Penicillin Allergy Testing Is Cost-Saving: An Economic Evaluation Study.

BACKGROUND: Having a penicillin allergy label is associated with the use of less appropriate and more expensive antibiotics and increased healthcare utilization. Penicillin allergy testing results in delabeling most allergy claimants and may be cost-saving. This study aimed to project whether penicillin allergy testing in patients reporting a penicillin allergy is cost-saving. METHODS: In this economic evaluation study, we built decision models to project the economic impact of 2 strategies for a patient with a penicillin allergy label: (1) perform diagnostic testing (drug challenges, with or without skin tests); and (2) do not perform diagnostic testing. The health service perspective was adopted, considering costs with penicillin allergy tests, and with hospital bed-days/outpatient visits, antibiotic use, and diagnostic testing. Twenty-four base case decision models were built, accounting for differences in the diagnostic workup, setting (inpatient vs outpatient) and geographic region. Uncertainty was explored via probabilistic sensitivity analyses. RESULTS: Penicillin allergy testing was cost-saving in all decision models built. For models assessing the performance of both skin tests and drug challenges, allergy testing resulted in average savings (in United States [US] dollars) of $657 for inpatients (US: $1444; Europe: $489) and $2746 for outpatients (US: $256; Europe: $6045). 75% of simulations obtained through probabilistic sensitivity analysis identified testing as the less costly option. CONCLUSIONS: Penicillin allergy testing was projected to be cost-saving across different scenarios. These results are devised to inform guidelines, supporting the adoption of policies promoting widespread testing of patients with a penicillin allergy label.

Fatal Asthma: An Audit of 30 Million Patient-Years of Health Plan Membership from 2007 to 2015.

BACKGROUND: Without accurate data on deaths directly caused by asthma, prevention will be difficult. OBJECTIVE: To determine how often asthma could be confirmed as a proximal cause of death in a large well-defined population with active health plan membership and no acute barriers to medical care. METHODS: All deaths occurring in active Kaiser Permanente Southern California health plan members between 2007 and 2015 were identified. Asthma-coded deaths were manually audited for cause. Health care and asthma medication use in the 6 months before death were determined. RESULTS: There were 248 (0.80 per 100,000 patient-years) unaudited asthma-coded deaths. There were only 63 (26.5%) (0.20 per 100,000 patient-years) asthma-confirmed deaths. Individuals with asthma-confirmed deaths were younger, less likely to have ever smoked, and had fewer emergency visits in the 6 months before death compared with those with asthma excluded. Individuals with asthma-confirmed deaths used preventative inhalers at very low rates. We unexpectedly found that ever inclusion in the 2016 National Committee for Quality Assurance health effectiveness data and information set (HEDIS) for persistent asthma was associated with a higher risk of all-cause early death. Individuals with asthma-confirmed deaths were also unlikely to be in the HEDIS asthma dataset in the year they died, thus not targeted for outreach. CONCLUSIONS: Audit-confirmed fatal asthma is more likely to occur in younger, nonsmoking, individuals, using very low rates of preventive inhalers. This will be a very difficult group to prospectively identify and manage effectively. Further research into the reasons for early death after HEDIS asthma dataset inclusion is warranted.

Current Epidemiology and Management of Radiocontrast-Associated Acute- and Delayed-Onset Hypersensitivity: A Review of the Literature.

Radiocontrast-associated acute-onset hypersensitivity reactions now occur less frequently than before 1990, when high-osmolar, ionic, radiocontrast agents were widely used. Premedication with corticosteroids and antihistamines does not reliably prevent recurrent low-osmolar radiocontrast-associated acute hypersensitivity reactions. Corticosteroid prophylaxis for acute hypersensitivity currently causes more morbidity than benefit. The specific radiocontrast agent that is associated with a patient's adverse reaction must be displayed in the drug intolerance or drug "allergy" field of their electronic health record to enable effective management and prevention of future reactions. The term iodine allergy should never be used in the context of radiocontrast-associated adverse reactions because it leads to poorer clinical outcomes. The time to onset of the reaction and the nature of the reaction must be noted in enough detail in the drug intolerance comment fields in the electronic health record to determine the potential mechanism for the reaction and to enable selection of the appropriate radiocontrast material for future exposures. Most individuals with a history of radiocontrast agent hypersensitivity can be effectively managed by selecting an alternative radiocontrast agent, without any premedication. Radiology Departments, catheterization laboratories, and all physicians who use parenteral radiocontrast media must have management plans in place to treat severe acute reactions when they occur. Patients should be informed that delayed-onset reactions, mostly benign rashes within one week of exposure, are as common or more common than acute reactions. Future radiocontrast-associated acute and delayed-onset reactions can be minimized, but never completely avoided, by using an appropriate alternative agent.

The Effect of Penicillin Allergy Testing on Future Health Care Utilization: A Matched Cohort Study.

BACKGROUND: The effect that penicillin allergy testing has on future health care utilization is uncertain. OBJECTIVE: Determine whether penicillin allergy testing affects future overall health care utilization as measured by outpatient department (OPD) visits, emergency department (ED) visits, and hospital days. METHODS: Potential cases and control subjects were penicillin allergic Kaiser Permanente Southern California members who had at least 2 visits between 2010 and 2012 and at least 1 year of continuous health plan coverage before their index visit. RESULTS: It was possible to match 308 (73.2%) of the potential cases to 1251 unique controls, on the basis of age, sex, weighted Charlson comorbidity index, drug class allergies, OPD visits, ED visits, and hospital days during the years before their index visit. Cases and controls were then followed for an average of 3.6 and 4.0 years, respectively. Based on results analyzed using a generalized linear mixed model, cases were estimated to have 0.09 fewer OPD visits (P < .001), 0.13 fewer ED visits (P = .29), and 0.55 fewer hospital days (P < .001) per health plan coverage year during follow-up compared with controls. Cases were exposed to more penicillins and first- and second-generation cephalosporins and less clindamycin and macrolides. CONCLUSIONS: Penicillin allergy testing, primarily done in the setting of an outpatient Allergy consultation, was associated with significantly less health care utilization during 3.6+ years of follow-up and greater use of narrow-spectrum antibiotics. Penicillin allergy testing has a favorable cost-benefit ratio for the incremental cost of testing versus future health care utilization and improves antibiotic stewardship.

Low-value care for acute sinusitis encounters: who's choosing wisely?

OBJECTIVES: To assess acute sinusitis (AS) encounters in primary care (PC), urgent care (UC), and emergency department (ED) settings for adherence to recommendations to avoid low-value care. STUDY DESIGN: A retrospective, observational study of adult AS encounters (2010-2012) within a large integrated healthcare system. METHODS: We compared ED and UC encounters with PC visits, adjusting for differences in patient characteristics. PRIMARY OUTCOMES: adherence to recommendations to avoid antibiotics and a computed tomography (CT) scan of the face, head, or sinuses. SECONDARY OUTCOMES: length of symptoms and adherence with AS recommendations. RESULTS: Of 152,774 AS encounters, 89.2% resulted in antibiotics and 1.1% resulted in a CT scan. Compared with PC encounters, ED encounters were less likely to result in antibiotics (adjusted odds ratio [AOR], 0.57; 95% CI, 0.50-0.65) but more likely to result in a CT scan (AOR, 59.4; 95% CI, 51.3-68.7), while UC encounters were more likely to result in both antibiotics (AOR, 1.12; 95% CI, 1.08-1.17) and CT imaging (AOR, 2.4; 95% CI, 2.1-2.7). Chart review of encounters resulting in antibiotics found that 50% were inappropriately prescribed for symptoms of ≤7 days' duration (95% CI, 41%-58%), while 35% were appropriately prescribed for symptoms of ≥14 days' duration (95% CI, 27%-44%). Only 29% (95% CI, 22%-36%) of encounters were consistent with guideline-adherent care. CONCLUSIONS: AS encounters in an integrated health system infrequently result in CT imaging, but antibiotic treatment is common. Differences exist across acute care settings, but improved antibiotic stewardship is needed in all settings.

Penicillin allergy: optimizing diagnostic protocols, public health implications, and future research needs.

PURPOSE OF REVIEW: Unverified penicillin allergy is being increasingly recognized as a public health concern. The ideal protocol for verifying true clinically significant IgE-mediated penicillin allergy needs to use only commercially available materials, be well tolerated and easy to perform in both the inpatient and outpatient settings, and minimize false-positive determinations. This review concentrates on articles published in 2013 and 2014 that present new data relating to the diagnosis and management of penicillin allergy. RECENT FINDINGS: Penicillin allergy can be safely evaluated at this time, in patients with an appropriate clinical history of penicillin allergy, using only penicilloyl-poly-lysine and native penicillin G as skin test reagents, if an oral challenge with amoxicillin 250 mg, followed by 1 h of observation, is given to all skin test negative individuals. SUMMARY: Millions of individuals falsely labeled with penicillin allergy need to be evaluated to safely allow them to use penicillin-class antibiotics and avoid morbidity associated with penicillin avoidance. Further research is needed to determine optimal protocol(s). There will still be a 1-2% rate of adverse reactions reported with all future therapeutic penicillin-class antibiotic use, even with optimal methods used to determine acute penicillin tolerance. Only a small minority of these new reactions will be IgE-mediated.

Health care use and serious infection prevalence associated with penicillin "allergy" in hospitalized patients: A cohort study.

BACKGROUND: Penicillin is the most common drug "allergy" noted at hospital admission, although it is often inaccurate. OBJECTIVE: We sought to determine total hospital days, antibiotic exposures, and the prevalence rates of Clostridium difficile, methicillin-resistant Staphylococcus aureus (MRSA), and vancomycin-resistant Enterococcus (VRE) in patients with and without penicillin "allergy" at hospital admission. METHODS: We performed a retrospective, matched cohort study of subjects admitted to Kaiser Foundation hospitals in Southern California during 2010 through 2012. RESULTS: It was possible to match 51,582 (99.6% of all possible cases) unique hospitalized subjects with penicillin "allergy" to 2 unique discharge diagnosis category-matched, sex-matched, age-matched, and date of admission-matched control subjects each. Cases with penicillin "allergy" averaged 0.59 (9.9%; 95% CI, 0.47-0.71) more total hospital days during 20.1 ± 10.5 months of follow-up compared with control subjects. Cases were treated with significantly more fluoroquinolones, clindamycin, and vancomycin (P < .0001) for each antibiotic compared with control subjects. Cases had 23.4% (95% CI, 15.6% to 31.7%) more C difficile, 14.1% (95% CI, 7.1% to 21.6%) more MRSA, and 30.1% (95% CI, 12.5% to 50.4%) more VRE infections than expected compared with control subjects. CONCLUSIONS: A penicillin "allergy" history, although often inaccurate, is not a benign finding at hospital admission. Subjects with a penicillin "allergy" history spend significantly more time in the hospital. Subjects with a penicillin "allergy" history are exposed to significantly more antibiotics previously associated with C difficile and VRE. Drug "allergies" in general, but most those notably to penicillin, are associated with increased hospital use and increased C difficile, MRSA, and VRE prevalence.

Multiple drug intolerance syndrome: prevalence, clinical characteristics, and management.

BACKGROUND: Population-based data on the demographics and clinical characteristics of patients with multiple unrelated drug class intolerances noted in their medical records are lacking. OBJECTIVES: To provide population-based drug "allergy" incidence rates and prevalence, and to identify individuals with multiple drug intolerance syndrome (MDIS) defined by 3 or more unrelated drug class "allergies," and to provide demographic and clinical information on MDIS cases. METHODS: Electronic medical record data from 2,375,424 Kaiser Permanente Southern California health plan members who had a health care visit and at least 11 months of health care coverage during 2009 were reviewed. Population-based drug "allergy" incidence rates and prevalence were determined for 23 unrelated medication classes. RESULTS: On January 1, 2009, 478,283 (20.1%) health plan members had at least one reported "allergy." Individuals with a history of at least 1 "allergy" and females, in general, reported higher population-based new "allergy" incidence rates. Multiple drug intolerance syndrome was present in 49,582 (2.1%). The MDIS cases were significantly older, 62.4 ± 16.1 years; heavier, body mass index 29.3 ± 7.1; and likely to be female, 84.9%, compared with average health plan members. They had high rates of health care utilization, medication usage, and new drug "allergy" incidence. They sought medical attention for common nonmorbid conditions. CONCLUSIONS: Multiple drug intolerance syndrome is in part iatrogenic. It is associated with overweight elderly women who have high rates of health care and medication usage. Urticarial syndromes only explain a small fraction of MDIS cases. Multiple drug intolerance syndrome is associated with anxiety, but not predominately with immunoglobulin E (IgE)-mediated allergy or life-threatening illness. Multiple drug intolerance syndrome can be managed by medication avoidance and judicious rechallenge.

How well do the HEDIS asthma inclusion criteria identify persistent asthma?

OBJECTIVES: (1) To determine if the Health Plan Employer Data and Information Set (HEDIS) asthma inclusion criteria consistently identify persistent asthma on a year-to-year basis and (2) to explore whether variation in the number of years of qualification is associated with medication and resource utilization outcomes. STUDY DESIGN: Retrospective observational study. METHODS: We identified 132 414 patients in a large healthcare program who were included in 1 or more HEDIS persistent asthma cohorts between 1999 and 2002 and who had continuous insurance and pharmacy benefit coverage for the entire 4-year observation period. Medication, emergency department, and hospital use in 2002 was identified using electronic claims and pharmacy information. RESULTS: Overall, 47.9% of the patients were identified as having persistent asthma in only 1 of 4 years, 40.8% had at least 2 consecutive years, and 28.2% had at least 3 consecutive years. In bivariate and multivariate analyses, more consecutive years of HEDIS persistent asthma qualification significantly increased the likelihood of frequent short-acting b-agonist use, inhaled antiinflammatory corticosteroid use, at least 1 emergency department visit, and at least 1 hospitalization. The strongest relationship was for 3 or more consecutive years of HEDIS qualification. CONCLUSIONS: A significant portion of the HEDIS persistent asthma cohort does not qualify on a year-to-year basis, suggesting that the current 1-year qualification period or the underlying administrative case definition for persistent asthma may be suboptimal. Further clinical validation studies are needed to determine the optimal criteria for a more useful HEDIS persistent asthma case definition.