Immunotherapy for Hymenoptera venom allergy: too expensive for European health care?

Abstract

We read with interest the commentary by Ru€ eff et al. (1) regarding our health economic appraisal of Pharmalgen â wasp and bee venom immunotherapy (VIT) for the National Institute for Health and Care Excellence (NICE) (2). We are grateful to the authors for highlighting the surprising results of our analysis to the European allergy community and would like to respond to the critique of our approach.Our main finding was that VIT is not considered to be cost-effective, when only the direct costs of fatal and nonfatal anaphylaxis outcomes are considered. The reasons for this are that for most people, wasp and bee stings are uncommon; nonfatal anaphylaxis is not an expensive outcome; and even in those with a prior systemic sting reaction, subsequent fatal sting anaphylaxis is rare (2). So although VIT is effective for preventing systemic reactions to stings (3), one needs to apply the treatment to a very large number of individuals to create any significant cost savings via anaphylaxis prevention. In contrast, if one takes quality of life (QoL) improvement associated with VIT into consideration, VIT becomes cost-effective for even modest improvements in QoL. This is because the QoL benefit affects most patients, whether or not they have any further stings (4). The practice implication is that when deciding which patient should have VIT, we should not simply assess for risk of anaphylaxis but also consider patients' anxiety about future reactions and the impact of this on their daily life. In patients who are not anxious about future stings, the cost-effectiveness of the treatment is in doubt (5). This message from our recent assessments of the clinical-(3) and cost-effectiveness (2) of VIT has been expressed and interpreted with clarity in the resulting NICE guidance (6), which is similar to existing European guidance (Table 1).We respectfully disagree with the criticisms raised by Ru€ eff et al. (1). They suggest the outcomes of our health economic analysis were predictablethis certainly seems so with the benefit of hindsight, but the outcomes could not have been so clearly quantified or relied upon without undertaking this rigorous piece of work. The authors suggest we should have assumed a QoL benefit for health economic assessment in the 'base case scenario'. The NICE appraisal process, for which this research was commissioned, recommends use of a preference-based QoL measure that can be mapped to generic health states in the general population (e.g EQ-5D) (7). Because we did not identify studies evaluating the effect of VIT on such measures, we could not quantify the expected QoL benefit. We did however take into consideration the likelihood of a QoL benefit in our analyses and conclusions, based on the evidence that disease-specific quality of life improves with treatment (4), and this is reflected in the NICE guidancethat VIT can be considered cost-effective in patients with anxiety related to future stings (6). Finally the authors suggest that we should have made assumptions around the possibility of long-te...

Comparing the ability of molecular diagnosis and CAP-inhibition in identifying the really causative venom in patients with positive tests to Vespula and Polistes species

“…Indeed, in times of spending review also the cost-effectiveness of VIT is questioned [ 21 ]. Nobody can argue its life-saving role when the culprit venom is used, but avoiding additional treatments with unnecessary venoms, as obtained by CAP-inhibition, that in our study spared 30 additional treatments in 54 patients, may allow to significantly reduce the costs.…”

Fatal Anaphylaxis: Mortality Rate and Risk Factors

“…A health economic analysis undertaken for the UK National Institute for Health and Care Excellence found that a highly effective treatment for venom allergy, subcutaneous venom immunotherapy, was only cost effective if quality of life improvement occurred, or in specific high-risk groups with frequent stings and frequent reactions, such as beekeepers. 72 , 73 , 74 This was due to the rarity of costly outcomes such as death or disability in patients with known venom allergy. Disability is not widely reported as an outcome of venom anaphylaxis, but anecdotal evidence suggests that persistent vegetative state after hypoxic encephalopathy in near-fatal venom anaphylaxis is a significant risk, and this may impact on health economic analyses.…”

Stinging insect allergy: current perspectives on venom immunotherapy

“…In general, they found that VIT is not cost-effective when only considering direct costs of outcomes. 87 This is because for most people, recurrent insect stings are rare, and even in those with a history of severe venom allergic reaction previously, the risk of fatal outcome following a sting is extremely low. However, immunotherapy was found to be cost-effective in patients at high risk of future stings (≥3.3 a year, for people such as bee keepers, their neighbors and children, roofers, and gardeners) and in those whom the quality of life indices show improvement with reduced anxiety.…”