | 0 | .33 |
Abbreviations: iREACH, Intervention to Reduce Early (Peanut) Allergy in Children; NA, not applicable.
Attained via χ2 tests.
For infants at low-moderate risk, pediatricians were fully adherent to guidelines for 75 infants (52.4%) in the iREACH clinic and 44 infants (14.1%) in the comparison clinic (Table 2; P < .001). Pediatricians in the iREACH clinic were partially adherent to guidelines for 133 of these infants (93.0%).
Table 2. Pediatrician Adherence and Partial Adherence to Guidelines.
| Outcome | Total No. (%) | P Valuea | |
|---|---|---|---|
| iREACH Clinic | Non-iREACH Clinic | ||
| Infants at low-moderate risk | 143 (100.0) | 311 (100.0) | NA |
| Partially adherent to guidelinesb,c | 133 (93.0) | NA | NA |
| Adherent to guidelinesb,d | 75 (52.4) | 44 (14.1) | <.001 |
| With peanut specific IgE ordered | 3 (2.1) | 0 | .03 |
| With allergy referral | 2 (1.4) | 5 (1.6) | >.99 |
| Infants at high risk | 8 (5.6) | 1 (0.3) | |
| Adherent to guidelines, No./total No. (%)b,d | 5/8 (62.5) | 0/1 | .44 |
| With peanut specific IgE ordered, No./total No. (%) | 2/8 (25.0) | 0/1 | >.99 |
| With allergy referral, No./total No. (%) | 3/8 (37.5) | 0/1 | >.99 |
Abbreviations: iREACH, Intervention to Reduce Early (Peanut) Allergy in Children; NA, not applicable.
Fisher exact test was used for all tests of association with expected cell sizes of fewer than 5 individuals.
The 2017 Addendum Guidelines for the Prevention of Peanut Allergy3 was used.
Being partially adherent to guidelines meant that an instructional handout was given to families, and/or peanut product introduction was recommended in the iREACH clinic.
Being adherent to guidelines meant that peanut product introduction was recommended.
Pediatrician adherence for infants at high risk was 62.5% (n = 5 of 8) in the iREACH clinic; however, the sample size of infants at high risk in the non-iREACH clinic (n = 1) was not sufficient to detect a difference (P = .44). Among all infants at high risk, pediatricians referred to allergists (n = 3 of 9) more often than they ordered a peanut sIgE (n = 2 of 9). Additionally, 10 infants (2.2%) at low-moderate risk from both clinics were referred to an allergist or had a peanut sIgE ordered.
Discussion
Higher pediatrician guideline adherence was observed among infants in the clinic that implemented iREACH. Interestingly, more infants at low-moderate risk received a sIgE order or allergist referral than infants at high risk. Limitations of this study include (1) a limited number of clinic sites and therefore a limited number of high risk infants and (2) patients were not randomized between the iREACH and comparison clinic. Since well-child visits for infants aged 4 to 6 months focus on a range of preventative and anticipatory guidance, an effective CDS tool such as iREACH may facilitate pediatrician guideline adherence. Further long-term research is necessary to study if iREACH reduces PA incidence.
References
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