Limitations
This study has several important limitations. Most importantly, this was a retrospective cohort, reliant on the EMR and e-prescribing records to obtain information. This resulted in a large number of excluded patient visits for which we could not determine prescription filling. In addition, patients in whom we could not determine EAI filling were slightly more likely to have out-of-state Medicaid or self-pay insurance and slightly more likely to be Hispanic. It’s possible that this patient demographic is less likely to use e-prescribing or less likely to use pharmacies participating inSureScripts. This could create a selection bias with a trend towards a lower reported EAI fill rate as this patient demographic is somewhat more likely to fill EAI prescriptions. However, the overall number of these patients was small compared to the larger population. We were also unable to determine if patients already had EAIs at home or if they had, previously or after the ED visit, received a prescription from their primary care physician or another health care provider that they may have filled. In addition, we were only able to collect a limited amount of data from the EMR and therefore have no first-hand knowledge as to the barriers to EAI filling. Finally, the unique definition of Washington, DC as an urban district that lies outside of any state, lends itself to creating variables that might not be generalizable to the greater population.
In conclusion, in this cohort of pediatric patients prescribed an EAI on ED discharge from the pediatric ED, only approximately half of the patients filled their EAI prescriptions. Further studies examining predictors of EAI filling are needed to develop patient and system-oriented strategies to improve prescription filling.
1. Campbell RL, Hagan JB, Manivannan V, et al. Evaluation of national institute of allergy and infectious diseases/food allergy and anaphylaxis network criteria for the diagnosis of anaphylaxis in emergency department patients. J Allergy Clin Immunol.2012;129(3):748-752.
2. Samant SA, Campbell RL, Li JT. Anaphylaxis: diagnostic criteria and epidemiology. Allergy Asthma Proc. 2013;34(2):115-119.
3. Pumphrey RS. Lessons for management of anaphylaxis from a study of fatal reactions. Clin Exp Allergy. 2000;30(8):1144-1150.
4. Lieberman P. Biphasic anaphylactic reactions. Ann Allergy Asthma Immunol. 2005;95(3):217-226; quiz 226, 258.
5. Fleming JT, Clark S, Camargo CA, Rudders SA. Early treatment of food-induced anaphylaxis with epinephrine is associated with a lower risk of hospitalization. J Allergy Clin Immunol Pract.2015;3(1):57-62.
6. Lieberman P, Nicklas RA, Randolph C, et al. Anaphylaxis–a practice parameter update 2015. Ann Allergy Asthma Immunol.2015;115(5):341-384.
7. Simons FE, Ebisawa M, Sanchez-Borges M, et al. 2015 update of the evidence base: World Allergy Organization anaphylaxis guidelines.World Allergy Organ J. 2015;8(1):32.
8. Campbell RL, Li JT, Nicklas RA, Sadosty AT, Force MotJT, Workgroup PP. Emergency department diagnosis and treatment of anaphylaxis: a practice parameter. Ann Allergy Asthma Immunol.2014;113(6):599-608.
9. Prince BT, Mikhail I, Stukus DR. Underuse of epinephrine for the treatment of anaphylaxis: missed opportunities. J Asthma Allergy.2018;11:143-151.
10. Westermann-Clark E, Pepper AN, Lockey RF. Economic considerations in the treatment of systemic allergic reactions. J Asthma Allergy.2018;11:153-158.
11. Coombs R, Simons E, Foty RG, Stieb DM, Dell SD. Socioeconomic factors and epinephrine prescription in children with peanut allergy.Paediatr Child Health. 2011;16(6):341-344.
12. Huang F, Chawla K, Järvinen KM, Nowak-Węgrzyn A. Anaphylaxis in a New York City pediatric emergency department: triggers, treatments, and outcomes. J Allergy Clin Immunol. 2012;129(1):162-168.e161-163.
13. Landsman-Blumberg PB, Wei W, Douglas D, Smith DM, Clark S, Camargo CA. Concordance with recommended postdischarge care guidelines among children with food-induced anaphylaxis. J Pediatr.2014;164(6):1444-1448.e1441.
14. Motosue M, Bellolio MF, Van Houten HK, Shah ND, Campbell RL. Predictors of epinephrine dispensing and allergy follow-up after emergency department visit for anaphylaxis. Ann Allergy Asthma Immunol. 2017;119(5):452-458.e451.
15. Soylu TG, Elashkar E, Aloudah F, Ahmed M, Kitsantas P. Racial/ethnic differences in health insurance adequacy and consistency among children: Evidence from the 2011/12 National Survey of Children’s Health. J Public Health Res. 2018;7(1):1280.
16. Clarke AR, Goddu AP, Nocon RS, et al. Thirty years of disparities intervention research: what are we doing to close racial and ethnic gaps in health care? Med Care. 2013;51(11):1020-1026.