Effectiveness of Clinical Decision Support Tools on Pediatrician Adherence to Peanut Allergy Prevention Guidelines

Peanut allergy (PA) affects 2.2% of children in the United States.¹ The Learning Early About Peanut Allergy (LEAP) study² prompted the National Institute for Allergy and Infectious Disease to create the 2017 Addendum Guidelines for the Prevention of Peanut Allergy. The guidelines recommend that clinicians screen infants aged 4 to 6 months for PA risk. Infants at high risk (those with severe eczema and/or egg allergy) should receive a specific IgE (sIgE) or an allergy referral for assessment prior to peanut product introduction, while infants with low or moderate risk (with mild-moderate or no eczema) can have peanut products introduced and maintained in their diet.³ The possible prevention of PA in infants depends on pediatricians incorporating guidelines in well-child visits for infants aged 4 to 6 months. Clinical decision support (CDS) tools are an effective way to facilitate physician adherence to clinical guidelines.⁴ This study examines the effectiveness of a pediatrician-designed CDS tool and training on pediatrician adherence to the guidelines.

The Intervention to Reduce Early (Peanut) Allergy in Children (iREACH) included pediatrician training and CDS tools implemented in the electronic medical record (EMR) for well-child visits for infants aged 4 to 6 months. Tools included (1) an order set for peanut sIgE or allergy referral for infants at high risk of PA, (2) a prompt to evaluate PA risk, (3) a prompt indicating peanut product–introduction counseling, (4) an instructional handout for caregivers, and (5) a best-practice advisory for infants with known eczema or egg allergy. The Ann & Robert H. Lurie Children’s Hospital of Chicago’s institutional review board ruled this study exempt from review and informed consent.

In June 2017, a pediatric clinic received the iREACH training module and CDS tool. A second, comparison clinic had no EMR modification or training. Data from visits from infants aged 4 to 6 months between June 2017 and March 2018 were collected for 151 infants from the iREACH clinic and a random sample of 312 infants from the comparison clinic. For infants at low-moderate risk, full pediatrician adherence was achieved if the pediatrician noted peanut product introduction was recommended in the infant’s EMR. Partial adherence was observed among infants at low-moderate risk in the iREACH clinic if the instructional handout was given to families and/or peanut introduction was recommended, as noted in the EMR. For infants at high risk, full pediatrician adherence was achieved if the pediatrician ordered a peanut sIgE or referred the infant to an allergist.

Descriptive statistics and Pearson χ² or Fisher exact test statistics are reported to identify associations between clinics. Two-sided P values <.05 were considered statistically significant. Analyses were conducted using SAS version 9.4 (SAS Institute).

Among 463 infants, 92 (19.9%) had an eczema diagnosis and 9 (1.9%) had a diagnosis of severe eczema. There were significant differences in demographic factors between the clinics. In the iREACH clinic, there were more male infants (96 of 151 [63.6%] vs 157 of 312 [50.3%]; P = .007), more infants identified as black (45 of 151 [29.8%] vs 2 of 312 [0.6%]) or of multiple/other races (74 of 151 [49.0%] vs 26 of 312 [8.3%]; both comparisons, P < .001), and more Hispanic infants (69 of 151 [45.7%] vs 9 of 312 [2.9%]; P < .001) (Table 1).

For infants at low-moderate risk, pediatricians were fully adherent to guidelines for 75 infants (52.4%) in the iREACH clinic and 44 infants (14.1%) in the comparison clinic (Table 2; P < .001). Pediatricians in the iREACH clinic were partially adherent to guidelines for 133 of these infants (93.0%).

Pediatrician adherence for infants at high risk was 62.5% (n = 5 of 8) in the iREACH clinic; however, the sample size of infants at high risk in the non-iREACH clinic (n = 1) was not sufficient to detect a difference (P = .44). Among all infants at high risk, pediatricians referred to allergists (n = 3 of 9) more often than they ordered a peanut sIgE (n = 2 of 9). Additionally, 10 infants (2.2%) at low-moderate risk from both clinics were referred to an allergist or had a peanut sIgE ordered.

Higher pediatrician guideline adherence was observed among infants in the clinic that implemented iREACH. Interestingly, more infants at low-moderate risk received a sIgE order or allergist referral than infants at high risk. Limitations of this study include (1) a limited number of clinic sites and therefore a limited number of high risk infants and (2) patients were not randomized between the iREACH and comparison clinic. Since well-child visits for infants aged 4 to 6 months focus on a range of preventative and anticipatory guidance, an effective CDS tool such as iREACH may facilitate pediatrician guideline adherence. Further long-term research is necessary to study if iREACH reduces PA incidence.

Accepted for Publication: May 1, 2019.

Corresponding Author: Ruchi S. Gupta, MD, MPH, Feinberg School of Medicine, Northwestern University, 750 N Lake Shore Dr, Ste 680, Chicago, IL 60611 (r-gupta@northwestern.edu).

Published Online: October 14, 2019. doi:10.1001/jamapediatrics.2019.3360

Author Contributions: Drs Bilaver and Gupta had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Bilaver, Martusiewicz, Gupta.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Bilaver.

Administrative, technical, or material support: Jiang, Gupta.

Supervision: Bilaver, Gupta.

Conflict of Interest Disclosures: Dr Bilaver reports grants from Thermo Fisher, Food Allergy Research & Education, National Confectioners Association, Genentech, Yobee Care Inc, and Before Brands outside the submitted work. Dr Gupta reports grants from Aimmune Therapeutics, Allergy and Asthma Network, Food Allergy Research & Education, Rho Inc, Stanford Sean N. Parker Center for Allergy Research, Genentech, Thermo Fisher, United Health Group, Mylan, and National Confectioners Association outside the submitted work; and serving as a medical consultant/advisor for Genentech, Institute for Clinical and Economic Review, DOTS Technology, Food Allergy Research & Education, DBV Technologies, Aimmune Therapeutics, Before Brands, Pfizer, and Kaleo Inc, over the past 3 years. No other disclosures were reported.

Additional Contributions: We would like to thank Jolanta Szkodon, BS, Ann & Robert H. Lurie Children’s Hospital of Chicago, and Gabriel Peirats Moore, BA, Northwestern Feinberg School of Medicine, for their contributions during medical record reviews. They were not compensated for their contributions.