Cost-effectiveness of oral food challenge in managing cow's milk allergy under the Brazilian Public Health perspective

OBJECTIVE: To analyze the cost-effectiveness and cost-utility of using oral food challenge test (OFC) to manage non-IgE-mediated gastrointestinal cow's milk protein allergy (non-IgE-GI-CMPA) in infants within the Brazilian public health system (SUS). METHOD: A decision model was developed to compare two strategies: 1. GUIDELINE-OFC: 100 % of physicians recommending OFC for diagnosis (D-OFC) and evaluation of oral tolerance (OT-OFC), and 2. REAL-WORLD-OFC: OFC performed according to the practices of pediatricians in Brazil (D-OFC indicated by 56 % and 45 % of physicians for mild-to-moderate and severe cases, respectively, and OT-OFC indicated by 93 % of physicians for both cases). The authors assumed that 10 % of parents would refuse the OFC and set the ages of 3.65 and 24 months for model admission and follow-up (time horizon), respectively. Clinical and epidemiological data, primarily from Brazil, data on public health costs, and a 5 % discount rate for both costs and outcomes were used. The effectiveness endpoint was the duration without a cow's milk elimination diet and quality-adjusted life-year (QALY) values of 0.84 (with allergy) and 0.94 (without allergy). RESULTS: GUIDELINE-OFC resulted in average savings of USD 241.98, a gain of +0.019 QALYs, and +70 days without a cow's milk elimination diet per patient. In the probabilistic sensitivity analysis, all cost-effectiveness and 96.5 % of cost-utility simulations demonstrated lower costs and greater effectiveness. Over five years, the public healthcare system would save USD 129 million. CONCLUSIONS: Using OFC in infants with non-IgE-GI-CMPA is a dominant strategy, yielding substantial savings for the SUS and potentially improving nutritional status and quality of life.