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Determining Levers of Cost-effectiveness for Screening Infants at High Risk for Peanut Sensitization Before Early
Matthew Greenhawt1, Marcus Shaker2,3
1Section of Allergy and Immunology, Food Challenge and Research Unit, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora.
Insights
Introducing peanuts early reduces allergy risk in infants. Current US screening guidelines for early peanut introduction are not cost-effective, with no screening being more beneficial overall.
Area of Science:
- Allergy and Immunology
- Health Economics
- Pediatric Public Health
Background:
- Early peanut introduction is proven to reduce peanut allergy risk, particularly in high-risk infants.
- Current US guidelines recommend screening high-risk infants before early peanut introduction.
- Existing screening strategies may not be cost-effective compared to international approaches.
Purpose of the Study:
- To determine specific scenarios where current US early peanut introduction guidelines, including screening, become cost-effective.
- To evaluate the economic impact of peanut skin prick test (SPT) screening versus no screening in high-risk infants.
Main Methods:
- A microsimulation and cohort economic evaluation using a Markov model was employed.
- The study simulated 100,000 high-risk infants per strategy over an 80-year horizon from a societal perspective.
- Outcomes included cost, quality-adjusted life-years (QALYs), and allergic reactions.
Main Results:
- A no-screening approach demonstrated lower costs and higher QALYs compared to screening.
- Screening resulted in a marginal increase in allergic reactions, severe reactions, and anaphylaxis.
- Screening could be cost-effective under specific, though unlikely, conditions of high allergy prevalence and specific reaction utilities.
Conclusions:
- The current US screening approach for early peanut introduction is generally not cost-effective.
- No screening is more economically favorable and yields better health outcomes.
- Further research is needed to clarify the utility of health states related to allergic reaction location.
Importance:
Early peanut introduction reduces the risk of developing peanut allergy, especially in high-risk infants. Current US recommendations endorse screening but are not cost-effective relative to other international strategies.
Objective:
To identify scenarios in which current early peanut introduction guidelines would be cost-effective.
Design, Setting, And Participants:
This simulation/cohort economic evaluation used microsimulations and cohort analyses in a Markov model to evaluate the cost-effectiveness of early peanut introduction with and without peanut skin prick test (SPT) screening in high-risk infants during an 80-year horizon from a societal perspective. Data were analyzed from April to May 2019.
Exposures:
High-risk infants with early-onset eczema and/or egg allergy underwent early peanut introduction with and without peanut SPT screening (100 000 infants per treatment strategy) using a dichotomous 8-mm SPT cutoff value (stipulated in the current US guideline).
Main Outcomes And Measures:
Cost, quality-adjusted life-years (QALYs), net monetary benefit, peanut allergic reactions, severe allergic reactions, and deaths due to peanut allergy.
Results:
In the simulated cohort of 200 000 infants and using the base case during the model horizon, a no-screening approach had lower mean (SD) costs ($13 449 [$38 163] vs $15 279 [$38 995]) and higher mean (SD) gain in QALYs (29.25 [3.28] vs 29.23 [3.30]) vs screening but resulted in more allergic reactions (mean [SD], 1.07 [3.15] vs 1.01 [3.02]), severe allergic reactions (mean [SD], 0.53 [1.66] vs 0.52 [1.62]), and anaphylaxis involving cardiorespiratory compromise (mean [SD], 0.50 [1.59] vs 0.49 [1.47]) per individual. In deterministic SPT sensitivity analyses at base-case sensitivity and specificity rates, screening could be cost-effective at a high disutility rate (the negative effect of a food allergic reaction) (76-148 days of life traded) for an at-home vs in-clinic reaction in combination with high baseline peanut allergy prevalence among infants at high risk for peanut allergy and not yet exposed to peanuts. If an equivalent rate and disutility of accidental and index anaphylaxis was assumed and the 8-mm SPT cutoff had 0.85 sensitivity and 0.98 specificity, screening was cost-effective at a peanut allergy prevalence of 36%.
Conclusions And Relevance:
The results of this study suggest that the current screening approach to early peanut introduction could be cost-effective at a particular health utility for an in-clinic reaction, SPT sensitivity and specificity, and high baseline peanut allergy prevalence among high-risk infants. However, such conditions are unlikely to be plausible to realistically achieve. Further research is needed to define the health state utility associated with reaction location.
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