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Objective: To determine whether the β-lactam allergy delabeling was safe and cost-saving in Primary Care (PC) patients., Design: We have conducted a retrospective chart review of PC patients with β-lactam allergy label evaluated in our Allergy Unit between 2017 and 2022. SITE: Allergy Department. Hospital Virgen del Rocio (Sevilla)., Participants: A total of 391 patients labeled for β-lactam allergy in PC were studied., Main Measurements: (a) Outcome evaluation of a β-lactam allergy delabeling procedure. (b) A ratio between the total e-prescribed antibiotic cost and the number of treatment days (the experimental daily antibiotic cost or EDAC) before and after delabeling was analyzed in delabeled and truly allergic patients., Results: The results of skin testing were positive in 9.2% of the reported cases (36 of 391 patients). The reactions to oral provocation challenge (OPC) occurred in 2.14% of the patients who underwent negative skin testing to offending β-lactam (in 15 of 699 OPC). A total of 307 patients (78.5%) were delabeled; 70 (17.9%) had a β-lactam selective response and 14 (3.59%) reacted to both penicillin and cephalosporin. The EDAC before and after the procedure in delabeled patients was significantly lower (0.88 € vs 0.62 €, p<10 -3 ), than that observed in truly allergic group (0.87 € vs. 0.76 €, p=not significant)., Conclusion: To delabel β-lactam allergy in Primary Care patients is safe in most patients, cost-saving in antibioticotherapy, and allows identify the main clinical β-lactam allergy phenotypes that benefit from this procedure., (Copyright © 2024 The Author(s). Publicado por Elsevier España S.L.U. All rights reserved.)

Background: Skin prick tests (SPTs), or intraepidermal tests, are often the first diagnostic approach for people with a suspected allergy. Together with the clinical history, SPTs allow doctors to draw conclusions on allergies based on the sensitization pattern. The purpose of this study is to investigate the potential cost consequences that would accrue to a Swiss University hospital after the adoption of computer vision-based SPTs., Methods: We conducted a cost-consequence analysis from a hospital's perspective to evaluate the potential cost consequences of using a computer vision-based system to read SPT results. The patient population consisted of individuals who were referred to the allergology department of one of the five university hospitals in Switzerland, Inselspital, whose allergology department averages 100 SPTs a week. We developed an early cost-consequence model comparing two SPT techniques; computer vision-based SPTs conducted with the aid of Nexkin DSPT and standard fully manual SPTs. Probabilistic sensitivity analysis and additional univariate sensitivity analyses were used to account for uncertainty., Results: The difference in average cost between the two alternatives from a hospital's perspective was estimated to be CHF 7 per SPT, in favour of the computer vison-based SPTs. Monte Carlo probabilistic simulation also indicated that SPTs conducted using the computer vision-based system were cost saving compared to standard fully manual SPTs. Sensitivity analyses additionally demonstrated the robustness of the base case result subject to plausible changes in all the input parameters, with parameters representing the costs associated with both SPT techniques having the largest influence on the incremental cost. However, higher sensitization prevalence rates seemed to favour the more accurate standard fully manual SPTs., Conclusion: Against the backdrop of rising healthcare costs especially in Switzerland, using computer-aided or (semi) automated diagnostic systems could play an important role in healthcare cost containment efforts. However, results should be taken with caution because of the uncertainty associated with the early nature of our analysis and the specific Swiss context adopted in this study., (© 2024. The Author(s).)

Purpose of Review: As drug allergy research aims to inform clinical practice, implementation of best practices may be influenced by financial resources required to incorporate new interventions and the resulting clinical and economic returns on those resource investments. The present review summarizes new insights into the economics of drug allergy over the past year., Recent Findings: While considering economic implications of recent drug allergy research, many studies have addressed different contextual factors related to the setting, provider, or outcomes. Advances in technology have enabled specialized allergists to support remote settings through telemedicine consultation. Training opportunities and interdisciplinary approaches to address drug allergy challenges have enabled multiple provider types to play a role in screening, diagnosis, and management. Penicillin allergy testing has been a major focus for many institutions, with several studies focused on de-labeling strategies including confirmatory skin testing and direct oral challenges., Summary: Studies over the past year provide new opportunities for the field of drug allergy research. The focus of current research to capture direct health costs or savings associated with drug allergy interventions demonstrates opportunity for more cost-effective care delivery and opportunity to explore greater benefits to society.

Objective: To evaluate the costs associated with evaluation of β-lactam allergy in children labeled as allergic., Study Design: We performed a prospective year-long real life observational study designed to evaluate all pediatric patients with suspected β-lactam allergy who consulted for allergy evaluation. Direct and indirect costs were systematically recorded. Direct healthcare costs were calculated by taking into account the number of visits and all complementary and diagnostic tests performed. Direct nonhealthcare costs were calculated by considering the number of visits and the kilometers from their homes to the clinic. Finally, indirect costs were evaluated by considering the absenteeism of parents or other companions who took the children to the clinic., Results: A total of 40 children with suspected allergy to β-lactams were evaluated in our outpatient clinic from June 1, 2017 to May 31, 2018. Total direct healthcare costs were $5038.03, with an average cost per patient of $125.95. Direct nonhealthcare costs reached $901.87 ($22.55 per patient) and indirect nonhealthcare costs reached $6384.35 ($159.61 per patient). The total cost was $12 324.25, a cost of $308.11 per patient., Conclusions: Elective evaluation of β-lactam allergy and delabeling children who are not allergic is not expensive. In addition, it could save future expenses because of an unnecessary lifelong use of alternative antibiotics that are usually more expensive, less effective, and more frequently associated with antimicrobial resistance and different side effects., (Copyright © 2020 Elsevier Inc. All rights reserved.)

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.

Background: Antibiotic allergy de-labeling using penicillin allergy skin testing (PAST) can reduce the use and cost of alternative, non-β-lactam antibiotics in general inpatient populations. This strategy's role in hematopoietic stem cell transplant (HSCT) recipients is unclear., Methods: This study aimed to determine the effect of a pre-transplant PAST protocol on antibiotic use, days of therapy (DOT), and cost in an immunocompromised population at a single center from 7/1/2010-2/1/2019. Patients who received chimeric antigen receptor (CAR) T-cell therapy and those who underwent transplantation in the outpatient setting were excluded., Results: Of 1560 patients who underwent inpatient HSCT during the study period, 208 reported β-lactam allergy (136/844 [16%] pre- and 72/716 [10%] post-implementation; P < .001). PAST was performed on 7% and 54% of HSCT recipients pre- and post-implementation, respectively. Only two positive PAST were noted. There were no adverse reactions to PAST. There were no significant differences in the disease and transplant characteristics between the two groups. Days of therapy and cost of alternative antibiotics significantly decreased post-implementation (mean 788 vs 627 days, P = .01; mean $24 425 vs $17 518, P = .009)., Conclusion: Penicillin allergy skin testing adjudicates reported β-lactam allergy in HSCT recipients, lowering use, DOT, and cost of alternative antibiotics and promoting effective formulary agents to treat immunocompromised HSCT recipients., (© 2019 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Competing Interests: Competing interests: None declared.

Background: Beta-lactams are the mainstay for treating methicillin-susceptible Staphylococcus aureus (MSSA) infections complicated by bacteremia due to superior outcomes compared with vancomycin. With approximately 11% of inpatients reporting a penicillin (PCN) allergy, many patients receive suboptimal treatment for MSSA bacteremia., Objective: Evaluate the cost-effectiveness of penicillin skin testing (PST) in adult patients with self-reported PCN allergy in an inpatient setting undergoing treatment for MSSA bacteremia., Methods: A decision analytic model was developed comparing an acute care PST intervention to a scenario with no confirmatory allergy testing. The primary outcome was the incremental cost-effectiveness ratio (ICER) from the health-sector perspective over a 1-year time horizon using quality-adjusted life years (QALYs) as the measure for effectiveness. One-way and probabilistic sensitivity analyses were conducted to assess the uncertainty of the ICER estimation., Results: Over a 1-year time horizon, PST services applied to all MSSA bacteremia patients reporting a PCN-allergy would result in a cost per patient of $12,559 and 0.73 QALYs while no PST services would have a higher cost per patient of $13,219 and 0.66 QALYs per patient. This resulted in a cost-effectiveness estimate of -$9,429 per QALY gained. Varying the cost of implementing PST services determined a break-even point of $959.98 where any PST cost less than this amount would actually be cost saving., Conclusions: Patients reporting a PCN allergy on admission may receive sub-optimal alternative therapies to beta-lactams, such as vancomycin, for MSSA bacteremia. This economic analysis demonstrates that inpatient PST services confirming PCN allergy are cost-effective for patients with MSSA bacteremia., Competing Interests: TJM reports personal fees from Summit Therapeutics, G&W Laboratories, and Paratek Pharmaceuticals outside the submitted work. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Background: Studies suggest early egg introduction (EEI) in the first year of life is associated with reduced risk of developing egg allergy. No US recommendations exist regarding optimally implementing EEI., Methods: Using simulation and Markov modelling over a 20-year horizon, we explored optimal EEI strategies applied to US, European and Canadian populations, comparing screening of high-risk infants (skin prick testing [SPT] or serum-specific IgE[sIgE]) before introducing cooked egg at 6 months of life vs egg introduction at home, without screening, for all infants., Results: A no-screen approach dominated egg SPT screening of high-risk infants with early-onset eczema. Base model per-patient incremental costs of SPT were $6865 US dollars (USD), 6801 euros and $10 610 Canadian dollars (CAD). For egg sIgE screening in primary care settings, base model incremental costs were $16 722 USD, 18 072 euros and $28 193 CAD. As the simulation concluded 2.5% were egg allergic without screening vs 9.5%, 12% and 21.4% of children undergoing SPT, delayed introduction or sIgE screening. Incremental societal costs from screening reached $2 009 351 175 USD for SPT and $4 894 445 790 USD for sIgE testing. In sensitivity analyses, if the risk of reaction with initial egg ingestion was ≥22.5%, SPT before EEI became a preferred strategy. A no-screen approach dominated both EEI of raw pasteurized egg and delayed cooked egg introduction approaches., Conclusions: Assuming initial reaction rates < 22.5%, a no-screening EEI cooked egg approach has superior health and economic benefits in terms of number of egg allergy cases prevented and total healthcare costs vs screening testing., (© 2018 EAACI and John Wiley and Sons A/S. Published by John Wiley and Sons Ltd.)

Background: Early peanut introduction (EPI) in the first year of life is associated with reduced risk of developing peanut allergy in children with either severe eczema and/or egg allergy. However, EPI recommendations differ among countries with formal guidelines., Methods: Using simulation and Markov modeling over a 20-year horizon to attempt to explore optimal EPI strategies applied to the US population, we compared high-risk infant-specific IgE peanut screening (US/Canadian) with the Australiasian Society for Clinical Immunology and Allergy (Australia/New Zealand) (ASCIA) and the United Kingdom Department of Health (UKDOH)-published EPI approaches., Results: Screening peanut skin testing of all children with early-onset eczema and/or egg allergy before in-office peanut introduction was dominated by a no screening approach, in terms of number of cases of peanut allergy prevented, quality-adjusted life years (QALY), and healthcare costs, although screening resulted in a slightly lower rate of allergic reactions to peanut per patient in high-risk children. Considering costs of peanut allergy in high-risk children, the per-patient cost of early introduction without screening over the model horizon was $6556.69 (95%CI, $6512.76-$6600.62), compared with a cost of $7576.32 (95%CI, $7531.38-$7621.26) for skin test screening prior to introduction. From a US societal perspective, screening prior to introduction cost $654 115 322 and resulted in 3208 additional peanut allergy diagnoses. Both screening and nonscreening approaches dominated deliberately delayed peanut introduction., Conclusions: A no-screening approach for EPI has superior health and economic benefits in terms of number of peanut allergy cases prevented, QALY, and total healthcare costs compared to screening and in-office peanut introduction., (© 2018 EAACI and John Wiley and Sons A/S. Published by John Wiley and Sons Ltd.)

Rosacea is a common inflammatory skin condition that impacts a large portion of fair-skinned populations. The redness associated with rosacea can be a significant challenge. Brimonidine sulfate and oxymetazoline HCL were both recently approved by the FDA for the management of facial redness. These agents, however, are costly, and not all patients respond to the medication. Herein, we describe a clinical pearl that helps to optimize patient selection for the medications. This saves the patient and the health care system both time and money. J Drugs Dermatol. 2018;17(5):692-693.

Purpose: An initiative to determine the effects of penicillin skin testing (PST) from an antimicrobial stewardship perspective is described., Summary: Penicillin allergy is one of the most frequently reported allergies; however, only about 10% of self-reports of penicillin allergy are accurate. Incorrect penicillin allergies are therefore a significant barrier to antimicrobial stewardship, with important clinical and economic implications, including increased antimicrobial resistance, an increased overall cost of care, increased length of stay, and, ultimately, increased mortality. As part of its antimicrobial stewardship program, a community health system launched a PST initiative in order to optimize therapy, reduce adverse events acquisition costs, and minimize development of antibiotic resistance. The PST program involves the use of a standardized protocol for the assessment of hypersensitivity to penicillin in patients with suspected penicillin allergy. Among 36 patients who completed the PST protocol during an eight-month period, all had a negative result; in 27 of those patients, a conversion of antimicrobial therapy to a penicillin or cephalosporin was implemented as a direct result of PST., Conclusion: In patients with a self-reported penicillin allergy, PST led to a reduction in the use of carbapenems, aztreonam, vancomycin, and other broad-spectrum agents within a health system. A decrease in drug costs was documented in a sample of patients switched to a penicillin or a cephalosporin after PST., (Copyright © 2017 by the American Society of Health-System Pharmacists, Inc. All rights reserved.)

Purpose of Review: To discuss the impact of current European Union regulations on the availability of commercially available skin test allergens in European member states., Recent Findings: European Union legislations now define diagnostic allergens to be medicine requiring market authorization of every individual diagnostic allergen with obligations including clinical trials, application dossiers, a regular update of the dossiers, handling of variation processes and ongoing stability testing of the source material and periodic safety update reporting. The financial expenses of the initiation and maintenance of approvals for diagnostic allergens far exceed their related revenues. Thus, the numbers of authorized test allergens are steadily decreasing., Summary: The current European Union regulations are anticipated to have an immense impact on in-vivo allergy diagnosis in Europe. Available skin test allergens decreased to less than half of what has been before in recent years. EAACI has addressed both the EU and EMA to resolve this situation.

Background: Allergic rhinitis is the most common type of allergy worldwide. The accuracy of skin testing for allergic rhinitis is still debated. This health technology assessment had two objectives: to determine the diagnostic accuracy of skin-prick and intradermal testing in patients with suspected allergic rhinitis and to estimate the costs to the Ontario health system of skin testing for allergic rhinitis., Methods: We searched All Ovid MEDLINE, Embase, and Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, CRD Health Technology Assessment Database, Cochrane Central Register of Controlled Trials, and NHS Economic Evaluation Database for studies that evaluated the diagnostic accuracy of skin-prick and intradermal testing for allergic rhinitis using nasal provocation as the reference standard. For the clinical evidence review, data extraction and quality assessment were performed using the QUADAS-2 tool. We used the bivariate random-effects model for meta-analysis. For the economic evidence review, we assessed studies using a modified checklist developed by the (United Kingdom) National Institute for Health and Care Excellence. We estimated the annual cost of skin testing for allergic rhinitis in Ontario for 2015 to 2017 using provincial data on testing volumes and costs., Results: We meta-analyzed seven studies with a total of 430 patients that assessed the accuracy of skin-prick testing. The pooled pair of sensitivity and specificity for skin-prick testing was 85% and 77%, respectively. We did not perform a meta-analysis for the diagnostic accuracy of intradermal testing due to the small number of studies (n = 4). Of these, two evaluated the accuracy of intradermal testing in confirming negative skin-prick testing results, with sensitivity ranging from 27% to 50% and specificity ranging from 60% to 100%. The other two studies evaluated the accuracy of intradermal testing as a stand-alone tool for diagnosing allergic rhinitis, with sensitivity ranging from 60% to 79% and specificity ranging from 68% to 69%. We estimated the budget impact of continuing to publicly fund skin testing for allergic rhinitis in Ontario to be between $2.5 million and $3.0 million per year., Conclusions: Skin-prick testing is moderately accurate in identifying subjects with or without allergic rhinitis. The diagnostic accuracy of intradermal testing could not be well established from this review. Our best estimate is that publicly funding skin testing for allergic rhinitis costs the Ontario government approximately $2.5 million to $3.0 million per year.

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., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: Determination of the number and type of allergens needed to be tested in epidemiological studies is important in order to identify most of the sensitized subjects with a cost-effective approach. This study aimed to investigate the minimum skin prick test panel for the identification of at least 95% of the sensitized subjects with symptoms of asthma and/or allergic rhinitis (AR) in Ankara, Turkey., Methods: Skin prick test results of 7492 patients who were referred to our outpatient clinic with clinical symptoms of asthma and/or AR between 1991 and 2005 were evaluated retrospectively. Seven allergens were tested in all and 13 allergens in 4202 patients. The allergen group needed for detection of 95% of the sensitized subjects was determined for both the 7 and 13 allergen panels. The study protocol was approved by the local ethics committee of Hacettepe University., Results: The atopy prevalences in the whole study population and in 4202 patients tested with the 13 allergen panel were calculated as 32.2% and 42.6%, respectively. Three allergens (Phleum pratense, Dermatophagoides pteronyssinus and Artemisia vulgaris) within the 7 allergen panel were adequate for the identification of at least 95% of the sensitized subjects. Olea europae was added to the previous three allergens when the 13 allergen panel was applied., Conclusion: Three to four allergens are sufficient for identification at least 95% of sensitized subjects with asthma and/or AR in Ankara, Turkey.

As the progression of multidrug-resistant organisms and lack of novel antibiotics move us closer toward a potential postantibiotic era, it is paramount to preserve the longevity of current therapeutic agents. Moreover, novel interventions for antimicrobial stewardship programs are integral to combating antimicrobial resistance worldwide. One unique method that may decrease the use of second-line antibiotics (e.g., fluoroquinolones, vancomycin) while facilitating access to a preferred β-lactam regimen in numerous health care settings is a penicillin skin test. Provided that up to 10% of patients have a reported penicillin allergy, of whom ~10% have true IgE-mediated hypersensitivity, significant potential exists to utilize a penicillin skin test to safely identify those who may receive penicillin or a β-lactam antibiotic. In this article, we provide information on the background, associated costs, currently available literature, pharmacists' role, antimicrobial stewardship implications, potential barriers, and misconceptions, as well as future directions associated with the penicillin skin test., (© 2013 Pharmacotherapy Publications, Inc.)

Background: Diagnostic provocation tests (ICD Z01.5) have a low cost weight in the German DRG system. We aimed at investigating a possible economic impact on the number of provocation tests in German university medical centers (UMC) for dermatology., Methods: We review quality records of 35 German UMC for 2008 and 2010 (ICD Z01.5, total number of patients as well as priority ranking)., Results: 33/35 hospitals gave full data for both years including the ten most frequent diagnoses. Between 2008 and 2010, total number of patients treated increased in 23/33 (70 %) UMC, those with ICD Z01.5 only in 11/24 (46 %) UMC with full data. In 2008, the ICD Z01.5 was in the top ten list of main diagnoses in 29/33 (88 %) hospitals, in 2010 in 25/33 (76 %); also, priority ranking tended to decrease. In contrast, total number of ICD Z01.5 in Germany tended to increase slightly., Conclusions: We noticed a tendency for decreasing numbers of provocation tests being performed in dermatological UMC in Germany. As there is no evidence for a decreasing number of patients suffering from allergies, one may speculate about a shift to non-university departments due to an economic impact., (© The Authors • Journal compilation © Blackwell Verlag GmbH, Berlin.)

We compared the cost of the tuberculin skin test (TST) with the QuantiFERON-TB Gold (QFT-G) test when screening for latent tuberculosis in 134 healthcare workers in Spain. The QFT-G test cost euro42.5 per healthcare worker, while the TST cost euro39.5. The tests varied in cost structure; most (70%) TST costs were due to time demands on the participants, whereas the QFT-G was more expensive in terms of consumables (50% of the total cost). Accordingly, the results depend on the hourly wages of the participants and the time they must dedicate to the tests. In the Spanish healthcare system, the societal costs of QFT-G are comparable to those of the TST, although their cost structures are quite distinct., (Copyright (c) 2009. Published by Elsevier Ltd.)

Background: Travelers to countries with high tuberculosis incidence can acquire infection during travel. We sought to compare four screening interventions for travelers from low-incidence countries, who visit countries with varying tuberculosis incidence., Methods: Decision analysis model: We considered hypothetical cohorts of 1,000 travelers, 21 years old, visiting Mexico, the Dominican Republic, or Haiti for three months. Travelers departed from and returned to the United States or Canada; they were born in the United States, Canada, or the destination countries. The time horizon was 20 years, with 3% annual discounting of future costs and outcomes. The analysis was conducted from the health care system perspective. Screening involved tuberculin skin testing (post-travel in three strategies, with baseline pre-travel tests in two), or chest radiography post-travel (one strategy). Returning travelers with tuberculin conversion (one strategy) or other evidence of latent tuberculosis (three strategies) were offered treatment. The main outcome was cost (in 2005 US dollars) per tuberculosis case prevented., Results: For all travelers, a single post-trip tuberculin test was most cost-effective. The associated cost estimate per case prevented ranged from $21,406 for Haitian-born travelers to Haiti, to $161,196 for US-born travelers to Mexico. In all sensitivity analyses, the single post-trip tuberculin test remained most cost-effective. For US-born travelers to Haiti, this strategy was associated with cost savings for trips over 22 months. Screening was more cost-effective with increasing trip duration and infection risk, and less so with poorer treatment adherence., Conclusion: A single post-trip tuberculin skin test was the most cost-effective strategy considered, for travelers from the United States or Canada. The analysis did not evaluate the use of interferon-gamma release assays, which would be most relevant for travelers who received BCG vaccination after infancy, as in many European countries. Screening decisions should reflect duration of travel, tuberculosis incidence, and commitment to treat latent infection.

Background: The prevalence of severe anaphylaxis, between 1 and 3 per 10,000, has increased sharply over recent years, with a rate of lethality of 1%. The economic burden is unknown., Objective: The aim of this study was to estimate the economic costs of anaphylaxis, including direct costs of treatment, hospitalization, preventive and long-care measures, and the indirect cost: absenteeism., Methods: Analysis of 402 patients of anaphylaxis declared by 384 allergists was reported to the Allergy Vigilance Network. The global cost was estimated from the national data of hospital admissions: ICD-10 coding available for 2003, 2004 and 2005., Results: Three work/classroom days were lost per patient. Diagnosis required oral challenge with hospitalization in 18% of cases. The estimated mean total cost was 1895 euros for food- and drug-related anaphylaxis (5610 euros for the most severe), and 4053 euros for Hymenoptera anaphylaxis. National statistics recorded 2575 patients in 2005; 22% more than in 2003. The estimated annual cost was 4,789,500 euros. The possible reasons for this being an under-estimate include: data coming only from hospitalized patients, poor identification by medical teams unfamiliar with ICD-10 codes, peri-operative anaphylaxis being insufficiently declared, rush-immunotherapy and maintenance treatments for Hymenoptera anaphylaxis. Similarly, the extra cost of cow milk substitutes, as well as insurance costs where deaths are followed by litigation were not taken into account., Conclusions: The mean cost of anaphylaxis was 1895-5610 euros in nonfatal patients. The prevalence was under-estimated because of many biases, leading to under-estimation of the national cost. Further studies would be necessary to evaluate the value of preventive strategies.

Background: Demand for expensive tests such as allergen-specific IgE is expanding far faster than for cheaper tests: at Burton Hospital the annual growth rate is 24%. Different hospitals have different policies on allergen testing. We report a comparison of the effect of requesting policy on diagnostic yield., Methods: All results from five years of allergen testing were downloaded from the data warehouse at Burton, and a representative sample of recent results was evaluated from Ipswich Hospital. Statistical analysis by chi(2) test and significance tests for differences of proportions were carried out., Results: Ipswich hospital used a standard four-allergen panel for respiratory patients and demonstrated a statistically significantly lower positivity rate for three of those four allergens. No relationship between the number of allergens tested and the probability of a positive result was shown - the probability of a positive result was approximately 0.3. Number of allergen-specific IgE tests requested/patient have remained roughly constant over 5(1/2) years but total demand has increased., Conclusions: Selective requesting for allergen-specific IgE testing may be more effective than use of a standard panel but this cannot be conclusively proven. It is not appropriate to attempt to limit workload by specifying a maximum number of tests that are allowed for any individual patient.

Background: The in vivo skin prick test (SPT) is widely considered less expensive than in vitro gamma-immunoglobulin E (IgE) determination in the diagnosis of allergy. The aim of the present paper is to evaluate the relevance of component-resolved in vitro diagnosis in comparison to extract-based diagnosis and the relative global costs in relation to clinical outcomes., Methods: For 50 individuals with suspected seasonal allergic rhinitis, we compared the costs of skin testing with those of specific IgE antibody measurement., Results: The costs were higher for in vitro than in vivo testing. However, the clinical information obtained using recombinant reagents allowed correct identification of the sensitizing molecule., Conclusions: Recombinant allergens for specific IgE in vitro measurement provide more reliable information for immunotherapy prescription. This should be translated into a significant reduction in the overall costs sustained by the healthcare system.

Health resources are limited and consequently real cost generators must be identified to optimize resources. In the present article, we describe the structure of the Homogeneous Functional Groups (HFG) for Diagnostic Techniques in the Allergy Department of the Virgen de la Arrixaca University Hospital in Murcia (Spain) and the healthcare products generated. Based on the 2005 budget, variable costing was used to calculate the costs of the healthcare products generated (skin tests, investigation of drug allergies, etc.) by one of the three HFG (the HFG for complementary investigations). On the basis of these costs, and taking as the unit the cost of one skin prick test, we assigned relative units of value (RUV) to each of the products in our services portfolio. The following conclusions can be drawn: 1) the current system of variable costing provides information, which should be useful to health professionals; 2) the real cost generators in the microcosm of daily clinical practice should be identified to allow resource reallocation; 3) the costing system used enables modifications to be made that allow decision making on optimal use of the budget; 4) to take the decisions required to optimize resources, clinical management and complementary tests should go hand-in-hand.

Background: The aim of our study was to compare clinical significance and economical factors of commonly used standard skin prick tests (SPT) method with new, modified and more handy way of performing SPT., Methods: Twenty-one subjects [with an average age of 23 years (SD +/- 2.72)] with known sensitivity to examined allergen extracts were tested with histamine, negative control solution and standard allergen extracts (Allergopharma, Reinbeck, Germany). SPT were applied to the volar surface of randomly assigned forearm with two methods: standard technique using lancet needle to prick the epidermis under small drop of extract and tested method using lancet needle which was dipped in extract before prick. In this method all extracts were placed in marked, small, plastic chambers., Results: Mean wheal to histamine was 5.49 (standard method) and 5.01 (modified method). There was no statistical difference between the standard and modified method for size of wheal to histamine (P = 0.654) and to allergen extracts (n = 36, P = 0.824, Wilcoxon test). Economical analysis revealed that examined SPT technique is cheaper than standard method., Conclusion: Examined method may be considered to be an alternative for performing SPT as it is safe, cheaper and more convenient than standard technique., Summary Statement: Comparison of standard and modified SPT method revealed the new method to be more economical.

Due to a rise in the number of cases of allergic disease and a need to increase financial resources for the diagnosis of these conditions, the possibility of reducing costs of skin pricks tests (SPT) was very welcome. In an attempt to reduce costs some practitioners use one lancet for several pricks in one patient. The purpose of this study was to determine whether this way of performing SPT influences the results. 52 subjects with (39) and without (13) atopy were tested with histamine, codeine and standard allergen extracts. SPT were applied to the volar surface of a randomly assigned forearm using two methods: one lancet-one prick on one forearm (single test method) and one lancet-multiple pricks ("multiple test" method) on the other. The false positive tests at the placebo site following allergen were recorded only in multiple test method, in 41 out of 72 pricks (p < 0.00001) when all reactions above baseline were considered and in 26 out of 72 (p = 0.00001) when a 3 mm cut-off was considered. The size of the false positive reaction depends on the intensity of the reaction to the preceding allergen (rang Spearman factor R = 0.706, p < 0.000001) and decreases in the second consecutive placebo test. Our data show that one lancet for multiple test method cannot be used to diagnose factors responsible for allergy, particularly in patients qualified for immunotherapy and in scientific studies. For financial reasons multiple test method can be used in screening and epidemiological studies where atopy is studied and there is no need to identify the specific allergen.

Background: Elective penicillin skin testing in advance of acute antibiotic need and amoxicillin challenge in patients with negative skin test responses have not been evaluated., Methods: I reviewed 236 patients previously entered in a study of new penicillin reagents who received at least 1 prescription drug over a 2-year period. Antibiotic use, outpatient visit rate, and adverse reactions to antibiotics during the year before and after skin testing were evaluated., Results: Forty (17%) of the 236 subjects had positive responses. Antibiotic courses dispensed to the 236 subjects fell 28% from 779 the year before testing to 558 the year after testing. The total cost for antibiotics dispensed fell 32% from $17,211.88 to $11,648.27, with a 5.5% reduction in the average cost per antibiotic. Outpatient visit rate did not change but shifted from primary to specialty departments in subjects with both positive and negative skin test responses. In 93 subjects with negative skin test responses, a total of 188 therapeutic courses of penicillin during the year after testing resulted in 3 (3.2%) unrechallenged mild adverse reactions. Optional amoxicillin challenge in 146 of the subjects with negative skin test responses resulted in complaints of an adverse reaction in 6 of these subjects. Four of these received a penicillin analogue in the next year without reaction., Conclusions: Elective penicillin skin testing done by an allergist was associated with unexpected declines in the number and cost of antibiotics used the year after testing but only modestly lowered the average cost per antibiotic. Adverse reactions to penicillins in subjects with negative skin test responses were infrequent, and amoxicillin challenge did not affect outcomes.

Controversy exists concerning the appropriate use of skin testing and in vitro testing for the diagnosis of allergy, particularly inhalant allergy. Earlier comparisons of skin testing and in vitro testing concluded that skin testing had superior accuracy at lower expense. In light of new developments with in vitro allergy testing, however, this issue should be reconsidered. A review of the recent scientific literature indicates that in vitro and skin testing are highly correlated. However, without the existence of an independent gold standard for inhalant allergy, it is not possible to determine which test is more accurate. The accuracy of either test can be compromised if conducted using different protocols or having insufficient quality control. Given their respective trajectories for technological advancement, quantification, and quality control, in vitro testing may offer the more standardized approach. Although the cost per test of in vitro testing remains greater than that of skin testing, the per-patient costs of the two modalities appear to be comparable, given the greater number of allergens typically used in skin testing. In summary, both skin testing and in vitro testing are acceptable as frontline diagnostic tools.

There exist several technics of application for allergy skin tests: intradermal in which the antigen is injected in the dermis: mean while in the other puncture method (PRICK), the antigen is applied on the skin and it is introduced with a device in the epidermis which there exist several technics of application. Realizing an analysis of different methods it's known that in the patients in which are indicated to realize direct skin test, we should practice first the puncture test, which are easy to apply with less or a minimum systemic and local reactions. To facilitate its application and reduce costs, we suggest the modified method, in a tray Multiwell with antigen, where are put sterilized reusable steel lancets previous sterilization to realize the punctures. We analyze different costs in materials that are used so they would be of easy acquisition.

This study was undertaken for two reasons: 1) It is more difficult to diagnose hypersensitivity to molds than to other allergens, so an evaluation of diagnostic tests was needed. 2) Alternaria is the principal cause of mold sensitization in our area. Sixty-six patients (20 +/- 4 years) were selected and divided into two groups. Group A was made up of patients with rhinitis and/or asthma due to Alternaria sensitization. Group B consisted of patients sensitized to other allergens and patients with nonrespiratory allergic disorders. Skin tests (prick and intradermal), challenge tests (conjunctival, nasal, and bronchial), and specific IgE determination were performed for all patients. A biologically standardized extract of Alternaria tenuis (Alergia e Inmunología Abelló, S. A., Madrid, Spain) obtained from a single batch was used for all tests. Our diagnostic criterion was a clinical history of rhinitis or asthma that coincided with the results of nasal/bronchial challenge. The diagnostic value of the other tests was compared to this criterion. In the group of rhinitic patients, skin tests and conjunctival challenge were more sensitive than specific IgE determination. In asthmatic patients, the most sensitive techniques were nasal and conjunctival challenges, followed by prick and intradermal skin tests, and, lastly, serum specific IgE determination. When rhinitis and asthma were considered jointly, the most sensitive test was conjunctival challenge, followed by skin-prick and intradermal tests. All tests had the same specificity, regardless of disorder. Nasal challenge was positive in all patients. Skin tests are easy to perform, cheap, non-traumatic for the patient, and sufficiently specific and sensitive for the diagnosis of Alternaria hypersensitivity.(ABSTRACT TRUNCATED AT 250 WORDS)

Six devices commonly used for immediate hypersensitivity epicutaneous skin testing were compared with regard to precision and diagnostic accuracy. Fifteen subjects were tested on the back to 10 mg/ml of histamine phosphate and 50% glycerosaline by prick technique with a smallpox needle (SN), bifurcated needle (BN), Greer "pen" (GP), and blood lancet, and by puncture with the Morrow-Brown needle (MB) and Multi-Test (MT). Five devices were tested in quintuplicate to histamine and once to glycerosaline in each subject; with MT, five histamine and three glycerosaline sites were used. Analysis of the wheal areas obtained with SN, BN, GP, and MB demonstrated comparable degrees of precision (coefficient of variation). The precision of MT was less than the other devices (p less than 0.05). The blood lancet demonstrated intermediate precision. Twenty-two of 45 (49%) of the glycerosaline skin tests performed with MT were falsely positive, significantly more than the other devices (p = 0.0001). We conclude that MB, BN, GP, and SP are comparable devices for use in immediate hypersensitivity skin testing. The low precision and reliability of MT used for testing on the back would appear to make this device less than adequate for diagnostic or research studies. Its high rate of false positive reactions requires caution in interpretation of results when it is used in the clinical diagnosis of allergy.