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Systematicreview ofpathways

for thedeliv eryofallergyservices

LavanyaDiw akar,

1

CaroleCummins,

2

Richard Lilford,

3

TracyRoberts

1

Tocite: DiwakarL,

CumminsC, LilfordR, et al.

Systematicreview of

pathwaysforthedelivery of allergy services.BMJ Open

2017;7:e012647.

doi:10.1136/bmjopen-2016-

012647

Prepublicationhistory and

additional materialis available.T oviewplease visit the journal(http://dx.doi. org/

10.1136/bmjopen-2016-

012647).

Received16Ma y2016

Revised3 January2017

Accepted 13January 2017

1

Health EconomicsUnit,

Universityof Birmingham,

Birmingham,UK

2

Instituteof AppliedHealth

Research,University of

Birmingham,Birmingham ,

UK 3

PopulationEvidenceand

TechnologiesUnit, Warwick

Medical School,Univ ersityof

Warwick,C oventry,UK

Correspondenceto

Dr LavanyaDiwakar;

l.diwakar@bham.ac.uk

ABSTRACT

Objectives:

The incidenceand prevalence ofallergies

worldwide hasbeen increasing andallergyservices globally areunableto keep upwith thisincreasein demand. Thiss ystematicreviewaimstounders tandthe deliveryof allergyservices worldwide,challenges faced and futuredirections forservicedelivery .

Methods:A systematicscopingreviewof Ovid,

EMBASE, HMIC,CINAHL, Cochr ane,DARE,NHSEED

and INAHTAdatabases wascarriedout using predefinedinclusion ande xclusioncriteria. Dataonthe geographicalr egion,studydesign andtreatment pathwaysdescribedwere collected,and thefindings werenarra tivelyreported.Thisreview followedthe PreferredReporting ItemsforSys tematic Revie wsand

Meta-analyses(PRISMA) guidelines.

Results:205 publicationswer escreenedand27

selected forr eview.Only3were prospectiv es tudies, and noneincluded acontr olgr oup.Therew ereno eligible publicationsidentifiedfr omNorth America,

Africa, Australiaandmost partsof Asia.Most

publicationsr elatetoallergyservicesin theUK. In general,allergy servicesglobally appearnot toha ve keptpa cewithincreasing demand.The review suggeststha tprimarycare pra ctitionersarenot being adequatelytr ainedinallergyand that there isa paucity of appropriatelytrainedspecialis ts,especiallyin paediatricallergy .Thereappear tobeconsiderable barriers toservice impro vement,includinglackof political willand reluctance toallocatefunds from local budgets.

Conclusions:Demand forallergy servicesappears to

havesignificantlyoutpa cedsupply .Primaryand secondary carepathw aysinallergyseeminadequate leading topoor referr alpractices,delay sinpatient management andconsequently pooroutcomes.

Improvementofservicesr equires str ongpublicand

political engagement.Ther eisaneed forw ell-planned, prospectivestudies inthisarea anda few arecurrently underway.Thereis noevidencetosugges ttha tany givenpa thwayofserviceprovision isbetter than another althoughda tafroma fewlong-term, prospectivestudies lookverypr omising.

INTRODUCTION

The incidenceand prevalence ofallergicdis-

eases hasbeen steadily increasingglobally . 1 It

is recognisedthatther ehasbeenan increasein thepr evalenceofallergiesin children andyoungadults with eachpassingdecade.

2

Despite thisincr easingneed,allergyser vices

havenotimpr ov edworldwide. 3

It isno wwell

establishedthat developedcountriesbear a higher burdenof allergicdisease. 14-6

However,servicesrend eredtothe affected

individuals inthese higherincome countries remaininadequa tewithde ciencies in primaryand secondary carepro vision. 37
The pictureis similar acrossmany countrieswith long waitingtimesforspecia list appoint- ments andwide heterogeneity inprovision of primarycar eandspecialist services. 78
In addition, thegr owingincidenceofserious allergic manifestationssuchasana phylaxis 9- 12 as wellastha tof individualswithmultiple, complexallergies 13 has promptedcalls for improvedservicesworldwi de. 313

The UKhas oneof thehighes tr ates of

allergy andr elateddiseasesinthe western hemisphere 1 with as teadyincreasein the prevalence,severit yandcomplexityof aller- gic diseasein thelas ttwo tothree decades.

214-17

It ises timatedthat30%of all

adults and40% ofchildr enin theUKwillbe affectedby allergy-r elatedconditions. 18

Nevertheless,allergy services haver emained

'woefullypoor ' 18 with verylimitedand patchyspecia listserviceavailability .This shortfall inser viceavailabilityand theinher- ent heterogeneityoflimited available services has beenthe focusof multiplee xpertbody reviewsinthe UK,which hav ecalled for

Strengthsand limitations ofthisstudy

The literaturerevieww ascarriedoutusingeight

major databasesandr eportingfollo wedthe

PRISMA guidelines.

This iscompr ehensivereviewof allthepublishedreportsand journalarticles onallergy services.

No eligiblepublica tionswere identifiedfromlarge geographicalareas suchasNorthAmerica, Africa, Australiaandmost ofAsia; mostpublica-tions wereUKbased.

Service pathwaysforallergyandeczemaw ere consideredin ther eview . DiwakarL, et al.BMJ Open2017;7:e012647. doi:10.1136/bmjopen-2016-0126471

OpenAc cessResearch

on July 2, 2023 by guest. Protected by copyright.http://bmjopen.bmj.com/BMJ Open: first published as 10.1136/bmjopen-2016-012647 on 7 February 2

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increasedinv estmentinallergymanagement andfor reorganisationofallergy services. 18 -22

One ofthe majorbarriers toser viceplann ingin

allergy isthe lack ofpoliticalengagementand reluc- tance toalloca tefundsfrom thelocal budgetforimpro v- ing allergyser vices. 23 24

Allergy isnot generally

perceivedasa seriouscondition with major implica tions for healthand qualityof life.Ther eis agr owingbodyof evidence tothe contr ary,however.Itis nowestablished thatchildr enwithfoodallergi esar em oreanxiousthan those withinsulin-dependent diabetesandtend tohave overprotectiveandvery anxiouspar ents. 25

This isalso

true ofadolescents witha histor yof anaphylaxis. 26
In addition, thecos tsofallergies canbe considerable.

Allergy andre latedconditionsarees timatedto cost

theUK NHSabout£ 1billi onper year. 27

Productivity

lossesasso ciatedwithallergicr hini tisintheUSA were higher thanthose dueto st re ss,migraineandde- pression. 28

Studies haveshown thateffective allergy

servicescann otonly impro ve qualityoflife,butcan alsobe cost -saving. 29 30

Hence, thereis anurgent

need toimpr essonp olicymakers theimportanceand wisdomofin ve stingintheimprovemento fallergy services.

Thereis currently noagreementon how allergyser-

vices shouldbe structur ed.IntheUKandEur ope,

PrimaryCa rePhysicians-knownas GPsor General

Practitionersinthe UK -(PCPs) diagnoseandmanage

the majorityof individualswith allergies 7 whereasin Australiaandthe USA,specia list services providethebulk of allergycar e. 8

Allergy servicedeliver ybynon-clinician

practitionerssuchas pharmacis tsand dieticians,while possible, isnot optimallyused. 22

Variouspa thwayshave

been suggestedandar ebeing tested.

23 3132

However,itis

not yetclearwheth erany particularmodelof service deliveryma ybepreferableto theothers. The aimof thiss ys tematicreviewistoassesspublished approachestoallergy service deliver y.Theobj ectiveisto identify andappr aisethesepublications togain an understandingof theadvantages asw ellas challenges associatedwith theseser vicepa thways; andalsoto explorecurrent ideasregardingthe future directionfor these services.

METHODS

The PreferredReportingItems forSystema ticR eviews and Meta-analyses(PRISMA)guidelinesw ere follow edin conducting thiss ystematicscopingreview.The PRISMA checklistis suppliedas onlinesupplementa ry le S1.

Datasour cesandsearch str ategy

A systematicsearchoftheliter aturew ascarri edout to identify articlesr elatedtoallergyservice pathw ay sin humans. Searchtermsincluded allergy, eczema, care, serviceand pathw ay(seeonlinesupplementaryle S2).

MEDLINE, EMBASE,HMIC,CINAHL, Cochr ane,

DARE, NHSEED andINAHT Aw ebsiteswere searchedfor thepurposes ofthis revie w. Searchesincludedpubli- cationsinde xeduntilthe4th ofOctober 2016.In order for theMEDLINE searches toberelevant, we stipula ted thattwo papersselected apriori 333
should beidenti ed in thesear ch.Referen ceswithinthepublicationsidenti- ed asr elevantwere individuallyexaminedto identify morearticles ofinte res t.Publicationscitingthechosen articlesw erealsocarefullye xamined forrelevance.

Selectionof litera ture

Afterdiscarding duplicates, thetitleandabs tra ctof the articlesw ereexaminedforr elevance.Where thesew ere not informative,thefulltext ofthe publication was reviewed.Articleswer eincluded forreviewifthe ydis- cussedpa thwaysforthedeliveryof allergyor eczemaser - vices.Publica tionswhichreported opinions,confer ence abstracts,casereportsor caseseries weree xcluded. Non-Englishlanguage articlesw ere notincludedinthe review.Asthmaser vicepathwa yswer ealsonotconsid- ered.One ofthe resear chers(LD) carriedoutthe searcheswith helpand advicefr oman information spe- cialistfrom theUniversityof Birmingham.LD screened all thearticles asper thepr edetermined criteria.A total of 50%of theunselected articles (25%ea ch)were reviewedindependentlybytwo ofthe coauthors(TR and CC).Disagr eements,ifany,w ere resolvedthr ough discussionand consensus.

The PRISMAowchar tforselectionof articles is

shownin gure1 .

Datae xtractionandanalysis

The dataextr actionformwaspilotedinitiallyusing afe w publications.Appropria temodicationsw eremade befores tartingthefulle xtra ctionpr ocess.

The datawer eextracted byLDusingextractiontable

thatw aspreviouslyagr eedwiththecoauthors. Data extractionwasscrutinisedindependently bytwoother authors(CC andTR). Forea chpublication,the author,year ofpublic ation, geographicalr egionofinterest, typeof study(report, discussion,consensu s,etc),study design( prospective, retrospective,crosssection),tr eatmentpathw ay (primary,secondaryor both),principalndings andk ey recommendationswer eextracted. Mostof theart iclesw eredescript ive;henc etheana- lysisfo llowedanarrative synt hesis.Thisiscomm onin reviewsof very heterogene ousstudieswhichaimto describeandscop ethearea ofinterest. 34

Sincet he

objectiveoft here portwasto exploreoptions for servicedeliv ery,thereview was designedtobeinclusive.

Publicationswere,therefore, notexclu dedbasedon

qualitycri teriabutwere describeda ndbrieycritiqued asa ppropriategiventhenat ureof thestu dies.We aimedtoma pthe curren tlitera tureandunderstan d thety peofevid ence availableinthisarea( ie,allergy pathways).

2DiwakarL, et al.BMJ Open2017;7:e012647. doi:10.1136/bmjopen-2016-012647

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on July 2, 2023 by guest. Protected by copyright.http://bmjopen.bmj.com/BMJ Open: first published as 10.1136/bmjopen-2016-012647 on 7 February 2

017. Downloaded from

RESULTS

Thedata basesearchident i▸ed 351articles ofwhich

158were du plicates.Additional 12articleswere

includedfollowing referenceandcitati onsearches. After considerationofthetitle anda bstr act,a further

142articles weree xcludedandatotal of63pub lica-

tionsweresc reen edthoroughlyfor theirrelevanceto

therev iew.Figure1showsa■owdiagr amofthepapers screened,identi ▸ed,retai nedorexclu dedat each

stage,and thereaso nsfore xclusionofa rticles asper the PRISMAguidelines. 35
Twenty-sevenpublications wereincludedinthe ▸nal reviewwhichar esummari sedintable 1.Only threepub- licationsdescribe prospectiv edatacollectionalongside servicer eorganisation.

23 4352

Therew erenoeligiblepro-

spective,randomised controlledtrials identi▸ed.

Figure1 Flowdiagr amshowingthe stagesinvolv edin choosingeligiblepublications forthesystema ticr eview (basedon the

PRISMA recommendations).

DiwakarL, et al.BMJ Open2017;7:e012647. doi:10.1136/bmjopen-2016-0126473

Open Access

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Table1 Summaryof chara cteristicsoftheincludedpublications (arranged inchr onologicalorder)

Author,( year)(ref)

Level RegionT ypeofstud yStud yaim1°2°Salient findingsKey reco mmenda tionsC omments

Isinkayeet al

(2016) 36

UK Retrospectivecohort

studyToasc ertainwhat proportionofr eferr alsto secondarycare couldbe manageda byGP with specialinter estinallergyAt leasttwo-fifthso fall referralstospecialis ts(42%) werefeltto be appropriateforaGPw SI setting. Therew assomedisagreementbetween reviewersre:suita bilityofa further 30%of ther eferrals

Intraobservervariation was

also seen(ie, revie wer changedthe irinitialopinion on referralaftersee ingthe letter fromspecialis t).GPwSIin allergy could effectivelyidentifyand managea largepr oportion of referralsmadeto paediatricallergy specialists.

Thisser viceshouldbe

introducedalongside other initiativestoimpro ve UK allergyservic es.TheGP referr allettersandthecliniclett ersfromspeciali stswererev iewedbythree paediatricallergis ts. Generalisabilityofresults may be anissue, although GPwSI shownto beuseful byLevy et alas well. Theauthor susedanagr eedset ofcrite riaforthe competenciesexpect edofa

GPwSI(not pro videdwiththe

paper).

Krishnaet al

(2016) 37

UK Report/non-systematic

literaturerevie wTodiscus sthepotent ialuse oftelemedic inein pathwaysfordiagnosis and managementofadult allergiesAdult allergyservices can potentiallybene fitfrom telemedicine.V arious pathwaysaresuggested .

Algorithmsfor possible

managementof allergic rhinitis, urticariaand anaphylaxisvia telemedicinear ediscussedAuthorsadv isethat prospectivestudies evaluating thesetechni quesshouldbe plannedTelemedicineusedsuccessfullyinsome areas of medicine,buts ys tematic prospectivestudiesin allergy arela cking.

Thereare potentialissues with

clinicalgo vernanceand confidentialityLa ckof adequatelytrainedspecial ists can affectimplementa tionof thesemeasu res.

Bousquetet al

(2015) 38

EuropeIntr oductionof

prospectivestudy using Informationand communications technology(ICT) methods.Plan fors tudywithICT methodsin allergy services.Many gapsin allergy diagnosisand management existwhich couldbe addressedusing advances in ICT.

The useof Visual Analogscoring,e-a llergyand

MASK aerobiologyapps

can helpin diagnosis, managementand monitoring ofaller gic rhinitis.Thes ystemswillbebasedon ARIAand Interna tional consensusof rhinitis guidelines.

Theuse ofICT canfacilitatecommunication

betweenclinician s, patients,pharma cistsand others takeholders.Thispr ojectaimstouseICT systemstotackle heterogeneityinAR managementacr ossEurope. Theclinical trialis beingplanned;but the uptakeofICT in others tudieshasbeenpoor.

Conlanet al

(2015) 39

IrelandRet rospectivecohort

studyReviewof

1. Newallergy referrals to

adult specialistclinic.

2. Apilo temail

communicationservice with non-specialists.A majorityofpa tients referredtosecondar ycar e had chronicspontaneous urticaria orangio edema.

Food/drugallergy or

intolerancea ccountedfor about aquarte rofall referrals.Studiese xaminingreferral patternscan behelpful in planningser viceslocallyby targetingeduc ationof non-specialists.

Newmo delsofcare

deliverysho uldbetried toStudydes ignedtohelpservic eplanningloc allydesignma ybe generalisablewhereas findingsquotesdbs_dbs14.pdfusesText_20

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