Cost-effectiveness of antibiotic treatment strategies for community-acquired pneumonia: results from a cluster randomized cross-over trial

Cornelis H van Werkhoven, Douwe F Postma, Marie-Josee J Mangen, Jan Jelrik Oosterheert, Marc J M Bonten, CAP-START study group, Cornelis H van Werkhoven, Douwe F Postma, Marie-Josee J Mangen, Jan Jelrik Oosterheert, Marc J M Bonten, CAP-START study group

Abstract

Background: To determine the cost-effectiveness of strategies of preferred antibiotic treatment with beta-lactam/macrolide combination or fluoroquinolone monotherapy compared to beta-lactam monotherapy.

Methods: Costs and effects were estimated using data from a cluster-randomized cross-over trial of antibiotic treatment strategies, primarily from the reduced third payer perspective (i.e. hospital admission costs). Cost-minimization analysis (CMA) and cost-effectiveness analysis (CEA) were performed using linear mixed models. CMA results were expressed as difference in costs per patient. CEA results were expressed as incremental cost-effectiveness ratios (ICER) showing additional costs per prevented death.

Results: A total of 2,283 patients were included. Crude average costs within 90 days from the reduced third payer perspective were €4,294, €4,392, and €4,002 per patient for the beta-lactam monotherapy, beta-lactam/macrolide combination, and fluoroquinolone monotherapy strategy, respectively. CMA results were €106 (95% CI €-697 to €754) for the beta-lactam/macrolide combination strategy and €-278 (95%CI €-991 to €396) for the fluoroquinolone monotherapy strategy, both compared to the beta-lactam monotherapy strategy. The ICER was not statistically significantly different between the strategies. Other perspectives yielded similar results.

Conclusions: There were no significant differences in cost-effectiveness of strategies of preferred antibiotic treatment of CAP on non-ICU wards with either beta-lactam monotherapy, beta-lactam/macrolide combination therapy, or fluoroquinolone monotherapy.

Trial registration: The trial was registered with ClinicalTrials.gov, number NCT01660204 , on May 2nd, 2012.

Keywords: Beta-lactam macrolide; Community acquired pneumonia; Cost-effectiveness; Fluoroquinolone.

Figures

Fig. 1
Fig. 1
Mean costs per patient. a 90-day time horizon. b 30-day time horizon. Legend: Mean costs per patient for the three treatment strategies taking four different perspectives and applying a 90-day (a) and 30-day (b) time horizon. Point estimates and confidence intervals are generated using the 50th, 2.5th and 97.5th percentiles of 2,000 bootstrapping samples. Exact numbers are given in Additional file 1: Table S3
Fig. 2
Fig. 2
Cost-effectiveness plots from a reduced third payer perspective. a Beta-lactam/macrolide strategy vs. beta-lactam strategy-90-day time horizon. b Beta-lactam/macrolide strategy vs. beta-lactam strategy-30-day time horizon. c Fluoroquinolone monotherapy strategy vs. beta-lactam strategy-90-day time horizon. d Fluoroquinolone monotherapy strategy vs. beta-lactam strategy-30-day time horizon. Legend: Grey points represent incremental costs and incremental effects of 2,000 bootstrapping samples for the beta-lactam/macrolide combination strategy compared to the beta-lactam monotherapy strategy within 90 (a) and 30 (b) days of admission, and for the fluoroquinolone monotherapy strategy compared to the beta-lactam monotherapy strategy within 90 (c) and 30 (d) days of admission. The black points and curves represent the point estimates and the 95% confidence ellipses. Proportions in each quadrant indicate the proportion of bootstrap samples in that quadrant. Point estimates in the north-west quadrant are in favour of the beta-lactam monotherapy strategy; point estimates in the south-east quadrant are in favour of the other strategy. Exact point estimates and 95% confidence intervals for incremental costs and incremental effects are given in Additional file 1: Table S3

References

    1. Welte T, Torres A, Nathwani D. Clinical and economic burden of community-acquired pneumonia among adults in Europe. Thorax. 2012;67:71–9. doi: 10.1136/thx.2009.129502.
    1. Jackson ML, Neuzil KM, Thompson WW, Shay DK, Yu O, Hanson CA, Jackson LA. The burden of community-acquired pneumonia in seniors: results of a population-based study. Clin Infect Dis. 2004;39:1642–50. doi: 10.1086/425615.
    1. Broulette J, Yu H, Pyenson B, Iwasaki K, Sato R. The incidence rate and economic burden of community-acquired pneumonia in a working-age population. Am Heal drug benefits. 2013;6:494–503.
    1. StatLine; Centraal Bureau voor de Statistiek (CBS). Statistics Netherlands. [Internet]. [cited 2015 Apr 27].Available from: .
    1. Spoorenberg SMC, Bos WJW, Heijligenberg R, Voorn PGP, Grutters JC, Rijkers GT, van de Garde EMW. Microbial aetiology, outcomes, and costs of hospitalisation for community-acquired pneumonia; an observational analysis. BMC Infect Dis. 2014;14:335. doi: 10.1186/1471-2334-14-335.
    1. Rozenbaum MH, Mangen M-JJ, Huijts SM, van der Werf TS, Postma MJ. Incidence, direct costs and duration of hospitalization of patients hospitalized with community acquired pneumonia: A nationwide retrospective claims database analysis. Vaccine. 2015;33:3193–9. doi: 10.1016/j.vaccine.2015.05.001.
    1. Malhotra-Kumar S, Lammens C, Coenen S, Van HK, Goossens H. Effect of azithromycin and clarithromycin therapy on pharyngeal carriage of macrolide-resistant streptococci in healthy volunteers: a randomised, double-blind, placebo-controlled study. Department of Medical Microbiology, University of Antwerp. Lancet. 2007;369:482–90. doi: 10.1016/S0140-6736(07)60235-9.
    1. Fuller JD, Low DE. A review of Streptococcus pneumoniae infection treatment failures associated with fluoroquinolone resistance. ClinInfectDis. 2005;41:118–21.
    1. Postma DF, van Werkhoven CH, van Elden LJR, Thijsen SFT, Hoepelman AIM, Kluytmans JAJW, Boersma WG, Compaijen CJ, van der Wall E, Prins JM, Oosterheert JJ, Bonten MJM. Antibiotic Treatment Strategies for Community-Acquired Pneumonia in Adults. N Engl J Med. 2015;372:1312–23. doi: 10.1056/NEJMoa1406330.
    1. Van Werkhoven CH, Postma DF, Oosterheert JJ, Bonten MJM. Antibiotic treatment of moderate-severe community-acquired pneumonia: design and rationale of a multicentre cluster-randomised cross-over trial. Neth J Med. 2014;72:170–8.
    1. Hakkaart-van Roijen L, Tan S, Bouwmans C. Methoden en standaard kostprijzen voor economische evaluaties in de gezondheidszorg. 2010.
    1. Tan SS, Bouwmans CAM, Rutten FFH, Hakkaart-van Roijen L. Update of the Dutch Manual for Costing in Economic Evaluations. Int J Technol Assess Health Care. 2012;28:152–8. doi: 10.1017/S0266462312000062.
    1. Tan-Torres Edejer T, Baltussen R, Adam T, Hutubessy R, Acharya A, Evans D, Murray C. Making choices in health: WHO guide to cost-effectiveness analysis. Geneva. 2003.
    1. Wiersinga WJ, Bonten MJ, Boersma WG, Jonkers RE, Aleva RM, Kullberg BJ, Schouten JA, Degener JE, Janknegt R, Verheij TJ, Sachs AP, Prins JM. SWAB/NVALT (Dutch Working Party on Antibiotic Policy and Dutch Association of Chest Physicians) guidelines on the management of community-acquired pneumonia in adults. Neth J Med. 2012;70:90–101.
    1. Rietbergen C, Moerbeek M. The Design of Cluster Randomized Crossover Trials. J Educ Behav Stat. 2011;36:472–90. doi: 10.3102/1076998610379136.
    1. Zhanel GG, Fontaine S, Adam H, Schurek K, Mayer M, Noreddin AM, Gin AS, Rubinstein E, Hoban DJ. A Review of New Fluoroquinolones : Focus on their Use in Respiratory Tract Infections. Treat Respir Med. 2006;5:437–65. doi: 10.2165/00151829-200605060-00009.
    1. Garin N, Genné D, Carballo S, Chuard C, Eich G, Hugli O, Lamy O, Nendaz M, Petignat P-A, Perneger T, Rutschmann O, Seravalli L, Harbarth S, Perrier A. β-Lactam monotherapy vs β-lactam-macrolide combination treatment in moderately severe community-acquired pneumonia: a randomized noninferiority trial. JAMA Intern Med. 2014;174:1894–901. doi: 10.1001/jamainternmed.2014.4887.
    1. MSH/WHO . International Drug Price Indicator Guide. Geneva: Management Sciences for Health/World Health Organization; 2014.
    1. Egger ME, Myers JA, Forest WA, Pass LA, Ramirez JA, Brock GN. Cost effectiveness of adherence to IDSA/ATS guidelines in elderly patients hospitalized for Community-Acquired Pneumonia. BMC Med Inform Decis Mak. 2016;16:34. doi: 10.1186/s12911-016-0270-y.

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