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Clinical Pharmacist Clinical Research/Infectious Diseases Barnes-Jewish Hospital 216 S. Kingshighway Mailstop 90-52-411 St. Louis, MO 63110-1092 fax 314/747-2185 McKinnon.Peggy{at}bjc.org
Research Scientist Center for Health Economics & Policy United BioSource Corp. Bethesda, MD
Director US Outcomes Research Pfizer Inc. New York, NY
Chief of Surgery Boston Veterans Affairs Health Care System Professor of Surgery Boston University Boston, MA
Published Online, November 14, 2006. www.theannals.com, DOI 10.1345/aph.1G728b
When multinational economic analyses are conducted, there are numerous issues to be considered,3 not the least of which is how differing reimbursement strategies influence incentive for hospital discharge. Selection of the US population, largely functioning under a diagnosis-related group-based reimbursement system, allows for assessment of the potential for reducing length of hospital stay when this is, in fact, in the best financial interest of the institution. As noted, our findings cannot necessarily be extrapolated to other systems or countries. Comparison of the clinical and demographic characteristics of the 717 US patients in Table 2 of our research report and the 1180 patients from the study population in Table 1 of Weigelt et al.'s study1 reveals nearly identical populations and, more importantly, that between-treatment group homogeneity has been maintained. Similarly, the distribution of diagnoses, rates of prior hospitalizations, MRSA infection rates, and clinical outcomes in the US population reflect those of the overall study sample. Only data from the US subset were used in our analyses; no multinational outcomes data were used for evaluation or interpretation of effect.
We agree with the critique that ideally, adverse event data should have been included as an individual category of resource utilization; however, details were not routinely collected to categorize costs as attributable to adverse events within the clinical trial. This does not mean that costs were not included. The total costs evaluated include the cost of concomitant medications, procedures, and hospital length of stay that may have been related to adverse events. Unfortunately, we were unable to discern these from overall resource utilization collected to know which component costs were specifically for adverse event management. Adverse event costs would not be ignored unless patients developed an adverse event beyond the trial period.
While a cost-minimization analysis was recommended for evaluation of these data, as clinical cure rates and costs associated with care are available, incremental cost-effectiveness analysis is more appropriate. Since costs were lower and cure rates were higher in the linezolid-treated patients, linezolid was always the dominant option and incremental costeffectiveness analyses were not performed. As such, the resulting costs are in essence reflective of a cost-minimization exercise demonstrating a cost savings for linezolid of $1125 in MRSA-infected patients. We did not report an incremental cost-effectiveness ratio, although in the MRSA subset, this would have resulted in a greater difference than the conservative $1125 per patient reported.
In conclusion, the 2.5 day reduction in length of hospital stay observed for linezolid-treated patients translated to significant cost savings, despite the higher drug acquisition cost. Use of the data for the US subset provides the most usefulness to practitioners in the US and in regions where efficient hospital discharge is desired. We acknowledge the potential limited generalizability to institutions where there is no financial incentive to reduce hospital length of stay.
Footnotes
Dr McKinnon receives honoraria from or is advisor to Cubist, Elan, Pfizer, Merck, Schering-Plough, and Wyeth.
References
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