Analysis of Value-Based Costs of Undesignated School Stock Epinephrine Policies for Peanut Anaphylaxis

Waheeda Samady; Ruchi Gupta

doi:10.1542/peds.2019-2461U

MS Shaker, MJ Greenhawt. JAMA Pediatr. 2019;173(2):169–175

Purpose of the Study:

To determine if laws that allow undesignated school stock epinephrine autoinjectors are cost-effective by defining value and cost of different school strategies.

Study Population:

Markov simulations of the Chicago Public Schools system were used over extended time horizons to model 2 school stock epinephrine autoinjector policies that provide access for students at risk for anaphylaxis at school. The dates of the data used in the analysis were September 2017 to June 2018 (the 2017–2018 school year).

Methods:

Researchers in this study compared the following 3 strategies: (1) no school epinephrine supply, in which the only devices available are personal autoinjectors provided by students with an allergic condition; (2) school undesignated supplemental epinephrine supply, in addition to student-supplied devices (supplemental model); and (3) school undesignated universal epinephrine supply, in which school-based devices supplant the need for student-supplied devices (universal model). Computer-based mathematical microsimulations (Markov simulations) were used to evaluate hypothetical cohorts of children with peanut allergy from kindergarten through high school graduation, with a continued horizon to age 80 years. The base-case model assumed a 10-fold reduced fatality risk with having undesignated stock epinephrine units available versus not having undesignated stock epinephrine units available. Costs of school stock epinephrine units available for acquisition by schools were evaluated from a societal perspective. Quality-adjusted life-years (QALYs) and total epinephrine acquisition expenses were calculated. These models were used because they can account for the annual costs and recurrent risks of peanut exposure and reactions.

Results:

The cost was $107 816 (95% confidence interval [CI]: $107 382–$108 250) for no school undesignated epinephrine supply compared with $108 160 (95% CI: $107 725–$108 595) for the supplemental model and $100 397 (95% CI: $99 979–$100 815) for the universal model. When comparing supplemental model stock epinephrine to the strategy without undesignated devices, the incremental cost-effectiveness ratio was high at $268 811 per QALY in the base-case simulation. However, the cost of the supplemental model fell to <$100 000 per QALY when the annual undesignated epinephrine acquisition costs did not exceed $338 per school (compared with stock epinephrine unavailability). The universal model dominated all others and was associated with significant cost savings ($7419 per student at risk who would otherwise be prescribed an individual school epinephrine supply).

Conclusions:

Undesignated school stock epinephrine is cost-effective if device acquisition costs do not exceed $338 per school per year, and a universal model versus a supplemental model is associated with superior health and economic outcomes.

Reviewer Comments:

Legislation to either permit or mandate school-based stock epinephrine programs has emerged to provide timely access to epinephrine for children, given that up to 8% of US children have food allergies and as many as 25% of first-time anaphylactic reactions occur in school. Currently, schools either have no designated stock epinephrine or supplemental epinephrine, where students are still asked to provide their own epinephrine autoinjectors. The authors argue that a universal model, in which all schools have stock epinephrine and do not require at-risk students to also provide autoinjectors, would achieve the desired health outcomes and is more cost-effective. This may reduce the cost burden on families and decrease the risk of further supply interruptions and shortages from pharmaceutical companies. However, although the universal model is cost-saving, there are important practical advantages to having students also carry their own designated individual epinephrine units because they would be available in close proximity daily, in transit to and from school (eg, on the school bus), on school field trips, and for after-school activities.