Billing fees for various common allergy tests vary widely across Canada

Varying Approaches to Management of IgE-Mediated Food Allergy in Children Around the World

Food allergy is a chronic disease that affects individuals of all ages and is a significant public health problem globally. This narrative overview examines clinical management strategies for IgE-mediated food allergy in children around the world to understand variations in practice. Information was drawn from clinical practice guidelines, recent research, the websites of professional and governmental bodies with expertise in food allergy, and clinical experts from a broad cross-section of geographical regions. The structure and delivery of clinical services, allergen avoidance and food labeling, and resources to support the management of allergic reactions in the community are discussed in detail. The adoption of emerging food immunotherapies is also explored. Wide variations in clinical management of food allergy were apparent across the different countries. Common themes were continuing issues with access to specialist care and recognition of the need to balance risk reduction with dietary and social restrictions to avoid unnecessary detrimental impacts on the quality of life of food allergy sufferers. Findings highlight the need for standardized presentation of practice and priorities, and may assist clinicians and researchers when engaging with government and funding agencies to address gaps.

Geographical discrepancy in oral food challenge utilization based on Canadian billing data

BACKGROUND

Oral food challenges (OFC) confer the highest sensitivity and specificity in diagnosis; however, uptake has been variable across clinical settings. Numerous barriers were identified in literature from inadequate training to resource access. OFC utilization patterns using billing data have not been previously studied.

OBJECTIVE

The objective of this study is to explore the geographic differences in utilization of OFCs across Ontario and Québec using anonymized billing data from 2013 to 2017.

METHODS

Anonymized OFC billing data were obtained between 2013 and 2017 from Ontario Health Insurance Plan (OHIP) and Régie de l'Assurance Maladie du Québec (RAMQ). The number of OFCs was extracted by location, billings, and physician demographics for clinic and hospital-based challenges.

RESULTS

Over the period studied, the number of OFCs increased by 92% and 85% in Ontario clinics and Québec hospitals, respectively. For Ontario hospitals, the number of OFCs increased by 194%. While Québec performed exclusively hospital-based OFCs, after controlling for the population, the number of OFCs per 100,000 residents annually were similar to Ontario at 50 and 49 OFCs, respectively. The number of OFCs varied across the regions studied with an annual rate reaching up to 156 OFCs per 100,000 residents in urban regions and as low as 0.1 in regions furthest from city centers.

CONCLUSION

OFC utilization has steadily increased over the last decade. There has been marked geographical discrepancies in OFC utilization which could be driven by the location of allergists and heterogeneity in their practices. More research is needed to identify barriers and propose solutions to them.

Economic burden of food allergy in Canada: Estimating costs and identifying determinants

BACKGROUND

Limited data exist on the economic burden of food allergy (FA).

OBJECTIVE

To assess FA-related direct (healthcare and out-of-pocket) and indirect (lost productivity) costs and their determinants in Canadian children and adults self-reporting FA.

METHODS

FA-individuals self-reporting a convincing history or physician diagnosis were recruited through FA registries, an anaphylaxis registry, and advocacy associations, and electronically surveyed regarding FA-related healthcare use, out-of-pocket expenditures, and time lost from paid and unpaid labor. Direct and indirect costs (2020 Canadian dollars [CAD]) were stratified on severe reaction vs mild, moderate or no reaction, and children vs adults; multivariate regressions assessed the association between costs and sociodemographic and disease characteristics.

RESULTS

Between May 2018 and July 2019, 2692 eligible individuals responded (2189 convincing history and 503 physician diagnosis only); 1020 experienced a severe reaction; 1752 were children. Per FA-individual, annual healthcare, out-of-pocket, and indirect costs were $1267, $2136, and $7950. Those with a severe reaction had higher healthcare and out-of-pocket costs than those with mild, moderate or no reaction. FA-children vs FA-adults had higher healthcare and out-of-pocket costs, and lower indirect costs. Multivariate results showed that lower age, a severe reaction ever, multiple FAs, and fair or poor general health were associated with higher healthcare and out-of-pocket costs. Higher age, lower household education and income, and fair or poor general health were associated with higher indirect costs.

CONCLUSION

The economic burden of FA in Canada is substantial, particularly for those with a severe reaction ever, multiple FAs, and fair or poor general health. It is crucial that those most adversely affected are allocated appropriate resources to support disease management.

The Cost-Effectiveness of Preschool Peanut Oral Immunotherapy in the Real-World Setting

BACKGROUND

Across North America, 1.4% to 4.5% of children and families live with peanut allergy (PA). Preschool peanut oral immunotherapy (POIT) has been shown to be safe and effective in the real-world setting.

OBJECTIVE

Evaluate the cost effectiveness of preschool POIT in North America.

METHODS

Markov cohort analyses and microsimulation was used to evaluate simulated preschool children with PA over an 80-year time horizon. Models incorporated the natural history of PA, comparing children treated with preschool POIT with those not receiving immunotherapy. Costs were expressed in U.S. and Canadian dollars.

RESULTS

A preschool POIT strategy was associated with cost savings while improving quality-adjusted life-years (QALY), dominating a nonimmunotherapy approach. Over the model horizon, when all costs (and effectiveness) of PA were included from a societal perspective, a POIT versus a non-POIT approach cost $82,514 (18.51 QALY) versus $84,367 (17.75 QALY) in the United States, and $40,111 (18.83 QALY) versus $53,848 (18.26 QALY) in Canada. In microsimulations, systemic reactions to POIT were less frequent than anaphylaxis from accidental exposure without POIT (United States: 3.59, SD 3.49 vs 19.53, SD 11.71; Canada: 3.63, SD 3.54 vs 4.56, SD 3.30), epinephrine use was reduced with POIT (United States: 5.85, SD 5.73 vs 9.76, SD 5.85; Canada: 0.34, SD 0.36 vs 0.53, SD 0.38), and fatalities were rare but lower in the POIT strategy (United States: 0.00005, SD 0.0071 vs 0.00015, SD 0.012; Canada: 0.00005, SD 0.0071 vs 0.00009, SD 0.0095).

CONCLUSIONS

Preschool POIT in a real-world setting improved health and economic outcomes in the United States and Canada.

Practical challenges in oral immunotherapy resolved through patient-centered care

Oral immunotherapy (OIT) is now widely recognized as a valid option for the management of IgE-mediated food allergies. However, in real-life practice, OIT can lead to a variety of unique situations where the best course of action is undetermined. In patient-centered care, individual patient preferences, needs and values, should guide all clinical decisions. This can be achieved by using shared-decision making and treatment customization to navigate areas of uncertainty in a way that is responsive to patient’s needs and preferences. However, in the context of OIT, lack of awareness of potential protocol adaptability or alternatives can become a barrier to treatment personalization. The purpose of this article is to review the theoretical bases of patient-centered care and shared decision-making and their practical implication for the patient-centered delivery of OIT. Clinical cases highlighting common challenges in real-life OIT practice are presented along with a discussion of potential personalized management options to be considered. While the practice of OIT is bound to evolve as additional scientific and experiential knowledge is gained, it should always remain rooted in the general principles of patient-centered care.

An Approach to the Office-Based Practice of Food Oral Immunotherapy

Oral immunotherapy (OIT) provides an active treatment option for patients with food allergies. OIT may improve quality of life and raise the threshold at which a patient with food allergy may react to an allergen, but it is a rigorous therapy that requires a high degree of commitment by the clinician, patients, and families. Recent guidelines from the Canadian Society for Allergy and Clinical Immunology have provided a framework for the ethical, evidence-based, and patient-oriented clinical practice of OIT, and the European Academy of Allergy, Asthma, and Immunology guidelines have also recommended that OIT can be used as a potential treatment. The recent Food and Drug Administration approval of an OIT pharmaceutical has accelerated the adoption of OIT. This review provides a summary of the recent Canadian Society for Allergy and Clinical Immunology guidelines and a consensus of practical experience of clinicians across the United States and Canada related to patient selection, office and staff preparation, the general OIT process, OIT-related reaction management, and treatment outcomes.