Impact of increasing treatment rates on cost-effectiveness of subcutaneous immunotherapy (SCIT) in respiratory allergy: a decision analytic modelling approach

  • Ann-Kathrin Richter
  • Ludger Klimek
  • Hans F. Merk
  • Norbert Mülleneisen
  • Harald Renz
  • Wolfgang Wehrmann
  • Thomas Werfel
  • Eckard Hamelmann
  • Uwe Siebert
  • Gaby Sroczynski
  • Jürgen Wasem
  • Janine Biermann-Stallwitz
Original Research



Specific immunotherapy is the only causal treatment in respiratory allergy. Due to high treatment cost and possible severe side effects subcutaneous immunotherapy (SCIT) is not indicated in all patients. Nevertheless, reported treatment rates seem to be low. This study aims to analyze the effects of increasing treatment rates of SCIT in respiratory allergy in terms of costs and quality-adjusted life years (QALYs).


A state-transition Markov model simulates the course of disease of patients with allergic rhinitis, allergic asthma and both diseases over 10 years including a symptom-free state and death. Treatment comprises symptomatic pharmacotherapy alone or combined with SCIT. The model compares two strategies of increased and status quo treatment rates. Transition probabilities are based on routine data. Costs are calculated from the societal perspective applying German unit costs to literature-derived resource consumption. QALYs are determined by translating the mean change in non-preference-based quality of life scores to a change in utility. Key parameters are subjected to deterministic sensitivity analyses.


Increasing treatment rates is a cost-effective strategy with an incremental cost-effectiveness ratio (ICER) of 3484€/QALY compared to the status quo. The most influential parameters are SCIT discontinuation rates, treatment effects on the transition probabilities and cost of SCIT. Across all parameter variations, the best case leads to dominance of increased treatment rates while the worst case ICER is 34,315€/QALY. Excluding indirect cost leads to a twofold increase in the ICER.


Measures to increase SCIT initiation rates should be implemented and also address improving adherence.


Cost-utility analysis Markov process State-transition model Respiratory allergy Subcutaneous immunotherapy 
JEL Classification I12 I11 I18 



This study was funded by a grant from the Medical Association of German Allergologists (AeDA). The funding source has not been involved in decisions about the study design and conduct, the analysis and interpretation of the data, the writing of the manuscript or the decision to submit the article for publication. Coauthors who are members of the funding source (Medical Association of German Allergologists AeDA) contributed to the study in their role of practicing medical experts.

Compliance with ethical standards

Conflict of interest

JB, JW and AKW declare that their institution has received funding from the Medical Association of German Allergologists (AeDA) outside the submitted work. LK reports personal fees from ALK Abelló, MEDA, Novartis, Allergopharma, Bionorica, Boehringer Ingelheim, GSK and Lofarma as well as grants from ALK Abelló, Novartis, Allergopharma, Bionorica, GSK, Lofarma, Biomay, HAL, Leti, Roxall and Bencard outside the submitted work. NM reports personal fees from ALK, AstraZeneca-Santis, Astellas, Bencard, Berlin Chemie, Boehringer Ingelheim, HAL, Leti, Novartis, and Medinfo outside the submitted work; NM is Secretary of UEMS Section and Board Allergology. HFM, HR, WW, WT, EH, US and GS declare that they have nothing to disclose.

Supplementary material

10198_2018_970_MOESM1_ESM.pdf (607 kb)
Supplementary material 1 (PDF 607 kb)


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  • Ann-Kathrin Richter
    • 1
  • Ludger Klimek
    • 2
  • Hans F. Merk
    • 3
  • Norbert Mülleneisen
    • 4
  • Harald Renz
    • 5
  • Wolfgang Wehrmann
    • 6
  • Thomas Werfel
    • 7
  • Eckard Hamelmann
    • 8
  • Uwe Siebert
    • 9
    • 10
    • 11
  • Gaby Sroczynski
    • 9
  • Jürgen Wasem
    • 1
  • Janine Biermann-Stallwitz
    • 1
  1. 1.Institute for Health Care Management and Research, University of Duisburg-EssenEssenGermany
  2. 2.Centre for Rhinology and AllergologyWiesbadenGermany
  3. 3.Clinic for Dermatology and AllergologyUniversity Clinic RWTHAachenGermany
  4. 4.Asthma and Allergy CentreLeverkusenGermany
  5. 5.Institute of Laboratory Medicine and Pathobiochemistry, Molecular Diagnostics, Philipps UniversityMarburgGermany
  6. 6.Dermatological Clinic Prof. WehrmannDr. Rödder-Wehrmann and colleaguesMünsterGermany
  7. 7.Division of Immunodermatology and Allergy Research, Dept of Dermatology and AllergyHannover Medical SchoolHanoverGermany
  8. 8.Children’s Center Bethel, Protestant Hospital Bielefeld and Allergy Center Ruhr-UniversityBochumGermany
  9. 9.Department of Public Health, Health Services Research and Health Technology Assessment, Institute of Public Health, Medical Decision Making and Health Technology AssessmentUMIT-University for Health Sciences, Medical Informatics and TechnologyHall in TirolAustria
  10. 10.Department of Radiology, Massachusetts General Hospital, Harvard Medical SchoolMGH-ITABostonUSA
  11. 11.Department of Health Policy and ManagementHarvard T.H. Chan School of Public HealthBostonUSA

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