44 Office Set-up
44.1 Why Add Allergy to an Existing Practice?
There are many reasons why a practitioner may consider adding allergy to a practice:
You may have always had an interest in allergies.
You may be filling a need in your community.
You may seek to provide comprehensive care for patients with aerodigestive tract inflammatory disease.
Whatever the reason or reasons may be for embarking on this journey, the prerequisites are believing that allergies have a significant impact on a patient’s quality of life and having the commitment to deliver allergy care in a safe and effective manner. Many of the patients who come into the office have allergies contributing in some way to their chief complaint, and in truth, allergy is already being practiced in most providers’ offices, whether he/she realizes it or not.
44.2 What Exactly Does It Mean to “Add Allergy” to the Office?
This may mean something different for each practice. Allergic disease can be diagnosed and treated without adding a single element to the office. A good history and physical examination can detect allergic disease and environmental control strategies can be discussed from that point. Medical trials can be initiated and adjusted based on symptomatic relief and this approach has proven to be very successful for many patients. “Adding allergy” to a practice really means that the clinician would like to confirm the presumptive diagnosis of allergy, identify suspected allergens through specific testing, and provide allergen-specific immunotherapy to those patients whose quality of life suffers despite pharmacotherapy and avoidance strategies.
When it comes to adding allergy to your practice, one size definitely does not fit all. Through time, each physician must learn how allergy works best in their particular situation. It is inevitable that many obstacles will be encountered, but if the physician is prepared to start slow, ask many questions, and always keep the welfare of their patients as the top priority, then the decision to add allergy to the practice will be a rewarding one for both doctor and patient.
44.3 Factors to Consider
If a practitioner is contemplating adding allergy to the practice, he/she must first consider the impact an allergy service would have on the practice. A practitioner may have decided that adding allergy is the best move for the practice, but the other partners in the practice may not necessarily be in agreement. Some partners may be concerned about a shift in the patient mix or the way such a change will be perceived by the community. If the practice is currently referring to other allergists in the community, adding allergy to the practice might affect the referrals coming from those sources, and these issues must be considered and thoroughly discussed before moving forward.
Another factor to consider is whether an allergy service is financially feasible for the practice at the moment. This is another area where the partners must all be in agreement, particularly when each member will be sharing the financial burden. There are significant start-up costs, and this chapter will help you understand all the elements that go into calculating this. Eventually, an allergy service will become a source of revenue for the practice, but this may take time depending on the situation. If the allergy service becomes busy quickly, start-up costs may be recovered in the first 6 months. But if there aren’t many practitioners referring allergy patients at first, it may take a year or even longer.
Once there is general agreement within the practice to add allergy, the next step is to look around the community and see how, where, and by whom allergy care is currently being provided. If there is a large general allergy practice down the road, or a nearby ENT practice that provides allergy services, you may encounter some difficulties in recruiting patients. However, if established offices are only able to offer new appointments in 3 months, a new allergy service may attract a great deal of business.
Fortunately, you can acquire a large number of allergy patients from your own practice. Ultimately, you must decide when and how aggressively to start advertising the new allergy service. Giving talks to other practices, schools, and community groups can be helpful in getting the word out and will also educate others about newer techniques, such as sublingual immunotherapy (SLIT) or possibly even oral mucosal immunotherapy (OMIT).
Once word spreads in the community about the new allergy practice, there may be some negative feedback. Some may respond to this medical and financial threat to their territory with statements that are unkind or simply untrue. In these unfortunate situations, you must stay focused on patient care rather than resorting to similar tactics. Satisfied patients speak loudly enough.
It may be useful to reach out to others during this part of the process. Talking to established allergists may provide new ideas on how to proceed and advice on how to avoid common pitfalls. If possible, a visit to one or two other offices that provide allergy services for a day of observation may provide even further inspiration. It is also helpful to talk to practice consultants who can estimate the financial ability of the practice to add allergy, estimate the necessary changes in staff and educate the physician about the current allergy codes and billing practices. Speaking to the practice lawyer is also useful to assure that there will be no legal ramifications of adding allergy to the practice, such as a restrictive clause in the lease prohibiting that type of practice in the building, and that it is considered within your scope of practice.
There also tends to be a shift in the patient mix and practitioner and their partners must be willing to accept this. Once allergy is added to the practice, there will invariably be a shift toward allergy and sinus patients, possibly at the expense of other types of patients. There may also be a shift in the surgical caseload, both in type and volume, if there are surgical providers in the practice. A practitioner may also start seeing patients with problems that are indirectly related to allergies, such as asthma and dermatitis. Each provider must decide where their comfort level is in evaluating these conditions and decide to refer to others or obtain additional training when necessary. A practitioner must also be prepared to make referrals to dermatologists or pulmonologists when appropriate.
44.4 Preparing the Office
44.4.1 Allergy Training
After making the decision to proceed with adding allergy to the practice, the next choice is whether the practitioner will be going to lead this service or hire someone else. This could include a general allergist or another physician who has allergy training. However, consideration should be given to whether or not the practice has reached the point where it can support another provider, particularly if that individual is not able to bring established patients right into the practice. Regardless of who is providing allergy services, when allergy testing and immunotherapy are taking place in the office, all physicians and staff members must be educated about recognizing the signs of anaphylaxis and a protocol must be in place to treat this emergency.
44.4.2 Which Services to Offer
In laying the foundation for the allergy service, a practitioner must decide whether to use exclusive serum-specific immunoglobulin E (IgE) testing (in vitro) or a combination of skin and in vitro testing. In vitro testing may be performed in the office, but this service is under strict regulation by the Clinical Laboratory Improvement Amendments (CLIA) of 1988, and special certification is required. For this reason, most send in vitro testing to reference laboratories and receive the results in less than a week. In vitro testing should be available for those patients who cannot or should not be skin tested, such as histamine nonreactors, those with dermatographia, very young children, and pregnant women. Panels for in vitro testing should be chosen as judiciously as those for skin testing.
A practitioner may choose to perform skin testing in allergy practices. This was discussed in detail in previous chapters, but usually involves skin prick testing (SPT), intradermal testing (IDT), or a combination of both, such as modified quantitative testing (MQT). Performing skin testing in the office naturally involves more training, office space, and lab personnel than in vitro testing. A practitioner may choose to use one method exclusively for testing, either a type of skin testing or in vitro testing, or may use both. Regardless of the chosen method, the best advice is to be safe, consistent, and always use clinical suspicion to guide testing.
Other skin testing which may be offered might include specific testing for penicillin allergy, which is now commercially available, or patch testing. Patch testing, which is most commonly performed by dermatologists, is used for chemicals and substances that may contact the skin and produce a delayed (type IV) reaction.
Another service that may be considered for the new allergy patients is pulmonary function testing (PFT). Pulmonary function testing is very useful when the practitioner is providing asthma medications. Pulmonary function testing changes may help the practitioner decide whether or not seasonal asthmatics should be tested or receive an immunotherapy injection, and may also be used to document their progress after a course of medication or immunotherapy. Small, portable PFT units are available which may be linked to a computer or network so results appear immediately in the patient’s chart. Testing may also be performed before and after inhalation of a short-acting beta agonist to demonstrate the reversibility of airway obstruction—a hallmark of asthma. Again, a practitioner must decide which asthma patients he/she is comfortable treating and recognize the right time to consult with a pulmonologist.
Immunotherapy, also known as desensitization, is a common service provided; usually reserved for allergic patients whose symptoms or comorbidities have not been adequately relieved with pharmacotherapy and environmental control strategies. Since it was introduced by Noon in 1911, subcutaneous immunotherapy (SCIT) has been administered through the injection route. But since the 1960s, sublingual immunotherapy (SLIT) has also been available using liquid extract drops. While adding allergy to the practice, a practitioner must decide whether to use one or more of these methods. While both methods have been found to be similar in terms of efficacy, SCIT is generally performed weekly in the office and is covered by most insurance plans, while SLIT is administered daily at home and is not covered by insurance. There are also FDA-approved SLIT tablets available for daily use at home. Each of these methods of immunotherapy can be started based on in vitro or skin testing.
If a practitioner is going to provide immunotherapy services, he/she must decide whether to formulate and prepare the vials in the office or have this done by an outside source. Outsourcing this service is useful if space and resources in the office are limited, but disadvantages include the loss of individualized control of the vials, the loss of revenue for this service, and the fact that the treating extract may differ from the testing extract. After the patient is tested, the practitioner decides which allergens should be included in the vial and the level of sensitivity to those allergens. Once the outside company returns the vials, an intradermal vial test is performed for SCIT vials to ensure safety and injections are begun. Treatment with SLIT drops or tablets may also be performed in a similar fashion, with the first dose administered in the office.
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