Alysse Wurcel, MD, of Boston Medical Center

Alysse Wurcel, MD

A new qualitative study of 119 patients, clinicians, and stakeholders across 3 Boston hospital systems identifies race, language, and communication gaps driving unequal access to penicillin allergy delabeling in primary care.¹

More than 95% of people who currently carry a penicillin allergy label are not truly allergic.² Multiple professional societies recommend evaluation and delabeling for anyone with an unconfirmed penicillin allergy, given the added risk of adverse effects associated with second-line agents. However, primary care adoption of these recommendations remains inconsistent.

Alysse Wurcel, MD, of Boston Medical Center, and colleagues carried out a qualitative multi-site study to understand, from a broad range of perspectives, the factors that help and hinder penicillin allergy delabeling, with the goal of shaping practical strategies to address them. The team conducted in-depth interviews and focus groups from March through September 2024 with 119 participants, including 69 patients and 50 clinicians and stakeholders, guided by the updated Consolidated Framework for Implementation Research.

Interview guides were translated into Spanish, Mandarin, and Cantonese to reach patients across each site's patient community.

 Brigham and Women's Hospital serves large numbers of Black residents from Dorchester, Mattapan, and Roxbury, including people of Haitian, Dominican, and Puerto Rican descent.

 Massachusetts General Hospital's Chelsea community health center, in particular, serves a population 50% Latino, with 30% of patients preferring Spanish. Tufts Medical Center, based in Boston's Chinatown, serves a predominantly Asian, Cantonese-speaking patient community.

In total, 6 barriers emerged: clinician avoidance of the topic, patients never being asked about their allergy, language barriers, time constraints, perceived risk of removing a label, and limited access to allergists.

Prior work from the same research group found an inverse relationship between social vulnerability and penicillin allergy delabeling rates in Boston, and current findings extend those results into direct patient and clinician accounts.

 Patients from underrepresented racial and ethnic groups and non-English speakers described facing distinct, additional barriers to even having the initial conversation about their allergy history.

 spoke with Wurcel about why an equity-focused qualitative approach was needed for this kind of research and what these 6 barriers reveal about current primary care practice.

Q&A: 6 Barriers to Penicillin Allergy Delabeling, With Alysse Wurcel, MD

What prompted this study, and why was a qualitative, multi-stakeholder approach the right way to investigate penicillin allergy delabeling?

: We recognized that several clinical societies worldwide recommend evaluation and potential delabeling for everyone with a penicillin allergy because most people who report one are not truly allergic. In our clinical practice, this [was] not happening a lot. Many patients who had penicillin allergy were never evaluated for whether this was a true or false allergy.

One of the reasons why that's important is, if you have a penicillin allergy, it means you can't often get the first-line antibiotics, and you have to get antibiotics that have more adverse side effects. That was the impetus for the study.

The reason why qualitative in-depth interviews and focus groups [were] chosen is the contextualization. You can say to someone in a survey, Do you have a penicillin allergy? Yes. Would you consider getting that allergy evaluated? They can say no, but you don't really know why they don't want that penicillin allergy evaluation.

What we were able to show was people had a lot of fears about getting penicillin allergy delabeling, and that's why the qualitative work was so powerful.

You found associations between penicillin allergy labeling and race/ethnicity reflecting differential treatment patterns rather than biology. Can you unpack that?

: It's not a quantitative study, so I [can’t] say statistically this happened. We tried to get people who were both male and female, and we also tried to get people from underrepresented minorities. What we saw was often people who either were from underrepresented minorities or spoke other languages faced barriers to discussing penicillin [allergy].

Language barriers emerged as a theme, with patients describing feeling ignored during communication gaps. What does that tell us about current practice?

: If you have a clinician who does not speak the same language as a patient, I think the clinician is often less likely to discuss penicillin allergy. Maybe the nuances of penicillin allergy would not be translated correctly, and maybe because of concerns that the clinician had to use 5 minutes or so to get the interpreter on the line, and so that extra 5 minutes would have been the 5 minutes that they could have used for penicillin allergy delabeling, but there [were] just like other things to talk about.

If a patient was given a penicillin allergy, let's say in another country, and then we're saying through a translator that we don't believe that that's a true penicillin allergy, sometimes that can come across as our feeling like the care in their country was poor. That's not what we're trying to say, but it's a very tricky conversation.

How did findings differ, if at all, across your 3 hospital sites?

: Our findings really didn't differ across the sites. It was just more that the populations varied a little bit between the sites.

Clinicians describe avoiding penicillin allergy conversations as delicate, while patients report frustration that it's not brought up enough. What's driving that mismatch?

: What happens is maybe a clinician has brought up the idea of penicillin, let's say 10 times, and 1 of those times the person got very sort of upset about it. The [1] conversation not going well kind of sits in the clinician's memory and prevents them from wanting to talk about it anymore.

On the other side, there's so many patients with penicillin allergy, and they're all out there not knowing anything about delabeling or that having a penicillin allergy [label] is not a good thing.

I also think that the amount of things that each primary care doctor needs to do in a 20-minute or 30-minute slot is excessive, and so it's just not a priority on the clinician's mind.

Time constraints and competing priorities came up repeatedly. Realistically, how does penicillin allergy delabeling compete for attention in a primary care visit?

: The average person coming into the primary care doctor has multiple things to talk about, whether it be diabetes or hypertension. It's very hard to carve out time to talk about penicillin allergies.

The other thing that's a little bit tricky is there's certain things that we can bill for, like you can bill for talking about diabetes.

There is a potential movement towards incentivizing clinicians to talk more about penicillin allergies with their patients, but that would have to have some sort of money associated with it, some sort of benchmarking where the clinician would be more likely to talk about penicillin allergy because they want to show that 90% of the people that they've spoken with about their penicillin allergy got delabeled, and that was attached to some sort of quality marker.

Wurcel A, Crabtree D, Asupoto O, et al. Strategies to increase equitable access to penicillin allergy de-labeling interactions: a qualitative multi-center study. JAMA Open. 

Shenoy ES, Macy E, Rowe T, Blumenthal KG. Evaluation and management of penicillin allergy: a review. JAMA. 2019;321(2):188-199. 

Blumenthal KG, King AJ, Stone VE, et al. Geospatial socioeconomic indicators and penicillin allergy delabeling in primary care patients. JAMA Netw Open. 2025;8(8):e2528714. 

Articles

Penicillin allergy labels are frequently inaccurate, yet primary care implementation of delabeling remains uneven despite guideline support. A multi-site qualitative study across three Boston health systems used interviews and focus groups with 119 patients, clinicians, and stakeholders—incorporating multilingual materials—to surface equity-relevant implementation barriers. Six recurring obstacles were identified, with underrepresented racial/ethnic groups and non-English speakers reporting additional friction even initiating discussions. Findings emphasize workflow, communication, and structural constraints that perpetuate unnecessary second-line antibiotic use and its attendant harms.

A multi-site qualitative study identifies communication, language, and access barriers standing in the way of removing incorrect penicillin allergy labels.