Pediatric Clinician Adherence to Peanut Allergy Prevention Guidelines: A Randomized Trial

BACKGROUND AND OBJECTIVES The 2017 US Addendum Guidelines for the Prevention of Peanut Allergy encourage clinicians to recommend early introduction of peanut-containing foods to infants’ diets to prevent peanut allergy (PA). However, clinician guideline adherence has been low. The Intervention to Reduce Early Peanut Allergy in Children (iREACH) Trial aims to increase pediatric clinicians’ adherence to the guidelines. METHODS iREACH is a practice-based, cluster randomized trial of 30 pediatric practices. Intervention practices received clinician education, a clinical decision support (CDS) tool embedded into electronic health record (EHR) systems, and visual aids, while those in the control arm did not. The primary outcome was clinician adherence to guidelines, documented in EHR data from 4- or 6-month well-child care visits. Clinicians were adherent for low-risk infants (no/mild/moderate eczema and no egg allergy) if they recommended the introduction of peanut-containing foods and, for high-risk infants (severe eczema and/or egg allergy), if they ordered a peanut-specific immunoglobulin E test and counseled appropriately or referred to an allergist. RESULTS Overall, 18 480 infants (intervention, n = 9290; control, n = 9190) were seen by 290 clinicians. Among low-risk infants (n = 18 182), intervention clinicians were adherent for 83.7%, while control clinicians were adherent for 34.7% (odds ratio [OR], 14.6; 95% CI, 7.0–30.5; P < .001). Among high-risk infants (n = 298), intervention clinicians were adherent for 26.8%, while control clinicians were adherent for 10.4% (OR, 3.1; 95% CI, 1.1–8.8; P = .03). CONCLUSIONS A multifaceted educational intervention improved clinician guideline adherence. Wide dissemination of the intervention and implementation of the guidelines could reduce the incidence of PA.