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Itchy costs of chronic urticaria call for scratching off tests

Published online: May 1, 2019

Chronic urticaria/angioedema (CUA) is a condition characterized by the presence of hives for more than 6 weeks. Guidelines regarding the management and treatment of CUA published in 2011 and the 2014 and 2018 updates, have consistently recommended limiting testing unless the clinical picture raises the need to rule out a diagnosis other than CUA.

In a recent study, Carrillo-Martin et al. assessed different tests used in the evaluation of CUA and the frequency in which these tests’ results lead to any changes in outcome and how these tests impact the cost of evaluation and therefore the cost of disease. They also sought to evaluate how the guideline’s 2014 update has impacted tendencies in type of tests ordered and differences in costs before and after the update. In their article published in The Journal of Allergy and Clinical Immunology: In Practice, Carrillo-Martin et al. describe their analysis of data from 725 patients who were being evaluated for CUA at a tertiary-care center in the United States. They collected information on how many tests a single patient had performed, the tests’ results and rate of abnormality, the cost for the entire CUA evaluation, and the frequency in which any abnormal test results benefited the patient through a change in outcome or diagnosis.

Out of their 725-patient cohort, 543 patients (74.8%) had at least one test performed, and most test results were normal in over 90% of the patients. Abnormal test results led to changes in outcome in only 5 patients (0.9%) and changed the diagnosis in only 8 patients (1.4%). The costs of CUA evaluations were as high as 2,573 USD with tests accounting for as much as 1,365 USD. Lastly, costs of evaluation and type of tests ordered remained similar from 2010 to 2018 except for a handful of tests that were ordered more frequently after the 2014 update, but did not have an impact in the outcome, management or diagnosis of the patients on whom they were performed.

CUA is a clinical diagnosis, and tests used in its evaluation rarely modify the outcome of disease or find underlying conditions while being an important generator of cost of disease. Having open discussions with patients to explain the lack of benefit from routine testing in CUA could help clinicians and their patients to reach a consensus on how to approach the condition through evidence-based decisions. This could help improving institutions’ use of resources and more importantly, lowering cost of disease while improving delivery of care.

The Journal of Allergy and Clinical Immunology: In Practice is an official journal of the AAAAI, focusing on practical information for the practicing clinician.