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Influence of bacterial resistances on the efficiency of antibiotic treatments for community-acquired pneumonia |
Sabes-Figuera R, Segu J L, Puig-Junoy J, Torres A |
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Record Status This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. CRD summary The objective of the study was to estimate the cost-effectiveness of of oral antibiotics used in Spain for the ambulatory treatment of community-acquired pneumonia. The authors concluded that moxifloxacin was the most effective and efficient option. Overall, the quality of the methodology was satisfactory and both the methods and the results were, in general, well reported. Given the scope of the analysis, the authors’ conclusions appear valid. Type of economic evaluation Cost-effectiveness analysis Study objective The objective of the study was to estimate the cost-effectiveness of of oral antibiotics used in Spain for the ambulatory treatment of community-acquired pneumonia (CAP). Interventions The authors investigated the use of the following 10-day antibiotic treatments: 400 mg/day moxifloxacin, 800 mg/day telithromycin, 1,000 mg amoxicillin three times daily, and 500 mg clarithromycin twice daily. Methods Analytical approach:A decision analysis model was used to simulate the impact of each antibiotic treatment on health and resource use. The time horizon of the study was between 10 and 20 days, depending on the antibiotic treatment used. The authors reported that the perspective adopted in the economic analysis was that of the public health system insurer.
Effectiveness data:The effectiveness data were derived from published data and the opinion of various Spanish clinical experts. To identify published data on effectiveness measures, the authors reported that a systematic review of MEDLINE was carried out. The search period and the main keywords used in the search were reported. Only double-blind, randomised controlled trials were included in the review, two authors selecting these. The main clinical estimate derived from the literature was the efficacy of each of the treatments under study.
Monetary benefit and utility valuations:None.
Measure of benefit:The measure of benefit was successful initial antibiotic treatment, as defined by the number of patients without complications.
Cost data:The direct costs to the health care system included in the study were the costs of: hospitalisation, casualty visits, primary care visits, diagnostic tests (including chest X-rays, sputum test, gram stain and conventional sputum culture) and the study drugs. With the exception of length of stay in hospital, which was derived from the Spanish Ministry of Health, all other resource use estimates, including hospitalisation rates, were derived from assumptions made by the authors and experts, who also derived the effectiveness estimates. The unit costs were derived from a national database of health costs and from the catalogue of proprietary medicinal products. The price year was 2004. All costs were reported in euros (EUR).
Analysis of uncertainty:A series of one-way sensitivity analyses were performed. The parameters varied were the efficacy rates (using the lower and upper 95% confidence intervals identified in the literature), unit costs of all resource use items, resistance patterns to antibiotic and aetiology of the infections. Results The percentage of patients without complications was 92.23% for moxifloxacin, 74.91% for clarithromycin, 90.28 for telithromycin and 54.65% for amoxicillin.
The average cost per patient was EUR 279.20 for moxifloxacin, 283.30 for clarithromycin, 352.10 for telithromycin and 458.50 for amoxicillin.
As moxifloxacin was found to be both more effective and less costly than the other treatments, the costs and benefits were not combined as moxifloxacin was the dominant treatment option.
The results of the sensitivity analysis showed that, under all scenarios tested, moxifloxacin remained the most effective treatment option. However, it became more costly when the lower limit of the confidence interval for its efficacy was used, the unit costs were set to their lowest value, there was no bacterial resistance, or when there were no infections caused by atypical pathogens. Authors' conclusions The authors concluded that moxifloxacin was the most effective and efficient option. CRD commentary Interventions:The interventions under study were well reported. Furthermore, an explicit justification was given for the choice of each treatment, namely that they represented the oral antibiotics used in Spain for the ambulatory treatment of CAP.
Effectiveness/benefits:The effectiveness data were derived from published data and the opinion of various Spanish clinical experts. The authors reported adequate details of the methods used to identify published research. Only MEDLINE was searched for evidence and, consequently, it is possible that not all relevant information was included in the review. However, the review only included double-blind randomised studies, which are considered to be the 'gold' standard study design when comparing health interventions. No details were reported on how the effectiveness data were derived from the clinical experts. The measure of benefit used (i.e. successful initial antibiotic treatment) did not cover important health outcomes such as quality of life or life expectancy.
Costs:The perspective adopted in the economic study was appropriately reported. All major relevant costs appear to have been included in the analysis. The resource use data were generally derived from assumptions made by clinical experts, with unit costs being derived from national sources and databases. The unit costs were adequately varied in the sensitivity analyses. Both the price year and the time horizon were reported.
Analysis and results:The time horizon used in the study was very short, 10 to 20 days. However, given the narrow measure of benefit used in the study, this would appear justified. Uncertainty in the model parameters was tested using a series of one-way sensitivity analyses. Although, this type of analysis goes some way toward measuring uncertainty, the use of probabilistic sensitivity analyses is a more thorough method of capturing uncertainty within a model. Overall, the level of reporting of both the methodology and the results was adequate, with the authors appropriately reporting the limitations of their study.
Concluding remarks:Overall, the quality of the methodology was satisfactory and both the methods and the results were, in general, well reported. Given the scope of the analysis, the authors’ conclusions appear valid. Funding Bayer Espana S.A; project Ciber de Respiratorio. Bibliographic details Sabes-Figuera R, Segu J L, Puig-Junoy J, Torres A. Influence of bacterial resistances on the efficiency of antibiotic treatments for community-acquired pneumonia. European Journal of Health Economics 2008; 9: 23-32 Other publications of related interest Najib MM, Stein GE, Goss TF. Cost-effectiveness of sparfloxacin compared with oral antimicrobials in outpatient treatment of community acquired pneumonia. Pharmacotherapy 2000;20:461-9.
Bartolome M, Almirall J, Morera J, et al. A population-based study of the cost of care for community acquired pneumonia. Eur Respir J 2004;23:1-7. Indexing Status Subject indexing assigned by NLM MeSH Anti-Bacterial Agents /administration & Community-Acquired Infections /drug therapy; Cost-Benefit Analysis; Costs and Cost Analysis; Decision Trees; Drug Resistance, Bacterial /drug effects; Humans; Spain; Treatment Outcome; dosage /economics /pharmacology AccessionNumber 22008008065 Date bibliographic record published 01/09/2008 Date abstract record published 30/09/2008 |
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