Introduction

Allergic diseases, including atopic dermatitis (AD), allergic rhinitis, asthma, and food allergies, have become a major global public health problem,¹ and are caused by a combination of genetic background, allergen exposure, and environmental factors.² Epidemiological findings show that 358 million people worldwide suffer from asthma,³ while allergic rhinitis has affected 10–20% of global population.⁴ Allergic diseases have a negative impact on the quality of life of patients and their families, reduce their daily performance, and cause a serious socioeconomic burden.^1,5

Although medications used to combat allergy are safe, they are only symptomatic. Therefore, patients often require multiple medications for relief of symptoms and often a lifelong course of treatment.^6–8 The principle of allergen immunotherapy (AIT), also known as desensitization, considers gradual exposure of patient to increasing amounts of triggering allergen over a period to allow the immune system to build natural tolerance, relieve symptoms, reduce the use of allopathic medicines, and improve patient’s quality of life.⁸ Since physicians play a fundamental role in patient’s adherence to the treatment,⁹ it is important to ensure that they have an adequate level of AIT knowledge. The aim of this study was to develop a specific questionnaire to assess and evaluate in a better manner the AIT-related knowledge of physicians working in all levels of hospitals and to provide recommendations for the widespread implementation of AIT.

Material and Method

We designed a questionnaire (Supplementary Table S1) that included the following information: characteristics of physicians (age, gender, years of work experience, whether the hospital is a public hospital, grade of the hospital where they work, and whether they are pediatricians), circumstances of their consultations (whether desensitization is carried out in their department, the time required to check patients with allergic diseases, and the immediate response of patients when AIT is introduced), and basic knowledge of allergen-specific immunotherapy (whether it is effective, whether there is an age limit, whether the treatment continues to be effective after it is stopped, what kind of diseases can be desensitized) and whether the factors that influence the correct judgment of desensitization are sought to provide a basis for the widespread implementation of allergen-specific immunotherapy.

The Questionnaire was designed using the Questionnaire Star tool. Of 1300 questionnaires, 1024 valid ones (one from each IP address) were collected from consenting physicians working in community, secondary, and tertiary hospitals of Shanghai, Zhejiang, Hebei, and Yunnan Provinces between September 2021 and June 2022. Secondary hospitals were defined as hospitals containing more than 100 but less than 500 beds, and tertiary hospitals are hospitals with a bed capacity exceeding 500 that are responsible for providing specialized health services.

Statistical analysis was done using SPSS 25.0. Counting data were expressed as frequencies and percentage values. Each positive answer for allergic rhinitis, conjunctivitis, bronchial asthma, and atopic dermatitis received a score of 1. A 0 score was given for food allergy and allergenic dust mite. A score of 4 comprised accurate judgment group, and a score <4 comprised inaccurate judgment group. Chi-square test and multi-factor logistic analysis were used to determine the influencing factors; P < 0.05 was considered statistically significant.

Results

Univariate analysis for determining indications for AIT

A total of 1024 physicians (648 females, 376 males) participated in this study. Of them, 517 were pediatricians (348 general pediatricians, 92 respiratory pediatricians, and 53 internal medicine pediatricians), and 507 were adult medicine physicians (92 general internal medicine physicians, 28 adult respiratory physicians, 217 other internal medicine physicians, and 133 community physicians). Based on the results of the questionnaire, physicians were divided into two groups: accurate judgment group (n = 374), and inaccurate judgment group (n = 650).

Statistical difference was observed between the groups regarding age, years of experience, hospital grade, specialty (pediatrician or general physician), whether AIT was carried out in the department, time spent in consultation of patients with allergies, immediate patient response, knowledge of AIT effectiveness, and possible age limit (P < 0.05; Table 1).

Logistic multifactorial regression analysis and situational analysis of indications

Factors that were statistically significant for univariate analysis (age, years of experience, hospital grade, pediatrician, whether the department carried out AIT, time spent in consultation of patients with allergic diseases, immediate patient response, whether AIT was effective, and whether AIT was age-restricted) were used as independent variables in a logistic multi-factor regression analysis. Physician characteristics, such as age, grade of physician’s hospital, and whether the physician was a pediatrician or a non-pediatrician, influenced the accurate determination of indications for AIT (Table 2).

Analysis of AIT indications

Most physicians (824; 80.5%) accurately assessed AIT for allergic rhinitis; 47.0% accurately assessed for allergic conjunctivitis; 727 (71.0%) accurately assessed for bronchial asthma, and 628 (61.3%) for atopic dermatitis, with a higher accuracy rate for pediatricians than for non-pediatricians (P < 0.05). There was no significant difference between pediatricians and non-pediatricians in judging AIT efficiency for food allergy and mite sensitization (P > 0.05; Table 3).

Discussion

Allergic diseases are immune system disorders characterized by sensitization and production of allergen-specific immunoglobulin E (sIgE).^10,11 Desensitization, or AIT, is an allopathic treatment that involves small, repeated, and incremental doses of allergen exposure to induce immune tolerance and ultimately achieve sustained symptom relief and/or prevent progression of disease.^1,8 However, AIT has not been universally accepted as a standard treatment for allergic conditions. One the main reasons for the lack of widespread implementation of AIT is the complex pathogenesis of allergic diseases, and the case to case variation in clinical presentation. Patients may be first examined in community hospitals, general pediatric clinics in secondary or tertiary hospitals as well as in different departments of a hospital. Therefore, overcoming the varying perception of AIT by different physicians in different departments is a key component in improving AIT acceptance and promoting accurate graded care.

The results of our study demonstrated that the following factors influenced the accuracy of AIT-related knowledge: physician’s age, hospital grade, and whether the practitioner was a pediatrician or a non-pediatrician. The accuracy rate increased from 47.6% (91/191) for physicians aged <25 years to 85.4% (105/123) for physicians aged >45 years; this could be related to the fact that younger junior physicians have less experience and less knowledge of possible allergic reactions than senior and experienced physicians. Our results also reflected the fact that physicians did not learn enough about allergy at undergraduate or postgraduate level. In many hospitals, undergraduate and postgraduate rotations are often focused on the traditional major disciplines of medicine whereas allergy and immunology are often neglected because they are newer or smaller specialties.¹² Since junior doctors are the mainstay of clinical workforce, standardized curriculum can be offered to students at the end of their rotations to encourage them to participate in teaching practice in allergic diseases, thus improving the overall knowledge of young practitioners about allergic diseases.

Tertiary hospitals had the highest rate of accurate judgment (70.1%), compared to community and secondary ones, possibly because of the higher education and overall knowledge level of physicians, better training system, and availability of more resources. Higher accurate judgment in pediatricians (57.2%), compared to non-pediatricians, could be explained by the increased incidence of allergic diseases in children and adolescents.¹⁰

When individual indications were analyzed, physicians (including pediatric and non-pediatricians) had the highest accuracy rate of allergic rhinitis judgment at 80.5% (824/1024), and pediatricians had a higher accuracy rate of 87.8% (454/517) than non-pediatricians (P < 0.05). The accuracy rate for bronchial asthma was also satisfactory for general physicians and pediatricians at 71.0% (727/1024) and 83.2% (430/517), respectively, being higher than for non-pediatricians (P < 0.05). Different judgments for allergic rhinitis and asthma could be related to the varying guidelines that often recommend AIT as the first line of treatment for allergic rhinitis but not for asthma. On the other hand, accuracy for allergic conjunctivitis was only 47% , probably because of its mild symptoms and few guidelines that recommend AIT for its treatment.^10,11,13 The rate of accurate judgment for atopic dermatitis by pediatricians was 69.6%, higher than that of non-pediatricians at 52.9% (P < 0.05). Study that retrospectively analyzed atopic dermatitis patients who had received mite allergen-specific immunotherapy for at least 3 years showed improvement in 88.4% of patients,¹⁴ indicating that AIT could be effective in some patients of persistent exogenous atopic dermatitis.¹¹

The accuracy rate for food allergy was only 47.9%, with no difference in the accuracy rate between pediatricians and non-pediatricians (P > 0.05). While some studies show that food AIT has clinical benefits during the treatment, its long-term efficacy is unclear. Owing to possible serious allergic reactions, the avoidance of allergic foods remains the primary therapy and desensitization is not advocated for food allergies.^13,15,16 The lowest rate of accurate judgment was detected for mite allergy (38.1%). Desensitization requires potential daily use of medications, frequent medical visits, increased risk of adverse events, and higher medical costs. In addition, it is not sufficient to evaluate the efficiency of AIT only at the current endpoints of 3 or 5 years. The degree of improvement in patients’ symptoms and drug scores, disease control, and quality of life should also be evaluated accordingly to assess the effectiveness of the treatment. If patient is a healthy person with allergen sensitization, the corresponding treatment endpoint cannot be assessed. Considering the pros and cons of performing AIT, it is not clinically recommended for healthy individuals.¹⁶

Conclusions

This study analyzed accurate judgments of clinicians regarding indications for AIT. We showed that age, higher grade of working hospitals, and whether the clinician was a pediatrician or a non-pediatrician were relevant influencing factors. Physicians have a high accuracy judgment rate for rhinitis, asthma, and dermatitis, and a low accuracy judgment rate for desensitization of healthy people with allergic conjunctivitis, food allergies, and allergen sensitization. Training for allergic diseases should be facilitated, especially for younger and lower hospital-level physicians, to improve guidelines treating patients with allergic diseases in clinical settings.