Dartmouth-Hitchcock Medical Center, Section of Allergy and Immunology, Lebanon, NH; Dartmouth Geisel School of Medicine, Hanover, NH.
Section of Inflammation, Repair and Development, National Heart and Lung Institute, Imperial College London, London, United Kingdom.
J Allergy Clin Immunol Pract. 2021 Jun;9(6):2440-2451.e3. doi: 10.1016/j.jaip.2021.01.007. Epub 2021 Jan 21.
Food-allergic patients are routinely prescribed 2 epinephrine autoinjectors (EAIs). The cost-effectiveness of this strategy is unknown.
To evaluate the cost-effectiveness of routinely prescribing all patients 2 EAI devices versus a risk-stratified approach (2 EAIs prescribed only for patients with a risk factor).
Markov models compared universal versus risk-stratified approaches on the basis of either a previous medical history of anaphylaxis (PMH-ana) or anaphylaxis requiring multiple epinephrine doses (multi-epi). Cohorts of children with peanut allergy were evaluated over an 80-year time horizon from both US and UK societal and health care perspectives. Models assumed prescribing a second EAI provided a baseline 10-fold risk reduction versus anaphylaxis-related fatality and hospitalization. Cost-effectiveness threshold was $100,000/quality-adjusted life-year (QALY).
From a US perspective, universal prescription of 2 EAIs to all patients with peanut allergy was not cost-effective in the base case versus risk stratification by PMH-ana. Universal prescription of 2 EAIs was associated with an incremental cost of $10,696,036/QALY versus the PMH-ana strategy, and $17,514,558/QALY versus the multi-epi strategy. However, the universal strategy became cost-effective versus a multi-epi strategy when single EAI costs were less than $80, second epinephrine dose requirements more than 25.5%, anaphylaxis hospitalization costs more than $18,453, annual anaphylaxis risk more than 76.5%, or anaphylaxis hospitalization rate more than 74.9%. From a UK perspective, universally prescribing 2 EAIs was also not cost-effective (incremental cost of $4,132,440/QALY vs PMH-ana and $6,208,227/QALY vs multi-epi) at single device costs more than $18.
At current EAI prices and low rates of needing 2 devices, limiting the second EAIs to patients with PMH-ana is more cost-effective than routinely prescribing 2 EAIs to all patients (particularly in resource-constrained settings).
食物过敏患者通常会被开 2 支肾上腺素自动注射器（EAI）。这种策略的成本效益尚不清楚。
评估常规为所有患者开 2 支 EAI 设备与风险分层方法（仅为有风险因素的患者开 2 支 EAI）的成本效益。
基于过敏反应的既往病史（PMH-ana）或需要多次肾上腺素剂量的过敏反应（multi-epi），使用 Markov 模型比较了通用方法和风险分层方法。评估了 80 年时间内，来自美国和英国社会和医疗保健角度的儿童花生过敏队列。模型假设开第二支 EAI 可使与过敏反应相关的死亡率和住院率降低 10 倍。成本效益阈值为 100000 美元/质量调整生命年（QALY）。
从美国的角度来看，在 PMH-ana 风险分层的情况下，常规为所有花生过敏患者开 2 支 EAI 在基础病例中并不具有成本效益。常规开 2 支 EAI 会导致增量成本为 10696036 美元/QALY，而 PMH-ana 策略为 17514558 美元/QALY，multi-epi 策略为 17514558 美元/QALY。但是，当单个 EAI 成本低于 80 美元，第二肾上腺素剂量需求超过 25.5%，过敏反应住院费用超过 18453 美元，年过敏反应风险超过 76.5%，或过敏反应住院率超过 74.9%时，通用策略相对于 multi-epi 策略变得具有成本效益。从英国的角度来看，在单个设备成本超过 18 美元的情况下，常规为所有患者开 2 支 EAI 也不具有成本效益（与 PMH-ana 相比增量成本为 4132440 美元/QALY，与 multi-epi 相比增量成本为 6208227 美元/QALY）。
在当前 EAI 价格和低需求 2 种设备的情况下，将第二支 EAI 限制在有 PMH-ana 的患者身上，比常规为所有患者开 2 支 EAI 更具成本效益（特别是在资源有限的环境中）。
