1
|
Ribes-Koninckx C, Amil-Dias J, Espin B, Molina M, Segarra O, Diaz-Martin JJ. The use of amino acid formulas in pediatric patients with allergy to cow's milk proteins: Recommendations from a group of experts. Front Pediatr 2023; 11:1110380. [PMID: 37033186 PMCID: PMC10073469 DOI: 10.3389/fped.2023.1110380] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 03/01/2023] [Indexed: 04/11/2023] Open
Abstract
One of the most common food allergies in children is cow's milk allergy (CMA). In breast-fed infants with CMA, the mother is encouraged to avoid dairy products. If this is not possible, or in formula fed infants, use of hypoallergenic replacement formulas such as extensively hydrolyzed formulas (EHF) is recommended. However, in ∼5% of patients EHFs are not tolerated and/or allergy symptoms can persist. When EHFs are ineffective and in severe forms of CMA, amino acid-based formulas (AAF) should be considered. Six pediatric gastroenterologists with extensive experience in food allergy management reviewed scientific publications and international clinical practice guidelines to provide practical recommendations on AAF. The guidelines reviewed had discrepancies and ambiguities around the specific indications for using formulas as a milk substitute. The panel recommends AAFs as the first therapeutic option in anaphylaxis due to CMA, in acute and chronic severe food protein-induced enterocolitis syndrome, in CMA associated with multiple food allergy, and in cases of eosinophilic esophagitis not responding to an extended exclusion diet or not eating solids. The main benefit of AAF is its absence of residual allergenicity, making it a safe treatment option in severe CMA patients who do not tolerate or respond to an EHF.
Collapse
Affiliation(s)
- Carmen Ribes-Koninckx
- Pediatric Gastroenterology, Hepatology and Nutrition La Fe University and Politechnic Hospital & La Fe Research Institute, Valencia, Spain
- Correspondence: Carmen Ribes-Koninckx
| | - Jorge Amil-Dias
- Emeritus, S. João University Hospital Center, Porto, Portugal
| | - Beatriz Espin
- Pediatric Gastroenterology and Nutrition Unit, Virgen del Rocio University Hospital, Seville, Spain
| | - Manuel Molina
- Department of Pediatric Gastroenterology and Nutrition, La Paz University Hospital, Madrid, Spain
| | - Oscar Segarra
- Pediatric Gastroenterology, Hepatology and Nutrition Unit, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Juan J. Diaz-Martin
- Pediatric Gastroenterology and Nutrition, Hospital Universitario Central de Asturias, Oviedo, Spain
| |
Collapse
|
2
|
Paquete AT, Martins R, Connolly MP, Meulle M, Pastor N, Benoist G, Tounian P. Cost-effectiveness of infant hypoallergenic formulas to manage cow's milk protein allergy in France. JOURNAL OF MARKET ACCESS & HEALTH POLICY 2022; 11:2154418. [PMID: 36518150 PMCID: PMC9744214 DOI: 10.1080/20016689.2022.2154418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 11/29/2022] [Accepted: 11/29/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND Clinician's choice of hypoallergenic formulas in the first-line management of cow's milk protein allergy (CMPA) should be informed by evidence on clinical efficacy and cost-effectiveness. OBJECTIVE We compare the cost-effectiveness of amino acid-based formula (AAF), extensively hydrolyzed casein formula with Lactobacillus rhamnosus Gorbach Goldin (EHCF+LGG), extensively hydrolyzed whey formula (EHWF), and rice hydrolyzed formula (RHF) in non-breastfed children in France. METHODS Immunotolerance and atopic manifestations' prevalence were based on a prospective non-randomized study with a 36-month follow-up. Resource utilization was sourced from a survey of French clinicians, and unit costs were based on national data. Costs and health consequences were discounted at 2.5% annually. Results were reported using the Collective and French National Health Insurance perspectives. RESULTS Children receiving EHCF+LGG were predicted to require less healthcare resources, given their reduced prevalence of CMPA symptoms at 3 years. In the base case, EHCF+LGG led to savings of at least €674 per child compared to AAF, EHWF, and RHF at 3 years, from both perspectives. Nutrition had the highest economic burden in CMPA, driven by hypoallergenic formulas and dietetic replacements costs. Results were robust to one-way and probabilistic sensitivity analyses. CONCLUSIONS EHCF+LGG was associated with more symptom-free time, higher immune tolerance, and lower costs.
Collapse
Affiliation(s)
- Ana Teresa Paquete
- Health Economics Unit, Health Economics Consultants, Global Market Access Solutions, St-Prex, Switzerland
| | - Rui Martins
- Health Economics Unit, Health Economics Consultants, Global Market Access Solutions, St-Prex, Switzerland
- Unit of PharmacoEpidemiology & PharmacoEconomics, Department of Pharmacy, University of Groningen, Groningen, The Netherlands
| | - Mark P. Connolly
- Health Economics Unit, Health Economics Consultants, Global Market Access Solutions, St-Prex, Switzerland
- Unit of PharmacoEpidemiology & PharmacoEconomics, Department of Pharmacy, University of Groningen, Groningen, The Netherlands
| | - Marie Meulle
- Benckiser Healthcare France, Reckitt Benckiser, Paris, France
| | - Nítida Pastor
- Medical and Scientific Affairs, Nutrition, Reckitt Benckiser, 47721, Evansville, IN, USA
| | - Grégoire Benoist
- Department of Pediatrics, CHU Ambroise Paré, APHP, 92100, Boulogne-Billancourt, France
| | - Patrick Tounian
- Pediatric Nutrition and Gastroenterology Department, Trousseau hospital, APHP, Sorbonne University, Paris, France
| |
Collapse
|
3
|
Paquete AT, Martins R, Connolly MP, Hegar B, Munasir Z, Stephanus S. Managing Cow's Milk Protein Allergy in Indonesia: A Cost-effectiveness Analysis of Hypoallergenic Milk Formulas from the Private Payers' Perspective. JOURNAL OF HEALTH ECONOMICS AND OUTCOMES RESEARCH 2022; 9:77-85. [PMID: 36168595 PMCID: PMC9452772 DOI: 10.36469/001c.36407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 06/13/2022] [Indexed: 06/16/2023]
Abstract
Background: Cow's milk protein allergy is very common in early childhood. Extensively hydrolyzed formulas are recommended in the first-line management of cow's milk protein allergy in non-breastfed children. Choice of formulas should be informed by efficacy and cost data. Objectives: This study aims to compare the cost-effectiveness of extensively hydrolyzed casein formula with Lacticaseibacillus rhamnosus Gorbach Goldin (EHCF+LGG), extensively hydrolyzed whey formula (EHWF), amino acid formula, and soy formula in the first-line management of cow's milk protein allergy in non-breastfed children in Indonesia. Methods: A trial-based decision analytic cohort model was adapted to simulate the occurrence of cow's milk protein allergy symptoms or being symptom free. The model was based on a prospective nonrandomized study that followed up children for 36 months. Costs and health consequences were discounted at 3% annually. Resources required to manage cow's milk protein allergy and unit costs for clinical appointments and exams were based on a panel of 15 clinicians, from a private payers' perspective. Other unit costs were based on publicly available national data. Results were reported as cost per additional child free from allergic manifestations or per additional immunotolerant child at 3 years, and per life-years under the same conditions. Uncertainty was assessed using deterministic and probabilistic sensitivity analysis. Results: Children receiving EHCF+LGG were associated with more symptom-free time, a higher probability of cow's milk tolerance at 3 years, and lower healthcare resources and transportation use when compared with children receiving other formulas (with 38%-49% lower costs). Formula costs were lower for soy, but EHCF+LGG was predicted to save 9% and 54% of overall costs compared with extensively hydrolyzed whey formula and amino acid formula, respectively. Results were robust to sensitivity analyses. Conclusion: Use of EHCF+LGG resulted in more symptom-free time and the highest 3-year probability of cow's milk tolerance. It also led to healthcare resource and transportation savings when compared with other hypoallergenic milk formulas. Soy formula remained an alternative if formula price represents a major constraint.
Collapse
Affiliation(s)
| | - Rui Martins
- Global Market Access Solutions, St-Prex, Switzerland
| | | | - Badriul Hegar
- Department of Pediatrics, Faculty of Medicine, University of Indonesia
| | - Zakiudin Munasir
- Division of Allergy and Clinical Immunology, Faculty of Medicine, University of Indonesia
| | | |
Collapse
|
4
|
Fong AT, Ahlstedt S, Golding MA, Protudjer JLP. The Economic Burden of Food Allergy: What We Know and What We Need to Learn. CURRENT TREATMENT OPTIONS IN ALLERGY 2022; 9:169-186. [PMID: 35502316 PMCID: PMC9046535 DOI: 10.1007/s40521-022-00306-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2022] [Indexed: 02/04/2023]
Abstract
Purpose of Review Food allergy management and treatment require dietary modification, are associated with significant burdens, and affect food choices and behaviours. Emerging therapies, such as oral immunotherapy (OIT), provide a glimmer of hope for those living with the condition. Some burdens have received substantial focus, whereas many knowledge gaps on the significance of other impacts, including economic burden, remain. Recent Findings Evidence from many countries, but disproportionately from the United States, supports that food allergy carries significant healthcare and societal costs. Early introduction for the prevention of food allergies is theoretically cost-effective, but remains largely undescribed. Unique considerations, such as those to cow’s milk protein allergy, which affects a substantial proportion of infants, and adrenaline autoinjectors, which have a high cost-per-use, require a balance between cost-effectiveness to the healthcare system and adverse outcomes. Household costs have largely been explored in two countries, but owing to different healthcare structures and costs of living, comparisons are difficult, as are generalisations to other countries. Stock epinephrine in schools may present a cost-effective strategy, particularly in economically disadvantaged areas. Costs relating to OIT must be examined within both immediate benefits, such as protection from anaphylaxis, and long-term benefits, such as sustained unresponsiveness. Summary Although the absolute costs differ by region/country and type of food allergy, a consistent pattern persists: food allergy is a costly condition, to those who live with it, and the multiple stakeholders with which they interact. Supplementary Information The online version contains supplementary material available at 10.1007/s40521-022-00306-5.
Collapse
Affiliation(s)
| | - Staffan Ahlstedt
- Centre for Allergy Research, Karolinska Institutet, Stockholm, Sweden
| | - Michael A. Golding
- The Children’s Hospital Research Institute of Manitoba, 501G-715 McDermot Avenue, Winnipeg, MB R3E 3P4 Canada
- Department of Pediatrics and Child Health, The University of Manitoba, 501G-715 McDermot Avenue, Winnipeg, MB R3E 3P4 Canada
| | - Jennifer L. P. Protudjer
- Centre for Allergy Research, Karolinska Institutet, Stockholm, Sweden
- The Children’s Hospital Research Institute of Manitoba, 501G-715 McDermot Avenue, Winnipeg, MB R3E 3P4 Canada
- Department of Pediatrics and Child Health, The University of Manitoba, 501G-715 McDermot Avenue, Winnipeg, MB R3E 3P4 Canada
- George and Fay Yee Centre for Healthcare Innovation, 501G-715 McDermot Avenue, Winnipeg, MB R3E 3P4 Canada
- Food and Human Nutritional Sciences, The University of Manitoba, 501G-715 McDermot Avenue, Winnipeg, MB R3E 3P4 Canada
| |
Collapse
|
5
|
Fanning L, Woods E, Hornung CJ, Perrett KP, Tang MLK, Dalziel K. Cost-Effectiveness of Food Allergy Interventions in Children: A Systematic Review of Economic Evaluations. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:1360-1376. [PMID: 34452717 DOI: 10.1016/j.jval.2021.02.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 02/10/2021] [Accepted: 02/18/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES To identify published economic evaluations of interventions aimed at preventing, diagnosing, or treating food allergies in children. METHODS We examined economic evaluations published from 2000 to 2019. Data analyzed included: food allergy type, study population/setting, intervention/comparator, and economic evaluation details. Quality assessment used reporting and economic modeling checklists. Two reviewers simultaneously undertook article screening, data extraction, and quality assessment. RESULTS 17 studies were included: 8 peanut allergy (PA) studies, 8 cow's milk allergy (CMA) studies, and 1 egg allergy (EA) study. All PA studies reported incremental costs per quality-adjusted life-year gained for diagnostic strategies, management pathways for peanut exposure, and immunotherapies. Immunotherapies rendered inconsistent cost-effectiveness results. CMA studies reported costs per symptom-free day or probability of developing CMA tolerance. Cost-effectiveness of extensively hydrolyzed casein formula for CMA treatment was consistently demonstrated. Early introduction of cooked egg in first year of life dominated all EA prevention strategies. Quality assessment showed average noncompliance for 3.5 items/study (range 0-11) for modeling methods and 3.4 items/study (range 0-8) for reporting quality. Key quality concerns included limited justification for model choice, evidence base for model parameters, source of utility values, and representation of uncertainty. CONCLUSION Recent cost-effectiveness literature of interventions in PA, CMA, and EA is limited and diverse. Interventions for diagnosis and treatment of CMA and prevention of EA were generally cost-effective; however, results for PA were variable and dependent on effectiveness and utility values used. There is a need to expand economic evaluation of interventions for childhood food allergy and to improve methods and reporting.
Collapse
Affiliation(s)
- Laura Fanning
- Health Economics Group, Centre for Health Policy, Melbourne School of Global and Population Health, University of Melbourne, Victoria, Australia; Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Centre for Health Economics, Monash Business School, Monash University, Victoria, Australia
| | - Ekaterina Woods
- Health Economics Group, Centre for Health Policy, Melbourne School of Global and Population Health, University of Melbourne, Victoria, Australia; Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | | | - Kirsten P Perrett
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia; Department of Allergy and Immunology, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Mimi L K Tang
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia; Department of Allergy and Immunology, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Kim Dalziel
- Health Economics Group, Centre for Health Policy, Melbourne School of Global and Population Health, University of Melbourne, Victoria, Australia; Murdoch Children's Research Institute, Melbourne, Victoria, Australia.
| |
Collapse
|
6
|
Martins R, Connolly MP, Minshall E. Cost-effectiveness Analysis of Hypoallergenic Milk Formulas for the Management of Cow's Milk Protein Allergy in the United Kingdom. JOURNAL OF HEALTH ECONOMICS AND OUTCOMES RESEARCH 2021; 8:14-25. [PMID: 34430667 PMCID: PMC8346363 DOI: 10.36469/jheor.2021.26010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 07/19/2021] [Indexed: 05/03/2023]
Abstract
Background: Cow's milk protein allergy (CMPA) is the most common food allergy in early childhood. In most children CMPA resolves by age 5 or 6; however, if not treated correctly can provoke nutritional deficiency resulting in poor growth. Management consists of excluding cow's milk from the diet, with hypoallergenic formulas (or non-dairy alternatives) being introduced to meet nutritional requirements. Objectives: To compare the cost-effectiveness of hypoallergenic formulas in reducing allergic manifestations and promoting immune tolerance in infants with immunoglobulin E (IgE)-mediated symptoms of CMPA. Methods: A trial-based decision analytic cohort model was developed to simulate the occurrence of urticaria, eczema, asthma, rhinoconjunctivitis, or being symptom-free in infants with CMPA in the United Kingdom. Amino acid-based formula (AAF), extensively hydrolysed casein formula containing Lactobacillus rhamnosus Gorbach Goldin (EHCF+LGG), extensively hydrolysed whey formula (EHWF), and soy formula (SF) were compared using the National Health Service (NHS) perspective, 3-year time horizon and 3.5% discount rate for cost and health consequences. Hypoallergenic formulas comparative efficacy was sourced from a prospective cohort study. Resources required to manage allergic symptoms were sourced from published literature, validated by a UK clinician, and applied to UK cost resources. Results were reported as cost per additional child free from allergic manifestations at 3 years and cost per additional immune tolerant child at 3 years. Results: In the base case, infants receiving EHCF+LGG were associated with lower NHS resource use and improved CMPA tolerance. Over the 3-year treatment period, savings of £119, £476, and £1094 were achieved with EHCF+LGG compared to SF, EHWF and AAF, respectively. Infant formula accounted for the largest proportion of resource consumption averaging 44% for all comparators, with a minimum of 31% for SF and a maximum of 53% for AAF over 3 years. General practitioners' visits constituted the second highest cost component, approximately 17% of total costs across comparators. The results were robust to deterministic and probabilistic sensitivity analyses. Conclusions: Compared to AAF, SF, and EHWF hypoallergenic formulas, EHCF+LGG was the most cost-effective, associated with lower total costs and contributing to a higher proportion of children being symptom-free and developing immune tolerance 3-years after diagnosis.
Collapse
Affiliation(s)
- Rui Martins
- Global Market Access Solutions, Health Economics Unit, St-Prex, Switzerland
| | - Mark P Connolly
- Unit of PharmacoEpidemiology & PharmacoEconomics, Department of Pharmacy, University of Groningen, Groningen, The Netherlands; GMAS Services LTD, London, England
| | - Eleanor Minshall
- Sheffield Children's NHS Foundation Trust, Sheffield, United Kingdom
| |
Collapse
|
7
|
Carucci L, Coppola S, Luzzetti A, Voto L, Giglio V, Paparo L, Nocerino R, Berni Canani R. Immunonutrition for Pediatric Patients With Cow's Milk Allergy: How Early Interventions Could Impact Long-Term Outcomes. FRONTIERS IN ALLERGY 2021; 2:676200. [PMID: 35386962 PMCID: PMC8974760 DOI: 10.3389/falgy.2021.676200] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 05/18/2021] [Indexed: 12/25/2022] Open
Abstract
Cow's milk allergy (CMA) is one of the most common food allergies and one of the main causes of food-induced anaphylaxis in the pediatric age. Moreover, up to 45% of CMA children develop other atopic manifestations later in life, a phenomenon commonly named atopic march. Thus, CMA imposes a significant cost to health care systems as well as to families, and has emerged as one of the most expensive allergic diseases. The immunonutrition strategy builds its foundation on the ability of selected dietary factors to modulate immune system development and function. Recent studies highlighted the potential of immunonutrition in the management of CMA. This review is focused on the mechanisms and long-term clinical outcomes of the immunonutrition approach in children with CMA.
Collapse
Affiliation(s)
- Laura Carucci
- Department of Translational Medical Science, University of Naples Federico II, Naples, Italy
- ImmunonutritionLab at the CEINGE Advanced Biotechnologies Research Center, University of Naples Federico II, Naples, Italy
- *Correspondence: Laura Carucci
| | - Serena Coppola
- Department of Translational Medical Science, University of Naples Federico II, Naples, Italy
- ImmunonutritionLab at the CEINGE Advanced Biotechnologies Research Center, University of Naples Federico II, Naples, Italy
| | - Anna Luzzetti
- Department of Translational Medical Science, University of Naples Federico II, Naples, Italy
- ImmunonutritionLab at the CEINGE Advanced Biotechnologies Research Center, University of Naples Federico II, Naples, Italy
| | - Luana Voto
- Department of Translational Medical Science, University of Naples Federico II, Naples, Italy
- ImmunonutritionLab at the CEINGE Advanced Biotechnologies Research Center, University of Naples Federico II, Naples, Italy
| | - Veronica Giglio
- Department of Translational Medical Science, University of Naples Federico II, Naples, Italy
- ImmunonutritionLab at the CEINGE Advanced Biotechnologies Research Center, University of Naples Federico II, Naples, Italy
| | - Lorella Paparo
- Department of Translational Medical Science, University of Naples Federico II, Naples, Italy
- ImmunonutritionLab at the CEINGE Advanced Biotechnologies Research Center, University of Naples Federico II, Naples, Italy
| | - Rita Nocerino
- Department of Translational Medical Science, University of Naples Federico II, Naples, Italy
- ImmunonutritionLab at the CEINGE Advanced Biotechnologies Research Center, University of Naples Federico II, Naples, Italy
| | - Roberto Berni Canani
- Department of Translational Medical Science, University of Naples Federico II, Naples, Italy
- ImmunonutritionLab at the CEINGE Advanced Biotechnologies Research Center, University of Naples Federico II, Naples, Italy
- European Laboratory for the Investigation of Food-Induced Diseases, University of Naples Federico II, Naples, Italy
- Task Force for Microbiome Studies, University of Naples Federico II, Naples, Italy
| |
Collapse
|
8
|
Guest JF, Singh H. Cost-effectiveness of using an extensively hydrolyzed casein formula supplemented with Lactobacillus rhamnosus GG in managing IgE-mediated cow's milk protein allergy in the UK. Curr Med Res Opin 2019; 35:1677-1685. [PMID: 31025591 DOI: 10.1080/03007995.2019.1612339] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Objective: To estimate the cost-effectiveness of using an extensively hydrolyzed casein formula (eHCF) plus the probiotic Lactobacillus rhamnosus GG (eHCF plus LGG; Nutramigen* LGG®) compared to an eHCF alone as first-line dietary management for Immunoglobulin E (IgE)-mediated cow's milk protein allergy (CMPA) in the UK. Methods: Decision modelling was undertaken to estimate the probability of IgE-mediated cow's milk allergic infants being symptom free (i.e. not experiencing urticaria, eczema, asthma or rhinoconjunctivitis) and developing tolerance to cow's milk by 5 years. The model also estimated the cost (at 2016/2017 prices) of healthcare resource use funded by the UK's National Health Service (NHS) over 5 years after starting a formula, as well as the relative cost-effectiveness of the two dietary formulae. Results: At 5 years after the start of a formula the probability of being symptom free was estimated to be 0.97 and 0.76 among infants who were originally fed eHCF plus LGG and an eHCF alone, respectively. This encompassed the probability of children being asthma free at 5 years after the start of treatment, which was 0.99 and 0.91 in the eHCF plus LGG and eHCF alone groups, respectively. Additionally, the probability of acquiring tolerance to cow's milk was estimated to be 0.94 and 0.66 among infants who were originally fed eHCF plus LGG and an eHCF alone, respectively. The estimated total healthcare cost over 5 years of initially feeding infants with eHCF plus LGG was less than that of feeding infants with an eHCF alone (£4229 versus £5136 per patient). Conclusions: First-line management of newly diagnosed infants with IgE-mediated CMPA with eHCF plus LGG instead of an eHCF alone improves outcome, releases healthcare resources for alternative use, reduces the NHS cost of patient management and thereby affords a cost-effective dietetic strategy to the NHS.
Collapse
Affiliation(s)
- Julian F Guest
- Catalyst Consultants , Rickmansworth , UK
- Faculty of Life Sciences and Medicine, King's College , London , UK
| | | |
Collapse
|
9
|
Guest JF, Kobayashi RH, Mehta V, Neidich G. Cost-effectiveness of using an extensively hydrolyzed casein formula containing Lactobacillus rhamnosus GG in managing infants with cow's milk allergy in the US. Curr Med Res Opin 2018; 34:1539-1548. [PMID: 29098889 DOI: 10.1080/03007995.2017.1400962] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To estimate the cost-effectiveness of using an extensively hydrolyzed casein formula containing the probiotic Lactobacillus rhamnosus GG (eHCF + LGG; Nutramigen LGG) compared with an eHCF alone and an amino acid formula (AAF) in treating cow's milk allergy (CMA) in the US, from the perspective of third-party insurers and from parents. METHODS A decision model was used to estimate the probability of cow's milk allergic infants developing tolerance to cow's milk by 18 months. The model also estimated the cost to insurers and parents (US dollars at 2016 prices) of managing infants over 18 months after starting one of the formulae, as well as the relative cost-effectiveness of each of the formulae. RESULTS The probability of developing tolerance to cow's milk was higher among infants who were fed eHCF + LGG compared with those fed an eHCF alone or an AAF. Infants who are initially fed with eHCF + LGG are expected to utilize fewer healthcare resources than those fed with one of the other formulae. Hence, the estimated total healthcare cost incurred by third-party insurers and parents of initially feeding infants with eHCF + LGG was less than that of feeding infants with an eHCF alone or an AAF. CONCLUSION Initial management of newly-diagnosed cow's milk allergic infants with eHCF + LGG was found to afford a cost-effective strategy to both third-party insurers and parents when compared to an eHCF alone or an AAF.
Collapse
Affiliation(s)
- Julian F Guest
- a Catalyst Health Economics Consultants , Rickmansworth, Hertfordshire , UK
- b Faculty of Life Sciences and Medicine , King's College , London , UK
| | | | - Vinay Mehta
- d Allergy, Asthma & Immunology Associates , PC , Lincoln , NE , US
| | - Gary Neidich
- e Sanford Children's Clinic and Sanford School of Medicine of the University of South Dakota , Sioux Falls , SD , USA
| |
Collapse
|
10
|
Sekerel BE, Seyhun O. Expert panel on practice patterns in the management of cow's milk protein allergy and associated economic burden of disease on health service in Turkey. J Med Econ 2017; 20:923-930. [PMID: 28602101 DOI: 10.1080/13696998.2017.1342171] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
AIMS To evaluate practice patterns in the management of cow's milk protein allergy (CMPA) and associated economic burden of disease on health service in Turkey. MATERIALS AND METHODS This study was based on experts' views on the practice patterns in management of CMPA manifesting with either proctocolitis or eczema symptoms and, thereby, aimed to estimate economic burden of CMPA. Practice patterns were determined via patient flow charts developed by experts using the modified Delphi method for CMPA presented with proctocolitis and eczema. Per patient total 2-year direct medical costs were calculated, including cost items of physician visits, laboratory tests, and treatment. RESULTS According to the consensus opinion of experts, 2-year total direct medical cost from a payer perspective and societal perspective was calculated to be $US2,116.05 and $US2,435.84, respectively, in an infant with CMPA presenting with proctocolitis symptoms, and $US4,001.65 and $US4,828.90, respectively, in an infant with CMPA presenting with eczema symptoms. Clinical nutrition was the primary cost driver that accounted for 89-92% of 2-year total direct medical costs, while the highest total direct medical cost estimated from a payer perspective and societal perspective was noted for the management of an exclusively formula-fed infant presenting either with proctocolitis ($US3,743.85 and $US4,025.63, respectively) or eczema ($US6,854.10 and $US7,917.30, respectively). The first line use of amino acid based formula (AAF) was associated with total direct cost increment $US1,848.08 and $US3,444.52 in the case of proctocolitis and eczema, respectively. LIMITATIONS Certain limitations to this study should be considered. First, being focused only on direct costs, the lack of data on indirect costs or intangible costs of illness seems to be a major limitation of the present study, which likely results in a downward bias in the estimates of the economic cost of CMPA. Second, given the limited number of studies concerning epidemiology and practice patterns in CMPA in Turkey, use of expert clinical opinion of the panel members rather than real-life data on practice patterns that were used to identify direct medical costs might raise a concern with the validity and reliability of the data. Also, while this was a three-step study with six experts included in the first stage (developing local guidelines for diagnosis, treatment, and follow-up of infants with CMPA in Turkey) and 410 pediatricians included in the second stage (a cross-sectional questionnaire-survey to determine pediatricians' awareness and practice of CMPA in infants and children), only four members were included in the present Delphi panel, which allows a limited discussion. Third, lack of sensitivity analyses and exclusion of indirect costs and costs related to alterations in quality of life, behavior of infants, and general well-being of infants and their parents from the cost-analysis seems to be another limitation that may have caused under-estimation of relative cost-effectiveness of the formulae. Fourth, calculation of costs per local guidelines rather than real-life practice patterns is another limitation that, otherwise, would extend the knowledge achieved in the current study. Notwithstanding these limitations, the present expert panel provided practice patterns in the management of CMPA and an estimate of the associated costs, depending on the symptom profile at initial admission for the first time in Turkey. CONCLUSIONS In conclusion, in providing the first health economic data on CMPA in Turkey, the findings revealed that CMPA imposes a substantial burden on the Turkish healthcare system from both a payer perspective and societal perspective, and indicated clinical nutrition as a primary cost driver. Management of infants presenting with eczema, exclusively formula-fed infants, and first line use of AAF were associated with higher estimates for 2-year direct medical costs.
Collapse
Affiliation(s)
- Bulent Enis Sekerel
- a Department of Pediatric Allergy and Asthma , Hacettepe University Faculty of Medicine , Ankara , Turkey
| | - Oznur Seyhun
- b ISPOR Nutrition Economics Special Working Group (NESWG) member of leadership
- c Abbott Laboratories , Istanbul , Turkey
| |
Collapse
|
11
|
Morais MBD, Spolidoro JV, Vieira MC, Cardoso AL, Clark O, Nishikawa A, Castro APM. Amino acid formula as a new strategy for diagnosing cow's milk allergy in infants: is it cost-effective? J Med Econ 2016; 19:1207-1214. [PMID: 27441755 DOI: 10.1080/13696998.2016.1211390] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
AIMS To estimate the cost-effectiveness of a new strategy that uses an amino acid formula in the elimination diet of infants with suspected cow's milk allergy (CMA). MATERIALS AND METHODS This pharmacoeconomic study was developed from the perspective of the Brazilian Public Healthcare System. The new strategy proposes using an amino acid formula in the diagnostic elimination diet of infants (≤24 months) with suspected CMA. The rationale is that infants who do not respond to the amino acid formula do not suffer from CMA. Patients with a positive oral challenge test receive a therapeutic elimination diet based on Brazilian Food Allergy Guidelines. This approach was compared to the current recommendations of the Brazilian Food Allergy Guidelines. A decision model was constructed using TreeAge Pro 2012 software. Model inputs were based on a literature review and the opinions of a panel of experts. A univariate sensitivity analysis of incremental cost-effectiveness ratios was performed. RESULTS The mean cost per patient of the new amino acid formula strategy was R$3,341.57, while the cost of the current Brazilian guidelines strategy was R$3,641.08. The mean number of symptom-free days per patient, which was used as an indicator of effectiveness, was 900.6 and 875.7 days, respectively. The new strategy is, therefore, dominant. In the sensitivity analysis, the dominance was maintained with parameter variation. LIMITATIONS In the absence of information in the literature, some premises were defined by a panel of specialists. CONCLUSIONS The new strategy, which uses an amino acid formula in the elimination diagnostic diet followed by an oral food challenge, is a dominant pharmacoeconomic approach that has a lower cost and results in an increased number of symptom-free days.
Collapse
Affiliation(s)
| | - José Vicente Spolidoro
- b School of Medicine - Pontifical University of Rio Grande do Sul (PUCRS) , Porto Alegre , Brazil
- c Hospital Moinhos de Vento , Porto Alegre , RS , Brazil
| | - Mário César Vieira
- d School of Medicine - Pontifical University of Paraná (PUCPR) , Curitiba , Brazil
- e Hospital Pequeno Príncipe, Curitiba , Brazil
| | - Ary Lopes Cardoso
- f Instituto da Criança, Hospital das Clínicas, Universidade de São Paulo , São Paulo , Brazil
| | - Otavio Clark
- g Evidencias - a Kantar Health Company, Campinas , Brazil
| | | | | |
Collapse
|
12
|
Guest JF, Yang AC, Oba J, Rodrigues M, Caetano R, Polster L. Relative cost-effectiveness of using an extensively hydrolyzed casein formula in managing infants with cow's milk allergy in Brazil. CLINICOECONOMICS AND OUTCOMES RESEARCH 2016; 8:629-639. [PMID: 27799804 PMCID: PMC5076537 DOI: 10.2147/ceor.s113448] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Objective To 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. Methods Decision 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. Results The 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. Conclusion Within 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.
Collapse
Affiliation(s)
- Julian F Guest
- Catalyst Health Economics Consultants, Northwood, Middlesex, UK; Faculty of Life Sciences and Medicine, King's College, London, UK
| | - Ariana C Yang
- Universidade de São Paulo, São Paulo & Universidade Estadual de Campinas, São Paulo, Brazil
| | - Jane Oba
- Hospital Israelita Albert Einstein, São Paulo, Brazil & Hospital Municipal Menino Jesus, São Paulo, Brazil
| | - Maraci Rodrigues
- Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil
| | | | | |
Collapse
|
13
|
Guest JF, Weidlich D, Kaczmarski M, Jarocka-Cyrta E, Kobelska-Dubiel N, Krauze A, Sakowska-Maliszewska I, Zawadzka-Krajewska A. Relative cost-effectiveness of using an extensively hydrolyzed casein formula containing the probiotic Lactobacillus rhamnosus GG in managing infants with cow's milk allergy in Poland. CLINICOECONOMICS AND OUTCOMES RESEARCH 2016; 8:307-16. [PMID: 27418845 PMCID: PMC4934487 DOI: 10.2147/ceor.s105748] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective To estimate the cost-effectiveness of using an extensively hydrolyzed casein formula (eHCF) containing the probiotic Lactobacillus rhamnosus GG (eHCF + LGG; Nutramigen LGG) as an initial treatment for cow’s milk allergy compared with eHCF alone and amino acid formulas (AAF) in Poland from the perspective of the Polish National Health Fund (Narodowy Fundusz Zdrowia [NFZ]) and parents. Methods Decision modeling was used to estimate the probability of cow’s milk allergic infants developing tolerance to cow’s milk by 18 months. The model also estimated the cost to the NFZ and parents (Polish Zloty [PLN] at 2013–2014 prices) for managing infants over 18 months after starting one of the formulas as well as the relative cost-effectiveness of each of the formulas. Results The probability of developing tolerance to cow’s milk by 18 months was higher among infants who were fed eHCF + LGG (0.82) compared with those fed eHCF alone (0.53) or an AAF (0.22). An infant who is initially managed with eHCF + LGG is expected to consume fewer health care resources than infants managed with the other formulas. Hence, the estimated total health care cost incurred by the NFZ for initially feeding infants with eHCF + LGG (PLN 5,693) was less than that of feeding infants with eHCF alone (PLN 7,749) or an AAF (PLN 24,333). However, the total cost incurred by parents for initially feeding infants with an AAF (PLN 815) was marginally less than that of feeding with eHCF + LGG (PLN 993), which was less than that of feeding with eHCF alone (PLN 1,226). Conclusion Using eHCF + LGG instead of eHCF alone or an AAF for first-line management of newly diagnosed infants with cow’s milk allergy affords a cost-effective use of NFZ-funded resources, since it improves outcome for less cost. Whether eHCF + LGG would be viewed as being cost-effective by parents is dependent on their willingness to pay an additional cost for additional tolerance acquisition to cow’s milk.
Collapse
Affiliation(s)
- Julian F Guest
- Catalyst Health Economics Consultants, Northwood, Middlesex; Faculty of Life Sciences and Medicine, King's College, London, UK
| | - Diana Weidlich
- Catalyst Health Economics Consultants, Northwood, Middlesex
| | - Maciej Kaczmarski
- Department of Pediatrics, Gastroenterology, and Allergology, Medical University of Bialystok, Białystok
| | - Elzbieta Jarocka-Cyrta
- Uniwersytet Warmińsko-Mazurski, Wydział Nauk Medycznych, Katedra Pediatrii Klinicznej, Olsztyn
| | - Natalia Kobelska-Dubiel
- Department of Pediatric Gastroenterology and Metabolic Diseases, Poznań University of Medical Sciences, Poznań
| | | | | | - Anna Zawadzka-Krajewska
- Department of Pediatric Pneumonology and Allergology, Medical University of Warsaw, Warsaw, Poland
| |
Collapse
|