Determining Levers of Cost-effectiveness for Screening Infants at High Risk for Peanut Sensitization Before Early Peanut Introduction
Determining Levers of Cost-effectiveness for Screening Infants at High Risk for Peanut Sensitization Before Early Peanut Introduction
复制标题
DOI：
10.1001/jamanetworkopen.2019.18041
复制
发表时间：
2019-12-01
影响因子：
13.8
通讯作者：
Shaker, Marcus
中科院分区：
文献类型：
--
作者：
Greenhawt, Matthew;Shaker, Marcus
早期引入花生可以降低花生过敏的风险，特别是在高危婴儿中。目前美国的建议赞同筛选，但不符合成本效益相对于其他international strategies. ObjectiveTo identify scenarios in which current early peanut introduction guidelines would be cost-effective.设计，设置，和参与者这个模拟/队列经济评估使用马尔可夫模型中的微观模拟和队列分析来评估早期花生引进的成本效益，有和没有花生皮肤点刺试验（SPT）从社会的角度来看，在80年的时间里对高危婴儿进行筛查。分析了2019年4月至5月的数据。EXPOSURES患有早发性湿疹和/或鸡蛋过敏的高危婴儿在进行和不进行花生SPT筛查的情况下接受了早期花生引入（每种治疗策略100 000名婴儿），使用二分8 mm SPT临界值主要结果和指标成本，质量调整生命年（QHMS），净货币效益，花生过敏反应，严重的过敏反应，以及由于花生过敏而导致的死亡。结果在20万婴儿的模拟队列中，并在模型范围内使用基础病例，无筛查方法的平均（SD）成本较低（13 449美元[38 163美元]对15 279美元[38 995美元]）和更高的平均（SD）收益（29.25 [3.28] vs 29.23 [3.30]）vs筛选，但导致更多过敏反应（平均值[SD]，1.07 [3.15] vs 1.01 [3.02]），重度过敏反应（平均值[SD]，0.53 [1.66] vs 0.52 [1.62]）和涉及心肺功能损害的速发过敏反应（平均值[SD]，0.50 [1.59] vs 0.49 [1.47]）。在基础病例敏感性和特异性率的确定性SPT敏感性分析中，在家庭与诊所反应的高负效用率（食物过敏反应的负面影响）（76-148天的生命交换）下，筛查可能具有成本效益。在花生过敏高风险且尚未接触过花生的婴儿中，结合高基线花生过敏患病率。如果假设意外和指数过敏反应的发生率和负效用相同，并且8 mm SPT临界值具有0.85的敏感性和0.98的特异性，则在花生过敏患病率为36%的情况下，筛查具有成本效益。结论和相关性本研究的结果表明，目前早期引入花生的筛查方法在特定的健康用途中对于临床反应来说可能具有成本效益，高危婴儿中SPT敏感性和特异性以及高基线花生过敏患病率然而，这些条件不太可能在现实中实现。需要进一步的研究来定义与反应位置相关的健康状态效用。
IMPORTANCE 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.OBJECTIVE To identify scenarios in which current early peanut introduction guidelines would be cost-effective.DESIGN, SETTING, AND PARTICIPANTS 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.EXPOSURES 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).MAIN OUTCOMES AND MEASURES Cost, quality-adjusted life-years (QALYs), net monetary benefit, peanut allergic reactions, severe allergic reactions, and deaths due to peanut allergy.RESULTS 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%.CONCLUSIONS AND RELEVANCE 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.