A review of food allergy-related costs with consideration to clinical and demographic factors.

PURPOSE OF REVIEW: To provide an overview of the magnitude and sources of food allergy-related costs, with a particular emphasis on the recent literature. We also aim to identify clinical and demographic factors associated with differences in food allergy-related costs. RECENT FINDINGS: Recent research has expanded upon previous studies by making greater use of administrative health data and other large sample designs to provide more robust estimates of the financial burden of food allergy on individuals and the healthcare system. These studies shed new light on the role of allergic comorbidities in driving costs, and also on the high costs of acute food allergy care. Although research is still largely limited to a small group of high-income countries, new research from Canada and Australia suggests that the high costs of food allergy extend beyond the United States and Europe. Unfortunately, as a result of these costs, newly emerging research also suggests that individuals managing food allergy, may be left at greater risk of food insecurity. SUMMARY: Findings underscore the importance of continued investment in efforts aimed at reducing the frequency and severity of reactions, as well as programs designed towards helping offset individual/household level costs.

Changes in food-related costs during the COVID-19 pandemic among families managing food allergy.

Background: The COVID-19 pandemic has affected the supply, cost, and demand for certain foods, but it is not clear how these changes have affected food-allergic households. Objective: To describe the changes in food-related costs that have followed COVID-19, as reported by higher- and lower-income households with a food-allergic member. Methods: Between May 1-June 30, 2020, Canadian households, with at least one food-allergic member, completed an online survey on food shopping and preparation habits before and during the COVID-19 pandemic. The sample was divided into binary groups, either higher or lower than the sample median income. Data were analyzed using descriptive statistics and multiple regression. Results: The sample was comprised of 102 participants (i.e., 51/ income group). The three most common food allergies amongst both groups were peanuts, tree nuts and milk. Since the start of the pandemic, both groups reported greater monthly direct grocery costs, although costs amongst the higher-income group were twice as high as the lower-income group ($212.86 vs. $98.89, respectively). Indirect food preparation costs were similarly elevated. Higher-income households with food procurement difficulties reported increased indirect shopping costs following the outbreak of COVID-19, whereas those without such difficulties reported decreased costs. Lower-income households with allergies to milk, wheat, or eggs (i.e., staple allergy) experienced a larger change in indirect food preparation costs following the outbreak of COVID-19 relative to those with other food allergies ($244.58 vs. -$20.28, respectively; p = 0.03). Conclusion: Both higher and lower income households with food allergy reported greater direct food costs and indirect food preparation costs following the COVID-19. Households with staple allergy and those with difficulties finding their typical food items were particularly affected.

The Economic Burden of Food Allergy: What We Know and What We Need to Learn.

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.

The perceived impact of pediatric food allergy on mental health care needs and supports: A pilot study.

Background: Evidence suggests a mental health impact of food allergy on affected children and their families; however, little is known about health care professionals' understanding of these impacts and the resources available to patients and their families. Objective: Our aim was to conduct a pilot study examining health care professionals' perceptions of the psychosocial and financial burden of food allergy to identify gaps in education and resources and thus better support families with food allergy moving forward. Methods: Between February 20 and November 19, 2020, we conducted audiorecorded interviews (n = 6) and profession-specific focus groups (n = 2 [representing 7 individuals]). The participants included pediatric allergists, allergy nurse educators, and clinical dietitians who were directly involved in pediatric food allergy care. The interviews were recorded and transcribed verbatim. Thematic analysis was subsequently applied to identify the main themes. Results: Our study consisted of an interdisciplinary group of Manitoban health care providers (N = 13) who were directly involved with pediatric food allergy care. We identified 3 main themes from these interviews: anxiety among families with food allergy, which is a common comorbidity; limited resources available within current public infrastructure; and empowerment through education. These themes describe issues surrounding access to information and resources and how this can affect anxiety and parenting styles among families with food allergy. Conclusions: Health care professionals perceive that many families experience anxiety as a result of their child's food allergy. They further advocate that access to information and suitability of public resources be considered when planning for related programs.

Living with Food Hypersensitivity as an Adolescent Impairs Health Related Quality of Life Irrespective of Disease Severity: Results from a Population-Based Birth Cohort.

Food hypersensitivity (FHS) refers to food-related symptoms, with or without concurrent Immunoglobulin E (IgE) antibodies related to food(s). It remains unclear how different FHS phenotypes affect health-related quality of life (HRQoL). We examined self-reported HRQoL (with the generic instrument EQ-5D (dimensions and a Visual Analogue Scale (VAS), range 0-100) in association with phenotypes of FHS, and food-specific symptoms among adolescents (n = 2990) from a population-based birth cohort. Overall, 22% of the adolescents had FHS. Compared to adolescents without FHS, those with FHS reported more problems in the dimensions of pain/discomfort (p < 0.001), and anxiety/depression (p = 0.007). Females with FHS reported more problems than males in these dimensions (p < 0.001). Different FHS phenotypes (IgE-sensitization, allergic co-morbidity, and severity of symptoms) were not associated with differences in HRQoL. EQ-VAS scores were lowest for adolescents with symptoms for wheat vs. no wheat, median 80 vs. 89, p = 0.04) and milk vs. no milk (median 85 vs. 90, p = 0.03). Physician-diagnosed lactose intolerance median EQ-VAS was 80 vs. 90, p = 0.03 and also associated with more problems in the dimension of anxious/depression. In conclusion, FHS is associated with lower HRQoL in adolescence, irrespective of phenotypes, but differentially affects females vs. males, and those with vs. without symptoms for milk or wheat.

Supporting families to protect child health: Parenting quality and household needs during the COVID-19 pandemic.

BACKGROUND: Supportive parenting is critical for promoting healthy child development in the face of stressors, such as those occurring during COVID-19. Here, we address a knowledge gap regarding specific household risk factors associated with parenting quality during the pandemic and incorporate first-person accounts of family challenges and needs. METHODS: Mixed methods were applied to data collected between April 14th - 28th, 2020 from the "Parenting During the Pandemic" survey. Participants included 656 primary caregivers (e.g., mothers, fathers, foster parents) of least one child age 1.5-8 years of which 555 (84.6%) responded to at least one parenting questionnaire. Parenting quality was assessed across stressful, negative, and positive parenting dimensions. Household risk was examined across pandemic- linked (e.g., caregiver depression, unmet childcare needs) and stable factors (i.e., annual income, mental illness history). Significant correlates were examined with regressions in Mplus. Thematic analysis identified caregiver challenges and unmet needs from open-ended questions. FINDINGS: Caregiver depression, higher child parity, unmet childcare needs, and relationship distress predicted lower-quality parenting. Caregiver depression was the most significant predictor across every parenting dimension, with analyses indicating medium effect sizes, ds = .39 - .73. Qualitative findings highlighted severe strains on parent capacities including managing psychological distress, limited social supports, and too much unstructured time. INTERPRETATIONS: Lower quality parenting during COVID-19 is associated with multiple household and pandemic risk factors, with caregiver depression consistently linked to parent- child relationship disruptions. Focused efforts are needed to address caregiver mental health to protect child health as part of the pandemic response.

Social and financial impacts of food allergy on the economically disadvantaged and advantaged families: A qualitative interview study.

BACKGROUND: Differences in the qualitatively-perceived burden of food allergy based on economic disadvantages have not been previously described. OBJECTIVE: To describe the perceptions of food allergy-related social and financial issues of families who have a child with food allergy, considering the similarities and differences between economically advantaged and disadvantaged families. METHODS: From March to July 2019, we interviewed parents of children being followed up for food allergy at a tertiary allergy clinic in central Canada. Interviews were recorded, transcribed, and analyzed thematically. Economic groups were categorized on the basis of the national cutoffs for low-income after-tax dollars. RESULTS: We interviewed 18 parents (17 [94.4% mothers]) of whom 6 (33.3%) were economically disadvantaged, and who represented 25 children (10 [40.0%] girls) with food allergy. We identified 3 common themes: food allergy had (1) resulted in the need to teach others in addition to contributing to tensions in relationships; (2) increased time costs for food shopping and preparation; and (3) contributed to concerns securing qualified child care. We also identified 2 divergent themes that underscored how this burden was perceived between economic groups: (1) medications and medical appointments are costly or inconvenient; and (2) allergy-friendly food choices: single vs several sources and servings. CONCLUSION: Despite some qualitative similarities in the social and financial burdens of food allergy, there are some notable differences between economic groups that underscore the need for further discussions surrounding the related policy.

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.

The excess costs of childhood food allergy on Canadian families: a cross-sectional study.

BACKGROUND: The impact of childhood food allergy on household costs has not been examined in Canada. The current study sought to examine differences in direct, indirect, and intangible costs among Canadian families with and without a food-allergic child. METHODS: Families with a child with a specialist-diagnosed food allergy (cases) were recruited from two tertiary pediatric allergy clinics in the Province of Manitoba, Canada, and matched, based on age and sex, to families without a food-allergic child (controls). Cost data for the two groups were collected via an adapted version of the Food Allergy Economic Questionnaire (FA-EcoQ). Consideration was given to income, defined as above vs. below the provincial annual median income. RESULTS: Results from 35 matched case/control pairs revealed that while total household costs did not significantly differ between cases and controls, food-allergic families did incur higher direct costs ($12,455.69 vs. $10,078.93, p = 0.02), which were largely attributed to spending on food. In contrast, cases reported lower, but not statistically significant, total indirect costs compared to controls ($10,038.76 vs. $12,294.12, p = 0.06). Families also perceived their food-allergic child as having poorer quality of life relative to their healthy peers. Lastly, stratification of the analyses by annual income revealed several differences between the higher and lower income groups. CONCLUSIONS: Relative to families without a food-allergic child, food-allergic families incurred higher direct costs across a number of different areas.

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.

Household costs associated with objectively diagnosed allergy to staple foods in children and adolescents.

BACKGROUND: We previously reported that indirect and intangible costs burden households with a food allergic adult. We now extend our investigation to households with food allergic children and adolescents. OBJECTIVE: The objective of this study was to estimate direct, indirect, and intangible costs of food allergy in households with a child and/or adolescent with objectively diagnosed allergy to staple foods (cow's milk, hen's egg, and/or wheat), and to compare these costs with age- and sex-matched controls. METHODS: Direct and indirect cost parent-reported data collected via the Food Allergy Socio-Economic Questionnaire of 84 children (0-12 years) and 60 adolescents (13-17 years) with objectively diagnosed allergy to staple foods ("cases") and age- and sex-matched controls (n = 94 children; n = 56 adolescents) were compared. Annual household costs were calculated. Total household costs included direct plus indirect costs. Intangible costs included parent-reported health of their child and/or adolescent, standard of living, and perceptions of well-being. RESULTS: Amongst cases, total household costs were higher by €3961 for children and €4792 for adolescents versus controls (P < .05), and were driven by direct (eg, medications) and indirect (eg, time with health care professionals) costs. For children only, a history of anaphylaxis was associated with higher direct costs than no anaphylaxis (€13,016 vs €10,044, P < .05). Intangible costs (eg, parent-reported health of a child and/or adolescent) were significantly impacted amongst cases versus controls (P < .01). CONCLUSION: Households with a child and/or adolescent with objectively diagnosed allergy to staple foods have higher total household costs than controls. Direct and indirect costs were significantly higher for cases versus controls amongst children only. Amongst both age groups, such allergy adversely impacted intangible costs.