Interprofessional Steering Committee
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Interprofessional Steering Committee
Cheri Lattimer RN, BSN Mirna Chehade, MD, MPH
Executive Director Associate Professor of Pediatrics and Medicine
National Transitions of Care Coalition Director, Mount Sinai Center for Eosinophilic Disorders
Norfolk, VA Icahn School of Medicine at Mount Sinai
New York, NY
Ikuo Hirano, MD, FACG
Professor of Medicine Mary Miller
Division of Gastroenterology and Hepatology Eosinophilic Esophagitis Patient Advocate
Northwestern University Feinberg School of Medicine
Chicago, IL
John J Russell, MD, FAAFP
Clinical Professor of Family and Community Medicine
Sidney Kimmel Medical College at Thomas Jefferson
University
Chair, Department of Family Medicine
Director, Family Medicine Residency
Abington Hospital-Jefferson Health
Philadelphia, PA
This activity is provided by PRIME Education. There is no fee to participate.
This activity is supported by an educational grant from Takeda Pharmaceuticals U.S.A., Inc.
© 2022 PRIME Education, LLC. All Rights Reserved. www.primeinc.org
John J Russell, MD, FAAFP
Clinical Professor of Family and Community Medicine
Instructions to obtain credit: Sidney Kimmel Medical College at Thomas Jefferson
University
1. Complete the activity in its entirety. Chair, Department of Family Medicine
2. Visit PRIME®’s Credit Center at www.primeinc.org/ Director, Family Medicine Residency
credit. Abington Hospital-Jefferson Health
Philadelphia, PA
3. Enter program code 65PR211.
4. Upon completion of the learner assessment tools, Mirna Chehade, MD, MPH
you will be able to print your certificate. Associate Professor of Pediatrics and Medicine
Director, Mount Sinai Center for Eosinophilic Disorders
Icahn School of Medicine at Mount Sinai
New York, NY
Release Date: February 25, 2022 Mary Miller
Expiration Date: February 24, 2023 EoE Patient Advocate
LEARNING OBJECTIVES The following individuals have identified relevant financial
relationships with commercial interests to disclose:
• Identify patients who should be evaluated for
Ikuo Hirano, MD, FACG (Contributing Author)
eosinophilic esophagitis (EoE) based on known
Consultant – Allakos, Arena, BMS/Celgene, Calypso/
risk factors, symptoms, adaptive behaviors, and Parexel, Ellodi/Adare, Gossamer Bio, Phathom,
common comorbidities Regeneron/Sanofi, Takeda/Shire
Grants / Research Support – Allakos, Arena, BMS/
• Describe current guidelines and evidence on Celgene, Ellodi/Adare, Regeneron/Sanofi, Takeda/Shire
novel therapies for the diagnosis, treatment, and
management of patients with EoE John J Russell, MD, FAAFP (Contributing Author)
Advisory Board or Panel – Bayer, GlaxoSmithKline,
• Identify and bridge critical gaps in the care of Pfizer, Sanofi
Speakers Bureau or other Promotional Education –
EoE patients as they move between healthcare
Sanofi
settings and providers
Mirna Chehade, MD, MPH (Contributing Author)
• Apply evidence-based and expert consensus Consultant – Adare/Ellodi, Allakos, AstraZeneca, Bristol-
strategies to support communication and care Myers Squibb, Phathom, Regeneron, Sanofi, Shire/Takeda
coordination among specialists involved in the Grants / Research Support – Adare/Ellodi, Allakos,
diagnosis and co-management of EoE patients AstraZeneca, Danone, Regeneron, Shire/Takeda
• Develop comprehensive care plans that Corinna S Bowser, MD, FAAAAI, FACAAI (Reviewer)
Speakers Bureau or other Promotional Education –
account for individual patients’ clinical needs,
Takeda
comorbidities, psychosocial concerns, and
treatment goals and preferences The following individuals have no relevant financial
relationships with commercial interests to disclose:
CONTRIBUTING AUTHORS Cheri Lattimer, RN, BSN (Author)
Mary Miller (Author)
Cheri Lattimer RN, BSN Ryan M Burke, PharmD (Planner)
Executive Director Tiffany Horn, RN, BSN, MS-L (Planner)
National Transitions of Care Coalition
Norfolk, VA All PRIME staff participating in planning and content
development have no relevant financial relationships with
Ikuo Hirano, MD, FACG commercial interests to disclose.
Professor of Medicine
Division of Gastroenterology and Hepatology
Northwestern University Feinberg School of Medicine
Chicago, IL
© 2022 PRIME Education, LLC. All Rights Reserved. www.primeinc.org 2
CONTINUING EDUCATION
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In support of improving patient care, PRIME® is jointly accredited by the Accreditation Council for
JOINTLY ACCREDITED PROVIDER TM
Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE),
INTERPROFESSIONAL CONTINUING EDUCATION
and the American Nurses Credentialing Center (ANCC) to provide continuing education for the
healthcare team.
INTERPROFESSIONAL TEAMS
This activity was planned by and for the healthcare team, and learners will receive 1.0
Interprofessional Continuing Education (IPCE) credit for learning and change.
PHYSICIAN CREDIT DESIGNATION STATEMENT
PRIME® designates this enduring material for a maximum of 1.0 AMA PRA Category 1 Credit™.
Physicians should claim only credit commensurate with the extent of their participation in the activity.
PHYSICIAN ASSISTANT ACCREDITATION STATEMENTT
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This knowledge-based activity has been approved for 1.0 contact hour (0.1 CEUs) by PRIME® for
pharmacists. The Universal Activity Number for this activity is JA0007144-0000-22-240-H01-P.
Pharmacy CE credits can be submitted to the NABP upon successful completion of the activity by
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with questions can contact NABP customer service (help@nabp.pharmacy).
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This activity is provided by PRIME Education. There is no fee to participate.
This activity is supported by an educational grant from Takeda Pharmaceuticals U.S.A., Inc.
© 2022 PRIME Education, LLC. All Rights Reserved. www.primeinc.org 3
TABLE OF CONTENTS
INTRODUCTION............................................................................................................................................................................................. 5
PURPOSE AND SCOPE......................................................................................................................................................... 5
BACKGROUND.............................................................................................................................................................................................. 5
WHAT IS EOSINOPHILIC ESOPHAGITIS?���������������������������������������������������������������������������������������������������������������������������� 5
WHAT CAUSES EOE?����������������������������������������������������������������������������������������������������������������������������������������������������������� 5
IMPACT OF EOE ON PATIENTS AND CAREGIVERS������������������������������������������������������������������������������������������������������������ 7
DIAGNOSIS OF EOE�������������������������������������������������������������������������������������������������������������������������������������������������������������� 7
CURRENT TREATMENT OF EOE������������������������������������������������������������������������������������������������������������������������������������������ 12
EMERGING TREATMENTS FOR EOE.................................................................................................................................... 13
CONSIDERATIONS IN TRANSITIONS OF CARE...................................................................................................................................... 16
GUIDING PRINCIPLES IN TRANSITIONS OF CARE������������������������������������������������������������������������������������������������������������� 16
THE ROLE OF MULTIDISCIPLINARY AND INTERPROFESSIONAL TEAMS IN EOE CARE������������������������������������������������� 17
BARRIERS TO INTERDISCIPLINARY AND COLLABORATIVE EOE CARE��������������������������������������������������������������������������� 21
System-Level Barriers����������������������������������������������������������������������������������������������������������������������������������������������������� 21
HCP-Level Barriers���������������������������������������������������������������������������������������������������������������������������������������������������������� 22
Patient-Level Barriers������������������������������������������������������������������������������������������������������������������������������������������������������ 23
Challenges With Transitioning From Pediatric to Adult Care��������������������������������������������������������������������������������������� 24
EXPERT CONSENSUS STRATEGIES FOR COORDINATION AND TRANSITION OF CARE ACROSS MULTISPECIALTY
TEAMS����������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� 24
Care Transition-Specific Education�������������������������������������������������������������������������������������������������������������������������������� 25
Promote Telehealth Services������������������������������������������������������������������������������������������������������������������������������������������ 25
Standardize and Streamline EHRs When Communicating With Other Members of the Patient’s Care Team�������� 25
Point-of-Care Resource: Sample EHR Template���������������������������������������������������������������������������������������������������������� 26
Clarify Referral Criteria���������������������������������������������������������������������������������������������������������������������������������������������������� 28
Establish Effective Transitions From Pediatric to Adult Care�������������������������������������������������������������������������������������� 29
PATIENT-CENTERED CONSIDERATIONS FOR TREATMENT DECISION-MAKING AND ENGAGEMENT IN EOE CARE���� 30
Example of Ambulatory Transitions of Care Checklist for HCP���������������������������������������������������������������������������������� 30
Point-of-Care Resource: Example of Patient Questionnaire��������������������������������������������������������������������������������������� 31
Point-of-Care Resource: Example of Patient & Family Caregiver Provider Visit Preparation Guide����������������������� 32
References������������������������������������������������������������������������������������������������������������������������������������������������������������������������ 34
© 2022 PRIME Education, LLC. All Rights Reserved. www.primeinc.org 4
This document contains point-of-care resources that
can be printed separately for use in daily practice.
INTRODUCTION
PURPOSE AND SCOPE
The purpose of this transitions of care (TOC) guide is to describe pathways that enable health care
professionals (HCPs) managing patients with eosinophilic esophagitis (EoE) to coordinate care
across multidisciplinary health care settings. The guide—developed by an interprofessional steering
committee that included two gastroenterologists, a primary care provider (PCP), a patient advocate,
and the executive director of the National Transitions of Care Coalition (NTOCC)—provides
foundational information, strategies, tools, and resources to support the implementation of
collaborative team-based approaches to EoE management.
BACKGROUND
WHAT IS EOSINOPHILIC ESOPHAGITIS?
EoE is a chronic, T helper type 2 (Th2)–associated inflammatory disease characterized by marked eosinophilic
inflammation of the esophagus (defined by a peak count of ≥15 eosinophils per high-power field [eos/hpf]
of esophageal biopsy tissue).1,2 EoE was recognized in the 1990s as a clinicopathologic disorder, which
is relatively recent compared with the identification of other allergic diseases such as asthma and allergic
rhinitis.3 EoE may affect people of any age or gender, with a reported predominance in White males.4 Over
the past 2 decades, both the incidence and prevalence of EoE have been rapidly increasing, with a pooled
prevalence of 34.4 cases per 100,000 inhabitants (adults 42.2/100,000; children 34/100,000) and a pooled
incidence of 7.7/100,000 person-years for adults and 6.6/100,000 person-years for children.5–7 Patients with
EoE have an estimated annual health care cost of as much as $1.4 billion in the United States.8 The median
total annual cost per EoE case has been calculated to be $3,304, with median costs including $2,508/year for
outpatient visits, $157 for endoscopies, and $325 for pharmacy claims.8
While significant advances have been made since its discovery, much work needs to be done in the
understanding of the causes, diagnosis, and treatment of this disease.3
WHAT CAUSES EOE?
Allergic Factors
Though specific allergens cannot be identified in every patient, multiple lines of evidence support an
underlying allergic mechanism for the development of EoE (Table 1).1,9 Food allergens appear to be the main
trigger for EoE, which is responsive to dietary elimination therapy and topical glucocorticoids.1 In some
patients, seasonal allergens may play a role.1 Cohort studies from major referral centers have revealed that
the most common foods associated with EoE are milk, egg, soy, and wheat—sharing some commonalities
with foods frequently associated with IgE-mediated food allergy (IgE-FA).9 The prevailing view at this time,
however, is that IgE may contribute to but is not required for EoE pathogenesis in most cases.9 Though a
subset of patients with EoE have increased levels of food-specific IgE compared with controls, these levels
are only modestly increased in patients with EoE compared with patients with food anaphylaxis.1
© 2022 PRIME Education, LLC. All Rights Reserved. www.primeinc.org 5Table 1. What Causes EoE?1
Cellular Genetic
Atopy Environment Gender Heritability
Pathology variants
• Activated • Seasonal • Cesarean birth • Mainly males • GWAS or • Mainly White
eosinophils variation • Antibiotics • Higher family candidate gene people
• Activated • Oral immuno- • Formula feeding association studies (STAT6, • High relative risk
lymphocytes therapy • Cold arid among males CAPN14, EMSY, among family
and mast cells –induced climates TSLP, LRRC32,
• Impaired • High rate of • H. pylori FLG)
epithelial barrier food allergy, • Associated
allergic Mendelian
rhinitis, atopic disorders
dermatitis, and (SPINK 5, DSG
asthma 1, TGFBR 1/2,
PTEN, DSP,
FBN)
GWAS = Genome-Wide Association Study
Genetic Factors
Several lines of evidence support a genetic contribution to EoE (Table 1). For example, families with
multiple vertically and/or horizontally related members who have EoE have been described.10–12 In
proband studies, the estimated risk for EoE in a first-degree relative is 2.4% and is higher in men.11,12
Three genes identified through single-gene association studies are those for eotaxin-3, filaggrin, and
TGFβ1, molecules that have been implicated in the pathogenesis of EoE.12,13 Additional prominent
gene abnormalities have been identified in genome-wide association studies.12
Early-Life Environmental Exposures
Predisposition to EoE may begin early in life with events that alter the gut microbiome (Table 1).1,14 For
example, patients with EoE are more likely to have been delivered by cesarean section, to have been
formula-fed, and to have had exposure to antibiotics at a young age.1,15 Studies have found abnormal
microbial populations in the esophageal epithelium and the stool of patients with EoE.12,16,17
Comorbidities of EoE
During childhood, patients who develop EoE also have a series of concomitant allergic disorders,
such as food allergy, atopic dermatitis, asthma, and allergic rhinitis.10 The greater the number of allergic
disorders present in a patient, the more likely they are to develop EoE.18 It is hypothesized that sequential
occurrence of these disorders during childhood signals an allergic march, with EoE as a result.18 It is
also suggested that other atopic disorders or allergy-based treatments (such as oral or sublingual
immunotherapy) may cause the onset or a flare of EoE.12,18–24
© 2022 PRIME Education, LLC. All Rights Reserved. www.primeinc.org 6IMPACT OF EOE ON PATIENTS AND CAREGIVERS
Although EoE does not appear to be life-threatening to patients, it can significantly impact patients’
health-related quality of life (HRQoL).25 Repeated endoscopies needed to monitor response to
treatment are inconvenient.26 Patients with EoE and their caregivers have reported feelings of
frustration, moodiness, and anxiety about the disease and symptoms.25 In fact, psychiatric
comorbidities are present in one-third of adults and more than 1 in 7 children with EoE, with similar
proportions receiving a prescription medication.27 In a retrospective review of an EoE patient registry,
elevated hypervigilance and anxiety were present in 46% of 103 patients and impacted severity
determined through various assessment tools.28 EoE also negatively affects work, school, social
activities, and relationships. Both patients and caregivers feel that this disease restricts their lives.
Adult EoE patients also describe feeling embarrassed about their condition. Furthermore, caregivers
indicate that they have difficulty taking care of their other children due to the amount of time they spend
caring for the child with EoE.25 Inadequate awareness of eosinophilic gastrointestinal conditions in
schools has also been reported to be a significant problem.26
You feel like an entire lonely island and you don’t know exactly how to live, what to eat, where to go. For years,
I would go to lunch with people and I would not eat. I think it is very easy to just withdraw, like I was doing
with, “I’m not going to eat those meals,” or “I’m not going to go out with those people.”
- Mary Miller, patient living with EoE
EoE also has a substantial financial impact on patients and caregivers, with significant proportions
indicating that they had to stop working or work fewer hours due to EoE.25 Some adults with EoE also
reported that they had to work extra hours or more than one job to cover the costs of living with EoE.25
EoE patients and caregivers have also expressed concerns about lack of insurance coverage.25
Even if they do have health insurance, existing off-label pharmacologic treatments and dietary therapies
are not typically covered by policies, thereby increasing out-of-pocket expenses for patients with EoE in
the United States.25 Indeed, out-of-pocket costs due to eosinophilic gastrointestinal disorders have been
reported to be a source of stress.26
DIAGNOSIS OF EOE
Patients with EoE and their families often have to wait years before obtaining a formal diagnosis, seeing
many health care professionals and undergoing a range of procedures in the process.25 The time gap
between symptom onset and time of diagnosis has been found to be age- and race-dependent (adults
and White patients with longer gap).10 Food allergy and atopic dermatitis were associated with a
decrease in this gap.10 The median delay in diagnosis of EoE has been shown to be 6 years (interquartile
range, 2−12 years).29 Patients and caregivers have reported that this journey to a diagnosis is
burdensome, contributing to feelings of frustration, anxiety, and helplessness.25
With a delayed diagnosis of EoE comes an increased risk of complications such as strictures, fibrosis,
esophageal narrowing, and dysphagia requiring dilation for relief.25,29–32 There are also short-term
consequences such as feeding dysfunction and failure to thrive among patients in their early years of
life.30 The Th2 inflammation and its effects on the epithelium and fibroblasts drive the remodeling process
of EoE.30 Some findings suggest that fibroblast activation may be reversible once inflammation and
stiffness cease, while others suggest that fibroblasts in culture have a “mechanical memory” and remain
at least partially activated even if returned to soft environment.33,34 Therefore, early diagnosis and
treatment prior to the onset of esophageal stiffening may lead to improved cessation of fibroblast
activity.30
© 2022 PRIME Education, LLC. All Rights Reserved. www.primeinc.org 7Familiarity with the typical symptoms of EoE, increased index of suspicion, early symptomatic screening
in patients with common comorbidities and risk factors, as well as an in-depth interrogation of feeding
behaviors, could lead to decreased diagnostic delay, decreased fibrostenotic complications, and
improved patient outcomes.30
Diagnostic Criteria
The diagnosis of EoE is both clinical and pathological. The International Consensus Diagnostic
Criteria for Eosinophilic Esophagitis was most recently updated in 2018 from proceedings of the AGREE
(A Working Group on PPI-REE) Conference, and a diagnostic algorithm was established (Figure 1).35
Upon clinical presentation suggestive of EoE, an upper endoscopy (ie, esophagogastroduodenoscopy
[EGD]) with biopsy should be performed. When endoscopy is performed, the HCP should evaluate
for endoscopic signs of EoE and for alternative esophageal disorders that may cause or potentially
contribute to esophageal eosinophilia.35 Regarding biopsies, multiple specimens from two or more
esophageal levels, targeting areas of apparent inflammation, are recommended to increase the
diagnostic yield, given the patchiness of the disease.35
Figure 1. Updated EoE Diagnostic Algorithm35
Clinical presentation suggestive of EoE
EGD with biopsy
Esophageal eosinophilia (≥ 15 eos/hpf)
(Eosinophilic infiltration isolated to esophagus)
Evaluate for non-EoE disorders that cause or potentially contribute to esophageal eosinophilia
Eosinophilic esophagitis
Because EoE presents with a wide range of symptoms, this algorithm cannot anticipate every clinical
possibility and provides leeway for the age-appropriate evaluation deemed necessary.35
Findings that should increase the suspicion for EoE include35:
• Concomitant atopic conditions
• Family history of EoE or dysphagia
• Endoscopic findings (Figure 2) of rings, furrows, exudates, edema, stricture, and narrowing
(ideally assessed using the EoE Endoscopic Reference Score [EREFS]36)
© 2022 PRIME Education, LLC. All Rights Reserved. www.primeinc.org 8Figure 2. Endoscopic Findings of EoE
Rings in the Esophagus Varying Degrees of Furrows and White Exudates
Images courtesy of Ikuo Hirano, MD, FACG
Chronic symptoms of esophageal dysfunction include but are not limited to35:
• Dysphagia
• Food impaction
• Food refusal
• Failure to progress with food introduction
• Heart burn
• Regurgitation
• Vomiting
• Chest Pain
• Odynophagia
• Abdominal pain
• Malnutrition
The clinical manifestations of EoE vary by age of the patient (Table 2).4 A careful history in children,
adolescents, and adults with EoE reveals that they have learned to compensate for these symptoms
by eating slowly, chewing excessively or taking small bites, drinking excessively with meals, lubricating
meals inordinately with sauces, and avoiding specific food consistencies such as meats or other foods
with tough, dense, and/or coarse textures.37
Due to the prolonged inflammation and potential for resultant scarring that has gone undetected,
adults presenting with EoE tend to have more episodes of esophageal food impaction as well as
other esophageal abnormalities such as Schatzki ring (a narrow ring of tissue located just above the
gastroesophageal junction), esophageal webs (small, thin growths of tissue that partially block the
esophagus) and, in some cases, achalasia (an esophageal motility disorder characterized by difficulty
swallowing and regurgitation).37
© 2022 PRIME Education, LLC. All Rights Reserved. www.primeinc.org 9Table 2. Clinical Manifestations of EoE37
Infants/Toddlers Children Adults
• Feeding aversion/intolerance • Dysphagia • Dysphagia (predominant)
• Vomiting • Choking/gagging w/ coarse textures • Food impactions
• Food refusal • Food impactions • Food avaoidance
• Choking with meals • Abdominal/chest pain • Intractable heartburn
• Failure to thrive • Throat pain • Regurgitation
• Sleep disturbance • Vomiting/regurgitation • Retrosternal pain
• Nausea • Chest pain
• Sleep disturbance
• Decreased appetite
Questions That Can Elicit Symptoms of EoE30,38
• Does it take you longer than others to eat?
• Do you need to drink always with meals?
• Do you need to cut food into small pieces?
• Do you have to be reminded to chew a lot?
• Do you eat dense bread?
• Do you need to make dense bread softer?
• Do you eat solid meat?
• Do you have problems eating “sticky,” “clumpy/doughy,” or starchy foods?
• Do you have problems eating hard foods such as raw vegetables?
• Do you have trouble eating thick foods?
Examples of foods that patients with EoE may have trouble eating include rice, French fries, potatoes,
peanut butter and jelly, thick cheeses, bagels, caramel, popcorn, nuts, tough meat, and sushi.38
The “IMPACT” acronym can be used to identify adaptive behaviors39:
• Imbibe fluids with meals
• Modify food (eg, cutting into small pieces, pureeing)
• Prolong meal times
• Avoid hard-texture foods
• Chew excessively
• Turn away tablets/pills
Non-EoE disorders that cause or potentially contribute to esophageal eosinophilia include35:
• Eosinophilic gastritis, gastroenteritis, or colitis with esophageal involvement
• Gastroesophageal reflux disease (GERD)
• Achalasia and other disorders of esophageal dysmotility
• Hypereosinophilic syndrome
• Crohn’s disease with esophageal involvement
• Infections (fungal, viral)
• Connective tissue disorders
• Hypermobility syndromes
• Autoimmune disorders and vasculitides
• Dermatologic conditions with esophageal involvement (ie, pemphigus)
• Drug hypersensitivity reactions
• Pill esophagitis
• Graft vs host disease
• Mendelian disorders (Marfan syndrome type II, hyper-IgE syndrome, PTEN hamartoma tumor syndrome,
Netherton syndrome, severe atopy metabolic wasting syndrome)
© 2022 PRIME Education, LLC. All Rights Reserved. www.primeinc.org 10The majority of disorders that can cause esophageal eosinophilia should be readily apparent by a review
of the patient’s past medical history, with a few caveats. Eosinophilic gastritis, gastroenteritis, or colitis can
have esophageal involvement.40,41 Abdominal pain, nausea, vomiting, or diarrhea are potential signs of these
disorders and may warrant biopsies of the stomach, duodenum, or colon.40–42
EoE and GERD can be differentiated by several factors (Table 3).2 The esophageal eosinophilia associated
with GERD is more low-grade. In adult patients, GERD typically presents with heartburn and regurgitation,
not dysphagia and food impaction, which is commonly observed in patients with EoE. Furthermore, the
endoscopic findings associated with these two conditions are also different (Table 3). However, making this
distinction between GERD and EoE can be complicated for a number of reasons.2 Among the pediatric
population, vomiting, abdominal pain, and food aversion have been manifested in both EoE and GERD
patients.2,43,44 Moreover, up to one-third of children with EoE might have a normal appearance to the
esophageal mucosa on endoscopy in contrast to less than one-tenth of adults.2 Furthermore, EoE and GERD
can coexist and share a complex relationship, where EoE can lead to secondary reflux due to decreased
esophageal compliance or dysmotility, and GERD can lead to decreased epithelial barrier integrity, allowing
antigen exposure and subsequent eosinophilia.35 Although a proton pump inhibitor (PPI) trial should not
be used to differentiate GERD from EoE, it can be used as a safe and practical initial management step in
patients for whom a diagnosis is uncertain, as it could be effective for either condition.2,45
Table 3. EoE vs GERD2
Factors EoE GERD
Dominant symptom Dysphagia Heartburn
Regurgitation
Food impaction Common Uncommon
Gender Male predominance Male = female
Age Children, young adults Middle-age
Endoscopic findings Edema, rings, exudates, furrows, Erosions, ulcers
strictures, crepe-paper esophagus, Barrett adenocarcinoma
narrow-caliber esophagus Strictures
Normal findings on endoscopy Normal findings on endoscopy
(< 10%) (majority)
Ambulatory pH testing Negative or positive Positive
Histology >15 eos/hpf < 7 eos/hpf
Etiology Immune-mediated or antigen- Acid reflux
mediated response
Primary treatment Steroids Antacid, H2 receptor blockers
Elimination diet PPI
PPI (?)
Previous iterations of the EoE diagnostic criteria did include a PPI trial to rule out inflammation due to
GERD because it had been believed that these two conditions were mutually exclusive. However, emerging
research suggested that this is not the case.35 Moreover, investigators were observing that many patients
who had esophageal eosinophilia ≥ 15 eos/hpf but did not have a clinical presentation consistent with GERD
responded to PPI treatment.46 In light of these observations, diagnostic guidelines published in 2011, 2013,
and 2014 defined a new condition termed PPI-responsive esophageal eosinophilia (PPI-REE).35 Growing
clinical and experimental evidence indicate that PPI-REE is, in most cases, a PPI-responsive form of EoE.2 In
response to these findings, a consensus was reached to remove the PPI trial from the most recent version of
the EoE diagnostic criteria.35
© 2022 PRIME Education, LLC. All Rights Reserved. www.primeinc.org 11CURRENT TREATMENT OF EOE
The primary goals of therapy for children and adults with EoE are focused on minimizing inflammation
and improving symptoms. In 2020, the American Gastroenterological Association (AGA) Institute and the
Joint Task Force on Allergy-Immunology Practice Parameters (JTF) published new clinical guidelines for
EoE management.47 The guidelines provide evidence-based recommendations for managing EoE, which
encompass three general categories of interventions: dietary modifications, pharmacologic therapy, and
esophageal dilation (Figure 3).
Figure 3. EoE Treatment Algorithm47,48
Suspected EoE
Confirmed EoE
Medical Therapya: Non-response Diet Therapy:
• Proton pump inhibitor • Empiric elimination
• Topical corticosteroids Non-response • Elemental formula
• Allergy testing-directed
Clinically relevant
Response esophageal stricture Response
Esophageal dilation
Maintenance Therapy
Off-label use
a
Diet Therapy
Given the role of food allergens in the etiology of EoE, dietary changes can be an effective treatment
for many patients.47,49 Three different dietary strategies have gained widespread acceptance among
HCPs.50 Elemental diets (amino acid-based formulas) have been shown to be highly effective in
achieving histologic remission.47,49,51 However, this strategy is also the strictest, and uptake is greatly
limited by patient adherence stemming from the cost of formula, narrow taste profile, and social
restrictions it imposes around meal times. Empiric elimination diets, such as the 6-food elimination diet,
involve the empiric avoidance of the most common food allergens (eg, dairy, soy, egg, wheat, peanut
and tree nuts, and seafood).47 However, adherence to diet is often difficult for patients and caregivers,
and patients must undergo endoscopy with anesthesia upon reintroduction of each food antigen to
identify the specific food trigger(s). Less restrictive empiric elimination diets (eg, 4-food elimination and
2-4-6 tiered elimination strategy) have been less studied but can potentially be used to balance efficacy
with treatment burden.12 Targeted elimination diets utilize allergy testing to identify foods to eliminate
from the diet; however, this approach is complicated by varying accuracy in identifying causative foods
in EoE and a tenuous link between standard allergy testing protocols and EoE exacerbation.47,49,51–53
A testing-directed elimination diet had the lowest effectiveness rate in a meta-analysis of dietary
interventions, and this type of diet is discouraged in EoE.53–55 In addition to adherence, challenges to diet
therapy include impact on nutritional status, eating pleasure, and quality of life.56 However, with
adequate guidance, these adverse outcomes can be mitigated.56
© 2022 PRIME Education, LLC. All Rights Reserved. www.primeinc.org 12Pharmacologic Treatment
Although the recent AGA/JTF clinical guidelines recommend the use of medications in the management
of EoE, there are currently no FDA-approved pharmacologic therapies specifically indicated for this
disease, and only one treatment is approved in Europe.25,47 Thus, the recommendations for use of topical
corticosteroids and PPIs are off-label.25
PPIs
PPIs are commonly used in patients with EoE, with an estimated histologic response of 50.5%.57,58 Data
are limited but have shown that adults on PPIs can remain in remission at 1-year follow-up.58,59 The
benefits of PPI therapy in EoE might be due to improved mucosal integrity (thereby potentially preventing
esophageal luminal antigen presentation for allergic sensitization) or direct anti-inflammatory effects.2
Symptomatic improvement with PPIs might not correlate with endoscopic and histologic improvement.
The AGA/JTF guidelines note that, because a subset of patients with EoE may respond to PPIs and
because PPIs possess a favorable safety profile and are easily administered, some patients may prefer
to start with a PPI before trying other dietary or pharmacologic therapies.47
Topical Steroids
The AGA/JTF guidelines strongly recommend the use of topical corticosteroids for EoE, noting their
safety profile in children and adults, as established through their use in asthma.47 In the absence of an
FDA-approved formulation optimized for esophageal delivery, inhaled corticosteroids developed for
asthma must be adapted for off-label use in EoE.30 These preparations include swallowing fluticasone
propionate from a metered-dose inhaler or creating a viscous slurry with aqueous budesonide and a
thickener, such as sucralose, honey, or maple syrup. Clinicohistologic remission is seen in up to 68% of
patients.58,60
Esophageal Dilation
For patients in the later stages of EoE that are experiencing dysphagia due to stricture, procedures to
dilate the esophagus may be required. However, as noted by the AGA/JTF guidelines, dilation does not
address the underlying eosinophilic infiltration or inflammation associated with EoE, and repeat dilations
are common.47,61
EMERGING TREATMENTS FOR EOE
Novel Topical Steroid Formulations
The off-label use of topical steroids designed for the treatment of asthma is suboptimal in the
management of EoE, as they are not formulated for drug delivery to the esophagus. Several new topical
corticosteroid formulations that enhance delivery to the esophagus and minimize the patients’ burden of
creating their own slurry are currently under development.6,58
© 2022 PRIME Education, LLC. All Rights Reserved. www.primeinc.org 13Budesonide Oral Suspension (BOS)
BOS is an immediate-release topical corticosteroid optimized as a viscous suspension to lengthen its
residence time on the esophageal mucosal surface following oral administration in patients with EoE.62
Notably, a pivotal study comparing a budesonide viscous suspension to a nebulized preparation showed
that the viscous budesonide had a significantly longer mucosal contact time and was more effective in
reducing esophageal eosinophil counts in patients with EoE.63 In a recent phase 3 trial of 318 patients
aged 11–55 years with EoE and dysphagia, significantly more BOS-treated patients than placebo-treated
patients achieved a stringent histologic response (≤ 6 eos/hpf) or a dysphagia symptom response
(defined as ≥ 30% reduction in Dysphagia Symptom Questionnaire [DSQ] scores) over 12 weeks
(Figure 4). BOS-treated patients also had greater improvements in least-squares mean DSQ scores and
the EoE Endoscopic References Score (EREFS) over 12 weeks vs placebo-treated patients.62 BOS was
well tolerated; most adverse events were mild or moderate in severity.62
Figure 4. Efficacy of BOS 2 mg BID at 12 Weeks in Patients With EoE Aged 11-55 Years: Data From a
Phase 3 Trial62,a
Placebo (n = 105) BOS 2 mg BID (n = 213)
60 60
53.1 52.6
Patients With Response, %
Patients With Response, %
50 50 P = .024
39.1
40 40
30 30
20 20
P < .001
10 10
1.0
0 0
Stringent Histologic Response Dysphagia Symptom Response
(≤ 6 eos/hpf) (≥ 30% Reduction in DSQ Score)
Data for coprimary endpoints are shown
a
Budesonide Orodispersible Tablet (BOT)
BOT has effervescent properties and was developed specifically for esophageal targeting.64 In a
6-week, double-blind, parallel study of 88 adult patients with active EoE in Europe, approximately 58%
of patients administered BOT were in complete remission compared with no patients given placebo
(Figure 5).65 The secondary endpoint of histologic remission was achieved by 93% of patients given
BOT vs no patients given placebo. Symptom remission was reported in 64% of the BOT group vs
24% of the placebo group. Six-week and 12-week BOT administration were safe and well tolerated; 3
(5.1%) patients who received BOT developed symptomatic, mild candida (2 patients with esophageal
symptoms and 1 with oral and esophageal symptoms), which was easily treated with an oral antifungal
agent.58,65
© 2022 PRIME Education, LLC. All Rights Reserved. www.primeinc.org 14Figure 5. Efficacy of BOT 1 mg BID for 6 Weeks in Adult Patients With Active EoE: Data From a Phase 3
Trial65,a
Placebo (n = 29) BOT 1 mg BID (n = 59)
100 93.2
Patients With Response, %
90
80
70 64.4
60 57.6
50
40 P = .0006
30 24.1
20 P < .00001 P < .0001
10
0.0 0.0
0
Clinico-Histologic Remission Histologic Remission Symptom Remission
(< 5 eos/hpf) (PatGA ≤ 2)
a
Primary endpoint was complete remission, based on clinical and histologic factors, including dysphagia and odynophagia severity ≤
2 on a scale of 0–10 on each of the 7 days before the end of the double-blind phase and a peak eosinophil count < 5 eos/hpf
PatGA = Patient’s Global Assessment
Another topical corticosteroid under investigation is an orally disintegrating formulation of fluticasone
propionate, APT-1011.58 Phase 3 studies are underway.66,67
Targeted Treatments
Based on insights into the pathogenesis of EoE, a number of targeted treatments inhibiting specific
molecules implicated in the development of this disease are being explored for potential use in EoE,
many of which are approved or being investigated for other Th2/eosinophilic conditions.1,68
Treatments Targeting Allergic Cytokines
Dupilumab, an IL-4 receptor inhibitor, currently has indications for atopic dermatitis, asthma, and chronic
rhinosinusitis with nasal polyposis and is being investigated for EoE. Part A of a 3-part phase 3 study
evaluated the efficacy and safety of weekly dupilumab 300 mg versus placebo in adolescent/adult EoE
patients. Co-primary endpoints, the proportion of patients achieving peak esophageal intraepithelial
eosinophil count ≤ 6 eos/hpf and change from baseline in DSQ score at week 24 were achieved
(Figure 6).69 Disease-specific HRQoL improved as well.70
Cendakimab (RPC4046) is a monoclonal antibody targeting IL-13. In phase 2 studies, it reduced
endoscopic and histologic features of EoE, and phase 3 studies are ongoing.71–73
Eosinophil-Targeting Agents
Targeting interleukin (IL)-5 has been explored, as this cytokine is required for the production of
eosinophils and has been implicated in driving mucosal esophageal eosinophilia and potentially in
mediating tissue remodeling.1 Mepolizumab and reslizumab are two anti—IL-5 biologics approved for
severe eosinophilic asthma, with mepolizumab also approved for other inflammatory and eosinophilic
disorders.74,75 While histologic outcomes were achieved in patients with EoE with these biologics,
symptom improvement was limited.68,76–78
© 2022 PRIME Education, LLC. All Rights Reserved. www.primeinc.org 15Figure 6. Efficacy of Dupilumab 300 mg QW After 24 Weeks in Adult and Adolescent Patients With EoE:
Data From Part A of a 3-Part Phase 3 Trial69,a
Placebo (n = 39) Dupilumab 300 mg QW (n = 42)
70 0
Absolute Change in DSQ Score,
59.5
Patients With Response, %
60
-5
50
LS Mean
40 -10
-9.6
30 -15 P < .001
20 P < .001
-20
10 5.1
-21.9
0 -25
Peak Esophageal Intraepithelial Absoute Change in DSQ Score
Eosinophil Count ≤ 6 eos/hpf
Data for coprimary endpoints are shown
a
Lirentelimab (alternative names: antolimab, AK002) is an antibody to sialic acid–binding
immunoglobulin-like lectin 8 (Siglec-8).58 Siglec-8 is a surface receptor found selectively on human
eosinophils and mast cells, both of which are elevated in EoE.58 Binding of a monoclonal antibody to
Siglec-8 induces apoptosis of activated eosinophils and inhibits mast cell activation.58 Phase 2/3 studies
of lirentelimab in EoE have recently been completed.79
Benralizumab targets IL-5 receptor α, which enhances antibody-dependent cellular cytotoxicity and
depletes eosinophils.58 It is FDA-approved for severe eosinophilic asthma.80 Benralizumab is currently
undergoing a phase 3 clinical trial in EoE.68,81
Additional Molecular Targets
Other potential targets that may warrant further investigation in EoE include thymic stromal
lymphopoietin (TSLP), transforming growth factor (TGF)-β, calcium channels, C-C chemokine
receptor type 3 (CCR3), IL-9, IL-15, IL-33, and α4β7.68
In summary, the pharmacologic landscape for EoE is likely to significantly expand and evolve in the near
future, and it will be important for HCPs to keep up with the status of these new medications and their
potential place in the EoE treatment algorithm.
CONSIDERATIONS IN TRANSITIONS OF CARE
GUIDING PRINCIPLES IN TRANSITIONS OF CARE
Because EoE is a multifaceted disease, its optimal management is dependent upon the expertise
of HCPs from a variety of specialties working in coordination, sometimes sequentially, but often
simultaneously. Moreover, due to the chronic nature of EoE, patients diagnosed in the pediatric setting
will eventually require transition to adult care providers as they age. Transitions and care coordination
require excellent communication among all providers at every level of care and must include the patient
and their identified family caregiver.
© 2022 PRIME Education, LLC. All Rights Reserved. www.primeinc.org 16Despite this centrality of coordinated care to EoE management, there is currently very little specific
guidance available on best practices for optimal collaboration to ensure quality care for patients with
EoE. As knowledge of disease assessment and treatment advances, there is an increasingly pressing
need to develop consensus standards to address these gaps in care.
The National Transitions of Care Coalition (NTOCC) developed Seven Essential Intervention
Categories (Figure 7) that align with key transitions of care policies crafted by national health care
organizations, including the American College of Physicians, the Society of General Internal Medicine,
the Society of Hospital Medicine, the American Geriatrics Society, the American College of Emergency
Physicians, and the Society of Academic Emergency Medicine.82 These categories emphasize the
importance of medication management, transition planning, patient/family engagement and education,
information transfer between providers and patients/caregivers, follow-up care, HCP engagement, and
shared accountability across providers and organizations.
Of note, the NTOCC categories are in the process of being revised to incorporate new information on
areas essential for assessment, such as physical health, mental health, and social determinants of
health (SDOH). According to the World Health Organization, SDOH encompass non-medical factors
that influence health outcomes and can have a substantial influence on health inequities.83 SDOH have
a marked impact not only on patients, but on health care systems as well, as demonstrated by a study
of 47,674 encounters with 37,568 patients from an academic medical center.84 This analysis showed
that SDOH contributed to more than 50% of hospital readmissions.84 Moreover, patients with higher
“transportation access risk” had an average of 41% more excess days in the hospital than those with
low transportation access risk.84 Patients with higher “home instability risk” were 32% more likely to
exceed the average hospitalization time.84 For patients with eosinophilic gastrointestinal disorders, SDOH
such as employment issues, financial difficulties, and housing stability are common, while issues such as
transportation and childcare access are associated with a higher likelihood of provider switching.85
THE ROLE OF MULTIDISCIPLINARY AND INTERPROFESSIONAL TEAMS IN EOE CARE
The optimal management of EoE is dependent upon the careful coordination of applied expertise from
multiple health care specialties. Patients with EoE must engage with a wide range of HCPs due to the
heterogeneity of the disease, multi-system involvement, frequent co-occurrence of atopic comorbidities,
and the variety of assessment and treatment approaches that may be needed.86
Unfortunately, specialty silos and gaps in care coordination exist across specialties, particularly between
gastroenterologists and allergist/immunologists, as well as dietitians, which may result in fragmented
patient care.87 There is a pressing need to enhance communication and coordination between
specialties, with a focus on the unique and important capabilities and expertise that each party
provides:
Primary Care Providers (PCPs)
PCPs are instrumental in promptly and accurately identifying the signs and symptoms of EoE.88
These providers also play a key role in specialist coordination and referral as well as ongoing
management of comorbidities. PCPs can also review adherence to the treatment plan during regular
visits to complement follow-up with specialists. It therefore remains important that PCPs educate
themselves about EoE and stay abreast of the latest updates on diagnosis and treatment.
© 2022 PRIME Education, LLC. All Rights Reserved. www.primeinc.org 17Figure 7. Seven Essential Intervention Categories in Designing Transition Strategies for Patients with
EoE
Find further information about these principles at https://www.ntocc.org/knowledge-and-resource-center
Adapted from NTOCC. Figure Courtesy of Cheri Lattimer, RN, BSN
Gastroenterologists
Often centrally involved in the management of EoE, gastroenterologists can assess symptoms and help
provide a definitive diagnosis through upper endoscopy and biopsy of the esophagus. These specialists
also prescribe treatment, monitor disease status, and assess responses to therapy. Gastroenterologists
have an additional responsibility to manage diets (food eliminations and food additions) in close
coordination with allergists and dietitians. Esophageal dilation by gastroenterologists is an important
adjunctive treatment for esophageal strictures. Education on EoE is especially important for
gastroenterologists, particularly regarding updates on the efficacy and safety of therapies that are
available or in development.
Allergists/Immunologists
These providers should be involved in the patient’s care, particularly in the management of comorbid
atopic conditions associated with EoE.89 They can be vital in evaluating food allergies and can provide
input to the gastroenterologist on food reintroduction in patients undergoing dietary elimination therapy.
They can also help to differentiate allergic reactions to foods from gastrointestinal symptoms associated
with foods due to EoE or other disorders. Allergists/immunologists may also assess EoE symptoms,
prescribe treatment, and monitor response to therapy, making education on treatment efficacy and
safety likewise important.
© 2022 PRIME Education, LLC. All Rights Reserved. www.primeinc.org 18Dietitians
Dietitians provide guidance to patients and caregivers who embark on dietary therapy. These
professionals are also essential for managing malnutrition and failure to thrive that may affect a subset
of patients. They may work in conjunction with feeding therapists in patients with early-onset EoE who
are experiencing feeding difficulties. While central to the management of EoE, elemental and elimination
diets can be difficult to select, implement, adjust, and maintain over the long term.90 Moreover,
nutritional status assessment can help to identify patients with EoE who have inadequate nutrient intake,
particularly if a very restrictive food elimination diet is required for optimal management.91 Dietitians can
also be helpful to patients with EoE when dietary therapy has failed, when excessive/unplanned weight
change has occurred, and when there are quality of life issues (eg, poor social support, issues
with access to substitute foods, social isolation caused by diet).
Feeding Therapists
Feeding therapists can help patients with EoE with sensory and motor issues by implementing oral
motor and feeding treatment strategies.92
Speech Pathologists
Speech pathologists can provide feeding therapy for infants and children prior to EoE diagnosis, during
EoE treatment, and for patients with persistent feeding and swallowing issues.92 They may assess oral
motor skills and provide exercises and techniques to improve them, and they may provide advice on
feeding bottles and utensils.93
Mental Health Professionals
Patients with EoE should be screened for anxiety and depression; ancillary support may be needed
from mental health professionals. These HCPs can follow up on screens and provide resources on
anxiety and depression, which commonly occur in this population. Moreover, the psychosocial
aspects of the disease can cause considerable stress at home, school, and work. Core members of
the multidisciplinary team should have referral lines to specialists in health psychology, behavioral
medicine, or psycho-gastroenterology, as EoE patients with psychiatric comorbidities may benefit
from cognitive behavioral therapy or other resources and interventions.94
Emergency Room (ER) Physicians
EoE represents a common cause of food bolus impaction among patients presenting to the emergency
department.95 Because ER physicians may encounter patients with (undiagnosed or diagnosed) EoE,
education and symptom recognition is crucial to ensure that they recognize EoE as a likely cause of food
impaction.
Otolaryngologists
Patients frequently present to otolaryngology with undiagnosed EoE.96 ER physicians sometimes
contact otolaryngologists instead of gastroenterologists for management of an esophageal food
impaction, depending upon who is available and the location of the food bolus impaction in the
esophagus. This emphasizes the importance of esophagoscopy with biopsy in children with refractory
aerodigestive symptoms, and underscores the role of otolaryngologists in facilitating early diagnosis
and referral, which may reduce long-term sequelae.
© 2022 PRIME Education, LLC. All Rights Reserved. www.primeinc.org 19Advanced Practice Providers
Physician assistants and nurse practitioners play an increasing role in facilitating access to care across
the continuum of primary and subspecialty health disciplines.97 In the setting of EoE, these advanced
practice providers are uniquely positioned to provide patient education and engage in follow-up of stable
patients, and therefore must educate themselves regarding recognition and management of this disease.
Pharmacists
Patient education, as well as medication assessment and management services, are key roles for
pharmacists in the management of EoE. These health care providers should also be aware of specific
challenges related to medication use among patients with EoE. For example, some patients may have
difficulty swallowing prescribed medication due to the nature of the disease. Moreover, pharmacists
must be aware that inhaled steroid formulations must be swallowed in the treatment of EoE (currently
an off-label use), which would influence their instructions to patients.
General Surgeons
General surgeons may be particularly important in the evaluation and management of EoE in rural areas
where specialists are scarce.
Pathologists
Pathologists play a fundamental role, as a diagnosis of EoE depends in part on accurate and competent
evaluation of esophageal biopsy pathology.
Case Managers and Social Workers
Roles that are often underrepresented in EoE multidisciplinary management include case managers and
social workers who could help fill gaps related to patient communication, assisting with resolution of
identified SDOH and coordination of care. Efforts to improve access to case managers and social
workers should be encouraged.
Tertiary Care Center/EoE or Esophageal Specialist
A tertiary care center or EoE/esophageal specialist may be necessary for very complex patients such
as those with refractory EoE, with complex esophageal strictures, or with significant esophageal
comorbidities and/or concomitant eosinophilic gastrointestinal disease. Tertiary centers may also have
greater resources and clinical experience with use of diet therapies for EoE. Patients being considered
for clinical trials should also be seen by these specialists.
It is critical that all of these HCPs educate themselves about EoE, its diagnosis, and its treatment. There
is a general lack of awareness among the medical community regarding this disease, as it has been
identified relatively recently.
I think education is key, because doctors don’t necessarily know what they are looking for. I lived in a small
town in Minnesota, and my brother told me to explain everything, because he had a lot of the symptoms. If you
are starting to have symptoms, you have to have someone who can help you.
- Mary Miller, patient living with EoE
© 2022 PRIME Education, LLC. All Rights Reserved. www.primeinc.org 20BARRIERS TO INTERDISCIPLINARY AND COLLABORATIVE EOE CARE
System-Level Barriers
Despite the obvious benefit that integrated multidisciplinary care would provide for patients with EoE,
there are many barriers to adopting this approach in practice. The end result is care fragmentation, with
patients attending individual specialists for different concerns, with little communication across care
settings and providers. In chronically ill patients, fragmented care is associated with increased costs and
lower quality of care.98 Patients with EoE frequently report dissatisfaction with uncoordinated, disjointed
care they have received from a variety of HCPs; in many cases, this occurs when a gastroenterologist
refers a patient to an allergist but subsequently does not engage in medical decisions or further
endoscopic procedures.87 The lack of multidisciplinary care coordination is exacerbated by a dearth
of guidelines and comprehensive reference documents on the best practices to employ as patients
transition between HCPs.
The lack of coordination also impacts patients with undiagnosed EoE, who often endure a long
diagnostic journey that includes visits with multiple PCPs, gastroenterologists, and allergists/
immunologists before a definitive diagnosis is reached.25 Diagnostic delays are thus frequent.10
Some teams that do implement multidisciplinary care models report encountering a number of
challenges to implementation. Sauer et al reported challenges such as the need to secure interest and
obtain buy-in from multiple team members.87 Another challenge they experienced was financial
considerations related to the care model (ie, the time and effort required by multiple providers and a
comprehensive visit), though longer visit times may translate into reduced need for communication
outside clinic visits, all while improving the patient’s experience. Patient billing can also be an issue,
as multiple copays may be required, and use of identical diagnosis codes may lead to claim denial for
both HCPs, though Sauer and colleagues have been successful in subsequently petitioning payment in
this regard, and reimbursement issues were overall few. Yet another challenge is the need for adequate
space for a clinic that accommodates multiple HCPs, leading this team to relocate twice over the course
of 5 years.
Telehealth Opportunities and Barriers
As in other areas of medical care, the use of telehealth has increased substantially in the provision of
routine EoE care. Results of a retrospective study conducted during the COVID-19 pandemic suggest
that telehealth visits for EoE reduced travel time and distance and involved considerable cost savings
relative to in-person visits.99 In the allergist/immunology community, it was recently recommended
that, even when COVID-19 cases plateau or decline and restrictions on in-person care are lifted,
telehealth should continue for lower acuity medical problems such as new-onset EoE. However, this
recommendation was contingent on current telehealth expanded guidelines remaining in place, which is
not guaranteed. Some state-level emergency regulations are being terminated, including those that had
allowed physicians to provide care remotely across state lines, while federal agencies may also curtail
the relaxed payment and platform rules that allowed for expanded use.100 The inability of physicians to
practice across state lines could negatively impact the quality and continuity of care of EoE patients,
particularly as the successive waves of the COVID-19 pandemic continue to impact travel and
in-person visits.
© 2022 PRIME Education, LLC. All Rights Reserved. www.primeinc.org 21You can also read
