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

Matthew Greenhawt,Marcus Shaker

doi:10.1001/jamanetworkopen.2019.18041

Abstract

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. To identify scenarios in which current early peanut introduction guidelines would be cost-effective. 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. 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). Cost, quality-adjusted life-years (QALYs), net monetary benefit, peanut allergic reactions, severe allergic reactions, and deaths due to peanut allergy. 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%. 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.

Highlights

Peanut allergy affects 1% to 4.5% of children, can potentially be severe, and is not readily outgrown in most individuals.[1]
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, skin prick test (SPT) sensitivity and specificity, and high baseline peanut allergy prevalence among high-risk infants
In this study, screening for peanut sensitization in high-risk infants and presumptively diagnosing the child with a peanut allergy based on large SPT result size or only providing the option for in-clinic introduction for those with small- to moderate-size SPT results was not found to be cost-effective compared with the general permissive strategy of recommending early introduction at home without any assessment

Summary

Introduction

Peanut allergy affects 1% to 4.5% of children, can potentially be severe, and is not readily outgrown in most individuals.[1] treatments are on the horizon, a cure remains elusive, and management involves strict avoidance and anaphylaxis preparedness.[2,3] For these reasons, peanut allergy is associated with impaired quality of life and anxiety.[4,5] Important advances have been made regarding prevention of peanut allergy through deliberate early introduction, in particular targeting populations of children at risk for developing peanut allergy, as demonstrated in the Learning Early About Peanut Allergy (LEAP) trial in which a dramatic risk reduction was noted against developing peanut allergy at 5 years of age through early peanut introduction at 4 to 11 months of life compared with delayed introduction.[6] The strength of these findings helped to reverse prior recommendations to avoid peanut in infants and young children until 3 years of age and resulted in the recent National Institutes for Allergy and Infectious Disease (NIAID) addendum guidelines that recommend early introduction to prevent peanut allergy.[7] This strategy was adopted in the United Kingdom, Canada, Australia, and New Zealand, the wording of the policy and the implementation of this guidance vary among these nations. For lower-risk infants (or infants not at risk), peanut introduction is advised as early as 6 months of age, without such medicalization or screening, in accordance with family values and preferences[7] (eTable in the Supplement)

Methods

Results

Discussion

Conclusion