Determining Levers of Cost-effectiveness for Screening Infants at High Risk for Peanut Sensitization Before Early Peanut Introduction

Abstract

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 PARTICIPANTSThis 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 MEASURESCost, quality-adjusted life-years (QALYs), net monetary benefit, peanut allergic reactions, severe allergic reactions, and deaths due to peanut allergy. RESULTSIn 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

Engaging patient partners in state-of-the-art allergy care

“…50,53 A better understanding of how allergy treatments influence patientreported health state utilities is needed, as evidenced by the significant effect health-state utility improvements may play in the cost-effectiveness of food allergy screening and food immunotherapy (Fig 6). 51,53,54 Preference reversals present a challenge in SDM. 52 Although utility and prospect theory assume stable behavioral risk preferences, 49 in reality human decision making may show unexpected variation.…”

“…12 Given the geographic variation in infant peanut screening, there is likely a role for SDM in counseling families in the United States, despite current guidance for universal screening of infants with severe eczema or egg allergy. 42,54 SDM could also be incorporated into decisions for reflex activation of emergency medical services 5 and prolonged hospital observation after resolved anaphylaxis, 8 discretionary prescription of selfinjectable epinephrine with AIT, 9 and a universal requirement for clinic-observed omalizumab. 6 Each of these universal practices is potentially low value.…”

Novel Approaches to Food Allergy Management During COVID-19 Inspire Long-Term Change

“… 11 , 12 This would be particularly concerning if combined with poor access to infant OFCs during a pandemic. 13 , 14 Compounding this issue further, recent evidence suggests a “screening creep” extending to non–at-risk groups. This phenomenon was demonstrated in a recent study at a large tertiary care center, where less than half of screened infants met NIAID criteria.…”

“…16 Indeed, unless a family is willing to trade the equivalent of 21% of a year of life for any peace of mind afforded by in-clinic versus at-home peanut introduction, screening is not cost-effective. 13 These figures are unlikely to improve given the significant access limitations clinicians are currently experiencing.…”

“…An option to consider for these families would be pre-emptively prescribing an epinephrine autoinjector to improve comfort with at-home introduction. 13 Others will prefer a virtually supported home peanut introduction. 21 Still, for some, screening may be preferred after engaging in a shared decision-making paradigm.…”