Wakerly L, Craig A M, Malek M, Hoffmeyer U, Lloyd A, Valette F, Phillips R, Zabihollah M
National Economic Research Associates, London, UK.
J Hosp Infect. 1996 May;33(1):35-48. doi: 10.1016/s0195-6701(96)90027-4.
This study compares 100 mg daily fluconazole with oral polyenes four times daily in the prophylaxis of fungal infections in immunocompromised patients, to determine a cost-minimization strategy. Data was gathered through a literature survey and clinical interviews conducted in nine different UK hospitals. This was used to construct a decision tree, modelling the drug choices available to a clinician at various stages of a patient's treatment, and assigning probabilities to the different corresponding outcomes. UK cost data were fed into this model to determine the expected cost per patient of the different prophylaxis strategies. Two different patient groups were considered: chemotherapy-only patients, and bone-marrow-transplant (BMT) patients who have higher risks of fungal infection. Probabilities derived from the literature suggest that a cost-minimization strategy to manage both chemotherapy patients and BMT patients is to administer oral fluconazole, both as prophylaxis and as first line treatment, against superficial fungal infection. Probabilities gathered from clinical interviews yield similar results, suggesting that the cost-minimization strategy with chemotherapy-only patients is to administer oral polyenes as prophylaxis, and oral fluconazole in case of superficial fungal infection, while for BMT patients it is a combination of fluconazole and oral polyenes as prophylaxis, with oral fluconazole for the treatment of superficial fungal infections. Using the probabilities from the literature, the lowest cost strategies produce an expected cost of pounds 567.20 for chemotherapy-only patients, and an expected cost of pounds 804.87 for BMT patients for a course of treatment lasting from seven to 28 days. The clinical interview probabilities produce expected costs of pounds 826.48 and pounds 1529.43, respectively. Sensitivity analysis was then conducted, and it was found that in the majority of cases, using the literature probabilities, the cost-minimizing strategy remained prophylaxis with oral fluconazole. The sensitivity analysis for chemotherapy-only patients using the interview probabilities tended to favour oral polyenes as the cost-minimization strategy, whereas for BMT patients the sensitivity analysis favoured a combination of fluconazole and oral polyenes in the majority of cases. The key economic advantage of prophylaxis with fluconazole or a combination of fluconazole with oral polyenes in the prophylaxis of fungal infection in immunocompromised patients, results from the reduction of the expected cost of subsequent fungal infection among those who are most at risk.
本研究比较了每日100毫克氟康唑与每日四次口服多烯类药物在免疫功能低下患者预防真菌感染中的效果，以确定成本最小化策略。数据通过在英国九家不同医院进行的文献调查和临床访谈收集。这些数据被用于构建一个决策树，模拟临床医生在患者治疗不同阶段可选用的药物，并为不同的相应结果赋予概率。将英国成本数据输入该模型，以确定不同预防策略下每位患者的预期成本。研究考虑了两个不同的患者群体：仅接受化疗的患者，以及真菌感染风险较高的骨髓移植（BMT）患者。从文献中得出的概率表明，针对化疗患者和BMT患者的成本最小化策略是使用口服氟康唑进行预防和作为一线治疗，以对抗浅表真菌感染。从临床访谈中收集的概率得出了类似的结果，表明对于仅接受化疗的患者，成本最小化策略是使用口服多烯类药物进行预防，出现浅表真菌感染时使用口服氟康唑；而对于BMT患者，成本最小化策略是氟康唑和口服多烯类药物联合预防，使用口服氟康唑治疗浅表真菌感染。根据文献中的概率，对于疗程为7至28天的治疗，成本最低的策略对于仅接受化疗的患者预期成本为567.20英镑，对于BMT患者预期成本为804.87英镑。临床访谈概率得出的预期成本分别为826.48英镑和1529.43英镑。随后进行了敏感性分析，发现在大多数情况下，采用文献中的概率，成本最小化策略仍然是口服氟康唑预防。使用访谈概率对仅接受化疗的患者进行敏感性分析倾向于将口服多烯类药物作为成本最小化策略，而对于BMT患者，敏感性分析在大多数情况下倾向于氟康唑和口服多烯类药物联合使用。在免疫功能低下患者预防真菌感染中，使用氟康唑或氟康唑与口服多烯类药物联合预防的关键经济优势在于降低了高危人群后续真菌感染的预期成本。
