key: cord-0834888-42lwsbe1
authors: Thomas, Iason; Siew, Leonard Q.C.; Rutkowski, Krzysztof
title: Synchronous Telemedicine in Allergy: Lessons Learned and Transformation of Care During the COVID-19 Pandemic
date: 2020-10-19
journal: J Allergy Clin Immunol Pract
DOI: 10.1016/j.jaip.2020.10.013
sha: 3e7f1dd8763beb8f60874cd8b7f7ad0c27c05e05
doc_id: 834888
cord_uid: 42lwsbe1

Background The outbreak of the COVID-19 pandemic facilitated a rapid transition to non-face-to-face models of care across the allergy services. Objective To describe the outcomes of the use of synchronous telemedicine for outpatient consultations in a tertiary adult allergy centre. Methods We retrospectively reviewed all non-face-to-face appointments during the second month of the pandemic in the UK. Results A total of 637 non-face-to-face appointments for unique patients were booked between 1 and 30 April 2020; 91% were new consultations. Most referrals (81.5%) were related to non-drug reactions. The overall ‘Did Not Attend’ rate was 15.7%. A total of 439 patients were assessed for non-drug reactions; 87% were new appointments. Food-related reactions (50.4%), urticaria/angioedema (23.2%) and rhinitis (18.1%) were the most common reasons for new referrals. Two hundred twenty-one (57.7%) of these patients required further allergy testing, primarily for suspected food allergy. More than 42% of the new patients, mainly referred for urticaria/angioedema, were discharged following their remote assessment. Less than 10% of the follow-up patients required additional testing. Ninety-seven new patients were assessed for a suspected drug reaction, predominantly to beta-lactam antibiotics (57.7%). Sixty-nine patients (71%) required further investigations, but a notable 29% did not require further allergy input. The overall experience was very good/good for most patients (85%). Conclusion Telemedicine can transform the current models of allergy care. Screening criteria for selecting suitable new patients are required. A telemedicine-based drug allergy service model can be more time- and cost-effective, and improve patient access to specialist care.

We retrospectively reviewed all Nf2f clinic appointments in the Department of Adult 128 Allergy, Guy's and St Thomas' NHS Foundation Trust, London, UK, which took place 129 between 1 and 30 April 2020 (2 nd month of the pandemic in the UK). All Nf2f appointments 130 were synchronous and conducted by telephone. The clinicians had full access to the 131 Electronic Patient Records (EPR, iSOFT Group Plc) and an electronic medical notes system 132 to document the consultation. The allocated duration of a Nf2f appointment was 20 minutes. 133 The clinical team included eight allergy consultants (specialists) and two specialty registrars 134 (residents in training). The referral letters had been previously vetted, and the patients were 135 deemed appropriate for a f2f allergy review. 136 We determined the number of new and follow-up appointments and the overall Did 137 Not Attend (DNA) rate. The patients who did not have a consultation were not included in 138 the analysis. We reviewed the reasons for the referral based on the information provided by 139 the referring clinician (all new appointments), and the working diagnosis from the previous 140 allergy review (follow-up appointments). Based on the reason for the referral, we divided the 141 Nf2f appointments into two groups: related to adverse drug reactions (ADR) and non-adverse 142 drug reactions (non-ADR). We then divided each into new and follow-up appointments. 143 We identified the Nf2f clinic outcomes, and the number of patients who required 144 further f2f allergy testing following their remote assessment. We identified how many 145 needed to return to our Department for testing and how many were advised to have the 146 diagnostic tests organised by the referring clinician. Finally, we determined how many 147 follow-up appointments were requested, and if a referral to a different specialty was required.

Patients' feedback was collected following their appointment by the Patient 149 Engagement team using an anonymous electronic survey (see Fig. E1 in the online repository). Descriptive statistics were used to summarise the results. This study was 151 conducted as part of an approved service evaluation within the Department. 

A total of 637 Nf2f appointments were booked for unique patients in April 2020. The 172 majority (91%) were new consultations. The mean age was 38.1 ± 16 years, with age range 173 from 16 to 89 years (Table I) . Two-thirds of patients were female. The majority of referrals 174 (81.5%) was not related to adverse drug reactions (non-ADR); 18.5% were for a suspected 175 ADR.

A total of 100 patients 'Did Not Attend' their Nf2f appointment (overall DNA rate 177 15.7%) and were excluded from further analysis (Fig. 1 , Table I ). The DNA rate was similar 178 across the non-ADR and ADR groups. In the non-ADR group, 97.5% of the patients who 179 'did not attend' were newly referred. Food-related reactions (53.75%), urticaria/angioedema 180 (27.5%) and rhinitis (11.25%) were the most common reasons for referral. All the patients 181 referred for a suspected ADR and 'did not attend' their appointments were new patients.

Adverse reactions to antibiotics (45%), mainly beta-lactams, and local anaesthetics (22%), 183 were the most common indications in this group (data not shown).

A total of 537 synchronous telephone encounters were conducted; 439 (81.75%) 185 related to non-ADR and 98 (18.25%) to a suspected ADR (Fig. 1 ). In the non-ADR group, 186 there were 87% new and 13% follow-up appointments. The mean age was 36.3 ± 15.1 years 187 (range 16 -89 years); 68.5% of the patients were female. 188 The most common non-ADR indication for a new patient to be referred to our service (Table I) . Of note, the patients with asthma are managed by the food-related reactions (37.5%). Most of the follow-up patients (91%) did not require further 218 allergy investigations, and the majority of them (80%) was fully discharged from the service.

Two of these patients (4.5%) were referred to dermatology for further review, one for Table I ). The rest of the suspected ADR referrals (13.5%) were 233 related to a heterogenous group of medications. Sixty-nine patients (71%) required further 234 f2f investigations (e.g. skin prick testing, intradermal testing, in vitro testing, drug 235 provocation test etc.). However, 29% of the patients referred with a suspected ADR did not 236 require further allergy input following their Nf2f review and were discharged (Fig. 1 ). The 237 one follow-up patient did not require further investigations either. Relevant models of care in allergy have been previously suggested (15). However, more than 310 half of these patients in our cohort required a further f2f visit for allergy testing, mostly for 311 suspected food allergy and rhinitis. Therefore, detailed screening criteria should be in place 312 to identify patients suitable for a remote assessment (Table II) . These criteria could be applied during the referral vetting process for Nf2f patient selection. The UK General 314 Medical Council (GMC) have also produced generic criteria to help determine whether a 315 remote consultation is appropriate (16).

TM appears exceptionally well suited for follow-up appointments. The reason for the 317 majority of such appointments was to evaluate the response to treatment for 318 urticaria/angioedema or allergic rhinitis, or assess any accidental exposure to allergen(s) in 319 patients with a new diagnosis of food allergy. Crucially, less than 10% of Nf2f follow-up 320 patients required a further in-person visit for additional allergy testing in agreement with a 321 previous report (7). Therefore, adult allergy centres might want to consider converting all or 322 most f2f follow-up visits to virtual clinics.

In the group of patients referred for suspected drug-induced hypersensitivity, the beta- specialist. This highlights a potential role for synchronous telemedicine as a triage tool in 330 drug allergy for patient selection before planning further investigations. As previously shown 331 by our team (17), the clinical history in beta-lactam hypersensitivity is a powerful tool with a 332 similar negative predictive value to skin testing in selected cases. 333 We propose a new drug allergy service model of care for UK adult allergy centres 334 (Fig. 2) . The referring clinician will be prompted to use a standardised questionnaire (18) to 335 record the relevant information when referring a patient to a drug allergy service. The 336 questionnaire will be available on the digital platform the primary care physicians are using to refer patients to the allergy service. The referral will be then vetted by the clinicians, and 338 if it is deemed appropriate for drug allergy assessment, a Nf2f appointment will be booked.

During the virtual clinic, the allergy specialist will obtain a comprehensive clinical history, 340 and further investigations will be arranged accordingly. As seen in the flowchart, if the 341 history is not suggestive of an ADR, the patient can be discharged from the service with 

As in other published studies (6, 7), patients with a working diagnosis of either food 364 or drug allergy were significantly more likely to be recommended further allergy testing and 365 an in-person visit. We acknowledge the fact that each allergist will have their own threshold 366 for recommending allergy investigations. Moreover, we found that the more junior members 367 of staff tended to request or recommend more allergy testing. 

American Telemedicine Association. Telemedicine, telehealth, and health information 412 technology. An ATA Issue Paper Consultado em

Telemedicine and emerging technologies 414 for health care in allergy/immunology

Telemedicine for Allergy Services to Rural 416

The Good, the Bad, and the Unknown of 418

Telemedicine in Asthma and Allergy Practice

The Use of Telemedicine for Penicillin 421

Synchronous telehealth for outpatient allergy consultations: A 2-year 423 regional experience

Outcomes From a Regional Synchronous

426 8. NHS. The NHS long term plan

Telemedicine in the Era of COVID-19

LEN/EDF/WAO guideline for the definition, classification, diagnosis and 439 management of urticaria

The diagnosis 441 and management of acute and chronic urticaria: 2014 update

Is there a role for telemedicine in adult allergy 444 services?

Tips for Seeing Patients via Telemedicine

 398 The authors acknowledge Zoe Bright for her assistance in obtaining the patient