Simulated Cost-effectiveness and Long-term Clinical Outcomes of Addiction Care and Antibiotic Therapy Strategies for Patients With Injection Drug Use–Associated Infective Endocarditis

Abstract

IMPORTANCEEmerging evidence supports the use of outpatient parenteral antimicrobial therapy (OPAT) and, in many cases, partial oral antibiotic therapy for the treatment of injection drug use-associated infective endocarditis (IDU-IE); however, long-term outcomes and cost-effectiveness remain unknown. OBJECTIVE To compare the added value of inpatient addiction care services and the costeffectiveness and clinical outcomes of alternative antibiotic treatment strategies for patients with IDU-IE. DESIGN, SETTING, AND PARTICIPANTS This decision analytical modeling study used a validated microsimulation model to compare antibiotic treatment strategies for patients with IDU-IE. Model inputs were derived from clinical trials and observational cohort studies. The model included all patients with injection opioid drug use (N = 5 million) in the US who were eligible to receive OPAT either in the home or at a postacute care facility. Costs were annually discounted at 3%. Costeffectiveness was evaluated from a health care sector perspective over a lifetime starting in 2020. Probabilistic sensitivity, scenario, and threshold analyses were performed to address uncertainty. INTERVENTIONS The model simulated 4 treatment strategies: (1) 4 to 6 weeks of inpatient intravenous (IV) antibiotic therapy along with opioid detoxification (usual care strategy), (2) 4 to 6 weeks of inpatient IV antibiotic therapy along with inpatient addiction care services that offered medication for opioid use disorder (usual care/addiction care strategy), (3) 3 weeks of inpatient IV antibiotic therapy along with addiction care services followed by OPAT (OPAT strategy), and (4) 3 weeks of inpatient IV antibiotic therapy along with addiction care services followed by partial oral antibiotic therapy (partial oral antibiotic strategy). MAIN OUTCOMES AND MEASURES Mean percentage of patients completing treatment for IDU-IE, deaths associated with IDU-IE, life expectancy (measured in life-years [LYs]), mean cost per person, and incremental cost-effectiveness ratios (ICERs). RESULTSAll modeled scenarios were initialized with 5 million individuals (mean age, 42 years; range, 18-64 years; 70% male) who had a history of injection opioid drug use. The usual care strategy resulted in 18.63 LYs at a cost of $416 570 per person, with 77.6% of hospitalized patients completing treatment. Life expectancy was extended by each alternative strategy. The partial oral antibiotic strategy yielded the highest treatment completion rate (80.3%) compared with the OPAT strategy (78.8%) and the usual care/addiction care strategy (77.6%). The OPAT strategy was the least expensive at $412 150 per person. Compared with the OPAT strategy, the partial oral antibiotic (continued) Key Points Question What is the most clinically beneficial and cost-effective antibiotic treatment strategy for injection drug use-associated infective endocarditis (IDU-IE)? Findings In this decision analytical modeling study simulating 4 treatment strategies among 5 million individuals with IDU-IE in the US, a va...

Estimated Clinical Outcomes and Cost-effectiveness Associated With Provision of Addiction Treatment in US Primary Care Clinics

“…The REDUCE model has been described in detail elsewhere. 19 , 20 , 21 Briefly, the model is a closed cohort microsimulation, with no new entrants, of the natural history of injection opioid use, including complications such as overdose, infective endocarditis, and severe SSTI (henceforth referred to as sequelae); treatment; and changes in injection behaviors. The model uses a weekly time step and tracks all individuals from model initiation until death.…”

“…We simulate the cohort stratified by sex, age, and injection behavior profile, which includes injection frequency (high, low, or not currently injecting drugs), sharing of injection equipment, and sterile injection technique. 21 We assume that initial age, sex, and injection profile does not differ among the strategies. In each strategy, we model adults 18 years or older who predominantly inject opioids and are not taking MOUD at the start of the simulation.…”

“…We simulate the cohort stratified by sex, age, and injection behavior profile, which includes injection frequency (high, low, or not currently injecting drugs), sharing of injection equipment, and sterile injection technique. 21 We assume that initial age, sex, and injection profile does not differ The 3 strategies were (1) primary care practitioner (PCP) services with external referral to addiction care (status quo), (2) PCP services plus onsite buprenorphine prescribing with referral to offsite harm reduction kits (BUP), and (3) PCP services plus onsite buprenorphine prescribing and harm reduction kits (BUP plus HR).…”

Current Views on Infective Endocarditis: Changing Epidemiology, Improving Diagnostic Tools and Centering the Patient for Up-to-Date Management

“…IE has a great economic impact. The standard treatment for IE is based on 4 to 6 weeks of intravenous (IV) antibiotic therapy, thus the cost for its management has to take into account the long hospitalization and cost of the IV therapy [ 8 ]…”

Um Panorama Sobre a Endocardite Infecciosa, Seus Mecanismos E Métodos De Tratamento Atualmente Utilizados

“…Além disso, a IE gera um grande impacto econômico. O tratamento padrão para EI é baseado em 4 a 6 semanas de antibioticoterapia intravenosa (IV), por isso o custo para seu manejo deve levar em consideração a longa internação e o custo da terapia intravenosa 7 .…”