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. 2017 Jan 19;12(1):e0170258.
doi: 10.1371/journal.pone.0170258. eCollection 2017.

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

Emilie Baro  1 , Tatiana Galperine  2 , Fanette Denies  3 , Damien Lannoy  4 , Xavier Lenne  5 , Pascal Odou  4 , Benoit Guery  2   6 , Benoit Dervaux  1
Affiliations

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

Emilie Baro et al. PLoS One. .

Abstract

Background: Clostridium difficile infection (CDI) is characterized by high rates of recurrence, resulting in substantial health care costs. The aim of this study was to analyze the cost-effectiveness of treatments for the management of second recurrence of community-onset CDI in France.

Methods: We developed a decision-analytic simulation model to compare 5 treatments for the management of second recurrence of community-onset CDI: pulsed-tapered vancomycin, fidaxomicin, fecal microbiota transplantation (FMT) via colonoscopy, FMT via duodenal infusion, and FMT via enema. The model outcome was the incremental cost-effectiveness ratio (ICER), expressed as cost per quality-adjusted life year (QALY) among the 5 treatments. ICERs were interpreted using a willingness-to-pay threshold of €32,000/QALY. Uncertainty was evaluated through deterministic and probabilistic sensitivity analyses.

Results: Three strategies were on the efficiency frontier: pulsed-tapered vancomycin, FMT via enema, and FMT via colonoscopy, in order of increasing effectiveness. FMT via duodenal infusion and fidaxomicin were dominated (i.e. less effective and costlier) by FMT via colonoscopy and FMT via enema. FMT via enema compared with pulsed-tapered vancomycin had an ICER of €18,092/QALY. The ICER for FMT via colonoscopy versus FMT via enema was €73,653/QALY. Probabilistic sensitivity analysis with 10,000 Monte Carlo simulations showed that FMT via enema was the most cost-effective strategy in 58% of simulations and FMT via colonoscopy was favored in 19% at a willingness-to-pay threshold of €32,000/QALY.

Conclusions: FMT via enema is the most cost-effective initial strategy for the management of second recurrence of community-onset CDI at a willingness-to-pay threshold of €32,000/QALY.

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Conflict of interest statement

The authors of this manuscript have read the journal's policy and have the following competing interests: TG reports personal fees from Astellas and MSD, outside the submitted work. All authors report no competing interests relevant to this article. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Figures

Fig 1
Fig 1. Decision tree comparing 5 strategies for the treatment of second recurrence of community-onset Clostridium difficile infection.
Note: expanded model details shown for vancomycin pulse/taper arm only. Abbreviations: CDI: Clostridium difficile infection; FMT: fecal microbiota transplantation.
Fig 2
Fig 2. Tornado diagram, FMT via enema versus pulsed-tapered vancomycin.
Name of the variable (lower bound of the parameter—higher bound of the parameter [base case]). The ICER corresponding to the lower parameter bound is shown in black, while the ICER corresponding to the higher parameter bound is shown in grey. This figure represents the impact of the uncertainty of six parameters on the base case results. Abbreviations: CDI: Clostridium difficile infection; FMT: fecal microbiota transplantation; ICER: incremental cost-effectiveness ratio.
Fig 3
Fig 3. Acceptability curve of treatments of second recurrence of Clostridium difficile infection.
This figure illustrates the proportion of the time each treatment was cost-effective at different willingness-to-pay thresholds. Abbreviations: FMT: fecal microbiota transplantation.
See this image and copyright information in PMC

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