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Primary Care

Top 10 Scientific Articles in the field of primary care published in 2017.

Results of an allergy educational needs questionnaire for primary care.
Ryan D, Angier E, Gomez M, Church D, Batsiou M, Nekam K, Lomidze N, Gawlik R. 
Allergy. 2017; 72:7. doi: 10.1111/all.13134. Epub 2017 Mar 17.
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Reviewer’s Comment: If allergy care is to improve in terms of reach and quality it is essential that the educational needs of practitioners other than allergists are met.

Abstract: It is well recognized that knowledge of allergic conditions is suboptimal in primary care. The Primary Care Interest Group of the European Academy of Allergy and Clinical Immunology undertook an educational needs survey to better understand what they were and how best to meet them, in the primary care environment. An electronic questionnaire was devised and distributed as widely as possible. A total of 2226 people from 63 countries opened the e-questionnaire of which 692 provided evaluable responses. In total, 81% were medical doctors with 299 possessing additional qualifications. Self-declared gaps in knowledge were expressed for most manifestations of allergy with a correspondingly high self-expressed educational need. The preferred learning modalities were online guidelines (69.6%) and courses (68.8%) followed closely by workshops (68%), structured online modules (63.9%) and small local working groups (59.75%). Podcasts and webinars scored poorly with only 25% expressing these as preferred learning modes although there was an age gradient. The preferred electronic platform was the personal computer (82.6%). A better understanding of the needs of primary care should help guide the design of educational initiatives to meet those needs.

 

Challenges in the implementation of the EAACI AIT guidelines: A situational analysis of current provision of allergen immunotherapy.
Ryan D, Gerth van Wijk R, Angier E, Kristiansen M, Zaman H, Sheikh A, Cardona V, Vidal C, Warner A, Agache I, Arasi S.
Allergy. 2018; 73:4. doi: 10.1111/all.13264. Epub 2017 Dec 12.
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Reviewer’s Comment: As immunotherapy becomes more mainstream it is important that care pathways are described and impediments to accessing this therapy are recognised and removed.

Abstract:
Purpose: The European Academy of Allergy and Clinical Immunology (EAACI) has produced Guidelines on Allergen Immunotherapy (AIT). We sought to gauge the preparedness of primary care to participate in the delivery of AIT in Europe.
Methods: We undertook a mixed‐methods, situational analysis. This involved a purposeful literature search and two surveys: one to primary care clinicians and the other to a wider group of stakeholders across Europe.
Results: The 10 papers identified all pointed out gaps or deficiencies in allergy care provision in primary care. The surveys also highlighted similar concerns, particularly in relation to concerns about lack of knowledge, skills, infrastructural weaknesses, reimbursement policies and communication with specialists as barriers to evidence‐based care. Almost all countries (92%) reported the availability of AIT. In spite of that, only 28% and 44% of the countries reported the availability of guidelines for primary care physicians and specialists, respectively. Agreed pathways between specialists and primary care physicians were reported as existing in 32%‐48% of countries. Reimbursement appeared to be an important barrier as AIT was only fully reimbursed in 32% of countries. Additionally, 44% of respondents considered accessibility to AIT and 36% stating patient costs were barriers.
Conclusions: Successful working with primary care providers is essential to scaling‐up AIT provision in Europe, but to achieve this, the identified barriers must be overcome. Development of primary care interpretation of guidelines to aid patient selection, establishment of disease management pathways and collaboration with specialist groups are required as a matter of urgency.

Summary of both of the above papers:

  • allergy is on the increase
  • primary care is failing to meet patients’ needs
  • educational, training and resources need to be found to correct this situation

 

Development of an allergy management support system in primary care.
Flokstra-de Blok BM, van der Molen T, Christoffers WA, Kocks JW, Oei RL, Oude Elberink JN, Roerdink EM, Schuttelaar ML, van der Velde JL, Brakel TM, Dubois AE.
J Asthma Allergy. 2017; 15:10. doi: 10.2147/JAA.S123260. PMID: 28352197.
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 Reviewer’s Comment: For non-allergy specialists, the deployment of decision support systems offer the prospect of improving diagnosis and management of patients. 

Abstract:
Background: Management of allergic patients in the population is becoming more difficult because of increases in both complexity and prevalence. Although general practitioners (GPs) are expected to play an important role in the care of allergic patients, they often feel ill-equipped for this task. Therefore, the aim of this study was to develop an allergy management support system (AMSS) for primary care.
Methods: Through literature review, interviewing and testing in secondary and primary care patients, an allergy history questionnaire was constructed by allergists, dermatologists, GPs and researchers based on primary care and specialists' allergy guidelines and their clinical knowledge. Patterns of AMSS questionnaire responses and specific immunoglobulin E (sIgE)-test outcomes were used to identify diagnostic categories and develop corresponding management recommendations. Validity of the AMSS was investigated by comparing specialist (gold standard) and AMSS diagnostic categories.
Results: The two-page patient-completed AMSS questionnaire consists of 12 (mainly) multiple choice questions on symptoms, triggers, severity and medication. Based on the AMSS questionnaires and sIgE-test outcome of 118 patients, approximately 150 diagnostic categories of allergic rhinitis, asthma, atopic dermatitis, anaphylaxis, food allergy, hymenoptera allergy and other allergies were identified, and the corresponding management recommendations were formulated. The agreement between the allergy specialists' assessments and the AMSS was 69.2% (CI 67.2-71.2).
Conclusion: Using a systematic approach, it was possible to develop an AMSS that allows for the formulation of diagnostic and management recommendations for GPs managing allergic patients. The AMSS thus holds promise for the improvement of the quality of primary care for this increasing group of patients.

Symptomatic treatment of pollen-related allergic rhinoconjunctivitis in children: randomized controlled trial.
Wartna JB, Bohnen AM, Elshout G, Pijnenburg MW, Pols DH, Gerth van Wijk RR, Bindels PJ.
Allergy. 2017; 72:4. doi: 10.1111/all.13056. Epub 2016 Oct 28.
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Reviewer’s Comment: Results obtained from randomized controlled trials need to be challenged constantly with “real life studies” to determine the optimum role of any treatment modality.

Abstract:
Background: About 12% of children are affected by allergic rhinoconjunctivitis (AR). Although the main symptomatic treatments are intranasal corticosteroids (INCS) (daily or on demand) and oral antihistamines, it remains unclear which treatment provides the best relief of symptoms. Therefore, this study examines whether daily use of INCS is superior to on-demand use or to oral antihistamines on demand.
Methods: A single-blinded randomized controlled trial in children (aged 6-18 years) with pollen-related AR. Patients received either INCS daily (fluticasone propionate), INCS on demand (fluticasone propionate) or oral antihistamine on demand (levocetirizine) for 3 months during the grass pollen season. A daily online symptom diary on both nose and eye symptoms was completed. The primary outcome was the percentage of symptom-free days.
Results: A total of 150 children were randomized. The percentage symptom-free days was in favor of INCS on demand (30%) compared with INCS daily (22%), that is 8% difference (95% CI -5 to +21%; not significant). The antihistamine on-demand group had 15% symptom-free days, that is 7% difference compared to INCS daily (95% CI -6 to +19%;, not significant). Patients in the INCS on-demand group used on average 61% less fluticasone than patients in the INCS daily group during the study period (P < 0.0001).
Conclusion: This trial with three parallel treatment groups shows that INCS daily was not superior to INCS on demand or to antihistamine on demand regarding the number of symptom-free days. An on-demand INCS strategy has the advantage of a lower overall corticosteroid exposure and less costs.

 

Risks for comorbidity in children with atopic disorders: an observational study in Dutch general practices.
Pols DHJ, Bohnen AM, Nielen MMJ, Korevaar JC, Bindels PJE.

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Reviewer’s Comment: The confluence of atopic disorders needs to be better understood cognizant of the fact that they may be confounded by the presence of non-atopic disorders.

Abstract:
Objective: This study aimed to investigate both atopic and non-atopic comorbid symptoms and diseases in children with physician-diagnosed atopic disorders (atopic eczema, asthma and allergic rhinitis).
Methods: All children aged 0–18 years listed in a nationwide primary care database (the Netherlands Institute for Health Services Research-Primary Care Database) with routinely collected healthcare data in 2014 were selected. Children with atopic disorders were matched on age and gender with non-atopic controls within the same general practice. A total of 404 International Classification of Primary Care codes were examined. Logistic regression analyses were performed to examine the associations between the presence of atopic disorders and (non-)atopic symptoms and diseases by calculating ORs.
Results: Having one of the atopic disorders significantly increased the risk of having other atopic-related symptoms, even if the child was not registered as having the related atopic disorder. Regarding non-atopic comorbidity, children with atopic eczema (n=15 530) were at significantly increased risk for (infectious) skin diseases (OR: 1.2–3.4). Airway symptoms or (infectious) diseases (OR: 2.1–10.3) were observed significantly more frequently in children with asthma (n=7887). Children with allergic rhinitis (n=6835) had a significantly distinctive risk of ear-nose-throat-related symptoms and diseases (OR: 1.5–3.9). Neither age nor gender explained these increased risks.
Conclusion: General practitioners are not always fully aware of relevant atopic and non-atopic comorbidity. In children known to have at least one atopic disorder, specific attention is required to avoid possible insufficient treatment and unnecessary loss of quality of life.

 

A young child with a history of wheeze.
Paton J, Bindels P, McMurray A, Biggins J, Nantanda R, Østergaard MS.
NPJ Prim Care Respir Med. 201; 27:1. doi: 10.1038/s41533-017-0020-3.
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Reviewer’s Comment: This is a worked clinical example which exemplifies the difficulties encountered when faced with a pre-school child with wheeze.

Abstract: The parents of a 3-year old boy are anxious about their son who has recurring episodes of wheezing. They are frustrated that no one seems to be able to give them answers to their questions and would like a referral to a specialist. Does their son have asthma and what is the prognosis; how can the recurrent wheezing be managed and can the risk of asthma be reduced; are there lifestyle changes that could improve the environment and avoid triggers? Communication and support from the family practice team were essential. Listening to the parents' concerns, explaining the diagnostic uncertainty, being realistic about what drug treatments could achieve, and providing practical advice on inhaler use and trigger avoidance reassured the parents that there was a strategy for managing their son's wheeze. The specialist referral was postponed.