ORLANDO – Children who have at least two diagnoses of the "allergic triad" – asthma, allergic rhinitis, and atopic dermatitis – often receive prescriptions from multiple physicians and may be at risk for substantial exposure to exogenous corticosteroids.
This finding, from a chart review of 197 pediatric patients seen between 2000 and 2010 at a single U.S. allergy/immunology clinic, "reinforces the need for improved communication and coordination of care," said Dr. Min Jung Lee of Cohen Children’s Medical Center of New York.
Of the 197 patients who had been diagnosed with at least two of the three ICD-9 codes for asthma, allergic rhinitis, and/or atopic dermatitis, 48% had all three conditions. Of the patients diagnosed with two of the three conditions, 67% had both asthma and allergic rhinitis, 16.5% had asthma and atopic dermatitis, and 16.5% had allergic rhinitis and atopic dermatitis, Dr. Lee said at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.
Of the patients with asthma, 74% were treated with inhaled steroids. Of those, 36% received steroid prescriptions from multiple physicians, 29% from allergists alone, 21% from primary care physicians alone, and 9% from pulmonologists alone. Of the patients with allergic rhinitis, 62% were treated with intranasal steroids, of which 20% were given prescriptions by multiple physicians, 67% by allergists alone, 5% by primary care physicians alone, and 3% by otolaryngologists alone. Of those with atopic dermatitis, 75% were treated with topical steroids; of those, 41% received steroid prescriptions from multiple physicians, 23% from dermatologists alone, 21% from allergists alone, and 7% from primary care physicians alone. (There were small numbers from each group for which the specialty of the prescriber was unknown.)
Among the children with both asthma and allergic rhinitis, 55% were treated with corticosteroids for both conditions and 38% for one of the two conditions, while just 7% were not treated with corticosteroids. For those with asthma and atopic dermatitis, 59% were prescribed corticosteroids for both conditions and 23% for just one of the two, while 18% received no corticosteroids. For the allergic rhinitis plus atopic dermatitis group, 6% were treated with corticosteroids for both conditions and 82% for just one, while 12% received none.
For the 95 patients who had all three conditions, 41% were treated with corticosteroids for all three, 36% for two of the three, and 19% for one of the three. Just 4% of that group was not treated with corticosteroids, Dr. Lee reported.
In response to an audience member’s question about whether the prescriptions were coordinated, she replied, "No, usually we didn’t see any communication between physicians."
In an interview, the study’s principal investigator, Dr. James C. Fagin, noted, "Our concern is the cumulative effect, because there are so many physicians involved and the communication is so poor that the primary care physician may not know what the [specialist] is prescribing, or if the [specialist] changes that prescription to a more potent drug. Without the electronic medical record to cement all of this, it becomes difficult to manage. We are certainly guilty in our speciality because we’re not always notifying the primary care physician every time we change a prescription."
However, "in terms of asthma care, we want the primary care physician to be actively involved, but they aren’t always good at communicating with specialists about changes they make. ... Communication has to go both ways," added Dr. Fagin, director of pediatric allergy and clinical immunology and director of the Center for Childhood Asthma at the Cohen children’s center.
In response to another audience member’s question regarding the role of electronic medical records, Dr. Lee responded that "access to electronic pharmacy records would also be very beneficial for each of us to know what our patients are getting."
Both Dr. Lee and Dr. Fagin stated that they had no disclosures.