Egger Michael E, Myers John A, Arnold Forest W, Pass Leigh Ann, Ramirez Julio A, Brock Guy N
The Hiram C. Polk, Jr., MD Department of Surgery, University of Louisville, School of Medicine, Louisville, KY, USA.
Present Affiliation: Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
BMC Med Inform Decis Mak. 2016 Mar 15;16:34. doi: 10.1186/s12911-016-0270-y.
Adherence to guidelines for the treatment of hospitalized elderly patients with community-acquired pneumonia (CAP) has been associated with improved clinical outcomes. This study evaluated the cost-effectiveness of adherence to guidelines for the treatment of CAP in an elderly hospitalized patient cohort.
Data from an international, multicenter observational study for patients age 65 years or older hospitalized with CAP from 2001 to 2007 were used to estimate transition probabilities for a multi-state Markov model traversing multiple health states during hospitalization for CAP. Empiric antibiotic therapy was classified as adherent, over-treated, and under-treated according to 2007 Infectious Disease Society of America/American Thoracic Society IDSA/ATS guidelines. Utilities were estimated from an expert panel of active clinicians. Costs were estimated from a tertiary referral hospital and adjusted for inflation to 2013 US dollars. Costs, utilities, and transition probabilities were all modeled using probability distributions to handle their inherit uncertainty. Cost-effectiveness analysis was based on the first 14 days of hospitalization. Patients admitted to the intensive care unit (ICU) were analyzed separately from those admitted to the ward. Sensitivity analyses with regards to time frame (out to 30 days hospitalization), cost estimates, and willingness to pay values were performed.
The model parameters were estimated using data from 1635 patients (1438 admitted to the ward and 197 admitted to the ICU). For the ward model, adherence to antibiotic guidelines was the dominant strategy and associated with lower costs (-$1379 and -$799) and improved quality of life compared to over- and under-treatment. In the ICU model, however, adherence to guidelines was associated with greater costs (+$13,854 and + $3461 vs. over- and under-treatment, respectively) and lower quality of life. Acceptance rates across the willingness to pay ranges evaluated were 42-48 % for guideline adherence on the ward and 61-64 % for over-treatment on the ICU. Results were robust over sensitivity analyses concerning cost and utility estimates.
While adherence to antibiotic guidelines was the most cost-effective strategy for elderly patients hospitalized with CAP and admitted to the ward, in the ICU over-treatment of patients relative to the guidelines was the most cost-effective strategy.
遵循社区获得性肺炎（CAP）住院老年患者的治疗指南与改善临床结局相关。本研究评估了老年住院患者队列中遵循CAP治疗指南的成本效益。
使用2001年至2007年期间65岁及以上因CAP住院的患者的一项国际多中心观察性研究数据，来估计多状态马尔可夫模型在CAP住院期间穿越多个健康状态的转移概率。根据2007年美国传染病学会/美国胸科学会（IDSA/ATS）指南，经验性抗生素治疗被分类为遵循、过度治疗和治疗不足。效用值由活跃临床医生专家小组估计。成本由一家三级转诊医院估计，并根据通货膨胀调整为2013年美元。成本、效用值和转移概率均使用概率分布进行建模，以处理其内在的不确定性。成本效益分析基于住院的前14天。入住重症监护病房（ICU）的患者与入住病房的患者分开分析。对时间范围（住院30天）、成本估计和支付意愿值进行了敏感性分析。
使用1635例患者（1438例入住病房，197例入住ICU）的数据估计模型参数。对于病房模型，与过度治疗和治疗不足相比，遵循抗生素指南是主导策略，且成本更低（分别为 -1379美元和 -799美元），生活质量更高。然而，在ICU模型中，遵循指南与更高的成本（分别比过度治疗和治疗不足高13854美元和3461美元）和更低的生活质量相关。在评估的支付意愿范围内，病房中遵循指南的接受率为42% - 48%，ICU中过度治疗的接受率为61% - 64%。关于成本和效用估计的敏感性分析结果具有稳健性。
虽然遵循抗生素指南是因CAP住院并入住病房的老年患者最具成本效益的策略，但在ICU中，相对于指南对患者进行过度治疗是最具成本效益的策略。
