Top Tips to Avoid “Practice Management Hypertension”

Saving Private Practice is a program created to assist physicians from solo, small, and medium medical practices. The webinar series are monthly educational sessions designed to help with office operations, decision making, and practice management. This one-hour session will be led by Debra Phairas, President of Practice & Liability Consultants, LLC. This webinar will provide tips to lower anxiety to successfully navigate the business side of the practice. It is just as important to invest in education about the business side of medical practice throughout your career as the clinical aspects.

Debra Phairas is President of Practice & Liability Consultants, LLC a nationally recognized firm specializing in practice management and malpractice prevention. Her background includes medical clinic administration and loss prevention management for NORCAL Mutual, a physician malpractice insurance carrier in Northern California. She has presented seminars and lectures nationwide for state and local medical/dental associations, management organizations and specialty societies. Please view website: www.practiceconsultants.net

By Anlin Xu, MD

Asthma is the most common long-term childhood disease, but it can also affect adults. As many as 1 in 12 children and 1 in 13 adults experience asthma. It affects 26 million Americans and results in a staggering $50 billion each year in healthcare costs. As with all chronic illnesses, the first step in treating asthma is educating patients on their condition, reviewing treatment options including controller verses rescue therapy, age-appropriate proper medication use, and the rules of 2’s – asthma is not well-controlled when using a rescue inhaler more than twice a week outside of exercise, and waking up more than twice a month at night with asthma symptoms.

In recent years, implementing SMART (Single Maintenance and Reliever Therapy) has simplified the medication regimen so a combination of an inhaled steroid (ICS) and an inhaled long-acting beta-agonist (LABA) can be used as needed during flares – for example, using Symbicort 8 puffs per day for 5 to 11 year olds and up to 12 puffs a day for 12 years and older. Recent trials also found SMART is helpful when used as needed in patients with mild asthma. Meta-analyses showed SMART has been associated with lower risk of severe asthma exacerbations in adolescents and adults when compared to ICS-LABA maintenance plus short-acting beta-agonist (SABA). Soon, we will also have an ICS-SABA combination that can be used as needed as well.

As allergists, we can identify potential triggers such as dust mites, pet dander and other inhalant allergies through skin and blood testing to decrease asthma symptoms and improve control. Simple environmental control measures can help to decrease allergen exposure including covering pillows, mattresses, and comforters with dust mite proof encasing, keeping the cat out of the bed and bedroom, running a HEPA air filter, and using Purina LiveClear cat food which decreases cat allergens by 47% in three weeks. In addition, for patients with allergic asthma, allergy immunotherapy can desensitize patients to their allergens, improve lung function, decrease medication dependence, and make a lasting impact.

For patients who are not well-controlled on a standard therapy of asthma medications and allergy shots, Xolair was the only biologic available for many years. Now we have several new biologics that can improve lung function, decrease not only oral steroid use and inhaled steroid dose, but also the number of exacerbations. Many of these biologics can reduce disease burden for other conditions at the same time – for example, using Dupixent for patients with recurrent nasal polyposis, moderate to severe atopic dermatitis, and/or poorly controlled eosinophilic esophagitis. Xolair is not only indicated for patients with asthma, but also those with chronic idiopathic urticaria and/or nasal polyps. Nucala is approved for hypereosinophilic syndrome, eosinophilic granulomatosis with polyangiitis as well as nasal polyps. Most asthma biologics target allergic inflammation. The newest biologic, Tezspire, can be use in patients with or without an allergic component.

The selection of a biologic that is right for each patient is dependent upon other concomitant diseases the patient may have. For example, I have a patient with allergic asthma and frequent exacerbations who is not compliant with medications/ allergy shots. He was started on Fasenra and was subsequently diagnosed with colon cancer. Despite having surgery and treatment for his cancer, having his asthma well-controlled likely improved his recovery and overall outcome.

We have come a long way from using epinephrine and theophylline for asthma to now more precision medicine in caring for our asthma patients. It will be exciting to see what the next 10-20 years will bring to hopefully alter the course of the disease and improve patients’ quality of life.

About the Author:

Anlin Xu, MD, is a board-certified allergist and immunologist and president and CEO of South Bay Allergy and Asthma Group, which offers convenient locations in San Jose, Los Gatos, Mountain View, and Redwood City, California. Certified by both the American Board of Internal Medicine and the American Board of Allergy & Immunology, Dr. Xu’s medical career began as a student at the University of Pittsburgh in Pennsylvania, where she graduated magna cum laude with a Bachelor of Science in molecular biology, and later a medical doctorate, which she earned with honors. Dr. Xu completed her internal medicine residency at Yale University, during which time, she received a postdoctoral fellowship award by the National Institute of Health (NIH) for her research in Cutaneous T Cell Lymphoma (CTCL). Dr. Xu relocated to the San Francisco Bay Area for her fellowship in Allergy, Asthma and Immunology at a combined program of Stanford University and the University of California, San Francisco (UCSF) Medical Centers. Dr. Xu’s areas of expertise include hay fever, food allergy, asthma, allergic contact dermatitis, hives, and eczema in children and adults. She speaks Mandarin and Shanghainese fluently. In addition to her clinical duties, Dr. Xu is the president of the Santa Clara County Medical Association, and a past and current co-president of the South Bay American Medical Women’s Association. She is a member of American Medical Association and a delegate to the California Medical Association. She is also a Fellow of the American Academy of Allergy, Asthma & Immunology; the American College of Allergy, Asthma & Immunology; and the American Contact Dermatitis Society.

There are 32 million people with food allergies in the U.S. and 5.6 million of them are children. Food allergies affect 1 out of every 13 children in schools. By addressing the significant over diagnosis of food allergies, implementing updated prevention guidelines and offering treatment options we can hopefully decrease these numbers over time.

60% of the time there is over diagnosis of food allergies. As

By June Zhang, MD

allergists, we not only are able to accurately diagnose the allergy but also, when possible, introduce more foods back into the patient’s diet. My personal favorite type of visit is a food challenge, where a patient can potentially tolerate a previous allergenic or thought to be allergenic food. Examples include an infant eating a baked egg product for the first time, an older child who outgrew their peanut allergy or an adult who thought they were allergic to shrimp. Food challenges can make a significant impact on a patient’s daily life.

ALLERGY,

In recent years, food allergy prevention has made dramatic changes due to the pivotal trial of Learning Early About Peanut study led by Dr. Gideon Lack, showing that consuming peanuts early and frequently in high-risk infants led to a more than 80% reduction in the development of peanut allergy. Early introduction of allergenic foods is key, especially for children with eczema when families are often avoiding many foods as they feel it improves their infant’s skin symptoms. Meta-analysis shows that avoiding foods that may flare eczema only marginally improves skin symptoms but dramatically increases the child’s risk of developing a food allergy. Instead, eczema can be very well-controlled with a good skin care regimen. It is crucial to treat eczema early and aggressively as we now know many of these infants are being sensitized to foods through their skin due to skin barrier breakdown. I always remind families if they are snacking on nuts to make sure to wash their hands thoroughly before touching the baby’s skin. Along the same lines, it is important to avoid using topical skin care products that contain foods. Lil Mixins Early Introduction Powder is a great way to incorporate allergenic foods into an infant’s diet. Barrier therapy, applying Vaseline around the mouth, before introducing new foods can also decrease topical irritation and misdiagnosis of food allergies especially for infants with facial eczema.

Current treatment options include avoidance, carrying EpiPen, and now oral immunotherapy. In 2020, Palforzia introduced peanut oral immunotherapy, the first FDA-approved treatment for food allergy. After six months of treatment, a patient is able to eat one peanut daily and reduce risk of severe allergic reactions by increasing the threshold that triggers reactions. Off-label treatments for nuts, milk, egg, wheat, sesame, and other foods can use similar dosing protocols. Even though it is a life changing treatment option as patients can now take control of their disease and improve psychosocial aspects of having a severe food allergy, oral immunotherapy is not a cure. Oral immunotherapy can rarely lead to treatment associated eosinophilic esophagitis and patients still need to carry EpiPen. Patients also need to observe a strict two-hour rest period after daily dosing for several years and possibly indefinitely. Current data is exciting as younger patients less than four years old tolerate the desensitization well and have a potentially higher chance of sustained unresponsiveness (“cure”).

The future of food allergy is bright, with numerous novel treatment options in the pipeline such as percutaneous immunotherapy in the near future, adjunct therapy with probiotics and multiple biologics. Soon there will be several options of needle-less epinephrine which will decrease usage hesitancy and improve outcomes. It is an exciting time to be an allergist. Even as a fellow, all we had was “avoid the food and carry an EpiPen.” Now we have the option to treat motivated patients and families to help decrease the burden of their disease and improve their quality of life, with more options in the near future. Hopefully, all these measures can help increase early introduction, decrease the development of food allergies, provide a painless way to administer epinephrine, offer more options to