Telehealth and Allergy Services in Rural and Regional Locations That Lack Specialty Services.

Secondary to the coronavirus disease 2019 pandemic, telehealth quickly peaked as the dominant health care modality and its use still remains high. Although allergists and health care systems adapted quickly to adopt telehealth, its increased use has both highlighted its benefits for patients and allergists and demonstrated known concerns with delivering allergy specialty care to rural and regional patient populations. With increased concentration of both patients and allergists in urban areas, the ability to provide allergy specialty care to the rural and remote population continues to remain a challenge despite the advantages leveraged through telehealth. Herein, we review aspects specific to the rural patient population, tele-allergy outcomes with these patient cohorts, and efforts, both past and present, taken at different levels within the allergy community to promote our specialty through specific telehealth modalities to address and engage the rural and regional patient.

Section 718 (Telemedicine): Virtual Health Outcomes From Regional Health Command Europe.

BACKGROUND: Section 718 of the Fiscal Year 2017 (FY17) National Defense Authorization Act (NDAA) outlines many reportable telemedicine outcomes. While the Military Health System Data Repository (MDR) and the Management and Reporting Tool M2 provide some telemedicine analyses, there are many outcomes that neither the MDR nor M2 provide. Understanding patient and provider attitudes towards telehealth and specialty-specific usage may assist initial or ongoing telehealth lines of effort within Defense Health Agency Medical Treatment Facilities (DHA MTFs). METHODS: A retrospective descriptive analysis of synchronous virtual health (VH) encounters and results from three internally developed telehealth surveys for calendar year (CY) 2016 was conducted. RESULTS: Three thousand seven hundred and seventy-eight synchronous VH visits for 2,962 unique patients were completed by 142 providers located within 27 distinct specialty clinics. 89.8% of patients were adults and 75.9% were Active Duty. Skill type I and II medical providers conducted 1,827 new consultations, 1,187 follow-up visits, and 371 readiness exams. Overall, specialty-specific VH use ranged from less than 1% to 39.9%. Patient satisfaction was 98% while provider satisfaction ranged from 91% to 93%. Additionally, significant intangible savings were recognized. CONCLUSION: Regional medical centers conducting synchronous VH will require both internal and external data sources to report Section 718 outcomes required by Congress. As the anticipated demand for direct provider-to-patient telehealth increases, understanding these outcomes may aid initial and ongoing efforts in other military treatment facilities conducting synchronous VH.

Outcomes From a Regional Synchronous Tele-Allergy Service.

BACKGROUND: Although the framework and potential benefits for using telemedicine have been described, allergy-specific outcomes are often limited or have a narrow focus. OBJECTIVE: To determine the percentage of new and follow-up visits conducted via synchronous telemedicine requiring an in-person visit. METHODS: A retrospective review evaluating synchronous tele-allergy appointments in a hospital-based allergy clinic was performed. RESULTS: A total of 360 unique patients participated in 423 synchronous tele-allergy visits from January 2016 to December 2017; 275 (65.0%) were new consultations, 54% were males, and 118 (28%) visits were for children. Allergic rhinitis (35%), asthma (24%), and food allergy (10%) represented the top 3 diagnoses. New and follow-up tele-allergy visits accounted for 13.1% (275 of 2097) and 10.4% (148 of 1426) of all outpatient visits during the study period, respectively. Sixty-five (23.4%) new patients and 14 (9.5%) follow-up patients were recommended for an in-person appointment (P < .001). Compared with follow-up tele-allergy visits, new visits were more likely to have medication prescribed (64.4% vs 49.0%; P < .002) and laboratory tests ordered (46.2% vs 7.4%; P < .001); there were no differences between new and follow-up tele-allergy visits for mean study observation period (P = .680), subsequent in-person visits conducted on the basis of provider recommendation (P = .120), or telephone consultations (P = .190). One hundred forty (33.1%) patients completed an anonymous satisfaction survey, with 98.8% of patients recommending telehealth and reporting high satisfaction. On the basis of 423 visits from 13 originating sites, patients saved an average of $485 in travel expenses, 438 driving miles, and 2.3 days of work or school per visit. CONCLUSIONS: Coupled with high patient satisfaction and significant time and cost savings, tele-allergy supported most of the new and follow-up visits without an in-person recommendation. Although not all tele-allergy efforts incorporate a synchronous modality with a dedicated patient presenter, allergists should continue to seek opportunities to incorporate synchronous tele-allergy with a trained patient presenter into their clinical practice.

Penicillin Allergy Maybe Not? The Military Relevance for Penicillin Testing and De-labeling.

INTRODUCTION: Penicillin allergy is the most common drug allergy reported. About 8-10% of individuals in the USA have a documented penicillin allergy, yet 90% are not truly allergic to penicillin. A penicillin allergy "label" results in increased antibiotic-related adverse reactions and increased health care costs, thus impacting the overall "readiness" of the military. MATERIALS AND METHODS: A review of the current literature and approaches to penicillin allergy and "de-labeling" a patient who reports penicillin allergy was conducted and future strategies to identify and assess military beneficiaries were outlined. Military allergists had a formal discussion at the Tri-service Military Allergy Immunology Assembly regarding the state of penicillin allergy testing in military allergy clinics. RESULTS: A PubMed search yielded 5,775 results for "penicillin allergy" and 484 results for "penicillin allergy testing." There were two formalized penicillin testing programs in the military treatment facilities. In 2017, the military trained nearly 165,000 new recruits. If 5-10% reported a penicillin allergy and 90% were de-labeled, that would yield a $15-30 million cost savings annually. Further, de-labeling of the 9.4 million active duty, beneficiaries and retirees with a 90% success rate could result in even greater savings for the military health care system. CONCLUSION: A penicillin allergy label is a risk to military readiness secondary to associated increases in the length of hospitalizations and emergency department and medical visits. Penicillin de-labeling is a simple intervention that can improve readiness, significantly decrease health care costs and prevent antibiotic resistance, as well as antibiotic-associated adverse events. The military allergist should be "front and center" providing expertise guidance and leadership for clinic and hospital-based penicillin de-labeling efforts which are nested within the antibiotic stewardship programs.

Military Medicine Implements In-home Virtual Health in Europe.

OBJECTIVE: This report outlines a multispecialty implementation effort which included 12 specialty practices and 28 clinicians within Regional Health Command Europe (RHCE) and Landstuhl Regional Medical Center (LRMC) to pilot an in-home virtual health (VH) program using existing resources. METHODS AND MATERIALS: Synchronous VH encounters were performed using an Acano desktop conferencing client (Cisco Systems, Inc, San Jose, CA) and a USB web camera at the provider (distant) site and the patient's own computer or device in the home. A web real-time conferencing (Web RTC) server provided the connections. RESULTS: Between October 2016 and May 2018, 310 synchronous VH appointments to patients' homes in 23 geographic locations in 9 countries on 3 different continents were completed; 28 skill type I and II specialty providers at LRMC, SHAPE Belgium Army Health Clinic (AHC), and Vilseck AHC, Germany Primary Care Clinic participated. The providers represented 9 distinct specialties and primary care. Appointment types were as follows: 85 (39%) follow-up type appointments; 70 (32%) group type appointments; 65 (30%) initial specialty care appointments. The 3 most active clinics were Pediatric Gastroenterology with 88 (28%), the Nutrition Clinic with 82 (26%), and the Traumatic Brain Injury Clinic with 63 (20%) encounters. Full audio and video connectivity rate was 97%, excluding reconnects after dropped calls which occasionally occurred. Patient satisfaction scores were high 16/17 (94%) with 5% of patients surveyed. CONCLUSION: Low complexity synchronous VH appointments were successfully accomplished across a broad spectrum of health care services and appointment types. Landstuhl RMC specialists received consults from sites across a vast geographic area including Europe, the Middle East, and Africa. An in-home VH option gives providers a special tool to extend services far beyond traditional boundaries. This pilot project helped RHCE and LRMC providers gain valuable experience extending care to the home and will provide foundational knowledge for future VH efforts targeting groups and outcomes.

Outcomes of a military regional multispecialty synchronous telehealth platform and the importance of the dedicated patient presenter.

Implementing a successful multispecialty synchronous telehealth program requires identifying and overcoming numerous barriers. One key aspect of synchronous telehealth involves the telehealth presenter; however, the impact that a dedicated patient presenter has supporting routine multispecialty synchronous telehealth is unknown. METHODS: We conducted a retrospective review of telehealth encounters conducted from a single regional medical center over a two-year period to 12 outlying health clinics which provided one of 3 levels of patient presenter support: category 1 locations had a dedicated telehealth registered nurse, category 2 locations had a nondedicated registered nurse or licensed vocational nurse, and category 3 locations were supported by an Army medic (military occupational specialty 68W). RESULTS: A total of 4,032 telehealth encounters occurred from January 2014 to December 2015 involving 26 distinct specialties located within a single regional medical center and 12 outlying health clinics which supported 60,232 beneficiaries. The 3 category 1 locations (3/12, 25%) supported the most telehealth encounters per month compared to either category 2 or category 3 locations (P<.0001). Category 1 and category 2 locations averaged a 239% and 122% year-to-year growth, respectively. Category 3 locations averaged a year-to-year decline of 11.7%. COMMENT: This is the first study of which we are aware that has compared different patient presenter levels and evaluated its effect on telehealth activity. Regional medical centers initiating a multispecialty synchronous telehealth program should strongly consider hiring, educating, and placing dedicated presenters at patient originating sites.

Multispecialty Synchronous Telehealth Utilization and Patient Satisfaction Within Regional Health Command Europe: A Readiness and Recapture System for Health.

BACKGROUND: Telehealth implementation within the Military Healthcare System continues to advance toward the goal of a mature regional health platform; however, specialty-specific usage or patient satisfaction regarding synchronous or "real-time" telehealth at the regional military hospital level has not been described. METHODS: A retrospective review of synchronous telehealth encounters and patient satisfaction surveys from Landstuhl Regional Medical Center (LRMC) specialty clinics engaging in synchronous telehealth to regional Army Health Clinics (AHCs) during 2015 was conducted. RESULTS: 2,354 synchronous telehealth encounters were conducted for 1,886 unique patients. The majority of patients were adults (88.4%), male (71.1%), and active duty (75%). Twelve distinct distant locations were engaged in synchronous telehealth with 31 distinct specialties. 1,552 (62.5%) patients had a single telehealth visit with a median (range) of 1 (1-7) visit. Median (range) visits per specialty was 25 (1-582) with sleep medicine (24.7%), general surgery (13.1%), nutrition (9.7%), orthopedics (9.0%), and ENT (6.0%) representing 62.5% of all encounters. Median (range) number of encounters per location was 146 (13-685). Surgical specialties preferentially evaluated patients at locations with a specialty-trained presenter (p < 0.001), whereas nonsurgical specialties did not (p > 0.05). Fifteen percent (372/2,354) of patients completed an anonymous survey at the time of their telehealth visit. Mean responses on a 5-point Likert scale ranging from "strongly disagree" (1) to "strongly agree" (5) was 4.8 ± 0.5 for both recommending and being satisfied with their telehealth visit. The 2,354 telehealth visits represented 2.4% (2,354/100,094) of all visits to LRMC during 2015 for 25 of 31 specialties whose total outpatient visits could be determined. CONCLUSION: Clinic utilization varied between specialties as well as whether a specialty-trained patient presenter was preferred. This robust multispecialty synchronous telehealth experience provides insight into both specialty-specific utilization and patient satisfaction which may aid regional medical centers recognizing avenues for specialty-specific telehealth initiatives.

Synchronous telehealth for outpatient allergy consultations: A 2-year regional experience.

BACKGROUND: Telehealth continues to advance as a health care modality; however, reported experience for synchronous TeleAllergy is limited. OBJECTIVE: To determine the percentage of new and follow-up visits conducted via TeleAllergy in a hospital-based clinic. METHODS: A retrospective study evaluating the first 2 years of a synchronous patient-to-allergist TeleAllergy platform. RESULTS: A total of 112 synchronous TeleAllergy encounters were conducted from January 2014 through December 2015; 66 (59%) of these were new consultations. The mean (SD) age was 26.9 (15.3) years, and 54% of the participants were female. Food allergy (30%), allergic rhinitis (20%), and urticaria (16%) represented the top 3 consultation reasons. Sixteen of 66 patients (24.2%) and 3 of 46 patients (6.5%) attending new and follow-up TeleAllergy visits, respectively, were recommended for an in-person appointment (P = .02). No difference was found between new and follow-up TeleAllergy visits regarding subsequent telephone communication (41% vs 26%, P = .11) or prescriptions ordered (50% vs 33%, P = .08). New TeleAllergy visits were more likely to have more than 1 laboratory test ordered (45% vs 17%, P = .002). On the basis of patient location, the 112 TeleAllergy visits resulted in an estimated savings of 200 workdays or schooldays, US$58,000 in travel-related costs, and 80,000 kilometers not driven. CONCLUSION: Both new and follow-up visits to the allergist/immunologist were well received by patients and demonstrated significant indirect cost savings, with less than one fourth of the patients recommended for an in-person visit. This appears to be the first systematic assessment of TeleAllergy for new and follow-up patient encounters in a clinic-based allergy/immunology practice.

Safe administration of a gelatin-containing vaccine in an adult with galactose-α-1,3-galactose allergy.

Immunoglobulin (Ig) E antibodies to galactose-α-1,3-galactose (α-Gal) are associated with delayed anaphylaxis to mammalian food products and gelatin-based foods (Commins et al., J Allergy Clin Immunol 2009;123:426; Caponetto et al., J Allergy Clin Immunol Pract 2013;1:302). We describe a patient with α-Gal allergy who successfully tolerated the live zoster vaccine and we review anaphylactic reactions reported to this vaccine. Our patient, who tolerated a vaccine containing the highest gelatin content, is reassuring but continued safety assessment of gelatin-containing vaccines for this patient cohort is recommended as there are multiple factors for this patient cohort that influence the reaction risk.

Inhalant horse allergens and allergies: a review of the literature.

A wealth of literature exists regarding common allergies to household pets such as cat or dog. Allergy to horse, however, is infrequently discussed in the medical literature despite significant sensitization rates among urban-dwelling subjects without direct exposure to horses. A literature search was conducted in PubMed and additional references were collected from surveying the references of the pulled articles. This review summarizes aspects of IgE-mediated horse allergy including the prevalence and mechanisms for sensitization, clinical presentation, molecular characterization of the major and minor horse allergens, and the role of allergen immunotherapy. There is currently only one horse immunotherapy study showing significant improvement in clinically sensitive patients. The 1997 World Health Organization Position Paper on Immunotherapy lists horse immunotherapy among the areas needing further clinical research. Inclusion of horse into the standard allergen panel for children and adults has been supported by several authors, although further identification and characterization of horse antigens is needed to provide the most efficacious extract. As clinicians, we need to be aware of the potential cross-reactivity among the common mammalian allergens and consider the possibility of known or occult exposure to horse as a possible source of symptom exacerbation in susceptible individuals.

Safety of chitosan bandages in shellfish allergic patients.

BACKGROUND: In 2005, the Office of the Surgeon General mandated that every soldier carry a HemCon bandage. Made from chitosan, a polysaccharide derived from shrimp shells, this bandage effectively stops bleeding. There are no studies reporting the safety of this bandage in shellfish allergic patients. METHODS: Patients who reported shellfish allergy were recruited. Initial assessment included a detailed history, IgE skin prick testing (SPT), and serum testing to shellfish allergens. Participants who demonstrated specific shellfish IgE underwent a bandage challenge. RESULTS: Nineteen participants were enrolled; 10 completed the study. Seven (70%) were male and the average age was 44.8 + 10 years. Nine (90%) reported a shrimp allergy history and five (50%) reported multiple shellfish allergies. All participants completing the study had positive SPT and serum IgE testing to at least one shellfish; eight (80%) had shrimp positive SPT and ten (100%) demonstrated shrimp-specific IgE. No participant had a positive SPT to chitosan powder or experienced an adverse reaction during bandage challenges. No protein bands were visualized during gel electrophoresis analysis of chitosan powder. CONCLUSION: All participants tolerated the HemCon bandage without reaction. This is the first study demonstrating the safety of this bandage in shellfish allergic subjects.

Incidence and characteristics of biphasic reactions after allergen immunotherapy.

BACKGROUND: The reported incidence of biphasic anaphylactic reactions varies from 1% to 20%. Reported risk factors for biphasic reactions include a delay in epinephrine administration and a longer interval to initial improvement. To date, only 4 cases of biphasic reactions after allergen immunotherapy have been reported. OBJECTIVE: We sought to determine the incidence, clinical characteristics, and risk factors for biphasic reactions after allergen-specific immunotherapy. METHODS: Patients who were treated with epinephrine for systemic reactions after allergen immunotherapy were prospectively enrolled. Patients were assessed initially and at 24 hours by using a 31-symptom scoring system. RESULTS: Sixty systemic reactions occurred in 55 patients; 14 (23%) biphasic reactions were reported. Patients experiencing biphasic reactions were more likely to be female (P = .03) and older (P = .01) and require greater than 1 dose of epinephrine (P = .001). There was no difference between groups (biphasic vs no biphasic reaction) regarding the type of immunotherapy, current asthma, initial symptom scores, or time to symptoms, initial epinephrine, or improvement. No specific symptom predicted biphasic reactions. Biphasic reactions were significantly less severe compared with the initial reaction (P < .001), did not occur in children, and did not require additional epinephrine. CONCLUSIONS: Twenty-three percent of patients requiring epinephrine for systemic reactions caused by allergen immunotherapy experienced biphasic symptoms. Patients treated promptly with epinephrine for systemic reactions should be cautioned regarding biphasic reactions; however, biphasic reactions after allergen immunotherapy were mild and did not require additional epinephrine.