van Engen Anke, Casamayor Montserrat, Kim Soyoung, Watt Maureen, Odeyemi Isaac
Quintiles Consulting, Hoofddorp, the Netherlands.
Quintiles Consulting, Barcelona, Spain.
Clinicoecon Outcomes Res. 2017 Dec 5;9:763-774. doi: 10.2147/CEOR.S141548. eCollection 2017.
The incidence of azole-resistant infections is increasing. Consequently, guidelines for treating systemic infection (SCI) recommend a "de-escalation" strategy: initial broad-spectrum antifungal agents (e.g., echinocandins), followed by switching to fluconazole if isolates are fluconazole sensitive, rather than "escalation" with initial fluconazole treatment and then switching to echinocandins if isolates are fluconazole resistant. However, fluconazole may continue to be used as first-line treatment in view of its low acquisition costs. The aim of this study was, therefore, to evaluate the budget impact of the de-escalation strategy using micafungin compared with the escalation strategy in France and Germany.
A budget impact model was used to compare de-escalation to escalation strategies. As well as survival, clinical success (resolution/reduction of symptoms and radiographic abnormalities associated with fungal infection), was considered, as was mycological success (eradication of from the bloodstream). Health economic outcomes included cost per health state according to clinical success and mycological success, and budget impact. A 42-day time horizon was used.
For all patients with SCI, the budget impact of using de-escalation rather than escalation was greater, but improved rates of survival, clinical success and mycological success were apparent with de-escalation. In patients with fluconazole-resistant isolates, clinical success rates and survival were improved by ~72% with de-escalation versus escalation, producing cost savings of €6,374 and €356 per patient in France and Germany, respectively; improvements of ~72% in mycological success rates with de-escalation versus escalation did not translate into cost savings.
Modeling provides evidence that when treating SCI in individuals at risk of azole-resistant infections, de-escalation from micafungin has potential cost savings associated with improved clinical success rates.
唑类耐药感染的发生率正在上升。因此，系统性感染（SCI）治疗指南推荐采用“降阶梯”策略：初始使用广谱抗真菌药物（如棘白菌素），如果分离株对氟康唑敏感则随后换用氟康唑，而不是采用“升阶梯”策略，即初始使用氟康唑治疗，若分离株对氟康唑耐药则再换用棘白菌素。然而，鉴于氟康唑采购成本较低，它可能仍被用作一线治疗药物。因此，本研究的目的是评估在法国和德国使用米卡芬净的降阶梯策略与升阶梯策略相比的预算影响。
采用预算影响模型对降阶梯策略和升阶梯策略进行比较。除了生存率外，还考虑了临床成功（与真菌感染相关的症状和影像学异常的缓解/减轻）以及真菌学成功（从血流中清除真菌）。卫生经济结果包括根据临床成功和真菌学成功划分的每个健康状态的成本以及预算影响。采用42天的时间范围。
对于所有SCI患者，使用降阶梯策略而非升阶梯策略的预算影响更大，但降阶梯策略的生存率、临床成功率和真菌学成功率均有明显提高。在分离株对氟康唑耐药的患者中，与升阶梯策略相比，降阶梯策略使临床成功率和生存率提高了约72%，在法国和德国分别为每位患者节省成本6374欧元和356欧元；与升阶梯策略相比，降阶梯策略使真菌学成功率提高了约72%，但并未转化为成本节约。
模型分析表明，在治疗有唑类耐药感染风险的个体的SCI时，从米卡芬净开始降阶梯治疗有可能节省成本，并提高临床成功率。
