Cost-Effectiveness of Stock Epinephrine Autoinjectors on Commercial Aircraft

Anaphylaxis: Definition and criteria

Anaphylaxis is a systemic allergic reaction that may be severe and life-threatening. With more than a dozen anaphylaxis definitions proposed over the past several decades and several diagnostic criteria in circulation, there is a need for a multinational consensus definition to simplify management across specialties. Anaphylaxis diagnostic criteria are more alike than they are different, and approaches of the National Institute of Allergy and Infectious Disease, World Allergy Organization, and Brighton Collaborative help to add granularity and perspective to patient management. Anaphylaxis occurs across a spectrum of severity within populations, although, among individual patients, there is some evidence to suggest more consistency for an individual allergen. Still, severity is influenced by a number of factors that demonstrate variability: factors that relate to allergen triggers, patient characteristics, and treatments received. Severity of anaphylaxis impacts management, and recent guidelines provide approaches that consider individual factors to inform both strong and conditional recommendations. Conditional recommendations serve as navigational signals for shared decision-making when patient expertise is leveraged to inform individual preferences and values together with clinician expertise in anaphylaxis management to provide patient care bespoke to each patient. As novel approaches to both prevention and treatment of anaphylaxis emerge, an understanding of the significance of strong and conditional recommendations becomes critical to providing individualized and appropriate care for patients at risk for anaphylaxis.

Pharmacoequity and Biologics in the Allergy Clinic: Providing the Right Care, at the Right Time, Every Time, to Everyone

Pharmacoequity refers to equity in access to pharmacotherapy for all patients and is an especially large barrier to biologic agents in patients with allergic diseases. Value-based care models can prompt clinicians to address social determinants of health, promoting pharmacoequity. Pharmacoequity is influenced by numerous factors including socioeconomic status, which may be mediated through insurance status, educational attainment, and access to specialist care. In addition to lower socioeconomic status, race and ethnicity, age, locations isolated from care systems, and off-label indications for biologic agents all constitute barriers to pharmacoequity. Whereas pharmaco-inequity is more apparent for expensive biologics, it also affects many other allergy treatments including epinephrine autoinjectors and SMART for asthma. Current programs aimed at alleviating cost barriers are imperfect. Patient assistance programs, manufacturer-sponsored free drug programs, and rebates often increase the complexity of care, with resultant inequity, particularly for patients with lower health literacy. Ultimately, single silver-bullet solutions are elusive. Long-term improvement instead requires a combination of research, advocacy, and creative problem-solving to design more intelligent and efficient systems that provide timely access to necessary care for every patient, every time.

Anaphylaxis: A 2023 practice parameter update

This practice parameter update focuses on 7 areas in which there are new evidence and new recommendations. Diagnostic criteria for anaphylaxis have been revised, and patterns of anaphylaxis are defined. Measurement of serum tryptase is important for diagnosis of anaphylaxis and to identify underlying mast cell disorders. In infants and toddlers, age-specific symptoms may differ from older children and adults, patient age is not correlated with reaction severity, and anaphylaxis is unlikely to be the initial reaction to an allergen on first exposure. Different community settings for anaphylaxis require specific measures for prevention and treatment of anaphylaxis. Optimal prescribing and use of epinephrine autoinjector devices require specific counseling and training of patients and caregivers, including when and how to administer the epinephrine autoinjector and whether and when to call 911. If epinephrine is used promptly, immediate activation of emergency medical services may not be required if the patient experiences a prompt, complete, and durable response. For most medical indications, the risk of stopping or changing beta-blocker or angiotensin-converting enzyme inhibitor medication may exceed the risk of more severe anaphylaxis if the medication is continued, especially in patients with insect sting anaphylaxis. Evaluation for mastocytosis, including a bone marrow biopsy, should be considered for adult patients with severe insect sting anaphylaxis or recurrent idiopathic anaphylaxis. After perioperative anaphylaxis, repeat anesthesia may proceed in the context of shared decision-making and based on the history and results of diagnostic evaluation with skin tests or in vitro tests when available, and supervised challenge when necessary.

Contextual community epinephrine prescribing: Is more always better?

OBJECTIVE

Prompt administration of epinephrine is first-line management of anaphylaxis. Although severe anaphylaxis may require more than 1 epinephrine dose, multiple epinephrine device packs may not be necessary for all patients at risk for allergic reactions.

DATA SOURCES

A narrative review was used to describe key considerations to contextualize community epinephrine prescribing.

RESULTS

Anaphylaxis has a lifetime prevalence of 1.6% to 5.1%. Meeting diagnostic criteria for anaphylaxis is not required for epinephrine treatment of a severe allergic reaction. A "1-2-3" approach to anaphylaxis treatment is important to clearly relay central management steps: promptly administer a first dose of intramuscular epinephrine with proper positioning, and activate emergency medical services if immediate symptom resolution does not occur; consider a second dose of intramuscular epinephrine with consideration of oxygen administration and intravenous fluid if initial epinephrine response is not adequate; and consider a third intramuscular epinephrine dose together with consideration of intravenous fluid support and oxygen for continued lack of appropriate response. Although multiple epinephrine doses may be required to treat severe anaphylaxis, 90% of anaphylaxis cases do not require more than 1 epinephrine dose. A universal requirement for multiple epinephrine devices in patients without a history of anaphylaxis is not cost-effective. Patients without a history of anaphylaxis may be managed without multiple device prescriptions within a patient-preference sensitive paradigm of care.

CONCLUSION

Anaphylaxis prevention involves appropriate education to avoid allergen triggers, recognize symptoms of an allergic reaction, rapidly access and administer intramuscular epinephrine, and appropriately activate emergency medical services when needed. For patients with previous anaphylaxis, particularly those who have required more than 1 dose of epinephrine to treat an allergic reaction, possessing multiple epinephrine devices is an important part of managing community anaphylaxis risk.

Food allergies on vacation-there and back again

OBJECTIVE

Food allergy is an important public health concern that affects all facets of life, and travel is no exception. We sought to provide a scoping review regarding the literature pertaining to management of FA while traveling.

DATA SOURCES

Medline and Embase were queried for English-language articles published in the last 20 years containing "food allergy" and "travel".

STUDY SELECTIONS

The search produced 83 references which were reviewed. After removal of duplicates and irrelevant material, 23 references that discussed travel and FA remained, 13 of which were conference abstracts published as supplemental material.

RESULTS

Priorities for consideration by patient-families and their allergist-immunologist include concern for reactions away from home, proximity to emergency medical services, risk for various methods of travel including potential for cross-contact exposure resulting in symptoms, and considerations for international travel including language barriers.

CONCLUSION

Patients with FA must use careful planning and preparation to ensure access to safe food and emergency medications at all times while away from home.

The frequency and characteristics of epinephrine use during in-flight allergic events

BACKGROUND

Allergic reactions account for 2% to 4% of medical events in-flight and 5.5% of all medical events in passengers 18 years and under.

OBJECTIVE

To evaluate the incidence of in-flight allergic events including availability, use of epinephrine, and final patient outcome.

METHODS

We conducted a retrospective study of the ground-based medical service (GBMS) database from January 2017 to December 2019 for all allergic events and epinephrine utilization.

RESULTS

A total of 140,579 in-flight medical events (IFMEs) were initially retrieved from the period between January, 2017 and December, 2019, of which 4230 (3.0%) unique cases were identified as allergic events. Epinephrine administration was recommended in 398 passengers by GBMS. Of those, 328 (82.4%) ultimately received at least 1 dose of epinephrine. In multivariate analysis, there was a significant difference in the involvement of volunteers (odds ratio [OR], 3.19; P value < .001; 95% confidence interval [CI], 2.43-4.16), availability of autoinjectors (OR, 2; P value < .001; 95% CI, 1.55-2.58), flight diversion (OR, 11.21; P value < .001; 95% CI, 3.60-34.89), and hospital transport (OR, 6.58; P value < .001; 95% CI, 4.62-9.38) between the 2 groups. Passengers older than 12 years of age were at a higher risk for epinephrine administration. In the secondary analysis of 51 airlines that consistently use GBMS for all IFMEs, the incidence of allergic events was found to be 0.91 cases per million passengers. The incidence of severe in-flight allergic emergencies requiring epinephrine administration was 0.08 cases per million passengers or 12.5 million passengers for 1 event.

CONCLUSION

IFME requiring epinephrine administration is rare with an incidence rate of 1 event in 12.5 million passengers. The risk for epinephrine administration is higher in passengers more than 12 years of age and is associated with significantly higher flight diversion, hospital transport, and involvement of medical volunteers.

Anaphylaxis: Advances in the Past 10 Years

In the past 10 years, anaphylaxis has grown into its own special area of study within Allergy-Immunology, both at the bench and at the bedside. This review focuses on some of the most clinically relevant advances over the past decade. These include simplified and more inclusive diagnostic criteria for adults and children, uniform definition of biphasic anaphylaxis, and improved systems for objective severity grading. Studies reported in the past decade have led to improved understanding of normal and abnormal regulation of mast cell function, translating into better diagnostic and therapeutic approaches to patients with anaphylaxis. Research has provided improved recognition and treatment of mast cell disorders and has identified a new condition, hereditary α-tryptasemia, that may impact anaphylactic syndromes. We have learned to recognize new causes (α-gal), new pathways (Mas-related G protein-coupled receptor-X2), and many risk factors for severe anaphylaxis. The stability of epinephrine in autoinjectors was reported to be very good for several years after the labeled expiry date, and it can tolerate freezing and thawing. Repeated and prolonged exposure to excessive heat leads to degradation of epinephrine activity. New treatments to prevent severe anaphylaxis have been described, using new ways to block the IgE receptor or modulate intracellular signaling pathways.

Recognition and Management of Food Allergy and Anaphylaxis in the School and Community Setting

Given the increasing prevalence of food allergy, schools and food service establishments must have procedures in place to accommodate those with the condition. Training staff on allergy management has been shown to improve knowledge and skills, although more research is needed to better understand its benefits. Furthermore, although there are challenges involved in maintaining unassigned stock epinephrine programs, they have the potential to reduce morbidity and mortality associated with anaphylaxis by improving access to potentially life-saving medication. Finally, food bans in schools may not be an effective part of food allergy management, and other measures should be considered instead.

Epinephrine in anaphylaxis: too little, too late

PURPOSE OF REVIEW

Epinephrine is the agreed-upon first line treatment for anaphylaxis, yet it continues to be underused by patients/caregivers and providers alike.

RECENT FINDINGS

There are unfortunately limited data on how epinephrine can best be utilized in anaphylaxis, which hinders how best to inform patients and providers. Studies reporting underuse suggest various barriers and themes on why this may happen.

SUMMARY

Continued education of patients, caregivers, and providers is needed; however, is not likely to be enough to close the gap. Thus, novel studies on how to increase use; increase availability in a cost-effective manner; and newer, effective delivery routes are still needed.

Update on food allergy

Food allergy is a major public health issue with growing prevalence in the urbanized world and significant impact on the lives of allergic patients and their families. Research into the risk factors that have contributed to this increase and their underlying immune mechanisms could lead us to definitive ways for treatment and prevention of food allergy. For the time being, introduction of peanut and other allergenic foods in the diet at the time of weaning seems to be an effective way to prevent the development of food allergy. Improved diagnosis and appropriate management and support of food allergic patients are central to patient care with food immunotherapy and biologics making the transition to clinical practice. With the new available treatments, it is becoming increasingly important to include patients' and family preferences to provide a management plan tailored to their needs.

Community Use of Epinephrine for the Treatment of Anaphylaxis: A Review and Meta-Analysis

BACKGROUND

Community use of epinephrine for the treatment of anaphylaxis is low. Knowledge of rates of epinephrine use in the pre-hospital setting along with identification of barriers to its use will contribute to the development of policies and guidelines.

OBJECTIVES

A search was conducted on PubMed and Embase in April 2020. Our systematic review focused on 4 domains: (1) epinephrine use in the pre-hospital setting; (2) barriers to epinephrine use in the pre-hospital setting; (3) cost evaluation and cost-effectiveness of epinephrine use; and (4) programs and strategies to improve epinephrine use during anaphylaxis.

METHODS

Two meta-analyses with logit transformation were conducted to: (1) calculate the pooled estimate of the rate of epinephrine use in the pre-hospital setting among cases of anaphylaxis and (2) calculate the pooled estimate of the rate of biphasic reactions among all cases of anaphylaxis.

RESULTS

Epinephrine use in the pre-hospital setting was significantly higher for children compared with adults (20.98% [95% confidence interval (CI): 16.38%, 26.46%] vs 7.17% [95% CI: 2.71%, 17.63%], respectively, P = .0027). The pooled estimate of biphasic reactions among all anaphylaxis cases was 3.92% (95% CI: 2.88%, 5.32%). Our main findings indicate that pre-hospital use of epinephrine in anaphylaxis remains suboptimal. Major barriers to the use of epinephrine were identified as low prescription rates of epinephrine autoinjectors and lack of stock epinephrine in schools, which was determined to be cost-effective. Finally, in reviewing programs and strategies, numerous studies have engineered effective methods to promote adequate and timely use of epinephrine.

CONCLUSION

The main findings of our study demonstrated that across the globe, prompt epinephrine use in cases of anaphylaxis remains suboptimal. For practical recommendations, we would suggest considering stock epinephrine in schools and food courts to increase the use of epinephrine in the community. We recommend use of pamphlets in public areas (ie, malls, food courts, etc.) to assist in recognizing anaphylaxis and after that with prompt epinephrine administration, to avoid the rare risk of fatality in anaphylaxis cases.

Self-injectable epinephrine: doctors' attitude and patients' adherence in real-life

PURPOSE OF REVIEW

Epinephrine is the only life-saving treatment of anaphylaxis. Prescription and administration rates of self-injectable epinephrine are generally low. It is unclear whether this is because of availability, low prescription rates, fear of using epinephrine, or a combination of these issues.

RECENT FINDINGS

This review focuses on what self-injectable epinephrine devices (SIED), such as auto-injectors and prefilled syringes, are preferred by patients and healthcare professionals (HCP). Our findings suggest that a device's ease to use, proper and frequent training on its operability, and availability have an impact on preferences and adherence to treatment with SIEDs. After prescribing a patient with a SIED, clinicians should emphasize its use in anaphylaxis, educate patients/caregivers to identify anaphylaxis and on how to use the SIED, and encourage constant practicing with training devices.

SUMMARY

Epinephrine is the sole recommended anaphylaxis treatment and SIEDs are of critical usefulness in the community setting. Further studying of these devices is needed to optimize education for HCPs and patients and their accessibility to SIEDs.

Health and Economic Outcomes of Home Maintenance Allergen Immunotherapy in Select Patients with High Health Literacy during the COVID-19 Pandemic: A Cost-Effectiveness Analysis During Exceptional Times

BACKGROUND

Allergen immunotherapy (AIT) is safe and effective but is typically administered under strict clinic observation to mitigate the risk of a systemic reaction to immunotherapy (SRIT). However, in the setting of the global coronavirus disease 2019 pandemic, alternative care models should be explored.

OBJECTIVE

To evaluate the cost-effectiveness of home immunotherapy self-administration (HITSA) in a highly idealized circumstance for provision of maintenance AIT in a shelter-in-place or other scenarios of unforeseen reduction in nonessential medical services.

METHODS

Markov modeling was used to compare in-office clinic AIT in selected patients using cohort analysis and microsimulation from the societal and health care perspectives.

RESULTS

Assuming similar SRIT rates, HITSA was found to be a cost-effective option with an incremental cost-effectiveness ratio of $44,554/quality-adjusted life-year when considering both incremental epinephrine autoinjector costs and coronavirus disease 2019 risks. Excluding epinephrine autoinjector costs, HISTA dominated other options. However, outside of pandemic considerations, HITSA was not cost-effective (incremental cost-effectiveness ratio, $198,877,286) at annual epinephrine autoinjector costs above $287. As the incremental HITSA SRIT rate increased above 15%, clinic AIT was the most cost-effective strategy. Excluding both pandemic risks and risk of motor vehicle accident fatality from round-trip clinic transit, clinic AIT dominated other strategies. Clinic AIT was the more cost-effective option at very high fatality relative risk for HITSA or at very low annual risk of contracting coronavirus disease 2019.

CONCLUSIONS

Under idealized assumptions HITSA can be a safe and cost-effective option during a global pandemic in appropriately selected patients provided home rates of SRIT remain stable.

The Journal of Allergy and Clinical Immunology: In Practice 2019 Highlights

This article provides highlights of the clinically impactful original studies and reviews published in The Journal of Allergy and Clinical Immunology: In Practice in 2019 on the subjects of anaphylaxis, asthma, dermatitis, drug allergy, food allergy, immunodeficiency, immunotherapy, rhinitis/sinusitis, and urticaria/angioedema/mast cell disorders. Within each topic, practical aspects of diagnosis and management are emphasized. Treatments discussed include lifestyle modifications, allergen avoidance therapy, positive and negative effects of pharmacologic therapy, and various forms of immunologic and desensitization management. We designed this review to help readers consolidate and use this extensive and practical knowledge for the benefit of their patients.

Commercial claims costs related to health care resource use associated with a diagnosis of peanut allergy

BACKGROUND

Peanut allergy (PA) affects approximately 1.6 million US children. The current standard of care is strict avoidance and prompt reaction treatment. Peanut allergy health care costs and health care resource utilization (HCRU) are poorly understood.

OBJECTIVE

To estimate PA health care costs and HCRU using a nationally representative commercial payer database.

METHODS

The IBM MarketScan Commercial Claims and Encounters Database was examined for PA diagnosis/reaction codes between January 2010 and October 2016 in patients 64 years of age or younger, with age cohort-matched controls. Outcomes were measured 12 months before and after the first claim date. Health care costs and HCRU were compared using Student's t tests and χ² tests.

RESULTS

Patients with a PA-related diagnostic code (n = 41,675) incurred almost double all-cause health care costs vs controls ($6436 vs $3493, P < .001), mainly from inpatient and outpatient medical costs ($5002 vs $2832, P < .001). More than one third of the PA group patients (36%) had a code indicative of an anaphylactic reaction during follow-up. Mean PA or reaction-related code costs per visit totaled $7921 for hospitalizations and $1115 for emergency department (ED) visits. Costs were 30% lower in patients with asthma codes without PA codes vs those with both codes ($5678 vs $8112, P < .001); all-cause ED costs were more than double in patients with atopic dermatitis codes with PA codes vs those without PA codes ($654 vs $308, P < .001).

CONCLUSION

National commercial payer claims data indicate a significant health care burden associated with a PA-related code, including over $6400/patient in annual all-cause costs and increased health care utilization.

The cost-effectiveness of requiring universal vs contextual self-injectable epinephrine autoinjector for allergen immunotherapy

BACKGROUND

Aeroallergen immunotherapy (AIT) is a safe and effective disease-modifying treatment associated with rare therapy-associated fatality. Significant practice variation surrounds universal or contextual prescription of self-injectable epinephrine (SIE) for patients receiving AIT.

OBJECTIVE

To characterize the cost-effectiveness of a universal vs contextual SIE requirement for patients receiving AIT.

METHODS

An economic evaluation using cohort and microsimulation was performed from both the societal and health care sector perspectives for patients undergoing AIT, assessing a universal requirement to fill SIE prescriptions at the outset of therapy compared with requiring this only after a systemic reaction to immunotherapy (SRIT).

RESULTS

A universal SIE requirement for AIT is not cost-effective, with the incremental cost-effectiveness ratio for this strategy estimated at $669,327,730 per quality-adjusted life-year (QALY). In the microsimulation (n = 10,000), the mean (SD) costs of a universal approach exceeded that of a more context-specific strategy where SIE was only prescribed for patients after an initial SRIT ($19,653.36 [$4296.66] vs $16,232.14 [$5204.32]), and given the effects on rates of AIT discontinuation, the universal approach was less effective (mean [SD], 25.555 [2.285] QALYs) compared with a contextualized approach (mean [SD], 25.579 [2.345] QALYs). Universal SIE prescription could be cost-effective if it provided a 1000 times protection against AIT fatality at a value-based cost of $24, and the annual AIT fatality rates unrealistically exceed 2.6 per 10,000 patients.

CONCLUSION

In a simulation of potential SIE-prescribing strategies for patients receiving AIT, a universal approach to an epinephrine autoinjector requirement was not cost-effective when compared with an approach in which an SIE is prescribed only to patients with prior SRIT.

A primer on cost-effectiveness in the allergy clinic

OBJECTIVE

To provide a cost-effectiveness primer for the practicing allergist.

DATA SOURCES

Articles assessing use of decision analysis and cost-effective healthcare delivery.

STUDY SELECTIONS

A narrative review detailing approaches to incorporate evidence based medicine into individualized patient-centered cost-effective practice.

RESULTS

Resources in medicine are finite and it has been estimated that more than 30% of healthcare spending is directed toward low-value care. Insurers and government agencies are increasingly looking to maximize health value. Cost-effective analyses (CEA) is a complex valuation that grades health outcomes and economic benefits of a specific aspect of clinical care over a particular time horizon. In the US, therapies are generally considered cost-effective at ceilings between $50,000 - $150,000 per QALY. Critical components of CEA include model development to accurately represent clinical decisions and outcomes, evidence-based inputs, appropriate sensitivity analyses, and clarity in selecting the target population, perspective, comparators, time horizon, discount rate, and health outcomes. CEA can better inform trade-offs in patient care and add clarity in the translation of evidence to medical recommendations. Future research is likely to provide a more complete understanding of variation across population health state utilities for allergic conditions to more accurately reflect quality adjusted life years for patients with allergies.

CONCLUSION

Viewing healthcare options through an economic lens has become the standard of care across the United States and internationally, whether mandated through government agencies or third party payers. Decision analysis with cost-utility models can provide a useful perspective for both individual practice and public health.