AAAI/WAO 2018 Perspectives - Episode 13

Jonathan Spergel, MD, PhD: Environmental Controls and Cost-Effectiveness in Allergy

Jonathan Spergel, MD, PhD, a professor of pediatrics at the Children’s Hospital of Philadelphia, sat down with MD Magazine to discuss the role that environmental controls play in the treatment of allergies. He also dove into the challenges of utilizing of cost-effectiveness strategies in different areas.

Jonathan Spergel, MD, PhD:

When we think about the role of environmental controls—these are like those dust mite covers for your mattress and pillow, removing cockroach dander, decreasing cat and allergen exposure—the data is very confusing because it's not consistent. When we looked at dust mites, in a lot of the studies, the control group had done mostly environmental controls already, so you weren't really decreasing things too substantially. But when you actually decrease things substantially, it makes a difference.

So now we want to think about this in 2 different ways. When we think about environmental controls—if you're allergic to a cat and you move the cat from the environment you're going to do better, but the opposite also occurs, if say, you're not allergic to a dog and you will always avoid the dog and then get exposed, you're actually more likely become allergic to a dog. So again, sort of this whole idea is figuring out what to do when.

That's what the studies have shown. That having 2 big dogs in the house would make you less allergic, but if you're allergic to the dogs, you have to get rid of them. You need to know exactly where you are. That's why the environmental story is not so simple. It's not like, “oh no cats and no dogs.” For some people, it's good to have a dog, and for some people, it's bad to have the dog, so you need to figure out which pile you are in.

When we think about the cost-effectiveness of medications and environmental controls, there are 2 big pockets we tend to think about. Of course, it's a very complex issue because are you just looking here in the United States? This was the world allergy meeting. It's a completely different answer if you're looking in a poor area of Africa if you’re comparing it to Europe. Or if you're looking in Southeast Asia, or you're looking in Taiwan, or China, or Singapore, or Brazil. Every area has different cost-effectiveness issues, so when you think about cost-effectiveness, it's a very complex issue.

Are you comparing just the cost of medicine, and to what? If I say this medicine costs X dollars and by giving someone X dollars they're doing better, so they're having fewer symptoms—what's the cost-effectiveness of making people feel better? People need to consider work, absenteeism from work, kids going to school, future incomes, cost of hospitalizations. So, what's your measure that you're comparing it to? That's why it gets really complex.

When we do cost-effectiveness, you need to make sure what you're comparing apples to apples, and you're comparing things from one thing to another. It’s a very tricky issue and it's also very dependent on what's available and what you can do. We know some medications, like oral steroids, are very cheap and very effective but have lots of adverse effects. So yes, they’re cheap, yes, they're effective, but you would never prescribe them to some people because the adverse effects are too high.

You have to figure all these things out, and I think we when we decide what is cost-effective, you need to look into all these things. One of the hardest things to figure out—it's easy to figure out how much you decrease hospitalizations because that's a very concrete thing, but an improvement of the quality of life is a very tricky thing. How much is it worth for society to make someone feel better every day? Not cough, not sneeze, not itch, not have a rash, and have a more productive life. What is that to society? Until we can really sort of agree on that issue, a lot of the cost-effectiveness research is a little hard to tell about—it depends on the eye of the beholder.