Infection Control & Hospital Epidemiology (2018), 39, 924–930 doi:10.1017/ice.2018.139
Original Article
Cost-effectiveness of three different strategies for the treatment of first recurrent Clostridium difficile infection diagnosed in a community setting
Simon W. Lam PharmD, MS-AHEOR, FCCM1, Elizabeth A. Neuner PharmD, BCPS (AQ-ID)1, Thomas G. Fraser MD2,
David Delgado PhD3 and Donald B. Chalfin MD, MS, MPH, FCCP, FCCM3 1Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio, 2Department of Infectious Diseases, Cleveland Clinic, Cleveland, Ohio and 3Thomas Jefferson University, Philadelphia, Pennsylvania
Abstract
Objective: A significant portion of patients with Clostridium difficile infections (CDI) experience recurrence, and there is little consensus on its treatment. With the availability of newer agents for CDI and the added burdens of recurrent disease, a cost-effectiveness analysis may provide insight on the most efficient use of resources. Design: A decision-tree analysis was created to compare the cost-effectiveness of 3 possible treatments for patients with first CDI recurrence: oral vancomycin, fidaxomicin, or bezlotoxumab plus vancomycin. The model was performed from a payer’s perspective with direct cost inputs and a timeline of 1 year. A systematic review of literature was performed to identify clinical, utility, and cost data. Quality- adjusted life years (QALY) and incremental cost-effectiveness ratios were calculated. The willingness-to-pay (WTP) threshold was set at $100,000 per QALY gained. The robustness of the model was tested using one-way sensitivity analyses and probabilistic sensitivity analysis. Results: Vancomycin had the lowest cost ($15,692) and was associated with a QALY gain of 0.8019 years. Bezlotoxumab plus vancomycin was a dominated strategy. Fidaxomicin led to a higher QALY compared to vancomycin, at an incremental cost of $500,975 per QALY gained. Based on our WTP threshold, vancomycin alone was the most cost-effective regimen for treating the first recurrence of CDI. Sensitivity analyses demonstrated the model’s robustness. Conclusions: Vancomycin alone appears to be the most cost-effective regimen for the treatment of first recurrence of CDI. Fidaxomicin alone led to the highest QALY gained, but at a cost beyond what is considered cost-effective.
(Received 20 February 2018; accepted 16 May 2018; electronically published July 2, 2018)
Clostridium difficile infection (CDI) is the leading cause of healthcare-associated diarrhea in the United States leading to significant morbidity and mortality.1,2 The economic burden associated with CDI is estimated to be $1.2–$5.9 billion annually in United States, with similar burdens observed in Europe.3,4 For a first episode of CDI, the standard of treatment is either oral vancomycin or fidaxomicin.5 However, when CDI recurs, the treatment approach is less clear. Recurrence is common, with reported rates ranging from 5% to 50% for healthcare-associated CDI, and most studies reporting between 10% and 30%.6,7 Fur- thermore, recurring patients have a higher risk for subsequent recurrences, which may contribute to diminished quality of life and further financial burden on the healthcare system.8 Evidence supporting the use of different treatments for
recurrent CDI is lacking. Current European Society of Clinical Microbiology and Infectious Diseases guidelines recommend treating the first recurrence of CDI with either oral vancomycin
Author for correspondence: Simon W. Lam, Cleveland Clinic, Department of Pharmacy, 9500 Euclid Avenue, JJN-01, Cleveland, OH 44195. E-mail:
lams@ccf.org Cite this article: Simon W. Lam et al. (2018). Cost-effectiveness of three different
strategies for the treatment of first recurrent Clostridium difficile infection diagnosed in a community setting. Infection Control & Hospital Epidemiology 2018, 39, 924–930. doi: 10.1017/ice.2018.139
© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved.
or oral fidaxomicin9; whereas the Infectious Disease Society of America Guidelines recommend treatment of first recurrence of CDI with either vancomycin, vancomycin taper, or fidaxomicin.10 For subsequent recurrences, the IDSA guidelines also mention the possibility of using tapered doses of oral vancomycin, fidax- omicin, or FMT.5 Recently, bezlotoxumab was FDA approved to reduce the recurrence of CDI, when used in combination with other CDI treatments. In a report of two phase 3 clinical studies, bezlotoxumab was associated with substantially lower rates of recurrent infection than placebo (MODIFY I: 17% vs 28%, P<.001; MODIFY II: 16 vs 26%, P<.001).11 Although bezlotoxumab is associated with lower rates of
recurrence, it is associated with substantial cost, approximately $4,500 per patient course. Given the substantial cost associated with the treatment, the lack of guideline consistency for the treatment of recurrent CDI, and the paucity of studies comparing existing therapies for the treatment of recurrent disease, a cost-effectiveness analysis (CEA) may be helpful to elucidate which regimen repre- sents the most efficient use of resources. Several CEAs have been performed regarding treatments of recurrent CDI12–16;however, only 1 has included bezlotoxumab as a treatment option, and this CEA did not specifically evaluate its use for recurrent CDI.16 As such, more cost-effectiveness data are necessary.
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68 |
Page 69 |
Page 70 |
Page 71 |
Page 72 |
Page 73 |
Page 74 |
Page 75 |
Page 76 |
Page 77 |
Page 78 |
Page 79 |
Page 80 |
Page 81 |
Page 82 |
Page 83 |
Page 84 |
Page 85 |
Page 86 |
Page 87 |
Page 88 |
Page 89 |
Page 90 |
Page 91 |
Page 92 |
Page 93 |
Page 94 |
Page 95 |
Page 96 |
Page 97 |
Page 98 |
Page 99 |
Page 100 |
Page 101 |
Page 102 |
Page 103 |
Page 104 |
Page 105 |
Page 106 |
Page 107 |
Page 108 |
Page 109 |
Page 110 |
Page 111 |
Page 112 |
Page 113 |
Page 114 |
Page 115 |
Page 116 |
Page 117 |
Page 118 |
Page 119 |
Page 120 |
Page 121 |
Page 122 |
Page 123 |
Page 124 |
Page 125 |
Page 126 |
Page 127 |
Page 128 |
Page 129 |
Page 130 |
Page 131 |
Page 132 |
Page 133 |
Page 134 |
Page 135 |
Page 136 |
Page 137 |
Page 138 |
Page 139 |
Page 140
