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Original Investigation
December 21, 2018

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

Author Affiliations
  • 1Section of Allergy and Immunology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
  • 2Dartmouth Geisel School of Medicine, Hanover, New Hampshire
  • 3Section of Allergy and Immunology, Food Challenge and Research Unit, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora
JAMA Pediatr. 2019;173(2):169-175. doi:10.1001/jamapediatrics.2018.4275
Key Points

Questions  Are laws that allow schools and child care centers to maintain 2 twin-pack units of non–patient-designated epinephrine autoinjectors to treat allergic reactions cost-effective?

Findings  Based on Markov simulations of the Chicago Public Schools system (371 382 students), the current policy (schools maintain 2 undesignated stock twin-pack units that supplement additionally provided student-designated units) is cost-effective when total school epinephrine acquisition expenses do not exceed $338 per school per year. However, a universal (stock only) model, without requiring student-designated units, provides superior value.

Meaning  This simulation suggests a value-based price for stock epinephrine under the current policy, with high cost savings if a universal model is adopted.


Importance  Children experiencing anaphylaxis at school may lack access to a personal epinephrine device, prompting recent legislation permitting undesignated (eg, non–student specific) stock epinephrine autoinjector units at school. However, epinephrine device costs vary, and the cost-effectiveness of undesignated school stock epinephrine is uncharacterized to date.

Objective  To define value-based strategies for undesignated school stock epinephrine programs.

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

Main Outcomes and Measures  This study compared the following 3 strategies: no school undesignated epinephrine supply, school undesignated supplemental epinephrine supply (supplemental model), and school undesignated universal epinephrine supply (universal model). The base-case model assumed a 10-fold reduced fatality risk with having undesignated stock epinephrine units available vs 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.

Results  Based on Markov simulations of the Chicago Public Schools system (371 382 students), the cost was $107 816 (95% 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. Undesignated stock epinephrine improved outcomes, with 26.869 (95% CI, 26.841-26.897) QALYs accrued as the model concluded compared with 26.867 (95% CI, 26.839-26.896) QALYs for the strategy without undesignated stock epinephrine. 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 below $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 and Relevance  Undesignated school stock epinephrine is cost-effective at device acquisition costs not exceeding $338 per school per year, although a universal model vs a supplemental model is associated with superior health and economic outcomes.