Relative cost-effectiveness of an extensively hydrolyzed casein formula containing the probiotic Lactobacillus rhamnosus GG in managing infants with cow’s milk allergy in Italy

Figures & data

Figure 1 Expected probability of infants developing tolerance to cow’s milk by 18 months after starting a formula.

Abbreviations: AAF, amino acid formula; eHCF, extensively hydrolyzed casein formula; HRF, hydrolyzed rice formula; LGG, Lactobacillus rhamnosus GG; SBF, soy-based formula.

Table 1 Expected levels of health care resource use and corresponding costs over 18 months from starting a formula

	eHCF + LGG		eHCF		SBF		HRF		AAF
	IgE-mediated	Non-IgE-mediated	IgE-mediated	Non-IgE-mediated	IgE-mediated	Non-IgE-mediated	IgE-mediated	Non-IgE-mediated	IgE-mediated	Non-IgE-mediated
Mean resource per patient
Number of visits to a pediatrician	4.23	1.32	4.68	1.52	4.85	1.66	4.93	1.74	4.97	1.69
Number of visits to a pediatric specialist	0.74	0.38	0.78	0.41	0.79	0.44	0.80	0.45	0.79	0.44
Number of skin prick tests	0.43	0.77	0.48	0.84	0.50	0.89	0.51	0.91	0.51	0.89
Number of RAST	1.12	1.02	1.17	1.05	1.18	1.07	1.19	1.09	1.19	1.08
Number of atopy tests	0.92	0.62	0.92	0.62	0.92	0.62	0.92	0.62	0.92	0.62
Number of oral food challenges	2.52	0.63	3.03	0.89	3.22	1.08	3.31	1.18	3.41	1.11
Mean cost of health service resource use per patient
Pediatrician visits	€62.30	€24.74	€68.22	€27.32	€70.40	€29.21	€71.36	€30.20	€71.87	€29.51
Pediatric allergist visits	€15.28	€7.75	€16.05	€8.52	€16.29	€9.09	€16.43	€9.38	€16.30	€9.18
Tests	€146.21	€72.46	€166.32	€84.00	€173.89	€92.44	€177.46	€96.88	€179.37	€93.77
Total	€223.79	€104.95	€250.60	€119.85	€260.58	€130.73	€265.25	€136.46	€267.53	€132.45
Mean cost of formula per patient to parents	€2,178	€1,640	€2,643	€2,179	€2,223	€2,043	€2,353	€1,983	€4,745	€4,136

Abbreviations: AAF, amino acid formula; eHCF, extensively hydrolyzed casein formula; HRF, hydrolyzed rice formula; LGG, Lactobacillus rhamnosus GG; RAST, radioallergosorbent test; SBF, soy-based formula.

Figure 2 (A) Distribution of expected INHS costs over 18 months from starting a formula and expected probability of developing tolerance to cow’s milk by 18 months among IgE-mediated allergic infants, generated by 100,000 iterations of the model. (B) Distribution of expected INHS costs over 18 months from starting a formula and expected probability of developing tolerance to cow’s milk by 18 months among non-IgE-mediated allergic infants, generated by 100,000 iterations of the model.

Abbreviations: AAF, amino acid formula; eHCF, extensively hydrolyzed casein formula; HRF, hydrolyzed rice formula; INHS, Italian National Health Service; LGG, Lactobacillus rhamnosus GG; SBF, soy-based formula.

Figure 3 (A) Distribution of expected costs to parents over 18 months from starting a formula and expected probability of developing tolerance to cow’s milk by 18 months among IgE-mediated allergic infants, generated by 100,000 iterations of the model. (B) Distribution of expected costs to parents over 18 months from starting a formula and expected probability of developing tolerance to cow’s milk by 18 months among non-IgE-mediated allergic infants, generated by 100,000 iterations of the model.

Abbreviations: AAF, amino acid formula; eHCF, extensively hydrolyzed casein formula; HRF, hydrolyzed rice formula; LGG, Lactobacillus rhamnosus GG; SBF, soy-based formula.

Figure 4 (A) Probability of being cost-effective at different cost-effectiveness thresholds for IgE-mediated allergy infants, from the perspective of the INHS. (B) Probability of being cost-effective at different cost-effectiveness thresholds for non-IgE-mediated allergy infants, from the perspective of the INHS.

Abbreviations: AAF, amino acid formula; eHCF, extensively hydrolyzed casein formula; HRF, hydrolyzed rice formula; INHS, Italian National Health Service; LGG, Lactobacillus rhamnosus GG; SBF, soy-based formula.

Figure 5 (A) Probability of being cost-effective at different cost-effectiveness thresholds for IgE-mediated allergy infants, from parents’ perspective. (B) Probability of being cost-effective at different cost-effectiveness thresholds for non-IgE-mediated allergy infants, from parents’ perspective.

Abbreviations: AAF, amino acid formula; eHCF, extensively hydrolyzed casein formula; HRF, hydrolyzed rice formula; LGG, Lactobacillus rhamnosus GG; SBF, soy-based formula.

Table 2 Sensitivity analyses

Scenario	Formula	Range in expected probability of developing tolerance to cow’s milk		Range in expected INHS costs		Range in expected parents’ costs
		IgE-mediated	Non-IgE-mediated	IgE-mediated	Non-IgE-mediated	IgE-mediated	Non-IgE-mediated
Assume no more infants develop tolerance to cow’s milk after 12 months	eHCF + LGG	0.70–0.55	0.95–0.90	Unchanged from baseline	Unchanged from baseline	Unchanged from baseline	Unchanged from baseline
	eHCF	0.35–0.25	0.75–0.60	Unchanged from baseline	Unchanged from baseline	Unchanged from baseline	Unchanged from baseline
	SBF	0.20–0.15	0.45–0.30	Unchanged from baseline	Unchanged from baseline	Unchanged from baseline	Unchanged from baseline
	HRF	0.15–0.10	0.65–0.60	Unchanged from baseline	Unchanged from baseline	Unchanged from baseline	Unchanged from baseline
	AAF	0.00–0.00	0.45–0.30	Unchanged from baseline	Unchanged from baseline	Unchanged from baseline	Unchanged from baseline
Assume no incremental improvement after 6 months and no more infants develop tolerance to cow’s milk after 12 months	eHCF + LGG	0.65–0.30	0.95–0.85	€220–260	€100–140	€2,100–2,700	€1,600–2,300
	eHCF	0.35–0.10	0.75–0.40	€240–270	€110–140	€2,600–2,900	€2,100–2,700
	SBF	0.20–0.10	0.45–0.20	€250–270	€120–140	€2,200–2,300	€2,000–2,200
	HRF	0.15–0.10	0.65–0.55	€260–270	€130–140	€2,300–2,400	€1,900–2,100
	AAF	0.00–0.00	0.45–0.25	€260–270	€130–140	€4,700–4,800	€4,100–4,500
The number of follow-up visits to a pediatrician ranges from 50% below to 50% above the base case value	eHCF + LGG	Unchanged from baseline	Unchanged from baseline	€210–260	€90–100	Unchanged from baseline	Unchanged from baseline
	eHCF	Unchanged from baseline	Unchanged from baseline	€240–290	€110–120	Unchanged from baseline	Unchanged from baseline
	SBF	Unchanged from baseline	Unchanged from baseline	€250–300	€120–130	Unchanged from baseline	Unchanged from baseline
	HRF	Unchanged from baseline	Unchanged from baseline	€250–300	€120–130	Unchanged from baseline	Unchanged from baseline
	AAF	Unchanged from baseline	Unchanged from baseline	€250–300	€120–130	Unchanged from baseline	Unchanged from baseline
The number of follow-up visits to a pediatric specialist ranges from 50% below to 50% above the base case value	eHCF + LGG	Unchanged from baseline	Unchanged from baseline	€210–250	€90–100	Unchanged from baseline	Unchanged from baseline
	eHCF	Unchanged from baseline	Unchanged from baseline	€240–290	€110–120	Unchanged from baseline	Unchanged from baseline
	SBF	Unchanged from baseline	Unchanged from baseline	€250–300	€120–130	Unchanged from baseline	Unchanged from baseline
	HRF	Unchanged from baseline	Unchanged from baseline	€250–300	€120–130	Unchanged from baseline	Unchanged from baseline
	AAF	Unchanged from baseline	Unchanged from baseline	€250–300	€120–130	Unchanged from baseline	Unchanged from baseline
The number of diagnostic tests ranges from 50% below to 50% above the base case value	eHCF + LGG	Unchanged from baseline	Unchanged from baseline	€160–300	€60–140	Unchanged from baseline	Unchanged from baseline
	eHCF	Unchanged from baseline	Unchanged from baseline	€180–400	€70–160	Unchanged from baseline	Unchanged from baseline
	SBF	Unchanged from baseline	Unchanged from baseline	€180–400	€80–170	Unchanged from baseline	Unchanged from baseline
	HRF	Unchanged from baseline	Unchanged from baseline	€180–400	€80–170	Unchanged from baseline	Unchanged from baseline
	AAF	Unchanged from baseline	Unchanged from baseline	€190–400	€80–170	Unchanged from baseline	Unchanged from baseline

Abbreviations: AAF, amino acid formula; eHCF, extensively hydrolyzed casein formula; HRF, hydrolyzed rice formula; INHS, Italian National Health Service; LGG, Lactobacillus rhamnosus GG; SBF, soy-based formula.