Allergic Rhinitis: The Impact of Discordant Perspectives of Patient and Physician on Treatment Decisions

doi:10.1016/j.clinthera.2007.07.013

Clinical Therapeutics

Volume 29, Issue 7, July 2007, Pages 1428-1440

https://doi.org/10.1016/j.clinthera.2007.07.013 Get rights and content

Abstract

Background: A wealth of literature is available that documents the effects of inadequately controlled allergic rhinitis (AR) on patients' daily activities, including impaired sleep, reduced cognitive functioning, and interference with sport and leisure activities. However, despite its high prevalence and significant impact on health-related quality of life (HRQOL) and productivity, AR may be undertreated. This might arise, in part, from the low priority given to the disease by physicians.

Objective: This article aims to assess the existence of disparities between the attitudes of patients and physicians to AR, and to comment on the impact these disparities may have on treatment choices.

Methods: A search was conducted of MEDLINE (1990–2006) and data presented at recent congresses (The 25th Congress of the European Academy of A1lergology and Clinical Immunology, June 10–14, 2006, Vienna, Austria, and the 62nd Annual American Academy of Allergy, Asthma and Immunology Meeting, March 3–7, 2006, Miami Beach, Florida) for articles that contained combinations of the terms allergic rhinitis, patient, physician, perspective, attitude, opinion, experience, or burden. Appropriate articles were selected for review in combination with data from a recent Adelphi Group Products (New York, New York) survey.

Results: A study of the impact of seasonal AR on HRQOL found that adolescent patients (n = 83) scored practical problems higher in terms of importance. AR was found to affect the home and social life of ≥33% of patients in a study from the United Kingdom. A European survey of 1494 patients with AR found that nasal congestion was the most common moderate or severe nasal symptom (55%) and that 44% of patients suffered moderate or severe ocular symptoms. A Danish study of adults and adolescents found that AR was undiagnosed in 32% of patients. In a study of 100 physicians in the United States, ~30% of physicians under-estimated the severity of AR and its impact on patients' work or school activities. Furthermore, 1 study indicated that ~99% of physicians did not issue adequate treatment, although no study was found that directly linked physicians' perspectives of AR and their treatment decisions to date.

Conclusions: In a review of the existing literature, evidence of disparities between patients' and physicians' perspectives of AR were found, although no studies linked perspectives to prescribing behavior; therefore, research into the impact on treatment decisions might be warranted. In the future, the patient-physician dialogue might be improved by a standardized questionnaire designed to identify the most bothersome symptoms of a patient's disease, so that the most appropriate treatments can be selected to maximize quality of life.

References (64)

W Phipatanakul
Allergic rhinoconjunctivitis: Epidemiology
Immunol Allergy Clin North Am.
(2005)
RM Sly
Changing prevalence of allergic rhinitis and asthma
Ann Allergy Asthma Immunol.
(1999)
AK Thompson et al.
Quality of life in patients with allergic rhinitis
Ann Allergy Asthma Immunol.
(2000)
RD O'Connor et al.
Assessing symptomatic burden of patients suffering from allergic rhinitis (AR)
J Allergy Clin Immunol.
(2006)
J Bousquet et al.
Allergic rhinitis and its impact on asthma
J Allergy Clin Immunol.
(2001)
P Khanna et al.
Categorization of patients with allergic rhinitis: A comparative profile of “sneezers and runners” and “blockers.”
Ann Allergy Asthma Immunol.
(2005)
BA Stuck et al.
Changes in day-time sleepiness, quality of life, and objective sleep patterns in seasonal allergic rhinitis: A controlled clinical trial
J Allergy Clin Immunol.
(2004)
PD Blanc et al.
The work impact of asthma and rhinitis: Findings from a population-based survey
J Clin Epidemiol.
(2001)
PS Marshall et al.
Effects of seasonal allergic rhinitis on selected cognitive abilities
Ann Allergy Asthma Immunol.
(2000)
EF Vuurman et al.
Effects of semprex-D and diphenhydramine on learning in young adults with seasonal allergic rhinitis
Ann Allergy Asthma Immunol.
(1996)

MA Corrao et al.

Prescription medication use following rhinitis diagnosis: An examination of,pharmacy claims in the Integrated Healthcare Information Services (IHCIS) database

J Allergy Clin Immunol.

(2006)

WH Crown et al.

Seasonal versus perennial allergic rhinitis: Drug and medical resource use patterns

Value Health

(2003)

P Stang et al.

Infrequent treatment of symptoms amoung rhinitis symptom sufferers during an allergy season

J Allergy Clin Immunol.

(2006)

BQ Lanier et al.

Comparison of the efficacy of combined fluticasone propionate and olopatadine versus combined fluticasone propionate and fexofenadine for the treatment of allergic rhinoconjunctivitis induced by conjunctival allergen challenge

Clin Ther.

(2002)

EO Meltzer et al.

Subjective and objective assessments in patients with seasonal allergic rhinitis: Effects of therapy with mometasone furoate nasal spray

J Allergy Clin Immunol.

(1998)

HB Kaiser et al.

Fluticasone furoate nasal spray: A single treatment option for the symptoms of,seasonal allergic rhinitis

J Allergy Clin Immunol.

(2007)

FC Hampel et al.

Once-daily fluticasone furoate nasal spray (FF) provides 24-hour symptom relief- in subjects with seasonal allergic rhinitis (SAR) caused by mountain cedar pollen

J Allergy Clin Immunol.

(2007)

P Ratner et al.

Once-daily fluticasone furoate nasal spray (FF) effectively treats ocular symptoms of-seasonal allergic rhinitis (SAR) caused by mountain cedar pollen

J Allergy Clin Immunol.

(2007)

G Settipane et al.

Triamcinolone acetonide aqueous nasal spray in patients with seasonal ragweed allergic rhinitis: A placebo-controlled, double-blind study

Clin Ther.

(1995)

ZM Munk et al.

Preseasonal, once daily triamcinolone acetonide nasal aerosol for seasonal allergic rhinitis

Ann Allergy Asthma Immunol.

(1997)

EF Juniper et al.

Assessment of quality of life in adolescents with allergic rhinoconjunctivitis: Development and testing of a questionnaire for clinical trials

J Allergy Clin Immunol.

(1994)

N Ricard et al.

Link between patient preferences and treatment outcomes in seasonal allergic rhinitis: An empiric investigation

Clin Ther.

(1999)

R Stanford et al.

Rhinitis symptoms sufferers report a significant symptom burden during an allergy season

J Allergy Clin Immunol.

(2006)

H Nolte et al.

Unawareness and under-treatment of asthma and allergic rhinitis in a general population

Respir Med.

(2006)

D Ryan et al.

Management of allergic rhinitis in UK primary care: Baseline audit

Prim Care Respir J.

(2005)

EF Juniper

Impact of upper respiratory allergic diseases on quality of life

J Allergy Clin Immunol.

(1998)

T de Graaf-in 't Veld et al.

The relationships between nasal hyper-reactivity, quality of life, and nasal symptoms in patients with perennial allergic rh i n it is

J Allergy Clin Immunol.

(1996)

MP Borres et al.

How many teenagers think they have allergic rhinoconjunctivitis and what they do about it

Ann Allergy Asthma Immunol.

(1997)

W Phipatanakul

Allergic rhinoconjunctivitis: Epidemiology

Immunol Allergy Clin North Am.

(2005)

IRA Nathan et al.

Prevalence of allergic rhinitis in the United States

J Allergy Clin Immunol.

(1997)

MS Blaiss

Cognitive, social, and economic costs of allergic rhinitis

Allergy Asthma Proc.

(2000)

G Majani et al.

Health-related quality of life assessment in young adults with seasonal allergic rhinitis

Allergy

(2001)

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Poor or inadequate access to specialty care often results in misdiagnosis and underdiagnosis of allergic and immunologic diseases.3 Although underdiagnosis of allergic disorders can lead to an underestimation of disease burden and negatively impact job or school performance,6 misdiagnosis or delayed diagnosis of primary immunodeficiency syndromes can lead to catastrophic and fatal outcomes.7,8 Allergic rhinitis, a common comorbid condition among patients with asthma, significantly increases morbidity and health care utilization for asthma.9
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However, AR is not being readily addressed or diagnosed in underserved children with uncontrolled asthma. In Project Nocturnal Asthma and Performance in School, an urban cohort of children with uncontrolled asthma, 53% of AR participants were newly diagnosed at the clinic study visit, thought to be linked to physician underestimation of the impact of AR on patient daytime functioning and low awareness of guideline recommendations.16 Implicit bias could be contributory to this underrecognition of AR.
Health disparities are health differences linked with economic, social, and environmental disadvantage. They adversely affect groups that have systematically experienced greater social or economic obstacles to health. Renewed efforts are needed to reduced health disparities in the United States, highlighted by the disparate impact on racial minorities during the coronavirus pandemic. Institutional or systemic patterns of racism are promoted and legitimated through accepted societal standards, and organizational processes within the field of medicine, and contribute to health disparities. Herein, we review current evidence regarding health disparities in allergic rhinitis, asthma, atopic dermatitis, food allergy, drug allergy, and primary immune deficiency disease in racial and ethnic underserved populations. Best practices to address these disparities involve addressing social determinants of health and adopting policies to improve access to specialty care and treatment for the underserved through telemedicine and community partnerships, cross-cultural provider training to reduce implicit bias, inclusion of underserved patients in research, implementation of culturally competent patient education, and recruitment and training of health care providers from underserved communities. Addressing health disparities requires a multilevel approach involving patients, health providers, local agencies, professional societies, and national governmental agencies.
Epidemiology of Allergy
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Allergic Rhinitis: The Impact of Discordant Perspectives of Patient and Physician on Treatment Decisions

Abstract

Immunol Allergy Clin North Am.

Ann Allergy Asthma Immunol.

Ann Allergy Asthma Immunol.

J Allergy Clin Immunol.

J Allergy Clin Immunol.

Ann Allergy Asthma Immunol.

J Allergy Clin Immunol.

J Clin Epidemiol.

Ann Allergy Asthma Immunol.

Ann Allergy Asthma Immunol.

J Allergy Clin Immunol.

Value Health

J Allergy Clin Immunol.

Clin Ther.

J Allergy Clin Immunol.

J Allergy Clin Immunol.

J Allergy Clin Immunol.

J Allergy Clin Immunol.

Clin Ther.

Ann Allergy Asthma Immunol.

J Allergy Clin Immunol.

Clin Ther.

J Allergy Clin Immunol.

Respir Med.

Prim Care Respir J.

J Allergy Clin Immunol.

J Allergy Clin Immunol.

Ann Allergy Asthma Immunol.

Allergic rhinoconjunctivitis: Epidemiology

Immunol Allergy Clin North Am.

Prevalence of allergic rhinitis in the United States

J Allergy Clin Immunol.

Cognitive, social, and economic costs of allergic rhinitis

Allergy Asthma Proc.

Health-related quality of life assessment in young adults with seasonal allergic rhinitis

Allergy