Relative cost-effectiveness of using an extensively hydrolyzed casein formula in managing infants with cow’s milk allergy in Brazil

Abstract

ObjectiveTo estimate the cost-effectiveness of three alternative dietetic strategies for cow’s milk allergy in Brazil: 1) using an extensively hydrolyzed casein formula (eHCF; Nutramigen) as a first-line formula, but switching to an amino acid formula (AAF) if infants remain symptomatic; 2) using an AAF as a first-line formula and then switching to an eHCF after 4 weeks once infants are symptom-free, but switching back to an AAF if infants become symptomatic; and 3) using an AAF as a first-line formula and keeping all infants on that formula. The analysis was conducted from the perspective of the Brazilian public health care system, Sistema Único de Saude.MethodsDecision modeling was used to estimate the probability of immunoglobulin E (IgE)-mediated and non-IgE-mediated allergic infants developing tolerance to cow’s milk by 12 months from starting a formula. The models also estimated the Sistema Único de Saude cost (at 2013/2014 prices) of managing infants over 12 months after starting a formula, as well as the relative cost-effectiveness of each of the dietetic strategies.ResultsThe probability of developing tolerance to cow’s milk by 12 months from starting a formula was higher among infants with either IgE-mediated or non-IgE-mediated allergy who were initially fed with an eHCF, compared with those who were initially fed with an AAF. The total health care cost of initially feeding an eHCF to cow’s milk allergic infants was less than that of initially feeding both IgE-mediated and non-IgE-mediated infants with an AAF.ConclusionWithin the study’s limitations, using an eHCF instead of an AAF for the first-line management of newly-diagnosed infants with cow’s milk allergy affords a cost-effective use of publicly funded resources, since it improves the outcome for less cost.

Cost-Effectiveness of Food Allergy Interventions in Children: A Systematic Review of Economic Evaluations

“…1), covering 3 types of food allergy and published between 2009 and 2019. Eight papers investigated PA, [24][25][26][27][28][29][30][31] 8 investigated CMA, [32][33][34][35][36][37][38][39] and 1 focused on EA. 40…”

“…For the 8 economic evaluations identified in CMA, 4 analyses were conducted in the UK and rest of Europe, 34,37-39 2 in Brazil, 33,35 and 2 in the United States. 32,36 Four evaluations were conducted from a public health payer perspective, 33,35,37,39 which included UK and Spanish healthcare systems; and 4 from both a parent's perspective and the perspective of a health insurer or public payer (Italian National Health Service, Polish National Health Fund, US third party insurers). 32,34,36,38 All studies used decision analytic modeling to evaluate various formulas (hydrolyzed casein, soy, rice, amino acid) used as substitutes to cow's milk, over 12-to 18-month time horizons.…”

“…42 Results demonstrated that over a 20-year time horizon, PPOIT was associated with $2141 USD per QALY gain from a US societal perspective. 30 Cow's milk allergy economic evaluations Among the 8 studies evaluating the cost-effectiveness of substitute milk products for CMA, 7 studies [32][33][34][36][37][38][39] compared a range of milk-substitute formula products for managing CMA, while 1 study evaluated the cost-effectiveness of using an amino acid formula in the elimination diet of infants with suspected CMA (diagnostic tool). 35 One study that compared extensively hydrolyzed casein formula (eHCF) compared to amino acid formula demonstrated dominant results for eHCF, 39 while a further 5 studies 32,34,[36][37][38] that compared eHCF plus lactobacillus rhamnosus GG (LGG) also demonstrated dominant results in direct comparisons to eHCF alone, 32,34,[36][37][38] amino acid formula, 32,34,[36][37][38] soy-based formula, 38 and hydrolyzed rice formula, 38 across UK, Italian, Spanish, Polish, and US settings.…”

“…35 One study that compared extensively hydrolyzed casein formula (eHCF) compared to amino acid formula demonstrated dominant results for eHCF, 39 while a further 5 studies 32,34,[36][37][38] that compared eHCF plus lactobacillus rhamnosus GG (LGG) also demonstrated dominant results in direct comparisons to eHCF alone, 32,34,[36][37][38] amino acid formula, 32,34,[36][37][38] soy-based formula, 38 and hydrolyzed rice formula, 38 across UK, Italian, Spanish, Polish, and US settings. Further, 2 studies conducted from a Brazilian healthcare system perspective demonstrated that using eHCF as first line instead of an amino acid formula resulted in better outcomes at a lower cost, 33 while the use of an amino acid formula in an elimination diagnostic diet followed by an oral food challenge resulted in lower costs and more symptom-free days and was a dominant diagnostic approach. 35…”

“…Six of the US peanut allergy studies applied utility weights for incorporation into economic models, using non-preference-based measures directly transformed to utilities for childhood food allergy, which is problematic. [24][25][26][28][29][30] Eleven [25][26][27][31][32][33][34][36][37][38][39] of the 17 studies performed probabilistic sensitivity analysis, and 5 studies [25][26][27]31,34 presented cost-effectiveness acceptability curves or probabilities. One-way sensitivity analyses were performed by the majority of studies (n = 14), which demonstrated that utility weights for children with food allergy, costs of treatment or…”