Allergy and immunology

Transcription

1 Practice area 124 Clinical PRIVILEGE WHITE PAPER Allergy and immunology Background According to the American Academy of Allergy, Asthma & Immunology (AAAAI), allergists/immunologists are trained in the prevention, diagnosis, and treatment of immune system problems such as allergies, asthma, inherited immunodeficiency diseases, and autoimmune diseases. Once a patient is referred to an allergist/immunologist, the physician works to diagnose the condition by taking a thorough history of the patient, including information about the illness, family history, and home and work environments. The allergist/immunologist also may conduct allergy skin testing. To help prevent future symptoms, the allergist/immunologist can also create a management plan so the patient can better control his or her environment. The AAAAI states that allergists/immunologists treat problems and/or conduct research about the following: Skin disorders, including atopic dermatitis (eczema), urticaria (hives), and contact dermatitis Adverse reactions to drugs, other pharmacologic agents, and diagnostic testing materials Immunogenetics Gastrointestinal disorders caused by immune responses to foods Diseases associated with autoimmune responses, including arthritis Stem cell, bone marrow, and organ transplantation Diseases of the respiratory tract, such as allergic rhinitis (hay fever), sinusitis, asthma, and hypersensitivity pneumonitis An allergist/immunologist is a physician who, after completing medical school, has gone on to complete three years of training to become either a pediatrician or an internist, followed by a two-year (or longer) fellowship in allergy/immunology.

2 Involved specialties Allergists/immunologists Positions of specialty boards ABAI The American Board of Allergy and Immunology (ABAI) is a conjoint board of the American Board of Internal Medicine (ABIM) and the American Board of Pediatrics (ABP). The ABAI offers certification in allergy/immunology. To sit for the general examination, a candidate must: Be certified by the ABIM and/or the ABP at the time of the ABAI examination. Have completed at least two years of full-time residency in an allergy/immunology program accredited by the Accreditation Council for Graduate Medical Education (ACGME) or in another equivalent allergy/immunology program. Provide four clinical competence evaluations and one procedural skills assessment form from the program director. Provide two letters of recommendation that verify the candidate s medical and professional standing and clinical competence as a specialist in allergy/immunology. Recommendations may come from heads of pediatrics or medicine as well as from ABAI-certified diplomates. They may also come from chiefs of community hospitals as well as from officers of state or regional societies. Have a valid, unrestricted license to practice medicine in a state, territory, possession, or province of the United States or Canada, or be able to provide a written explanation of extenuating circumstances. Formal special pathways also exist for individuals who want to obtain dual ABAI certification in allergy/immunology and: Pediatric pulmonology Adult rheumatology Pediatric rheumatology According to the ABAI, individuals seeking dual certification must complete all requirements for both boards before sitting for either examination. ACOI The American College of Osteopathic Internists (ACOI)/American Board of Osteopathic Internal Medicine offers subspecialty certification in allergy/immunology. To become certified, applicants must meet the following minimum criteria: 2

3 Be certified in internal medicine by the ACOI Have completed two years of American Osteopathic Association (AOA) approved subspecialty training in the subspecialty area examined Have been a member in good standing of the AOA for at least two continuous years prior to the date of certification Be able to show evidence or conformity to the standards set in the Code of Ethics of the AOA if requested Demonstrate clinical competence in allergy/immunology as documented by the program director in the subspecialty training program by means of the program director s report form Possess an unrestricted, unchallenged, valid medical license Positions of societies, academies, colleges, and associations AAAAI AAI ACAAI JCAAI The AAAAI is a professional advocacy organization dedicated to the advancement of research and treatment of allergic diseases. The AAAAI publishes the Journal of Allergy and Clinical Immunology but does not publish guidelines for the delineation of clinical privileges in allergy/immunology. The American Association of Immunologists (AAI) is a nonprofit organization composed of more than 7,000 scientists conducting immunology research work. It primarily advocates for issues of research funding and science policy at a federal level, but it also promotes education in immunology. The AAI publishes The Journal of Immunology. The AAI does not publish guidelines for the delineation of clinical privileges in allergy/ immunology. The American College of Allergy, Asthma & Immunology (ACAAI) is a professional association of 5,000 allergists/immunologists. The ACAAI is dedicated to improving the quality of patient care in allergy/immunology through research, advocacy, and professional and public education. It does not publish privileging guidelines for allergists/immunologists but does publish a series of scientifically based allergy and asthma practice parameters. The Joint Council of Allergy, Asthma and Immunology (JCAAI) is the socioeconomic/political advocate of the AAAAI and the ACAAI and represents approximately 4,200 allergists. The JCAAI works to keep allergists/immunologists aware of socioeconomic issues that could affect their practices and represents allergy/ 3

4 immunology at the federal and state regulatory level. The JCAAI does not take a public stand about privileging guidelines for allergists/immunologists; however, it does publish a series of scientifically based allergy and asthma practice parameters developed by the Joint Task Force on Practice Parameters, which is composed of members from the AAAAI, the ACAAI, and the JCAAI. ACGME In its Program Requirements for Graduate Medical Education in Allergy and Immunology, the ACGME states that a subspecialty educational program in allergy/immunology must include in its curriculum specific competencies in regard to patient care. Among other things, residents must study asthma, allergic disorders, immunologic disorders, and immunodeficiency diseases as well as be provided with opportunities to apply immunologic theories, principles, and techniques to the investigation, diagnosis, and treatment of a wide variety of allergic/immunologic diseases. Program requirements also state that residents must devote half of their time (a 12-month equivalent) to direct patient care activities and must have at least 20% of the required minimum twomonth equivalent direct patient care activity in cross- training experience, including continuity of care in the inpatient and outpatient settings. Further, residents must have direct patient contact with children and adults with: Allergy to drugs and other biological agents Anaphylaxis Asthma Atopic dermatitis Contact dermatitis Food allergy Primary and acquired immunodeficiency Ocular allergies Rhinitis Sinusitis Stinging insect allergy Urticaria and angioedema The ACGME strongly encourages direct contact with or caseconference discussions concerning patients with autoimmune disease, allergic bronchopulmonary aspergillosis, eosinophilic disorders, hypersensitivity pneumonitis, vaccine reactions, mastocytosis, occupational lung disease, and vasculitis. In regard to medical knowledge, residents must have a structured curriculum that covers diseases and circumstances including: 4

5 Anaphylaxis Asthma Atopic dermatitis Contact dermatitis Drug allergy Food allergy Rhinitis and nasal polyps Sinusitis Stinging insect sensitivity Ocular allergy Acute and chronic urticaria/angioedema Hereditary and acquired angioedema Primary immunodeficiency Acquired immunodeficiency Autoimmune diseases Allergic bronchopulmonary aspergillosis Eosinophilic disorders Hypersensitivity pneumonitis Mastocytosis Occupational lung disease Vasculitis Autoinflammatory disorders Cystic fibrosis Allergens Pharmacology Diagnostic testing of allergic diseases AOA The AOA publishes Specific Requirements for Osteopathic Subspecialty Training in Allergy/Immunology. The training requirements state that the majority of the program must be devoted to patient care activities. At least 12 months should be spent in the direct care of adult and pediatric patients with allergic and immune disorders, with no less than 25% of this time being devoted to the care of adult patients and no less than 25% being devoted to the care of pediatric patients. The remainder of the time can be allocated to further patient care, research and scholarly activities, preparation of the required research paper, and community education activities. Additionally, fellows must acquire the skills to conduct a comprehensive history and physical appropriate to the field, select and interpret applicable diagnostic tests, assess the risks and benefits of therapies, counsel patients about their disorders, and work with other specialties and healthcare professionals to coordinate the allergy and immunology care provided to the patient. 5

6 Fellows must demonstrate proficiency in the following procedures: Allergen immunotherapy Delayed hypersensitivity skin testing Drug desensitization and challenge Immediate hypersensitivity skin testing Intravenous immunoglobulin therapy Performance and interpretation of pulmonary function tests Physical urticaria testing Fellows should be exposed to the following procedures, with demonstration of proficiency highly recommended: exercise challenge testing, methacholine challenge testing, nasal cytology, oral challenge tests, patch testing, and rhinolaryngoscopy. Fellows must have continuous ambulatory experience in both adult and pediatric allergy and immunology that ensures exposure to a broad range of diagnoses and treatment plans. Experience in the management of the following diagnoses must be included: Anaphylaxis Asthma Atopic dermatitis Contact dermatitis Drug allergy Food allergy Immunodeficiency Rhinitis Sinusitis Stinging insect hypersensitivity Experience in management of patients with the following diseases is also highly recommended: autoimmune disease, bronchopulmonary aspergillosis, eosinophilic disorders, hypersensitivity, pneumonitis, mastocytosis ocular allergies, occupational lung disease, and vasculitis. Positions of other interested parties AAFP In a statement published by the American Academy of Family Physicians (AAFP) in conjunction with the ACAAI and other groups, family medicine practitioners also provide treatment for patients with allergic/immunologic diseases and emphasize comprehensive and continuing care. The AAFP also publishes Recommended Curriculum Guidelines for Family Medicine Residents Allergy and Immunology, which is 6

7 endorsed by the AAFP, the ACAAI, and several other family medicine associations. According to the document, family medicine practice includes the care of adults and children with allergic and immunologic diseases. It states, Every family physician should be aware of the impact of allergic and immunologic problems on the individual and his or her family, as well as be able to perform diagnostic, preventive and therapeutic services to these patients. Preventive services may include identification and management of environmental and occupational factors. Interaction with the patient and his or her family is an integral part of family medicine education. The document outlines the competencies, knowledge, attitudes, and skills related to allergy and immunology that family medicine residents should have by the end of training. Positions of accreditation bodies CMS CMS has no formal position concerning the delineation of privileges for allergy and immunology. However, CMS Conditions of Participation (CoP) define a requirement for a criteria-based privileging process in (c)(6), stating, The bylaws must include criteria for determining the privileges to be granted to individual practitioners and a procedure for applying the criteria to individuals requesting privileges (a)(6) states, The governing body must assure that the medical staff bylaws describe the privileging process. The process articulated in the bylaws, rules or regulations must include criteria for determining the privileges that may be granted to individual practitioners and a procedure for applying the criteria to individual practitioners that considers: Individual character Individual competence Individual training Individual experience Individual judgment The governing body must ensure that the hospital s bylaws governing medical staff membership or the granting of privileges apply equally to all practitioners in each professional category of practitioners. Specific privileges must reflect activities that the majority of practitioners in that category can perform competently and that the hospital can support. Privileges are not granted for 7

8 tasks, procedures, or activities that are not conducted within the hospital, regardless of the practitioner s ability to perform them. Each practitioner must be individually evaluated for requested privileges. It cannot be assumed that every practitioner can perform every task, activity, or privilege specific to a specialty, nor can it be assumed that the practitioner should be automatically granted the full range of privileges. The individual practitioner s ability to perform each task, activity, or privilege must be individually assessed. CMS also requires that the organization have a process to ensure that practitioners granted privileges are working within the scope of those privileges. CMS CoPs include the need for a periodic appraisal of practitioners appointed to the medical staff/granted medical staff privileges ( [a][1]). In the absence of a state law that establishes a time frame for the periodic appraisal, CMS recommends that an appraisal be conducted at least every 24 months. The purpose of the periodic appraisal is to determine whether clinical privileges or membership should be continued, discontinued, revised, or otherwise changed. The Joint Commission The Joint Commission (formerly JCAHO) has no formal position concerning the delineation of privileges for allergy and immunology. However, in its Comprehensive Accreditation Manual for Hospitals, The Joint Commission states, The hospital collects information regarding each practitioner s current license status, training, experience, competence, and ability to perform the requested privilege (MS ). In the introduction for MS , The Joint Commission states that there must be a reliable and consistent system in place to process applications and verify credentials. The organized medical staff must then review and evaluate the data collected. The resultant privilege recommendations to the governing body are based on the assessment of the data. The Joint Commission introduces MS by stating, The organized medical staff is responsible for planning and implementing a privileging process. It goes on to state that this process typically includes: Developing and approving a procedures list Processing the application 8

9 Evaluating applicant-specific information Submitting recommendations to the governing body for applicant-specific delineated privileges Notifying the applicant, relevant personnel, and, as required by law, external entities of the privileging decision Monitoring the use of privileges and quality-of-care issues MS further states, The decision to grant or deny a privilege(s) and/or to renew an existing privilege(s) is an objective, evidence-based process. The EPs for standard MS include several requirements as follows: The need for all licensed independent practitioners who provide care, treatment, and services to have a current license, certification, or registration, as required by law and regulation Established criteria as recommended by the organized medical staff and approved by the governing body with specific evaluation of current licensure and/or certification, specific relevant training, evidence of physical ability, professional practice review data from the applicant s current organization, peer and/or faculty recommendation, and a review of the practitioner s performance within the hospital (for renewal of privileges) Consistent application of criteria A clearly defined (documented) procedure for processing clinical privilege requests that is approved by the organized medical staff Documentation and confirmation of the applicant s statement that no health problems exist that would affect his or her ability to perform privileges requested A query of the NPDB for initial privileges, renewal of privileges, and when a new privilege is requested Written peer recommendations that address the practitioner s current medical/clinical knowledge, technical and clinical skills, clinical judgment, interpersonal skills, communication skills, and professionalism A list of specific challenges or concerns that the organized medical staff must evaluate prior to recommending privileges (MS , EP 9) A process to determine whether there is sufficient clinical performance information to make a decision related to privileges 9

10 A decision (action) on the completed application for privileges occurring within the time period specified in the organization s medical staff bylaws Updating of information regarding any changes to practitioners clinical privileges as they occur The Joint Commission further states, The organized medical staff reviews and analyzes information regarding each requesting practitioner s current licensure status, training, experience, current competence, and ability to perform the requested privilege (MS ). In the EPs for standard MS , The Joint Commission states that the information review and analysis process is clearly defined and that the decision process must be timely. The organization, based on recommendations by the organized medical staff and approval by the governing body, develops criteria that will be considered in the decision to grant, limit, or deny a request for privileges. The criteria must be consistently applied and directly relate to the quality of care, treatment, and services. Ultimately, the governing body or delegated governing body has the final authority for granting, renewing, or denying clinical privileges. Privileges may not be granted for a period beyond two years. Criteria that determine a practitioner s ability to provide patient care, treatment, and services within the scope of the privilege(s) requested are consistently evaluated. The Joint Commission further states, Ongoing professional practice evaluation information is factored into the decision to maintain existing privilege(s), to revise existing privileges, or to revoke an existing privilege prior to or at the time of renewal (MS ). In the EPs for MS , The Joint Commission says there is a clearly defined process facilitating the evaluation of each practitioner s professional practice, in which the type of information collected is determined by individual departments and approved by the organized medical staff. Information resulting from the ongoing professional practice evaluation is used to determine whether to continue, limit, or revoke any existing privilege. HFAP The Healthcare Facilities Accreditation Program (HFAP) has no formal position concerning the delineation of privileges for 10

11 allergy and immunology. The bylaws must include the criteria for determining the privileges to be granted to the individual practitioners and the procedure for applying the criteria to individuals requesting privileges ( ). Privileges are granted based on the medical staff s review of an individual practitioner s qualifications and its recommendation regarding that individual practitioner to the governing body. It is also required that the organization have a process to ensure that practitioners granted privileges are working within the scope of those privileges. Privileges must be granted within the capabilities of the facility. For example, if an organization is not capable of performing openheart surgery, no physician should be granted that privilege. In the explanation for standard related to membership selection criteria, HFAP states, Basic criteria listed in the bylaws, or the credentials manual, include the items listed in this standard. (Emphasis is placed on training and competence in the requested privileges.) The bylaws also define the mechanisms by which the clinical departments, if applicable, or the medical staff as a whole establish criteria for specific privilege delineation. Periodic appraisals of the suitability for membership and clinical privileges are required to determine whether the individual practitioner s clinical privileges should be approved, continued, discontinued, revised, or otherwise changed ( ). The appraisals are to be conducted at least every 24 months. The medical staff is accountable to the governing body for the quality of medical care provided, and quality assessment and performance improvement ( ) information must be used in the process of evaluating and acting on re-privileging and reappointment requests from members and other credentialed staff. DNV Det Norske Veritas (DNV) has no formal position concerning the delineation of privileges for allergy and immunology. MS.12 Standard Requirement (SR) 1 states, The medical staff bylaws shall include criteria for determining the privileges to be granted to individual practitioners and a procedure for applying the criteria to those individuals that request privileges. 11

12 The governing body shall ensure that under no circumstances is medical staff membership or professional privileges in the organization dependent solely upon certification, fellowship, or membership in a specialty body or society. Regarding the Medical Staff Standards related to Clinical Privileges (MS.12), DNV requires specific provisions within the medical staff bylaws for: The consideration of automatic suspension of clinical privileges in the following circumstances: revocation/restriction of licensure; revocation, suspension, probation of a DEA registration; failure to maintain professional liability insurance as specified; and noncompliance with written medical record delinquency/deficiency requirements Immediate and automatic suspension of clinical privileges due to the termination or revocation of the practitioner s Medicare/Medicaid status Fair hearing and appeal The Interpretive Guidelines also state that core privileges for general surgery and surgical subspecialties are acceptable as long as the core is properly defined. DNV also requires a mechanism (outlined in the bylaws) to ensure that all individuals provide services only within the scope of privileges granted (MS.12, SR.4). Clinical privileges (and appointments or reappointments) are for a period as defined by state law or, if permitted by state law, not to exceed three years (MS.12, SR.2). Individual practitioner performance data must be measured, utilized, and evaluated as a part of the decision-making for appointment and reappointment. Although not specifically stated, this would apply to the individual practitioner s respective delineation of privilege requests. CRC draft criteria The following draft criteria are intended to serve solely as a starting point for the development of an institution s policy regarding allergy and immunology. The core privileges and accompanying procedure list are not meant to be all-encompassing. They define the types of activities, procedures, and privileges that the majority of practitioners in this specialty perform. Additionally, it cannot 12

13 be expected or required that practitioners perform every procedure listed. Instruct practitioners that they may strike through or delete any procedures they do not wish to request. Minimum threshold criteria for requesting core privileges in allergy and immunology Basic education: MD or DO Minimal formal training: Successful completion of an ACGMEor AOA-accredited residency program in internal medicine or pediatrics, followed by an accredited fellowship training program in allergy/immunology, and/or current certification or active participation in the examination process (with achievement of certification within [n] years) leading to certification in allergy/immunology by the ABAI or subspecialty certification in allergy/immunology by the AOBIM. Required current experience: Allergy/immunology services reflective of the scope of privileges requested to 24 inpatients or outpatients during the past 12 months, or successful completion of an ACGME- or AOA-accredited residency or clinical fellowship within the past 12 months. References Core privileges in allergy/immunology If the applicant is recently trained, a letter of reference should come from the director of the applicant s training program. Alternatively, a letter of reference may come from the applicable department chair and/or clinical service chief at the facility where the applicant most recently practiced. Core privileges in allergy/immunology include the ability to admit, evaluate, diagnose, consult, manage, and provide therapy and treatment for patients of all ages presenting with conditions or disorders involving the immune system, both acquired and congenital. Selected examples of such conditions include asthma, anaphylaxis, eczema/atopic dermatitis, contact dermatitis, sinusitis, rhinitis, urticaria, and adverse reactions to drugs, foods, and insect stings, as well as immune deficiency diseases (both acquired and congenital), defects in host defense, and problems related to autoimmune disease, organ transplantation, or malignancies of the immune system. Physicians may provide care to patients in the intensive care setting in conformance with unit policies. They may assess, stabilize, and determine disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services. Core procedures include but are not limited to: Allergen immunotherapy Allergy testing, including blood (RAST) testing and prick testing 13

14 Delayed hypersensitivity skin testing Drug desensitization and challenge Drug testing Exercise challenge testing Food challenge testing Immediate hypersensitivity skin testing Intravenous immunoglobulin treatment and administration Methacholine challenge testing Nasal cytology Oral challenge testing Patch testing Performance and interpretation of pulmonary function tests Performance of history and physical exam Physical urticaria testing Provocation testing for hyper-reactive airways Rapid desensitization Rhinolaryngoscopy Reappointment To be eligible to renew privileges in allergy/immunology, the applicant must meet the following criteria: Applicants must demonstrate current competence and an adequate volume of experience (48 inpatients or outpatients) with acceptable results, reflective of the scope of privileges requested, for the past 24 months based on results of ongoing professional practice evaluation and outcomes. Evidence of current physical and mental ability to perform privileges requested is required of all applicants for renewal of privileges. In addition, continuing medical education related to allergy/immunology should be required. For more information Accreditation Council for Graduate Medical Education 515 North State Street, Suite 2000 Chicago, IL Telephone: 312/ Fax: 312/ Website: 14

15 American Academy of Allergy, Asthma & Immunology 555 East Wells Street, Suite 1100 Milwaukee, WI Telephone: 414/ Fax: 414/ Website: American Academy of Family Physicians Tomahawk Creek Parkway Leawood, KS Telephone: 913/ Fax: 913/ Website: American Association of Immunologists 9650 Rockville Pike Bethesda, MD Telephone: 301/ Fax: 301/ Website: American Board of Allergy and Immunology 111 South Independence Mall East, Suite 701 Philadelphia, PA Telephone: 215/ Fax: 215/ Website: American Board of Internal Medicine 510 Walnut Street, Suite 1700 Philadelphia, PA Telephone: 215/ Fax: 215/ Website: American College of Allergy, Asthma & Immunology 85 West Algonquin Road, Suite 550 Arlington Heights, IL Telephone: 847/ Fax: 847/ Website: 15

16 American College of Osteopathic Internists 3 Bethesda Metro Center, Suite 508 Bethesda, MD Telephone: 301/ Fax: 301/ Website: American Osteopathic Association 142 East Ontario Street Chicago, IL Telephone: 312/ Fax: 312/ Website: Centers for Medicare & Medicaid Services 7500 Security Boulevard Baltimore, MD Telephone: 877/ Website: DNV Healthcare, Inc. 400 Techne Center Drive, Suite 350 Milford, OH Website: Healthcare Facilities Accreditation Program 142 East Ontario Street Chicago, IL Telephone: 312/ Website: The Joint Commission One Renaissance Boulevard Oakbrook Terrace, IL Telephone: 630/ Fax: 630/ Website: Joint Council of Allergy, Asthma and Immunology 50 North Brockway, 3-3 Palatine, IL Telephone: 847/ Website: 16

17 Editorial Advisory Board Clinical Privilege White Papers Associate Group Publisher: Erin Callahan, Associate Editor: Julie McCoy, William J. Carbone Chief Executive Officer American Board of Physician Specialties Atlanta, GA Darrell L. Cass, MD, FACS, FAAP Codirector, Center for Fetal Surgery Texas Children s Hospital Houston, TX Jack Cox, MD Senior Vice President/Chief Quality Officer Hoag Memorial Hospital Presbyterian Newport Beach, CA Stephen H. Hochschuler, MD Cofounder and Chair Texas Back Institute Phoenix, AZ Bruce Lindsay, MD Professor of Medicine Director, Cardiac Electrophysiology Washington University School of Medicine St. Louis, MO Sally J Pelletier, CPCS, CPMSM President - Best Practices Consulting Group Intervale, NH Beverly Pybus Senior Consultant The Greeley Company, a division of HCPro, Inc. Marblehead, MA Richard A. Sheff, MD Chair and Executive Director The Greeley Company, a division of HCPro, Inc. Marblehead, MA The information contained in this document is general. It has been designed and is intended for use by hospitals and their credentials committees in developing their own local approaches and policies for various credentialing issues. This information, including the materials, opinions, and draft criteria set forth herein, should not be adopted for use without careful consideration, discussion, additional research by physicians and counsel in local settings, and adaptation to local needs. The Credentialing Resource Center does not provide legal or clinical advice; for such advice, the counsel of competent individuals in these fields must be obtained. Reproduction in any form outside the recipient s institution is forbidden without prior written permission. Copyright 2011 HCPro, Inc., Marblehead, MA