Simulated Cost-effectiveness and Long-term Clinical Outcomes of Addiction Care and Antibiotic Therapy Strategies for Patients With Injection Drug Use-Associated Infective Endocarditis.
Simulated Cost-effectiveness and Long-term Clinical Outcomes of Addiction Care and Antibiotic Therapy Strategies for Patients With Injection Drug Use-Associated Infective Endocarditis.
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DOI：
10.1001/jamanetworkopen.2022.0541
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发表时间：
2022-02-01
影响因子：
13.8
通讯作者：
Barocas JA
中科院分区：
文献类型：
--
作者：
Adams JW;Savinkina A;Hudspeth JC;Gai MJ;Jawa R;Marks LR;Linas BP;Hill A;Flood J;Kimmel S;Barocas JA
注射药物相关性感染性心内膜炎（IDU-IE）的最佳临床获益和成本效益的抗生素治疗策略是什么？在这项决策分析建模研究中，在美国500万IDU-IE患者中模拟了4种治疗策略，经验证的微观模拟模型表明，门诊胃肠外抗菌治疗是治疗IDU-IE的最具成本效益的策略。当耐甲氧西林金黄色葡萄球菌不是致病病原体时，部分口服抗生素治疗策略与最高的治疗完成率相关，并且最具成本效益。本研究发现，门诊胃肠外抗菌治疗和部分口服抗生素治疗方案可能与6周住院静脉内抗生素治疗IDU-IE一样具有临床获益，且成本更低。新出现的证据支持使用门诊肠外抗菌药物治疗（OPAT），在许多情况下，部分口服抗生素治疗注射药物使用相关的感染性心内膜炎（IDU-IE）;然而，长期结果和成本效益仍然未知。比较IDU-IE患者住院成瘾护理服务的附加值和替代抗生素治疗策略的成本效益和临床结局。本决策分析建模研究使用经验证的微观模拟模型比较IDU-IE患者的抗生素治疗策略。模型输入来自临床试验和观察性队列研究。该模型包括美国所有有资格在家中或急性后护理机构接受OPAT的注射阿片类药物使用患者（N = 500万）。成本每年以3%贴现。从医疗保健部门的角度评估了从2020年开始的整个生命周期的成本效益。进行概率敏感性、情景和阈值分析以解决不确定性。该模型模拟了4种治疗策略：（1）4至6周的住院静脉内（IV）抗生素治疗，同时沿着阿片类药物解毒（常规护理策略），（2）4至6周的住院IV抗生素治疗，沿着提供阿片类药物使用障碍药物的住院成瘾护理服务（常规护理/成瘾护理策略），（3）3周住院患者IV抗生素治疗，沿着成瘾护理服务，随后进行OPAT（OPAT策略），和（4）3周的住院IV抗生素治疗沿着成瘾护理服务，随后是部分口服抗生素治疗（部分口服抗生素策略）。完成IDU-IE治疗的患者平均百分比、IDU-IE相关死亡、预期寿命（以生命年[LY]衡量）、人均成本和增量成本-效果比（ICER）。所有模拟场景均以500万有注射阿片类药物使用史的个体（平均年龄，42岁;范围，18-64岁; 70%男性）为初始值。常规护理策略导致18.63例LY，人均费用为416570美元，77.6%的住院患者完成治疗。每种替代策略都延长了预期寿命。与OPAT策略（78.8%）和常规护理/成瘾护理策略（77.6%）相比，部分口服抗生素策略的治疗完成率最高（80.3%）。OPAT战略是最便宜的，每人412 150美元。与OPAT策略相比，部分口服抗生素策略的ICER为163 370美元/LY。与OPAT策略相比，增加IDU-IE治疗吸收和减少治疗中断使得部分口服抗生素策略更具成本效益。当假设所有IDU-IE患者都有资格接受部分口服抗生素治疗时，该策略节省了成本，并导致额外的0.0247折扣LY。当治疗中止率从每周3.30%降至2.65%时，与OPAT相比，部分口服抗生素策略在每LY 100 000美元的阈值下具有成本效益。在这项决策分析模型研究中，与仅提供住院IV抗生素治疗的常规护理策略相比，OPAT或部分口服抗生素方法沿着成瘾护理服务用于治疗IDU-IE患者与完成治疗的人数增加、死亡率降低和成本节省相关。这项决策分析模型研究评估了住院成瘾护理服务的附加值，并在美国500万注射药物使用相关感染性心内膜炎患者中比较了不同抗生素治疗策略的成本效益和临床结局。
What is the most clinically beneficial and cost-effective antibiotic treatment strategy for injection drug use–associated infective endocarditis (IDU-IE)? In this decision analytical modeling study simulating 4 treatment strategies among 5 million individuals with IDU-IE in the US, a validated microsimulation model suggested that outpatient parenteral antimicrobial therapy was the most cost-effective strategy for the treatment of IDU-IE. A partial oral antibiotic treatment strategy was associated with the highest treatment completion rate and was most cost-effective when methicillin-resistant Staphylococcus aureus was not a causative pathogen. This study found that outpatient parenteral antimicrobial therapy and partial oral antibiotic therapy regimens were likely to be as clinically beneficial as and less costly than 6 weeks of inpatient intravenous antibiotic therapy for the treatment of IDU-IE. Emerging evidence supports the use of outpatient parenteral antimicrobial therapy (OPAT) and, in many cases, partial oral antibiotic therapy for the treatment of injection drug use–associated infective endocarditis (IDU-IE); however, long-term outcomes and cost-effectiveness remain unknown. To compare the added value of inpatient addiction care services and the cost-effectiveness and clinical outcomes of alternative antibiotic treatment strategies for patients with IDU-IE. This decision analytical modeling study used a validated microsimulation model to compare antibiotic treatment strategies for patients with IDU-IE. Model inputs were derived from clinical trials and observational cohort studies. The model included all patients with injection opioid drug use (N = 5 million) in the US who were eligible to receive OPAT either in the home or at a postacute care facility. Costs were annually discounted at 3%. Cost-effectiveness was evaluated from a health care sector perspective over a lifetime starting in 2020. Probabilistic sensitivity, scenario, and threshold analyses were performed to address uncertainty. The model simulated 4 treatment strategies: (1) 4 to 6 weeks of inpatient intravenous (IV) antibiotic therapy along with opioid detoxification (usual care strategy), (2) 4 to 6 weeks of inpatient IV antibiotic therapy along with inpatient addiction care services that offered medication for opioid use disorder (usual care/addiction care strategy), (3) 3 weeks of inpatient IV antibiotic therapy along with addiction care services followed by OPAT (OPAT strategy), and (4) 3 weeks of inpatient IV antibiotic therapy along with addiction care services followed by partial oral antibiotic therapy (partial oral antibiotic strategy). Mean percentage of patients completing treatment for IDU-IE, deaths associated with IDU-IE, life expectancy (measured in life-years [LYs]), mean cost per person, and incremental cost-effectiveness ratios (ICERs). All modeled scenarios were initialized with 5 million individuals (mean age, 42 years; range, 18-64 years; 70% male) who had a history of injection opioid drug use. The usual care strategy resulted in 18.63 LYs at a cost of $416 570 per person, with 77.6% of hospitalized patients completing treatment. Life expectancy was extended by each alternative strategy. The partial oral antibiotic strategy yielded the highest treatment completion rate (80.3%) compared with the OPAT strategy (78.8%) and the usual care/addiction care strategy (77.6%). The OPAT strategy was the least expensive at $412 150 per person. Compared with the OPAT strategy, the partial oral antibiotic strategy had an ICER of $163 370 per LY. Increasing IDU-IE treatment uptake and decreasing treatment discontinuation made the partial oral antibiotic strategy more cost-effective compared with the OPAT strategy. When assuming that all patients with IDU-IE were eligible to receive partial oral antibiotic therapy, the strategy was cost-saving and resulted in 0.0247 additional discounted LYs. When treatment discontinuation was decreased from 3.30% to 2.65% per week, the partial oral antibiotic strategy was cost-effective compared with OPAT at the $100 000 per LY threshold. In this decision analytical modeling study, incorporation of OPAT or partial oral antibiotic approaches along with addiction care services for the treatment of patients with IDU-IE was associated with increases in the number of people completing treatment, decreases in mortality, and savings in cost compared with the usual care strategy of providing inpatient IV antibiotic therapy alone. This decision analytical modeling study assesses the added value of inpatient addiction care services and compares the cost-effectiveness and clinical outcomes of different antibiotic treatment strategies among 5 million individuals with injection drug use–associated infective endocarditis in the US.
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影响因子：
4.2
作者：
Caudarella, Alexander;Dong, Huiru;Hayashi, Kanna
通讯作者：
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影响因子：
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影响因子：
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影响因子：
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作者：
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影响因子：
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