Economic evaluation of a 100% whey-based partially hydrolyzed infant formula in the prevention of atopic dermatitis among Danish children

Hydrolysed formula, delayed food introduction and fatty acids for atopic dermatitis prevention in infancy

AIM

The role of nutrition in preventing atopic diseases including atopic dermatitis has recently gained interest in the medical community. Caregivers of infants and children at an increased risk for developing atopic dermatitis often employ exclusion diets or other measures in hopes of preventing the development of this burdensome disease. This paper reviews the current literature in regard to the role of preventative dietary measures in the context of atopic dermatitis, with a special focus on the topics of hydrolysed formula, early vs. delayed introduction of certain foods and fatty acid supplementation.

METHODS

Literature pertaining to preventative dietary measures for infants at risk for atopic dermatitis was reviewed.

RESULTS

Analysis of the literature suggests that hydrolysed formula should not be routinely offered to infants for prevention of atopic dermatitis. Formulas utilised should contain concentrations of polyunsaturated fatty acids similar to that in breast milk. Finally, infant caregivers should not delay or restrict introduction of food, which can be more harmful than helpful to the patient.

CONCLUSION

Recommendations to caretakers providing for infants at risk for atopic dermatitis should include infant consumption of breast milk and avoid delayed introduction of foods.

Understanding economic evidence for the prevention and treatment of atopic eczema

Background

Atopic eczema is an inflammatory skin condition, with a similar impact on health‐related quality of life as other chronic diseases. Increasing pressures on resources within the National Health Service increase the importance of having good economic evidence to inform their allocation.

Objectives

To educate dermatologists about economic methods with reference to currently available economic evidence on eczema.

Methods

The role of different types of economic evidence is illustrated by evidence found in a systematic literature search conducted across 12 online databases up to 22 May 2017. Primary empirical studies either reporting the results of a cost‐of‐illness study or evaluating the cost, utility or full economic evaluation of interventions for preventing or treating eczema were included. Two reviewers independently assessed studies for eligibility and performed data abstraction, with disagreements resolved by a third reviewer. Evidence tables of results were produced for narrative discussion. The reporting quality of economic evaluations was assessed.

Results

Seventy‐eight studies (described in 80 papers) were deemed eligible. Thirty‐three (42%) were judged to be economic evaluations, 12 (15%) cost analyses, six (8%) utility analyses, 26 (33%) cost‐of‐illness studies and one a feasibility study (1%). The calcineurin inhibitors tacrolimus and pimecrolimus, as well as barrier creams, had the most economic evidence available. Partially hydrolysed infant formula was the most commonly evaluated prevention.

Conclusions

The current level of economic evidence for interventions aimed at preventing and treating eczema is limited compared with that available for clinical outcomes, suggesting that greater collaboration between clinicians and economists might be beneficial.

What's already known about this topic?

Resources available for health care are limited and their efficient allocation should be informed by robust economic evidence about value for money.

The scale and quality of economic evidence available for atopic eczema has not previously been examined.

What does this study add?

By comparison with the considerable clinical evidence for interventions to prevent and treat eczema, there is limited economic evidence available.

The economic evidence available is limited in scope with regard to the types and range of interventions evaluated.

The quality of future economic studies could be improved by greater collaboration between economists and clinicians.

https://doi.org/10.1111/bjd.18391 available online

The Use of Decision-Analytic Models in Atopic Eczema: A Systematic Review and Critical Appraisal

OBJECTIVE

The objective of this systematic review was to identify and assess the quality of published economic decision-analytic models within atopic eczema against best practice guidelines, with the intention of informing future decision-analytic models within this condition.

METHODS

A systematic search of the following online databases was performed: MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, Cochrane Database of Systematic Reviews, NHS Economic Evaluation Database, EconLit, Scopus, Health Technology Assessment, Cost-Effectiveness Analysis Registry and Web of Science. Papers were eligible for inclusion if they described a decision-analytic model evaluating both the costs and benefits associated with an intervention or prevention for atopic eczema. Data were extracted using a standardised form by two independent reviewers, whilst quality was assessed using the model-specific Philips criteria.

RESULTS

Twenty-four models were identified, evaluating either preventions (n = 12) or interventions (n = 12): 14 reported using a Markov modelling approach, four utilised decision trees and one a discrete event simulation, whilst five did not specify the approach. The majority, 22 studies, reported that the intervention was dominant or cost effective, given the assumptions and analytical perspective taken. Notably, the models tended to be short-term (16 used a time horizon of ≤1 year), often providing little justification for the limited time horizon chosen. The methodological and reporting quality of the studies was generally weak, with only seven studies fulfilling more than 50% of their applicable Philips criteria.

CONCLUSIONS

This is the first systematic review of decision models in eczema. Whilst the majority of models reported favourable outcomes in terms of the cost effectiveness of the new intervention, the usefulness of these findings for decision-making is questionable. In particular, there is considerable scope for increasing the range of interventions evaluated, for improving modelling structures and reporting quality.

Should Partial Hydrolysates Be Used as Starter Infant Formula? A Working Group Consensus

Partially hydrolyzed formulas (pHFs) are increasingly used worldwide, both in the prevention of atopic disease in at-risk infants and in the therapeutic management of infants with functional gastrointestinal manifestations. Because prevention is always preferable to treatment, we reviewed the literature aiming to find an answer for the question whether pHF may be recommended for feeding all infants if breast-feeding is not possible. PubMed and Cochrane databases were searched up to December 2014. In addition, to search for data that remained undetected by the searches, we approached authors of relevant articles and major producers of pHFs asking for unpublished data. Because few data were found, nonrandomized, controlled trials and trials in preterm infants were included as well. Overall, only limited data could be found on the efficacy and safety of pHF in healthy term infants. Available data do not indicate that pHFs are potentially harmful for healthy, term infants. With respect to long-term outcomes, particularly referring to immune, metabolic and hormonal effects, data are, however, nonexistent. From a regulatory point of view, pHFs meet the nutrient requirements to be considered as standard formula for term healthy infants. Cost, which is different from country to country, should be considered in the decision-making process. Based on limited available data, the use of pHF in healthy infants is safe with regard to growth. The lack of data, in particular for metabolic consequences and long-term outcomes, is, however, the basis for our recommendation that health authorities should develop and support long-term follow-up studies. Efficacy and long-term safety data are required before a recommendation of this type of formula for all infants can be made.

Comparison Among Commonly Available Infant Formula Milks in the Iraqi Market

Breast-feeding is the best method of feeding infants. In some cases, formula milk can be a suitable alternative, so this study aimed to compare the safety and nutritional adequacy of commonly available formula milks in the Iraqi market. An observational study for the commonly available formula milks was conducted in the largest supermarkets of Baghdad, Iraq, during January-March 2015. The macronutrient and micronutrient contents as presented in the label of each type of formula milk was compared with the standard requirement of formula milk according to the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) guidelines. Dielac formula milk is the commonest formula milk in the Iraqi market, with the lowest price when compared with other formula milks. All infant formula milks (Similac, Guigoz, and S-26 Gold) except Dielac have the mandatory contents within the specified ranges, according to the ESPGHAN guidelines. Dielac lacks more than 1 of the major mandatory contents besides lacking all optional contents in its formula. Guigoz formula milk lacks the optional ingredients arachidonic acid, docosahexaenoic acid, and nucleotides. Similac milk was supplemented with a higher-than-specified level of nucleotides, and its l-carnitine contents were not declared. Only S26 Gold formula milk contained all mandatory and optional ingredients within the specified range, according to the ESPGHAN guidelines. In conclusion, no formula milk can resemble breast milk; however, S26 Gold formula milk is the most acceptable formula, and Dielac formula milk is the worst. Therefore, it is recommended that Dielac be withdrawn from the Iraqi market.

Economic value of atopic dermatitis prevention via infant formula use in high-risk Malaysian infants

Background

Breastfeeding is best for infants and the World Health Organization recommends exclusive breastfeeding for at least the first 6 months of life. For those who are unable to be breastfed, previous studies demonstrate that feeding high-risk infants with hydrolyzed formulas instead of cow's milk formula (CMF) may decrease the risk of atopic dermatitis (AD).

Objective

To estimate the economic impact of feeding high-risk, not exclusively breastfed, urban Malaysian infants with partiallyhydrolyzed whey-based formula (PHF-W) instead of CMF for the first 17 weeks of life as an AD risk reduction strategy.

Methods

A cohort Markov model simulated the AD incidence and burden from birth to age 6 years in the target population fed with PHF-W vs. CMF. The model integrated published clinical and epidemiologic data, local cost data, and expert opinion. Modeled outcomes included AD-risk reduction, time spent post AD diagnosis, days without AD flare, quality-adjusted life years (QALYs), and costs (direct and indirect). Outcomes were discounted at 3% per year. Costs are expressed in Malaysian Ringgit (MYR; MYR 1,000 = United States dollar [US $]316.50).

Results

Feeding a high-risk infant PHF-W vs. CMF resulted in a 14% point reduction in AD risk (95% confidence interval [CI], 3%-23%), a 0.69-year (95% CI, 0.25-1.10) reduction in time spent post-AD diagnosis, additional 38 (95% CI, 2-94) days without AD flare, and an undiscounted gain of 0.041 (95% CI, 0.007-0.103) QALYs. The discounted AD-related 6-year cost estimates when feeding a high-risk infant with PHF-W were MYR 1,758 (US $556) (95% CI, MYR 917-3,033) and with CMF MYR 2,871 (US $909) (95% CI, MYR 1,697-4,278), resulting in a per-child net saving of MYR 1,113 (US $352) (95% CI, MYR 317-1,884) favoring PHF-W.

Conclusion

Using PHF-W instead of CMF in this population is expected to result in AD-related costs savings.

Cost-Effectiveness of Partially Hydrolyzed Whey Protein Formula in the Primary Prevention of Atopic Dermatitis in At-Risk Urban Filipino Infants

OBJECTIVE

To estimate, from a Filipino societal perspective, the cost-effectiveness of preventing atopic dermatitis (AD) via early nutritional intervention with 100% whey-based partially hydrolyzed formula (PHF-W) versus standard cow's milk formula (SF) in healthy, urban infants with atopic heredity who are not exclusively breast-fed.

METHODS

A Markov model was used to simulate over 6 years the incidence of AD, days with AD symptoms, quality-adjusted life-years (QALYs), and AD-related direct and indirect (i.e., parents'/caregivers' productivity loss) costs incurred by hypothetical cohorts of healthy, at-risk infants fed with either PHF-W or SF as AD prevention for ≤ 17 weeks. Efficacy estimates of PHF-W versus SF in preventing AD were literature-based. The resources used to manage AD (by severity, age, and treatment modality) were estimated using clinical pathways derived from clinical expert opinion. Local costs were applied to resource use. Results were presented as point estimates and as 95 percent credible intervals (CIs, i.e., range of values around the point estimate that include 95% of model simulations) generated via multivariate probabilistic sensitivity analysis using Monte-Carlo simulation techniques. All costs are reported in Philippines pesos (₱, where ₱1000 = US $22.24). All reported outcomes were discounted at a rate of 3.5% per year.

RESULTS

Based on the 6-year simulation, compared with SF, PHF-W was predicted to result in a 14-percentage point reduction (i.e., 39% vs. 25%) (95% CI 0.09-0.19) in the incidence of AD and a gain of 0.03 (i.e., 5.46 vs. 5.43) (95% CI 0.01-0.07) QALYs/patient. PHF-W's higher feeding formula cost (+₱1,304/patient) (95% CI -₱3,090 to ₱5,779) were offset by reductions in AD-related costs (-₱11,959/patient; i.e., ₱27,228 vs. ₱15,269) (95% CI -₱14,685 to -₱7,284), including, in particular, the costs of pharmacotherapy, formula used as treatment, and visits to physicians. As a result, PHF-W became a net cost-saving strategy within 38 weeks. Overall, PHF-W resulted in net savings of -₱10,654 (-US $237) (CI -₱4,240 [-US $94] to -₱14,544 [-US $323]) (i.e., ₱27,228 [US $606] vs. ₱16,574 [US $369]). Sensitivity analysis confirmed the robustness of results; the most influential variable was the first-year risk reduction in AD.

CONCLUSIONS

Based on the present modeling exercise, compared with SF, PHF-W appears to substantially reduce the risk of AD and its associated direct and indirect medical costs in healthy, at-risk urban Filipino infants over a 6-year period.

Cost-effectiveness of partially-hydrolyzed formula for prevention of atopic dermatitis in Australia

OBJECTIVE

To perform an economic evaluation of a specific brand of partially hydrolyzed infant formula (PHF-W) in the prevention of atopic dermatitis (AD) among Australian infants.

METHODS

A cost-effectiveness analysis was undertaken from the perspectives of the Department of Health and Aging (DHA), of the family of the affected subject and of society as a whole in Australia, based on a decision-analytic model following a hypothetical representative cohort of Australian newborns who are not exclusively breastfed and who have a familial history of allergic disease (i.e., are deemed 'at risk'). Costs, consequences, and incremental cost-effectiveness ratios (ICER) were calculated for PHF-W vs standard cow's milk based infant formula (SF), and, in a secondary analysis, vs extensively hydrolyzed infant formula (EHF-Whey), when the latter was used for the prevention of AD.

RESULTS

From a representative starting cohort of 87,724 'at risk' newborns in Australia in 2009, the expected ICERs for PHF-W vs SF were AU$496 from the perspective of the DHA and savings of AUD1739 and AU$1243 from the family and societal perspectives, respectively. When compared to EHF-Whey, PHF-W was associated with savings for the cohort of AU$5,183,474 and AU$6,736,513 from the DHA and societal perspectives.

LIMITATIONS

The generalizability and transferability of results to other settings, populations, or brands of infant formula should be made with caution. Whenever possible, a conservative approach directing bias against PHF-W rather than its comparators was applied in the base case analysis. Assumptions were verified in one-way and probabilistic sensitivity analyses, which confirmed the robustness of the model.

CONCLUSIONS

PHF-W appears to be cost-effective when compared to SF from the DHA perspective, dominant over SF from the other perspectives, and dominant over EHF-Whey from all perspectives, in the prevention of AD in 'at risk' infants not exclusively breastfed, in Australia.