Cost-Effectiveness Analysis of Six Strategies to Treat Recurrent Clostridium difficile Infection

Abstract

ObjectiveTo assess the cost-effectiveness of six treatment strategies for patients diagnosed with recurrent Clostridium difficile infection (CDI) in Canada: 1. oral metronidazole; 2. oral vancomycin; 3.oral fidaxomicin; 4. fecal transplantation by enema; 5. fecal transplantation by nasogastric tube; and 6. fecal transplantation by colonoscopy.PerspectivePublic insurer for all hospital and physician services.SettingOntario, Canada.MethodsA decision analytic model was used to model costs and lifetime health effects of each strategy for a typical patient experiencing up to three recurrences, over 18 weeks. Recurrence data and utilities were obtained from published sources. Cost data was obtained from published sources and hospitals in Toronto, Canada. The willingness-to-pay threshold was $50,000/QALY gained.ResultsFecal transplantation by colonoscopy dominated all other strategies in the base case, as it was less costly and more effective than all alternatives. After accounting for uncertainty in all model parameters, there was an 87% probability that fecal transplantation by colonoscopy was the most beneficial strategy. If colonoscopy was not available, fecal transplantation by enema was cost-effective at $1,708 per QALY gained, compared to metronidazole. In addition, fecal transplantation by enema was the preferred strategy if the probability of recurrence following this strategy was below 8.7%. If fecal transplantation by any means was unavailable, fidaxomicin was cost-effective at an additional cost of $25,968 per QALY gained, compared to metronidazole.ConclusionFecal transplantation by colonoscopy (or enema, if colonoscopy is unavailable) is cost-effective for treating recurrent CDI in Canada. Where fecal transplantation is not available, fidaxomicin is also cost-effective.

Cost-Effectiveness Analysis of Five Competing Strategies for the Management of Multiple Recurrent Community-Onset Clostridium difficile Infection in France

“…Similar results have been demonstrated by other economic analyses evaluating FMT for treatment of recurrent CDI [10,14,15]. A cost-effectiveness analysis of strategies for treatment of recurrent CDI performed from a societal perspective in the USA concluded that FMT via colonoscopy was cost-effective with an ICER of $17,016 compared with vancomycin at a willingness-to-pay threshold of $50,000/QALY [10].…”

“…A recent study performed in Canada compared 6 strategies to treat recurrent CDI using the perspective of the Ontario Ministry of Health and Long-Term Care. The authors concluded that FMT via colonoscopy dominated all other strategies in the base case at a willingness-to-pay threshold of $50,000/QALY [15]. However, route of FMT often depends on the delivery method which is considered the safest for the patient [8].…”

“…All analyses were performed using the TreePlan add-in (Decision Toolworks, San Francisco, USA) for Excel 2010 (Microsoft Corporation, USA) and PopTools [16]. Our model was based, in part, on previously published decision analytic models that investigated the potential value of FMT for CDI and cost-effectiveness analyses evaluating fidaxomicin versus vancomycin in CDI [10,12–15,17–20]. …”

“…To date, published cost-effectiveness analyses of CDI involving FMT have been performed in the USA and in Canada using cost data that may not apply to European countries [10–15]. The aim of this study was to analyze the cost-effectiveness of 5 strategies constructed from the ESCMID guideline for the management of multiple recurrence of CDI in adults where the first-line treatments were pulsed-tapered vancomycin, fidaxomicin, FMT via colonoscopy, FMT via duodenal infusion, and FMT via enema.…”

Editorial Commentary: Where to Place the New Treatments forClostridium difficileInfection?

“…Recurrent CDI is a prime example of this phenomenon. While metronidazole has the lowest list price of all registered CDI treatments, it is the least cost-effective option, due to its high associated recurrence rate [11].…”