The Cost of Penicillin Allergy Evaluation

J Allergy Clin Immunol Pract. 2018 May-Jun;6(3):1019-1027.e2. doi: 10.1016/j.jaip.2017.08.006. Epub 2017 Sep 22.


Background: Unverified penicillin allergy leads to adverse downstream clinical and economic sequelae. Penicillin allergy evaluation can be used to identify true, IgE-mediated allergy.

Objective: To estimate the cost of penicillin allergy evaluation using time-driven activity-based costing (TDABC).

Methods: We implemented TDABC throughout the care pathway for 30 outpatients presenting for penicillin allergy evaluation. The base-case evaluation included penicillin skin testing and a 1-step amoxicillin drug challenge, performed by an allergist. We varied assumptions about the provider type, clinical setting, procedure type, and personnel timing.

Results: The base-case penicillin allergy evaluation costs $220 in 2016 US dollars: $98 for personnel, $119 for consumables, and $3 for space. In sensitivity analyses, lower cost estimates were achieved when only a drug challenge was performed (ie, no skin test, $84) and a nurse practitioner provider was used ($170). Adjusting for the probability of anaphylaxis did not result in a changed estimate ($220); although other analyses led to modest changes in the TDABC estimate ($214-$246), higher estimates were identified with changing to a low-demand practice setting ($268), a 50% increase in personnel times ($269), and including clinician documentation time ($288). In a least/most costly scenario analyses, the lowest TDABC estimate was $40 and the highest was $537.

Conclusions: Using TDABC, penicillin allergy evaluation costs $220; even with varied assumptions adjusting for operational challenges, clinical setting, and expanded testing, penicillin allergy evaluation still costs only about $540. This modest investment may be offset for patients treated with costly alternative antibiotics that also may result in adverse consequences.

Keywords: Allergy; Beta-lactam; Challenge; Hypersensitivity; Resource; Skin test; Test dose.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Allergens / immunology*
  • Ambulatory Care
  • Amoxicillin / immunology
  • Costs and Cost Analysis*
  • Diagnostic Tests, Routine / economics*
  • Drug Hypersensitivity / diagnosis
  • Drug Hypersensitivity / economics*
  • Humans
  • Immunoglobulin E / metabolism
  • Penicillins / immunology*
  • Skin Tests


  • Allergens
  • Penicillins
  • Immunoglobulin E
  • Amoxicillin