Allergy versus asthma as the focus of the subspecialty

The current subspecialty of allergy and clinical immunology has a central mechanistic focus on broad aspects of immunology, both beneficial and pathologic. However, 90% of our practice concerns diseases caused by immediate hypersensitivity responses. Indeed, skin testing, education, and immunotherapy dominate the medical activity in our clinics. The description of skin tests dates to 1873; that of immunotherapy dates to 19!1; and the description of the association of rhinitis, asthma, and atopic dermatitis with immediate skin tests to common inhalant allergens was fully established before 1950. From 1960 to 1980 there was a dramatic increase in our scientific understanding of the immunology of allergy, purification of pollen allergens, IgE and specific IgE antibodies, basophils, mast cells, and T cells. This increased understanding was paralleled by a retrenchment of the subspecialty to focus on those conditions whose causes and mechanisms we could be certain that we understood. Since 1975 major advances have occurred in our understanding of the role of hypersensitivity in other diseases, particularly perennial asthma, atopic dermatitis, venom allergy, and drug reactions. In addition, it is increasingly clear that a real change has occurred in the pattern of disease, the most important of which is the increase in the prevalence and morbidity of asthma. The magnitude of the increase in the United States is not well documented, but today asthma is present in 5% to 10% of children (although up to 18% have had symptoms as judged by the prescription of an inhaler); asthma is the most common cause of hospital admission for children. Whether asthma has increased among adults is less clear; however, sales of asthma medicine, hospital admissions, and clinic load suggest that such an increase has taken place. During the past 10 years, evidence has been published to show that asthma is an inflammatory disease of the bronchi characterized by eosinophils and that the most common cause of this inflammation is indoor allergens. During the same period, the investigation and management of asthma have become major foci of our clinics, and many allergy clinics have added asthma to their name. Asthma will become an increasingly important source of patients for the allergist. Quality-of-care measures suggest that specialist care is more cost effective for moderate-to-severe asthma than generalist care. Thus managed care organizations may divert patients with asthma to the allergist for management as a cost-saving device~ The cost saved will largely reflect reduced hospitalization and emergency room visits, which far outweigh the cost of a specialist visit. In addition, it !s likely that allergic rhinitis will become less important in the referral base for the allergist during the next two decades. This belief is based on the effectiveness of current agents and the promise of new ones to manage most patients with rhinitis. Thus the allergist may become a consultant in the management of allergic rhinitis: making the diagnosis, establishing allergy avoidance regimens, and occasionally initiating immunotherapy, but passing patient management and administration of therapy to the primary care physician. In many respects, this division of labor makes sense by permitting the allergist to serve a much larger population of patients at a lower cost. It is expected that patients with urticaria, eczema, anaphylaxis, stinging insect hypersensitivity, and drug allergy will continue to be cared for by both the academic allergist and the practicing allergist. Another disease that may become more important for the allergist !s sinusitis. Currently patients with acute sinusitis are cared for by the primary care physician, and those with chronic sinusitis are referred to the otolaryngologist. Data suggest that patients with sinusitis who are managed by allergist s have fewer treatment failures and require less surgery. The question now is whether we need to change the focus of the subspecialty either in fact or in name. The reality is that we have far more to offer in the management of asthma than any other