What is the Most Cost Effective C. difficile Treatment?

MARCH 21, 2017
Rachel Lutz
In a new analysis assessing various treatments for recurrent Clostridium difficile (C. difficile) infection, researchers determined that the most cost effective first-time treatment was fecal microbiota transplantation (FMT) via enema.
 
The research team from France led by Emilie Baro, MD, MSc (photo), developed an analytical simulation model to compare 5 treatments for the management of recurrent community onset C. difficile infection based on their cost effectiveness. The 5 methods the study authors included in their analysis were pulsed-tapered vancomycin, fidaxomicin, FMT via colonoscopy, FMT via duodenal infusion, and FMT via enema.
 
Each of these methods was compared using incremental cost effectiveness ratio (ICER) expressed as the cost per quality adjusted life year (QALY). The researchers used the benchmark  €32,000/QALY (about $34,200/QALY) as their willingness to pay threshold.
 
Quality of life estimates were extrapolated from the European Quality of Life 5 Dimensions questionnaires, as they did not find quality of life estimates for C. difficile infected patients available in the current published literature.
 
The researchers determined the following costs for each procedure:
-        Pulsed-tapered vancomycin (€1,235/ about $1,320)
-        Fidaxomicin (€2,464/ about $2,630)
-        FMT via colonoscopy (€1,834/ about $1,960)
-        FMT via duodenal infusion (€1,610/ about $1,720)
-        FMT via enema (€1,816/ about $1,940)
 
After applying the QALY modifications, the researchers found that FMT via enema was more expensive, though more effective, than pulsed tapered vancomycin with an ICER of €18,092/QALY (about $19,310/QALY). Subsequently, FMT via colonoscopy cost more and was more effective than FMT via enema with an ICER of €73,653/QALY (approximately $78,615/QALY).
 
Fidaxomicin and FMT via duodenal infusion were both more expensive and less effective than the other two FMT delivery mechanisms.
 
The research team explained that many success factors had an impact on the analysis model as well:
 
·      Probabilities of cure and probability of relapse of vancomycin
·      Probability of cure of FMT via enema
·      Cost of severe C. difficile infection
·      Utilities of mild and severe C. difficile infection
Results showed that the probabilities of cure and relapse of pulsed-tapered vancomycin and FMT via enema were the most impactful on the model. According to the researchers, this was also true for cost of severe C. difficile infection and utility of mild C. difficile infection, though to a lesser extent. For example, the researchers wrote that FMT via enema because either less effective and costlier than FMT via colonoscopy, or more effective and less costly than FMT via colonoscopy when considering parameters such as probability of cure with FMT via enema.
 
“The current standard approach using pulsed tapered vancomycin is less costly than FMT, but FMT is more effective regardless of mode of delivery,” the study authors concluded, adding that they believed this is the first cost effectiveness study involving the treatment methods for C. difficile infection. “This study, performed from a societal perspective, may give insights to healthcare decision makers when considering treatment for second recurrence of community onset C. difficile infection.”
 
The paper, titled “Cost-Effectiveness Analysis of Five Competing Strategies for the Management of Multiple Recurrent Community-Onset Clostridium difficile Infection in France,” was published in the journal PLOS One.
 
 
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