Decisions with patients, not for patients: Shared decision-making in allergy and immunology.

Shared Decision-Making (SDM) is an increasingly implemented patient-centred approach to navigating patient preferences regarding diagnostic and treatment options and supported decision-making. This therapeutic approach prioritizes the patient's perspectives, considering current medical evidence to provide a balanced approach to clinical scenarios. In light of numerous recent guideline recommendations that are conditional in nature, and are clinical scenarios defined by preference-sensitive care options, there is a tremendous opportunity for SDM and validated decision aids. Despite the expansion of the literature on SDM, formal acceptance among clinicians remains inconsistent. Surprisingly, a significant disparity exists between clinicians' self-reported adherence to SDM principles and patients' perceptions of its implementation during clinical encounters. This discrepancy underscores a fundamental issue in the delivery of healthcare, where clinicians may overestimate their integration of SDM, while patients' experiences suggest otherwise. This review critically examines the factors contributing to this inconsistency, including barriers within the healthcare system, clinician attitudes and behaviours, and patient expectations and preferences. By elucidating these factors in the fields of food allergy, asthma, eosinophilic esophagitis, and other allergic diseases, this review aims to provide insights into bridging the gap between clinician perception and patient experience in SDM. Addressing this discordance is crucial for advancing patient-centred care and ensuring that SDM is not merely a theoretical concept but a tangible reality in the practice of Allergy and Immunology.

The Challenges and Opportunities for Shared Decision Making Highlighted by COVID-19.

Shared decision making (SDM) is a management paradigm that empowers patients as partners in their own care in a bidirectional exchange of information and values, and optimize the decision-making process. During the current coronavirus disease 2019 pandemic, there is a greater need to encourage participation in the SDM process. The pandemic has created both challenges and opportunities for delivering care, as system adaptations influence the physician-patient relationship. Although social distancing and health service reallocation can interfere with preference for an in-person visit, these measures also provide an avenue to study and implement virtual SDM processes. Communicating risk at a time of heightened uncertainty may pose a barrier to SDM engagement but provides the opportunity to foster a patient-centered approach within a more personalized context. Social media influence during coronavirus disease 2019 has resulted in an "infodemic" but highlights the importance of patient engagement. The pandemic has changed how we deliver care but allows us to re-evaluate common practices and enhance effectiveness of our management strategies. Navigating the uncertainty of subsequent pandemic waves creates confusion about how to safely reinitiate clinical service. This will require ongoing SDM with our patients and among colleagues through current-and future-challenges. Coronavirus disease 2019 has created many difficulties but has forced us to reexamine how to provide more patient-centered and high-quality care.

Development and acceptability of a shared decision-making tool for commercial peanut allergy therapies.

BACKGROUND: Shared decision making (SDM) is the process through which patients and their medical provider mutually explore therapy goals, risk/benefit, and treatment options regarding medical care. Decision aids are tools that aid in the process of values clarification and help assess decisional needs and potential decisional conflicts. OBJECTIVE: To develop and assess acceptability of a decision aid for commercial peanut allergy therapies. METHODS: The creation of this decision aid occurred in 3 stages, including a qualitative study to assess decisional needs, development of a draft decision aid through multiple iterations in accordance with international guidelines and decision aid experts, and assessment of decisional acceptability, decisional conflict, and decisional self-efficacy related to using the decision aid. RESULTS: The decision aid went through 9 iterations, resulting in a 4-page aid with 7 parts, explaining the therapies, key risks and benefits of therapy choices, relative importance of key attributes of the therapies, and a self-check assessment regarding informational adequacy and how to take the next steps. A total of 24 subjects assessed the decision aid, noting it had good acceptability, high decisional self-efficacy (mean score 91.9/100), and low decisional conflict (mean score 20.2/100). Respondents rated the information content as adequate and sufficient and the information regarding the therapy choices as fair and balanced without a clear bias or presenting a "best choice." CONCLUSION: We have developed this decision aid as a tool to help caregivers navigate the complexity of decision making for peanut allergy treatment options. The decision aid was noted to have good acceptability, with scores reflective of the instrument enhancing decisional self-efficacy and reducing decisional conflict.

The long-acting beta-agonist controversy: a clinical dilemma.

The Food and Drug Administration approved new safety labeling on March 2, 2006 for medication containing salmeterol, a long-acting beta-agonist (LABA), because of data suggesting an increased risk of fatal or potentially fatal asthma episodes. The "black box" warning, public health advisory, and label change for salmeterol, salmeterol-fluticasone combination, and formoterol has heightened public and physician concern over the risk-to-benefit ratio and the medicolegal implications of prescribing these agents for patients with asthma. A problem-based learning (PBL) case was presented to several breakout groups at the Eastern Allergy Conference, May 6, 2006, in Naples, FL, focusing on the LABA controversy in the context of an actual patient. The consensus of opinion during the interactive group sessions among approximately 100 allergists was that (1) the patient had poorly controlled asthma on inhaled corticosteroid (ICS) monotherapy and that warranted a change of therapy; (2) each physician must choose which option presents the best benefit-to-risk ratio after a thorough and open discussion with the patient; (3) of the several choices for step-up therapy when a patient is not well controlled on an ICS alone, the best choice based on current evidence is combined ICS plus LABA. After the PBL case discussion, a didactic lecture was presented describing the evidence pertaining to the LABA controversy, which is detailed in this article.

Facial angioedema in children due to ladybug (Harmonia axyridis) contact: 2 case reports.

BACKGROUND: Only 9 adult cases of immediate-hypersensitivity reaction to ladybugs, also known as Asian lady beetles (Harmonia axyridis), have been documented in the literature. These patients have all shown symptoms of allergic rhinoconjunctivitis or asthma from exposure to ladybugs. OBJECTIVE: To describe the first pediatric patients with severe allergic facial angioedema requiring emergency department management after exposure to ladybugs. METHODS: Evidence of IgE-mediated hypersensitivity to ladybugs was documented by positive skin prick test reactions, correlating with exposure history. RESULTS: Two cases in preschool boys had similar features, although they were evaluated and tested by 2 different allergists. Both patients developed severe facial or periocular angioedema with no significant respiratory involvement after exposure to ladybugs outside their infested homes. Both patients required an emergency department visit for treatment. Allergy evaluation using ladybug extract for skin prick testing showed markedly positive reactions in both patients. There were no further episodes after environmental control measures were instituted. CONCLUSIONS: Although allergic respiratory or cutaneous reactions to ladybugs are uncommon, a high index of suspicion from exposure history and confirmatory skin testing can be conclusive for the diagnosis.

Chronic cough: an interactive case discussion.

The following case was presented at the Eastern Allergy Conference May 2005 to each of four small group sessions in an attempt to incorporate problem-based learning (PBL) into the curriculum of the conference for the first time in its 18-year history. Before this, the format had always been non-stop lectures for four days. The attempt to use PBL in breakout sessions was due to the well-documented improved learning experience with PBL demonstrated by multiple studies in the literature of PBL for CME. This PBL case on an adult who presents with a "chronic cough" was linked to a series of three didactic lectures to reinforce the differential diagnoses in this patient. The three lectures followed the PBL breakout sessions (during the morning of the conference) and were entitled Laryngeal Pharyngeal Reflux (LPR), Chronic Sinusitis: A Surgical Perspective and Chronic Cough. Although the best learning scenario for this case occurs when there is interaction with one's peers, review of this case and answering the questions that were posed by the facilitators can still provide a great learning experience.

Changing physician prescribing patterns through problem-based learning: an interactive, teleconference case-based education program and review of problem-based learning.

BACKGROUND: Although asthma guidelines have recommended the use of anti-inflammatory controller medications since 1991, studies have consistently shown widespread failure to follow the guidelines. Major barriers include lack of knowledge and the inability to operationalize knowledge. Improved continuing medical education methods should result in more effective learning by physicians and other health care professionals, leading to better adherence to guidelines, resulting in better outcomes. OBJECTIVE: To evaluate the effectiveness of an interactive, case-based, educational intervention, also known as problem-based learning, using a series of interactive, case-based teleconferences. METHODS: A series of interactive, case-based teleconferences was completed with 20 primary care physicians. Each case involved a child aged 16 months to 12 years with asthma. A 12-month analysis of physician prescribing patterns was conducted. RESULTS: Program acceptance by the 20 physicians was uniformly positive. Significant improvement was noted, with an overall increase in controller use. Review of prescription data showed an increase in inhaled corticosteroid use from an average of 2.54 to 7.76 refills per month for the 6 months after the intervention (P < .001). CONCLUSIONS: After participating in a unique educational intervention-problem-based learning using interactive, case-based teleconferences-the prescribing patterns of physicians were altered significantly toward better adherence to asthma guidelines, as demonstrated by an increased use of anti-inflammatory controller medications (inhaled corticosteroids and leukotriene antagonists).