LOUISVILLE, LEXINGTON Imagine needing to buy milk, but when you get to the grocery store they tell you the product has been so successful it will not be available for three months. That is how James L. Sublett, MD, founder and managing partner of Family Allergy & Asthma, describes the irony of medical practices that measure success in how far out they are booked. Focusing on the guiding principal of “patient satisfaction first,” Sublett prides the practice on “certain initiatives like getting people in when they’re sick, not making them wait days or weeks.”
Established in 1979 by Sublett, and Stephen J. Pollard, MD, Family Allergy & Asthma began with one office in Louisville’s east end. “One of the early things we realized was there was a need for outreach to smaller communities for specialty services,” says Sublett, who says they were the first allergy practice to do so in the Commonwealth. They now have 22 office sites and 22 providers in Kentucky and southern Indiana.
Their expansion strategy is a hub and spoke model, with hub offices in Louisville, Lexington, Paducah, and Florence. Offices in Somerset, Campbellsville, and Bullitt County are considered sub-hubs with essentially full-time coverage by a physician or nurse practitioner. From there, satellite offices branch out throughout the region.
Seven of Family Allergy & Asthma’s 22 providers are nurse practitioners, and one is a physician’s assistant. Sublett explains they use a “tag team” approach, where every new patient sees a team consisting of one physician, on APRN, and two nurses. On subsequent visits the patients will alternate seeing the physician and APRN, which expands the use of providers but helps to maintain the high level of quality patients and referring physicians expect.
Allergy and Asthma
An equal mix of children and adults, the most common diagnoses they see are chronic sinusitis, allergic rhinitis, and asthma.
Allergies occur in about one-in-four people, half of which will self-identify as moderate to severe, with symptoms interfering with their daily life. “Those are the patients allergists can help with,” says Sublett. “Oftentimes what people call sinus problems are chronic allergies. Two-thirds of people have year-round allergies. There’s this misconception that it’s seasonal,” he adds. Evaluating indoor and outdoor inhalant allergies and food allergies through prick skin testing and intradermal testing and a three-legged approach to treatment – avoidance measures, medications, and immunotherapy – are services Family Allergy & Asthma provides.
Sublett estimates 25% of people with allergies have asthma, putting their asthmatic patient population over 10,000. Dual diagnoses are common because allergies can trigger inflammation of the airways, a hallmark of asthma. Contrary to common myths, asthma can occur in the over 65 population and never really goes away, although the severity can change over time.
According to Rajiv Arora, MD, who heads Family Allergy & Asthma’s Lexington office, close follow up is the key to “better control of symptoms, maintaining control with less medicine, and maintaining more long-term control.” Pulmonary function testing and exhaled nitrous oxide, a new technique to measure airway inflammation, are used to diagnose and monitor asthma. While many primary care physicians treat asthmatics, Arora offers that an allergist can be helpful in testing for potential allergic triggers, evaluating for immunotherapy, and educating patients on avoidance measures and the proper use of medications.
A less common condition, whose presentation is more ambiguous and more difficult to identify, immune deficiency occurs when a defect does not allow the immune system to fight infection effectively. Often undiagnosed, patients with immune deficiency may present with frequent infections, infections unresponsive to typical antibiotics and requiring multiple courses or IV antibiotics, and atypical infections.
“In our fellowship, a lot of it is developed on immune deficiency and the immune system, so we are uniquely trained to identify, evaluate, and treat immune deficiency patients,” says Arora. In order to diagnose and identify immune deficiency, “It’s a matter of looking at the different types of antibodies and immune cells, the numbers of them, and how they’re working,” he says. The presentation of the infection and the age of the patient help allergists determine what part of the immune system is affected. Treatment can include antibody replacement therapy such as IV or subcutaneous immunoglobulins, prophylactic antibiotics, and blood cell transplants in children with severe cases.
Arora’s advice to practitioners with potential immune deficiency patients is “to have a high index of suspicion.” A primary care manager is crucial to help identify patients with frequent or unresponsive infections who may require further evaluation.
Another early initiative of Family Allergy & Asthma’s founding partners was research. The practice has a full-time research department housed at their Sts. Mary & Elizabeth Hospital campus office, which employs three full-time certified research nurse coordinators. “Any allergy or asthma medication that’s been developed in the last 25 years we’ve been involved in,” says Sublett. Although not a significant profit center, studying medications, biologicals, and allergy responses gives their physicians early firsthand knowledge of new treatments. In a recent paper, they reported 17% of pediatric patients were positive for mouse allergen, which Family Allergy & Asthma now includes in their battery of indoor inhalant testing.
One upcoming pilot project Sublett is particularly excited about is Asthmapolis, a study in conjunction with Metro Louisville utilizing an inhaler sensor on reliever medications and mobile phone technology to track inhaler use and measure asthma control. Louisville received a grant from IBM to provide evaluation of the city’s environmental triggers and computer analysis of the data. The project will enroll 500 participants in Metro Louisville through November 2012, including 100 who will also receive a sensor for controller medications.