Table I.
An approach to priority ranking of in-person allergy clinic visits and services
| Highest acuity | |
|---|---|
| Allergic condition | Specific circumstance and/or disease characteristic |
| Allergic rhinoconjunctivitis/sinusitis | • No circumstance or characteristic meets this priority |
| Anaphylaxis | • New onset in last 6 months: recurrent anaphylaxis >2 episodes in past year (unless seen by another allergist and stable in the past 3 months, or seen as an inpatient consult and stable and this is the visit to establish care) • New-onset anaphylaxis in last 6-12 months, with very clear trigger (eg, venom and perioperative, seminal fluid) • Suspected systemic mastocytosis with elevated tryptase, 1 or more episodes in the past 6 months, and evidence of cytopenia • Established systemic mastocytosis patients experiencing breakthrough anaphylaxis |
| Asthma | • Patients with asthma of any severity who have required ED care or have been hospitalized for an exacerbation within the past 3-6 months, have received ≥2 oral steroid courses in the past 3-6 months, or have required ≥1 dose escalation(s)/addition(s) of any daily controller medication in the past 3-6 months |
| Drug/vaccine allergy | • Drug/vaccine allergy patient (including aspirin) where there is an urgent or critical need for evaluation and/or delabeling, drug challenge, or desensitization in the next few weeks or months |
| Food allergy, including FPIES/EoE | • New-onset index reaction occurring within last 3-6 months, clear trigger/history • New-onset additional food in established patient occurring within last 3-6 months, clear trigger/history • Early peanut introduction if meeting NIAID addendum 1 criteria (severe eczema and/or egg allergy) for early peanut introduction to prevent peanut allergy • Infant in first year of life with allergy to 1 or more 8 common foods where misdiagnosis is suspected and food being withheld (eg, panel avoidance for eczema) or there is question of formula tolerance |
| Immunodeficiency/immune dysregulation/blood cell disorder | • Newly identified SCID, combined immunodeficiency , or critical B-cell defect (agammaglobulinemia or severe hypogammaglobulinemia) patient at risk for recurrent, life-threatening infections that may/will require immunoglobulin replacement therapy, antimicrobial prophylaxis, protective isolation, and/or other related therapies • Newly identified severe congenital neutropenia and bone marrow failure syndrome patients • Newly identified patients with defects of phagocyte function and motility (eg, chronic granulomatous disease and leukocyte adhesion deficiency) • Newly identified patients with primary immune regulatory disorders, autoinflammatory disorders, complement deficiencies, and select innate immune defects in which prompt therapeutic interventions are warranted • Newly identified patients with hypereosinophilic syndromes and accompanying end-organ involvement • Follow-up of conditions listed above if remote (telehealth) care is insufficient to meet needs of the patient • Follow-up of abnormal newborn screens that are highly suggestive of SCID |
| Skin/other | • New patient visits for particularly severe cases of suspected angioedema, such as events with pharyngeal/laryngeal edema, abdominal or genital involvement • New or follow-up visits with severe atopic dermatitis (on high- potency topical corticosteroids, on alternative anti-inflammatory topical therapy, history of superinfections, significant negative impact of skin on quality of life, infants with extensive body surface area involvement, candidates for biologic therapy) |
| Moderate acuity | |
|---|---|
| Allergic condition | Specific circumstance and/or disease characteristic |
| Allergic rhinoconjunctivitis/sinusitis | • Acute sinusitis not responding to initial antibiotic where imaging and/or culture/referral is being considered and telehealth is not an option • Patients with chronic sinusitis, AERD, or nasal polyposis who are on biologic controller therapy or those pending nasal polypectomy |
| Anaphylaxis | • New visit for anaphylaxis occurring >1 year ago • Suspected systemic mastocytosis with elevated tryptase but no evidence of cytopenia, 1 or more episodes in the past 6 months • Established patients with mastocytosis experiencing new- onset symptoms or symptoms breaking through current controller medications |
| Asthma | • Patients with asthma of any severity who have required ED care or have been hospitalized for an exacerbation within the past 6-12 months, have received ≥2 oral steroid courses in the past 6-12 months, or have required ≥1 dose escalation(s)/addition(s) of any daily controller medication in the past 6-12 months • Patients with chronically uncontrolled symptoms based on impairment • Patients with history of poor control in upcoming season |
| Food allergy | • Children entering into kindergarten in the fall (or younger) with food allergy that will influence classroom/school policy • OIT updosing on patients in whom therapy was initiated, with some build up, but was held because of the pandemic |
| Immunodeficiency/immune dysregulation/blood cell disorder | • Patients with a history of recurrent/severe infections or autoimmune/autoinflammatory complications not requiring inpatient management, but for whom an evaluation is time-sensitive (yet not urgent/emergent) • Hypereosinophilia of >6-month duration with no suspected end-organ dysfunction |
| Skin/other | • New or follow-up visits for refractory urticaria with evidence of failed first-line management • Visits for new-onset or less-severe angioedema • New or established patients with moderate atopic dermatitis (on moderate potency topical corticosteroids) • Established urticaria pigmentosa with history of rising tryptase level or other indicator of possible systemic involvement |
| Immunotherapy (SCIT, SLIT, OIT) | • Maintenance IT visits/resumption • Case-by-case initiation of new IT can be considered, but only if benefits are strongly outweighing risks of therapy |
| Lower acuity | |
|---|---|
| Allergic condition | Specific circumstance and/or disease characteristic |
| Allergic rhinoconjunctivitis/sinusitis | • Patients with chronic sinusitis, AERD, or nasal polyposis except for those on in-person biologic therapy or those pending nasal polypectomy • Patients with poor control of symptoms (including sleep disruption or reduced quality of life) despite multiple medications (ie, candidates for potential future immunotherapy, with the understanding that new starts may not be possible and/or symptoms will not immediately respond) • Patients who have previously seen other specialists and allergy evaluation was recommended to optimize allergy symptom control |
| Anaphylaxis | • Annual follow-up for recurrent anaphylaxis if stable • Second opinion for anaphylaxis if stable • Follow-up for systemic mastocytosis if has been stable in the past 12 months |
| Asthma | • Patients with asthma of any severity who have been well controlled in the past 6-12 months, including no record of ED visits, who have had ≤1 oral steroid burst or hospitalization in the immediate 6 months, or ≤2 exacerbations in the past year • Routine follow-up visits with any patient with mild to moderate or well-controlled asthma |
| Drug/vaccine allergy | • New-onset evaluation for reaction occurring >1 year ago • Proactive penicillin delabeling with no imminent therapeutic need • Other drug/vaccine evaluation for reported/suspected allergic reaction • Second opinion for penicillin allergy with no readministration plan in next 6 months |
| Food allergy | • New evaluation of a food allergy occurring >1 year previously • New-onset EoE not seen by GI or newly diagnosed EoE seen by GI with or without impaction history • Second/additional opinions not meeting aforementioned prioritization • Allergic proctocolitis • New evaluation, any duration, dye or other 8 noncommon/seed allergen (eg, atypical culprits such as fruit, vegetable, and meat) • New evaluation/updosing for oral immunotherapy |
| Immunodeficiency/immune dysregulation/blood cell disorder | • Patients with a history of recurrent, common infections without severe manifestations • New evaluation of patients with mildly/moderately low immunoglobulin levels, mild/moderate cytopenia, or another similar mild/moderate finding, in which there is no history of severe or otherwise worrisome infections • History of intermittent or new- onset low to moderate eosinophilia of less than 6-months duration |
| Skin/other | • New or follow-up visits for refractory urticaria except for those on in-office biologic therapy (who are higher acuity) • New or follow-up evaluation for cutaneous mast cell disorder • Ongoing evaluation of established urticaria • New or established patients with mild atopic dermatitis (currently on low-potency topical corticosteroids) • Suspected mast cell activation syndrome • Evaluation or follow-up for allergic contact dermatitis |
| Immunotherapy (SCIT, SLIT, OIT) | • Maintenance IT visits/resumption • Initiation of all forms of new IT |
AERD, Aspirin-exacerbated respiratory disease; ED, emergency department; EoE, eosinophilic esophagitis; FPIES, food protein–induced enterocolitis syndrome; GI, gastrointestinal; IT, immunotherapy; NIAID, National Institute of Allergy and Infectious Diseases; OIT, oral immunotherapy; SCID, severe combined immunodeficiency; SCIT, subcutaneous immunotherapy; SLIT, sublingual immunotherapy.