Identifying Region-Specific Allergy Sensitization Clusters to Optimize Diagnosis and Reduce Costs.

OBJECTIVE: To delineate quantitatively the allergen sensitization patterns in a large pediatric cohort and inform the selection of a region-specific panel of allergen tests for timely and cost-effective in vitro atopy screening. STUDY DESIGN: IgE levels for specific allergens from patients in the Texas Children's Health System were analyzed retrospectively. Statistical and network analyses were conducted to reveal sensitization patterns. RESULTS: Network analysis of 114 distinct allergens among 12 065 patients identified 2 main groups of allergens: environmental and food. Approximately 67.5% of patients were sensitized to environmental allergens, 47.2% to food allergens, and 7.3% to at least 1 allergen from both groups. We identified a novel panel of 13 allergens that could detect sensitization in 95% of patients, whereas panels of 7 allergens within each category effectively identified sensitization in 95% of patients with specific sensitivities. This data-driven approach is estimated to reduce overall testing costs by 52%. In agreement with literature, we observed correlations among allergens within specific categories, such as pollen, shellfish, nuts, and dairy allergens. CONCLUSIONS: This study provides insights into allergen sensitization patterns informing an algorithmic testing approach tailored for primary care settings. The use of a region and population-specific test panel can efficiently identify atopy, leading to more targeted testing. This strategy has the potential to refine laboratory testing, reduce costs, and improve the appropriateness of referrals to allergy specialists, ultimately enhancing diagnostic accuracy and resource allocation.

The Finnish Allergy Program 2008-2018: Society-wide proactive program for change of management to mitigate allergy burden.

A 10-year national program to improve prevention and management of allergic diseases and asthma was implemented in Finland (population 5.5. million) in 2008-2018. The main aim was to reduce the long-term burden of these conditions. The strategy was changed from traditional avoidance to tolerance and resilience of the population. Health was endorsed instead of medicalization of mild symptoms. Disease severity was reevaluated, and disabling clinical manifestations were given high priority. For health care, 5 quantitative goals and 1 qualitative goal were set. For each of the goals, specific tasks, tools, and outcome evaluation were stipulated. During the program, 376 educational sessions gathered 24,000 health care participants. An information campaign targeted the lay public, and social media was used to contact people. In the 10 years of the program, the prevalence of allergic diseases and asthma leveled off. Asthma caused fewer symptoms and less disability, and 50% fewer hospital days. Food allergy diets in day care and schools decreased by half. Occupational allergies were reduced by 45%. In 2018, the direct and indirect costs of allergic diseases and asthma ranged from €1.5 billion to €1.8 billion, with the 2018 figures being 30% less than in the respective figures in 2007. The Finnish proactive and real-world intervention markedly reduced the public health burden of allergic disorders. The allergy paradigm was revisited to improve management with systematic education.

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.

A scoping review of the caregiver burden of pediatric food allergy.

OBJECTIVE: Although a number of articles have described the psychosocial impact of raising a child with a food allergy, recent attempts at synthesizing this literature have been narrow in focus or methodologically limited. Consequently, this study aimed to synthesize both the quantitative and qualitative literature to achieve a better understanding of the psychosocial and financial burdens faced by families who raise children with food allergy. DATA SOURCES: Searches were performed on PubMed, Scopus, PsycInfo, and Cumulative Index to Nursing and Allied Health Literature databases for articles related to the psychosocial and financial burden experienced by individuals who care for a child with food allergy. STUDY SELECTIONS: English language, original research articles were included in this review. RESULTS: A total of 54 articles were deemed eligible for review. Results from the quantitative literature revealed that parents of children with food allergy (ie, food allergy and food protein-induced enterocolitis, proctocolitis, and enteropathy) consistently reported lower quality of life than their comparison groups. Within-group analyses suggest that this burden is increased for parents who manage multiple food allergies, severe food allergy, and comorbid allergic conditions. Thematic synthesis of the qualitative literature suggests that the psychosocial burden shouldered by parents of children with food allergy stems, in part, from the unpredictable threat of exposure and the practical and social burdens of managing a food allergy. In addition to psychosocial burdens, a small but growing body of literature suggests that families with food allergy also incur greater financial costs. CONCLUSION: Findings suggest that pediatric food allergy imposes considerable burdens on parents both quantitatively and qualitatively.

Milk allergy most burdensome in multi-food allergic children.

BACKGROUND: Food allergy is a substantial health burden, which disproportionately affects children. Among children with food allergy, as many as 70% have multiple food allergies. Whereas the overall burden of food allergy on quality of life has been described, little is known about the burden of individual allergens. We aimed to examine the perception of burden among families with multiple food-allergic children. METHODS: Parents of children with 1 + children with multiple food allergies including milk responded to online questions, including both open-ended and closed-ended questions on food allergy-related burdens of time, financial costs, social restrictions, and emotional demands. RESULTS: Overall, 64 children (69.8% boys) of whom (73.0%) most were aged 10 and younger were included. Most had been diagnosed with food allergy in infancy and by a (pediatric) allergist. Other common allergies included peanut (65.6%), tree nuts (57.8%), egg (76.6%), and sesame (31.3%). Quantitatively, milk allergy was reported as carrying the most burden, including most socially limiting (81.5%), requiring the most planning (75.9%), causing the most anxiety (68.5%), most challenging to find "safe" or allergy-friendly foods (72.2%), and costly (81.5%). Qualitatively, we identified five themes that captured burdens associated with costs, marketing of milk products to children, risk of cross-contamination, ubiquity of milk/dairy and public confusion with lactose intolerance, and an unwillingness of others to accommodate the allergy. CONCLUSION: Parents whose children have multiple food allergies, including milk, report milk as the allergy associated with the greatest time, financial, social, and emotional burdens.

Structured intervention plan including component-resolved diagnostics helps reducing the burden of food allergy among school-aged children.

BACKGROUND: Food allergies can substantially burden patients and families by negatively affecting finances, social relationships, and personal perceptions of health. This study was performed under the Finnish Allergy Programme aimed at reducing avoidance diets to foods in schoolchildren by 50%. The main goal of this study was to investigate how many children could be freed from diet restrictions in a Finnish school district through a diagnostic algorithm including component-resolved diagnostics and food challenge. The secondary aim was to provide a crude estimate of the burden of the elimination food diets in the region, and the savings associated with the proposed intervention. METHODS: A total of 205 children on a food avoidance diet according to the school register because of food allergy were invited into the study. One hundred and fifty-seven children were interviewed, tested for IgE to extracts and allergen components and food challenged in respective order. RESULTS: After two years, 12 children still had an avoidance diet and three of them were treated successfully with sOTI; the rest suspended their avoidance diet (n = 134) or dropped out of the study (n = 11). The cost of the elimination diets was estimated in 172 700€ per year at start and 13 200€ per year at the end of the study; total savings were 128 400€ yearly. CONCLUSIONS: The results demonstrate a 65% reduction of avoidance diets to foods in school-aged children, exceeding the 50% aim of the Finnish Allergy Programme. Therefore, it is possible to actively reduce the number of food allergy diagnoses that remain unmonitored in the society through a tailored diagnostic work-up.

Economic burden of food allergy: A systematic review.

OBJECTIVE: To assess the economic burden of food allergy (FA) worldwide. DATA SOURCES: PubMed MEDLINE, Embase, and Cochrane Central Register of Controlled Trials on the Wiley platform were searched to identify literature that assessed direct, out-of-pocket, and opportunity costs of FA. All databases were searched back to their inception, and no language or date limits were applied. STUDY SELECTIONS: We included primary studies that examined direct medical, out-of-pocket, or opportunity costs and/or lost labor productivity in food allergic adults and/or children and their families. RESULTS: Eleven papers met our inclusion criteria, of which ed7 addressed direct medical, 7 addressed out-of-pocket, and 5 addressed opportunity costs. Estimates were based on data that reflected costs for a patient with FA (individual level) or costs for a household with a food allergic patient (household level). The mean individual-level direct medical costs ($2081) were much higher than the mean household-level costs ($806). The mean individual-level out-of-pocket ($1874) and opportunity ($1038) and opportunity cost were lower than the mean household-level out-of-pocket ($3339) and opportunity ($4881) costs. Household-level estimates of lost opportunity costs imposed the largest economic burden attributable to FA. CONCLUSION: Most of the economic burden studies reviewed measured components of economic burden that are unique to individuals with FA but did so in noncomparable ways. Addressing cost burdens and measuring them using standardized instruments and methods will be critical to better understand the economic burden of FA globally.

Providing cost-effective care for food allergy.

OBJECTIVE: To review the cost-effectiveness of food allergy management strategies. DATA SOURCES AND STUDY SELECTIONS: A narrative review and synthesis of literature identified using a PubMed search of relevant articles describing cost-effectiveness evaluations of food allergy management. RESULTS: Screening at-risk infants for peanut allergy carries risk of overdiagnosis and is not cost-effective. Evidence suggests that cost-effective care could be better optimized by minimizing delay in oral food challenges for eligible patients, clarifying the role of precautionary allergen labeling, incorporating patient-preference sensitive care in activation of emergency medical services for resolved allergic reactions, and considering value-based pricing and school-supply models for epinephrine. Finally, the annual value-based cost (willingness to pay [WTP] $100,000/quality-adjusted life years [QALY]) of peanut immunotherapy has been estimated to be between $1568 and $6568 for epicutaneous immunotherapy (EPIT) and between $1235 and $5235 for probiotic with peanut oil immunotherapy (POIT), with each therapy showing more favorable cost-effectiveness with greater improvements in health utility, particularly if sustained unresponsiveness can be achieved. CONCLUSION: Many aspects of food allergy management are not cost-effective, and recent evaluations suggest a greater role for incorporating patient and family preferences into guideline-based and traditionally reflexive management decisions. Caregiver understanding of food allergy screening tradeoffs is critical, given that screening children before allergen exposure has significant costs and results in overdiagnosis, especially when oral food challenges are omitted from diagnostic algorithms. Cost-effectiveness analysis can help to identify important decision levers in patient management across a wide range of topics. Further research is needed to better understand health state utilities of specific patient populations.

Health economic analysis of allergen immunotherapy for the management of allergic rhinitis, asthma, food allergy and venom allergy: A systematic overview.

BACKGROUND: The European Academy of Allergy and Clinical Immunology (EAACI) is developing guidelines for allergen immunotherapy (AIT) for the management of allergic rhinitis, allergic asthma, IgE-mediated food allergy and venom allergy. To inform the development of clinical recommendations, we undertook systematic reviews to critically assess evidence on the effectiveness, safety and cost-effectiveness of AIT for these conditions. This study focusses on synthesizing data and gaps in the evidence on the cost-effectiveness of AIT for these conditions. METHODS: We produced summaries of evidence in each domain, and then, synthesized findings on health economic data identified from four recent systematic reviews on allergic rhinitis, asthma, food allergy and venom allergy, respectively. The quality of these studies was independently assessed using the Critical Appraisal Skills Programme tool for health economic evaluations. RESULTS: Twenty-three studies satisfied our inclusion criteria. Of these, 19 studies investigated the cost-effectiveness of AIT in allergic rhinitis, of which seven were based on data from randomized controlled trials with economic evaluations conducted from a health system perspective. This body of evidence suggested that sublingual immunotherapy (SLIT) and subcutaneous immunotherapy (SCIT) would be considered cost-effective using the (English) National Institute for Health and Clinical Excellence (NICE) cost-effectiveness threshold of £20 000/quality-adjusted life year (QALY). However, the quality of the studies and the general lack of attention to characterizing uncertainty and handling missing data should be taken into account when interpreting these results. For asthma, there were three eligible studies, all of which had significant methodological limitations; these suggested that SLIT, when used in patients with both asthma and allergic rhinitis, may be cost-effective with an incremental cost-effectiveness ratio (ICER) of £10 726 per QALY. We found one economic modelling study for venom allergy which, despite being based largely on expert opinion and plausible assumptions, suggested that AIT for bee and wasp venom allergy is only likely to be cost-effective for very high-risk groups who may be exposed to multiple exposures to venom/year (eg bee keepers). We found no eligible studies investigating the cost-effectiveness of AIT for food allergy. CONCLUSIONS: Overall, the evidence to support the cost-effectiveness of AIT is limited and of low methodological quality, but suggests that AIT may be cost-effective for people with allergic rhinitis with or without asthma and in high-risk subgroups for venom allergy. We were unable to draw any conclusions on the cost-effectiveness of AIT for food allergy.

National allergy programme had little impact on parent-reported food allergies in children aged 6-7 years.

AIM: The ten-year Finnish national allergy programme was launched in 2008 to lessen the disease and psychological burden of allergy. This study assessed the prevalence of parent-reported food allergies requiring avoidance diets at primary school in children aged six and seven years. METHODS: The cohort comprised 1937 children (51% boys) who started primary school in Tampere, Finland, in August 2016. School health nurses charted parent-reported, doctor-diagnosed food allergies requiring avoidance diets as part of the routine health examination. RESULTS: We found that 127 (6.6%) children had parent-reported, doctor-diagnosed allergies to at least one food and 37 (1.9%) were allergic to basic foods, namely cows' milk, wheat and one other grain. All required an avoidance diet. The figure did not differ significantly from the 2.7% and 2.5% found by studies of this age group in 2009 and 2013, respectively. Allergies to fresh fruit and vegetables decreased from 5.8% in 2009 to 3.6% in 2016. CONCLUSION: We studied the national allergy programme that started in 2008 and found that there was a nonsignificant overall decrease in the number of children aged six to seven years on avoidance diets for allergies between 2009 and 2016. The only allergies that showed significant decreases were fresh fruit and vegetables.

Patient-Centered Outcomes in Food Allergy.

PURPOSE OF REVIEW: Food allergy prevalence is increasing very rapidly, causing a significant disease burden. The threat of severe allergic reactions occurring unexpectedly and in settings that are not equipped to recognize and treat anaphylaxis is a constant source of worry for individuals and families with food allergies. Inadequate knowledge and understanding in the community significantly impairs the overall quality of life of these individuals and families. Additionally, families face challenges in finding and affording appropriate allergen-free foods. RECENT FINDINGS: Advancements have been made in understanding the impact of food allergies on patient-centered outcomes such as quality of life and economic impact, and attempts have been made to develop tools to assess patient-centered variables. Innovative national and regional initiatives are helping to spread awareness of the disease condition and to create resources, including access to allergen-free foods. While there is a growing momentum toward recognition of food allergic disorders as a condition that profoundly impacts activities of daily living, greater effort needs to be expounded to develop validated tools and interventions that can adequately address these issues.

The emotional, social, and financial burden of food allergies on children and their families.

BACKGROUND: As the prevalence of food allergy has risen among children and young adults, both in the United States and around the world, investigators have become increasingly aware of the daily emotional toll on patients and their families of living with food allergy. OBJECTIVE: To review the literature regarding the emotional, social, and financial impact of food allergy on pediatric patients and their families, and to provide evidence-based suggestions for clinicians on how to most effectively address these issues. METHODS: A literature search was performed to identify relevant articles related to the emotional, social, and financial impact of food allergy. RESULTS: There is a growing body of literature that demonstrates that living with food allergy adversely affects patients and families in the domains above. CONCLUSION: Food allergy can significantly impact pediatric patients and their families in all areas of their lives. Clinicians should be aware of these issues when working with these families. Implementing a multidisciplinary approach can help families cope with emotional, social, and financial burdens.

Food allergen panel testing often results in misdiagnosis of food allergy.

OBJECTIVE: To determine the utility of food allergy panel testing among patients referred to a pediatric food allergy center. STUDY DESIGN: Retrospective chart review of all new patients seen between September 2011 and December 2012 by 1 provider in a tertiary referral pediatric food allergy center. A cost analysis was performed to calculate the estimated cost of evaluation for patients who have received a food allergy panel. RESULTS: Of 797 new patient encounters, 284 (35%) patients had received a food allergy panel. Only 90 (32.8%) individuals had a history warranting evaluation for food allergy; 126 individuals were avoiding a food based on recommendations from the referring provider and 112 (88.9%) were able to re-introduce at least 1 food into their diet. The positive predictive value of food allergy panel testing in this unselected population was 2.2%. The estimated cost of evaluation for this population was $79,412. CONCLUSIONS: Food allergy panel testing often results in misdiagnosis of food allergy, overly restrictive dietary avoidance, and an unnecessary economic burden on the health system.

Socioeconomic evaluation of well-characterized allergy to staple foods in adults.

BACKGROUND: The aim of the present study was to evaluate if total, direct, indirect, and intangible costs differ between a cohort of adults with well-characterized allergy to staple foods ('cases') and controls. METHODS: Swedish adults with objectively diagnosed food allergy to cow's milk, hen's egg, and/or wheat were recruited at an outpatient allergy clinic. Controls age- and sex-matched to cases were recruited from the same geographic area. For assessing the household costs of food allergy, a disease-specific socioeconomic questionnaire, developed within EuroPrevall, was utilized. RESULTS: Overall annual total costs at the household level were significantly higher among adults with food allergy compared with controls (the difference amounted to 8164 €), whereas direct costs did not differ between cases and controls. However, household healthcare costs and costs for medicines were significantly higher for cases vs controls. Furthermore, indirect costs were significantly higher for households with food-allergic adults vs households without food-allergic adults. Specifically, more time was spent on performing domestic tasks due to a family member's food-allergy-related illness, as well as shopping and preparing food, and seeking food-allergy-related information. Presence of food allergy also affected intangible costs. Adults with food allergy experienced overall lower health status compared with controls. CONCLUSIONS: Swedish adults with allergy to staple foods have higher total costs determined as direct, indirect, and intangible costs using the disease-specific socioeconomic questionnaire. Thus, total costs were 8164 € higher per year in households with at least one adult allergic to staple foods compared with controls.

The impact of double-blind placebo- controlled food challenge (DBPCFC) on the socioeconomic cost of food allergy in Europe.

BACKGROUND: Double-blind placebo controlled food challenge (DBPCFC) is the gold standard diagnostic test in food allergy because it minimizes diagnostic bias. OBJECTIVE: To investigate the potential effect of diagnosis on the socioeconomic costs of food allergy. METHODS: A prospective longitudinal cost analysis study was conducted in Spain and Poland within the EuroPrevall project. Food-allergic patients were enrolled into the study and in all cases diagnosis was confirmed through a standardized DBPCFC. Data were collected through a self-administered survey on all aspects of health and social care resource use, costs of living, and costs of leisure activities. Costs were measured before and 6 months after the DBPCFC and reported in international dollars with 2007 as the benchmark year. RESULTS: Forty-two patients were enrolled. Twenty-one patients had a negative DBPCFC and the suspected food was reintroduced into their diet. Comparing total direct costs before and after the DBPCFC, the reactive group spent a significantly higher amount (median increase of $813.1 over baseline), while the tolerant group's spending decreased by a median of $87.3 (P = .031). The amount of money spent on food 6 months after diagnosis was also significantly higher in the reactive group (P = .040). Finally, a larger, but not statistically significant, decrease in total indirect costs was observed in the tolerant group compared with the reactive group ($538.3 vs $32.3). CONCLUSION: DBPCFC has an impact on indirect and direct costs of living. The main contribution to this increase was money spent on food.

The Cost-Effectiveness of Omalizumab for Treatment of Food Allergy.

BACKGROUND: Omalizumab is an anti-IgE therapy newly approved by the Food and Drug Administration for allergen agnostic treatment of single or multiple food allergies in patients aged 1 year or older. OBJECTIVE: Evaluate the cost-effectiveness of omalizumab as a food allergy treatment. METHODS: We evaluated health and economic outcomes in Markov cohorts of simulated food allergic infants randomized to receive omalizumab using a 15-year horizon. Monte Carlo simulation was used (n = 40,000 subjects) to evaluate cost-effectiveness from a societal perspective, incorporating both a family-level and individual-level analysis. We included family-level analysis to incorporate a broad perspective for health utility change, given treatment effects likely benefit all parties at home (eg, caregivers, siblings), not just the patient, representing the sum of changes in all such persons. Supplemental analyses explored lower omalizumab cost and home initiation. We performed deterministic and probabilistic sensitivity analyses. RESULTS: In the family-level cohort analysis, omalizumab exceeded cost-effectiveness thresholds ($185,183/quality-adjusted life-years [QALY]). In a comparison of the omalizumab strategy (OMA) with the non-omalizumab strategy, the cost of OMA exceeded the non-omalizumab strategy ($315,020 vs $136,609) with greater incremental effectiveness (12.668 vs 11.699 QALY). In the individual-level analysis, the cost-effectiveness of OMA was $573,698/QALY. In base-case assessments, OMA was cost-effective (willingness to pay, $100,000/QALY) at a health state utility (HSU) improvement of 0.265. The value-based cost of OMA ranged from $14,166 to $23,791 when it was considered at the individual and family-unit levels. Requiring OMA administration in the clinic was not cost-effective (incremental cost-effectiveness ratio, $260,239). CONCLUSIONS: In the base case and at current pricing, omalizumab is not cost-effective, but it could be at a lower retail price or when use creates large health utility shifts in the family and patient.