Consultation and referral guidelines citing the evidence: How the allergist-immunologist can help

Michael Schatz, MD, MS Donald Y.M. Leung, MD, PhD Stanley Goldstein, MD Guest Editors: Donald Leung, MD, PhD, FAAAAI, and Michael Schatz, MD, MS, FAAAAI

Author address: 

AAAAI Consultation and Referral Guidelines Citing the Evidence Task Force Chair AAAAI Consultation and Referral Guidelines Citing the Evidence Task Force Co-Chair AAAAI Practice and Policy Division Chair


Preface Allergic diseases affect at least 20% of the population, which means that at least 56,284,381 Americans have allergic diseases. Although there are currently only 5400 board-certified allergist-immunologists in this country, their expertise and services are often underused. We believe a major part of this underuse is a result of physicians and patients not really knowing what allergist-immunologists do and how we can help. It is the main purpose of these guidelines to define both the expertise of the allergist-immunologist and under what circumstances they can be of added value in the treatment of patients. These guidelines started as a presidential initiative designed to help the American Academy of Allergy, Asthma and Immunology (AAAAI) fulfill its mission of "œthe advancement of the knowledge and practice of allergy, asthma, and immunology for optimal patient care." The guidelines were subsequently developed as summarized in Fig 1, with the input of many AAAAI committees and individuals who are acknowledged in this supplement. The guidelines were reviewed and approved by the AAAAI leadership and presented to the AAAAI membership for comments before being finalized. The guidelines will be regularly updated on our Web site ( When one speaks of "œreferral," there may be "œbusiness" or "œturf" connotations. In an attempt to transcend such considerations, we based the consultation and referral guidelines on evidence that allergist-immunologist care improves patient outcomes. As described in the "œIntroduction," this was either direct evidence that outcomes improved with allergist-immunologist care or evidence that diagnostic or therapeutic interventions performed by allergist-immunologists improved outcomes. Because there has been a paucity of controlled intervention trials addressing this issue, the evidence is often observational. Moreover, some of the rationale statements are only supported by consensus or expert opinion. Nonetheless, we believe that trying to provide a rationale for each guideline and citing the best available evidence is a step forward in creating rational, useful, and evidence-based guidelines for consultation and referral. We look forward to future studies that would increase the evidence base for such guidelines. The title Consultation and referral guidelines sends another important message. Although some patients will require ongoing allergist-immunologist management, others might require just a single or a limited number of consultations. Still others might benefit from coordinated primary care and allergist-immunologist follow-up (co-management). We hope these guidelines will allow the allergist-immunologist to function optimally as a member of the health care team for the ultimate benefit of the patients we serve. Introduction Allergic diseases affect more than 20% of the US population and are the sixth leading cause of chronic disease in the United States.1 Allergic rhinitis alone leads to approximately 16.7 million office visits to health care providers each year,2 and asthma causes nearly 2 million emergency department visits and 465,000 hospitalizations each year.3 Indirect costs from asthma are reported to be more than $4.6 billion.4 Allergies and asthma cause unnecessary deaths each year: about 100 persons in the United States die from food-related anaphylaxis,5 and another 40 die from insect stinginduced anaphylaxis.6 Asthma leads to about 4300 deaths each year.4 For many patients with asthma and allergic diseases, working with an allergist-immunologist can assist them in managing their disease and preventing morbidity and mortality. What is an allergist-immunologist? An allergist-immunologist is a physician who has been trained in either internal medicine or pediatrics and who has completed an additional 2 (or more) years of training in allergy and immunology at an accredited training program. Most are certified in internal medicine, pediatrics, or both and have passed the examination given by the American Board of Allergy and Immunology. The allergist-immunologist is uniquely trained7 in the following: "¢allergy testing (skin test, in vitro studies); "¢history-allergy test evaluation; "¢bronchoprovocation testing (eg, exercise and methacholine); "¢environmental control instructions; "¢inhalant immunotherapy; "¢immunomodulator therapy (eg, anti-IgE, intravenous immunoglobulin); "¢venom immunotherapy; "¢food and drug challenges; "¢drug desensitization; "¢evaluation of immune competence; "¢education (disease, medications, and monitoring); and "¢management of chronic or recurrent conditions in which allergy is not always identified: rhinosinusitis, conjunctivitis, asthma, cough, urticaria-angioedema, eczema, anaphylaxis. How the allergist-immunologist can help This Consultation and referral guideline developed by the American Academy of Allergy Asthma and Immunology is designed to assist patients and health care professionals in determining when referral to an allergist-immunologist could be helpful. This referral might be a single or limited consultation, lead to co-management between a primary care provider and an allergist-immunologist, or require ongoing specialty care by the allergist-immunologist. Providing information based on evidence to assist patients and health care providers in the decision-making process should benefit not only the individuals but our health care system as a whole. The evidence included in this guide is based on the following: "¢diagnostic evidence: tests performed or interpreted by allergist-immunologists facilitate diagnosis; "¢direct outcome evidence: evidence that intervention by an allergist-immunologist improves outcomes; and "¢indirect outcome evidence: evidence that interventions performed by allergist-immunologists improve outcomes (evidence to support established pharmacologic management will generally not be reviewed). The evidence cited for each allergic disease category is also graded according to the following system: Ia.Meta-analysis of randomized controlled trials Ib.Randomized controlled trial II.Nonrandomized, controlled intervention study III.Observational cohort or case-control study IV.Review article, expert opinion. This document includes specific referral guidelines for 14 categories of allergic diseases, along with the rationale for the referral, references, and the type and grade of evidence provided (Tables I-XIV). The tables are presented alphabetically for easy navigation and do not refer to the prevalence of the individual disease. This information will be regularly updated on the AAAAI Web site (

abstract No: 

Pages S495-S523

Full conference title: 

2006 American Academy of Allergy, Asthma, and Immunology Annual Meeting
    • AAAAI 2006 (62nd)