{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,15]],"date-time":"2026-07-15T01:03:28Z","timestamp":1784077408716,"version":"3.55.0"},"reference-count":16,"publisher":"BMJ","issue":"12","license":[{"start":{"date-parts":[[2025,12,2]],"date-time":"2025-12-02T00:00:00Z","timestamp":1764633600000},"content-version":"unspecified","delay-in-days":1,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100007602","name":"Programme Grants for Applied Research","doi-asserted-by":"publisher","award":["RP_PG_1214_20007 ALABAMA"],"award-info":[{"award-number":["RP_PG_1214_20007 ALABAMA"]}],"id":[{"id":"10.13039\/501100007602","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2025,10,10]]},"published-print":{"date-parts":[[2025,12]]},"abstract":"<jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>To evaluate the cost-effectiveness of implementing a penicillin allergy assessment pathway (PAAP) versus usual care within the NHS.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design<\/jats:title>\n                    <jats:p>A decision tree analysis over a 5-year time-period, informed by a randomised controlled trial (RCT) of PAAP and systematic review. Value of information analysis was also conducted to estimate the value of conducting a new trial.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Data sources<\/jats:title>\n                    <jats:p>Model inputs were informed by the ALABAMA RCT participants included in the primary analysis, 811 adults with penicillin allergy labels and recent antibiotic prescriptions, and data from published literature.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Interventions<\/jats:title>\n                    <jats:p>Participants in the ALABAMA trial included in the primary analysis: PAAP (n=401) and usual care (n=410).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Primary and secondary outcome measures<\/jats:title>\n                    <jats:p>Costs are presented in GBP (\u00a3) at 2022\u20132023 prices, quality-adjusted life years (QALYs), incremental cost-effectiveness ratio, incremental net monetary benefit (INMB), the probability of cost-effectiveness at the \u00a320,000 and \u00a330,000 per QALY threshold, and the cost effectiveness of a new follow-on trial.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>PAAP had incremental costs of \u00a3\u221283 (probability of cost saving 47.5%) and incremental QALYs of 0.036 (probability of positive benefits 47.5%). The INMBs (probability of cost-effectiveness) were \u00a3806 (48%) and \u00a31167 (48%) under the decision thresholds of \u00a320,000 and \u00a330,000 per QALY, respectively. PAAP was more cost-effective among females, people aged &gt;65 years, and more frequent antibiotic users. A new follow-on trial involving 1267 participants was estimated to cost \u00a32.4 million and, by reducing uncertainty in the evidence, would avoid \u00a319.6 million in costs of incorrect management decisions for eligible patients over the next 10 years.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>The PAAP was considered cost-effective, but significant uncertainty remained. Future trials with adequate power and longer follow-up are needed to determine the most cost-effective models for penicillin allergy testing.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Trial registration number<\/jats:title>\n                    <jats:p>\n                      <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" ext-link-type=\"isrctn\" xlink:href=\"ISRCTN20579216\">ISRCTN20579216<\/jats:ext-link>\n                      .\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2025-104168","type":"journal-article","created":{"date-parts":[[2025,12,3]],"date-time":"2025-12-03T18:21:04Z","timestamp":1764786064000},"page":"e104168","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":1,"title":["The cost-effectiveness of penicillin allergy assessment pathway (PAAP): a decision analysis"],"prefix":"10.1136","volume":"15","clinical-trial-number":[{"clinical-trial-number":"isrctn20579216","registry":"10.18810\/isrctn"}],"author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-7975-374X","authenticated-orcid":false,"given":"Miaoqing","family":"Yang","sequence":"first","affiliation":[{"name":"Leeds Institute of Health Sciences, University of Leeds, Leeds, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rebecca","family":"Bestwick","sequence":"additional","affiliation":[{"name":"Leeds Institute of Health Sciences, University of Leeds, Leeds, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8052-2893","authenticated-orcid":false,"given":"Daniel","family":"Howdon","sequence":"additional","affiliation":[{"name":"Leeds Institute of Health Sciences, University of Leeds, Leeds, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"S","family":"Ahmed","sequence":"additional","affiliation":[{"name":"St James\u2019s University Hospital, Leeds, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6113-9810","authenticated-orcid":false,"given":"Neil","family":"Powell","sequence":"additional","affiliation":[{"name":"Royal Cornwall Hospitals NHS Trust, Truro, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5438-5290","authenticated-orcid":false,"given":"Kelsey Fiona","family":"Armitage","sequence":"additional","affiliation":[{"name":"Nuffield Department of Primary Care Health Sciences, Clinical Trials Unit, University of Oxford, Oxford, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joanne","family":"Fielding","sequence":"additional","affiliation":[{"name":"Dental Translational and Clinical Research Unit, School of Dentistry, University of Leeds, Leeds, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Catherine E","family":"Porter","sequence":"additional","affiliation":[{"name":"Dental Translational and Clinical Research Unit, School of Dentistry, University of Leeds, Leeds, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sinisa","family":"Savic","sequence":"additional","affiliation":[{"name":"Clinical Immunology and Allergy, University of Leeds, Leeds Institute of Medical Research at St James\u2019s, Leeds, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7305-3654","authenticated-orcid":false,"given":"Robert M","family":"West","sequence":"additional","affiliation":[{"name":"Leeds Institute of Health Sciences, University of Leeds, Leeds, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Philip","family":"Howard","sequence":"additional","affiliation":[{"name":"School of Health Care, University of Leeds, Leeds, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ushma","family":"Galal","sequence":"additional","affiliation":[{"name":"Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sue","family":"Pavitt","sequence":"additional","affiliation":[{"name":"Dental Translational and Clinical Research Unit, School of Dentistry, University of Leeds, Leeds, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jonathan AT","family":"Sandoe","sequence":"additional","affiliation":[{"name":"Department of Microbiology, University of Leeds, Faculty of Medicine and Health, Leeds, UK"},{"name":"Leeds teaching Hospitals NHS Trust, Leeds, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ruben Ernesto","family":"Mujica-Mota","sequence":"additional","affiliation":[{"name":"Leeds Institute of Health Sciences, University of Leeds, Leeds, UK"},{"name":"Health and Community Sciences, University of Exeter, Exeter, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2025,12,3]]},"reference":[{"key":"2026010703455785000_15.12.e104168.1","doi-asserted-by":"publisher","DOI":"10.1093\/jac\/dkz127"},{"key":"2026010703455785000_15.12.e104168.2","doi-asserted-by":"crossref","DOI":"10.1136\/bmj.k2400","article-title":"Risk of meticillin resistant Staphylococcus aureus and Clostridium difficile in patients with a documented penicillin allergy: population based matched cohort study","volume":"361","author":"Blumenthal","year":"2018","journal-title":"BMJ"},{"key":"2026010703455785000_15.12.e104168.3","doi-asserted-by":"crossref","first-page":"152","DOI":"10.1016\/j.ijid.2022.11.026","article-title":"The effectiveness of interventions that support penicillin allergy assessment and delabeling of adult and pediatric patients by nonallergy specialists: a systematic review and meta-analysis","volume":"129","author":"Powell","year":"2023","journal-title":"Int J Infect Dis"},{"key":"2026010703455785000_15.12.e104168.4","doi-asserted-by":"crossref","first-page":"705","DOI":"10.1016\/j.jaip.2017.02.012","article-title":"The Effect of Penicillin Allergy Testing on Future Health Care Utilization: A Matched Cohort Study","volume":"5","author":"Macy","year":"2017","journal-title":"J Allergy Clin Immunol Pract"},{"key":"2026010703455785000_15.12.e104168.5","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2023-072253","article-title":"Penicillin allergy status and its effect on antibiotic prescribing, patient outcomes and antimicrobial resistance (ALABAMA): protocol for a multicentre, parallel-arm, open-label, randomised pragmatic trial","volume":"13","author":"Armitage","year":"2023","journal-title":"BMJ Open"},{"key":"2026010703455785000_15.12.e104168.6","doi-asserted-by":"crossref","first-page":"100006","DOI":"10.1016\/j.lanprc.2025.100006","article-title":"Penicillin allergy assessment pathway versus usual clinical care for primary care patients with a penicillin allergy record in the UK (ALABAMA): an open-label, multicentre, randomised controlled trial","volume":"1","author":"Sandoe","year":"2025","journal-title":"Lancet Primary Care"},{"key":"2026010703455785000_15.12.e104168.7","doi-asserted-by":"crossref","first-page":"296","DOI":"10.1016\/j.jaci.2020.04.058","article-title":"Accuracy of penicillin allergy diagnostic tests: A systematic review and meta-analysis","volume":"147","author":"Sousa-Pinto","year":"2021","journal-title":"J Allergy Clin Immunol"},{"key":"2026010703455785000_15.12.e104168.8","unstructured":"R Core Team . R: a language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria; 2024. Available: https:\/\/www.R-project.org\/"},{"key":"2026010703455785000_15.12.e104168.9","unstructured":"National Institute for Health and Care Excellence . Position statement on use of the EQ-5D-5L value set for England, Available: https:\/\/www.nice.org.uk\/about\/what-we-do\/our-programmes\/nice-guidance\/technology-appraisal-guidance\/eq-5d-5l"},{"key":"2026010703455785000_15.12.e104168.10","doi-asserted-by":"crossref","DOI":"10.1001\/jamanetworkopen.2024.29621","article-title":"Risk of Self-Reported Penicillin Allergy Despite Removal of Penicillin Allergy Label: Secondary Analysis of the PALACE Randomized Clinical Trial","volume":"7","author":"Copaescu","year":"2024","journal-title":"JAMA Netw Open"},{"key":"2026010703455785000_15.12.e104168.11","doi-asserted-by":"publisher","DOI":"10.1002\/hec.635"},{"key":"2026010703455785000_15.12.e104168.12","doi-asserted-by":"publisher","DOI":"10.1016\/S0091-6749(98)70097-1"},{"key":"2026010703455785000_15.12.e104168.13","doi-asserted-by":"publisher","DOI":"10.1093\/jac\/dky575"},{"key":"2026010703455785000_15.12.e104168.14","unstructured":"National Institute for Health and Care Excellence . Drug allergy: diagnosis and management of drug allergy in adults children and young people. NICE clinical guideline (CG183). 2014."},{"key":"2026010703455785000_15.12.e104168.15","doi-asserted-by":"crossref","first-page":"1883","DOI":"10.1111\/imj.16543","article-title":"Adult penicillin allergy programmes in Australian hospitals: a practical guide from the National Antibiotic Allergy Network","volume":"54","author":"Hannah","year":"2024","journal-title":"Intern Med J"},{"key":"2026010703455785000_15.12.e104168.16","doi-asserted-by":"crossref","first-page":"1649","DOI":"10.1016\/j.jaip.2017.12.033","article-title":"The Cost of Self-Reported Penicillin Allergy: A Systematic Review","volume":"6","author":"Mattingly","year":"2018","journal-title":"J Allergy Clin Immunol Pract"}],"container-title":["BMJ Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bmjopen-2025-104168","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,1,7]],"date-time":"2026-01-07T11:46:50Z","timestamp":1767786410000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmjopen.bmj.com\/lookup\/doi\/10.1136\/bmjopen-2025-104168"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,12]]},"references-count":16,"journal-issue":{"issue":"12","published-online":{"date-parts":[[2025,12,3]]},"published-print":{"date-parts":[[2025,12]]}},"alternative-id":["10.1136\/bmjopen-2025-104168"],"URL":"https:\/\/doi.org\/10.1136\/bmjopen-2025-104168","relation":{},"ISSN":["2044-6055","2044-6055"],"issn-type":[{"value":"2044-6055","type":"print"},{"value":"2044-6055","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,12]]}}}