Cryptococcal meningitis treatment strategies in resource-limited settings: a cost-effectiveness analysis.

<h4>Background</h4>Cryptococcal meningitis (CM) is the most common form of meningitis in Africa. World Health Organization guidelines recommend 14-d amphotericin-based induction therapy; however, this is impractical for many resource-limited settings due to cost and intensive monitoring...

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Autores principales:	Radha Rajasingham, Melissa A Rolfes, Kate E Birkenkamp, David B Meya, David R Boulware
Formato:	article
Lenguaje:	EN
Publicado:	Public Library of Science (PLoS) 2012
Materias:	Medicine R
Acceso en línea:	https://doaj.org/article/79df12c32dd0465b8e097284eb5ace99
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spelling	oai:doaj.org-article:79df12c32dd0465b8e097284eb5ace992021-11-18T05:42:51ZCryptococcal meningitis treatment strategies in resource-limited settings: a cost-effectiveness analysis.1549-12771549-167610.1371/journal.pmed.1001316https://doaj.org/article/79df12c32dd0465b8e097284eb5ace992012-01-01T00:00:00Zhttps://www.ncbi.nlm.nih.gov/pmc/articles/pmid/23055838/?tool=EBIhttps://doaj.org/toc/1549-1277https://doaj.org/toc/1549-1676<h4>Background</h4>Cryptococcal meningitis (CM) is the most common form of meningitis in Africa. World Health Organization guidelines recommend 14-d amphotericin-based induction therapy; however, this is impractical for many resource-limited settings due to cost and intensive monitoring needs. A cost-effectiveness analysis was performed to guide stakeholders with respect to optimal CM treatment within resource limitations.<h4>Methods and findings</h4>We conducted a decision analysis to estimate the incremental cost-effectiveness ratio (ICER) of six CM induction regimens: fluconazole (800-1,200 mg/d) monotherapy, fluconazole + flucytosine (5FC), short-course amphotericin (7-d) + fluconazole, 14-d of amphotericin alone, amphotericin + fluconazole, and amphotericin + 5FC. We computed actual 2012 healthcare costs in Uganda for medications, supplies, and personnel, and average laboratory costs for three African countries. A systematic review of cryptococcal treatment trials in resource-limited areas summarized 10-wk survival outcomes. We modeled one-year survival based on South African, Ugandan, and Thai CM outcome data, and survival beyond one-year on Ugandan and Thai data. Quality-adjusted life years (QALYs) were determined and used to calculate the cost-effectiveness ratio and ICER. The cost of hospital care ranged from $154 for fluconazole monotherapy to $467 for 14 d of amphotericin + 5FC. Based on 18 studies investigating outcomes for HIV-infected individuals with CM in resource-limited settings, the estimated mean one-year survival was lowest for fluconazole monotherapy, at 40%. The cost-effectiveness ratio ranged from $20 to $44 per QALY. Overall, amphotericin-based regimens had higher costs but better survival. Short-course amphotericin (1 mg/kg/d for 7 d) with fluconazole (1,200 mg/d for14 d) had the best one-year survival (66%) and the most favorable cost-effectiveness ratio, at $20.24/QALY, with an ICER of $15.11 per additional QALY over fluconazole monotherapy. The main limitation of this study is the pooled nature of a systematic review, with a paucity of outcome data with direct comparisons between regimens.<h4>Conclusions</h4>Short-course (7-d) amphotericin induction therapy coupled with high-dose (1,200 mg/d) fluconazole is "very cost effective" per World Health Organization criteria and may be a worthy investment for policy-makers seeking cost-effective clinical outcomes. More head-to-head clinical trials are needed on treatments for this neglected tropical disease. Please see later in the article for the Editors' Summary.Radha RajasinghamMelissa A RolfesKate E BirkenkampDavid B MeyaDavid R BoulwarePublic Library of Science (PLoS)articleMedicineRENPLoS Medicine, Vol 9, Iss 9, p e1001316 (2012)
institution	DOAJ
collection	DOAJ
language	EN
topic	Medicine R
spellingShingle	Medicine R Radha Rajasingham Melissa A Rolfes Kate E Birkenkamp David B Meya David R Boulware Cryptococcal meningitis treatment strategies in resource-limited settings: a cost-effectiveness analysis.
description	<h4>Background</h4>Cryptococcal meningitis (CM) is the most common form of meningitis in Africa. World Health Organization guidelines recommend 14-d amphotericin-based induction therapy; however, this is impractical for many resource-limited settings due to cost and intensive monitoring needs. A cost-effectiveness analysis was performed to guide stakeholders with respect to optimal CM treatment within resource limitations.<h4>Methods and findings</h4>We conducted a decision analysis to estimate the incremental cost-effectiveness ratio (ICER) of six CM induction regimens: fluconazole (800-1,200 mg/d) monotherapy, fluconazole + flucytosine (5FC), short-course amphotericin (7-d) + fluconazole, 14-d of amphotericin alone, amphotericin + fluconazole, and amphotericin + 5FC. We computed actual 2012 healthcare costs in Uganda for medications, supplies, and personnel, and average laboratory costs for three African countries. A systematic review of cryptococcal treatment trials in resource-limited areas summarized 10-wk survival outcomes. We modeled one-year survival based on South African, Ugandan, and Thai CM outcome data, and survival beyond one-year on Ugandan and Thai data. Quality-adjusted life years (QALYs) were determined and used to calculate the cost-effectiveness ratio and ICER. The cost of hospital care ranged from $154 for fluconazole monotherapy to $467 for 14 d of amphotericin + 5FC. Based on 18 studies investigating outcomes for HIV-infected individuals with CM in resource-limited settings, the estimated mean one-year survival was lowest for fluconazole monotherapy, at 40%. The cost-effectiveness ratio ranged from $20 to $44 per QALY. Overall, amphotericin-based regimens had higher costs but better survival. Short-course amphotericin (1 mg/kg/d for 7 d) with fluconazole (1,200 mg/d for14 d) had the best one-year survival (66%) and the most favorable cost-effectiveness ratio, at $20.24/QALY, with an ICER of $15.11 per additional QALY over fluconazole monotherapy. The main limitation of this study is the pooled nature of a systematic review, with a paucity of outcome data with direct comparisons between regimens.<h4>Conclusions</h4>Short-course (7-d) amphotericin induction therapy coupled with high-dose (1,200 mg/d) fluconazole is "very cost effective" per World Health Organization criteria and may be a worthy investment for policy-makers seeking cost-effective clinical outcomes. More head-to-head clinical trials are needed on treatments for this neglected tropical disease. Please see later in the article for the Editors' Summary.
format	article
author	Radha Rajasingham Melissa A Rolfes Kate E Birkenkamp David B Meya David R Boulware
author_facet	Radha Rajasingham Melissa A Rolfes Kate E Birkenkamp David B Meya David R Boulware
author_sort	Radha Rajasingham
title	Cryptococcal meningitis treatment strategies in resource-limited settings: a cost-effectiveness analysis.
title_short	Cryptococcal meningitis treatment strategies in resource-limited settings: a cost-effectiveness analysis.
title_full	Cryptococcal meningitis treatment strategies in resource-limited settings: a cost-effectiveness analysis.
title_fullStr	Cryptococcal meningitis treatment strategies in resource-limited settings: a cost-effectiveness analysis.
title_full_unstemmed	Cryptococcal meningitis treatment strategies in resource-limited settings: a cost-effectiveness analysis.
title_sort	cryptococcal meningitis treatment strategies in resource-limited settings: a cost-effectiveness analysis.
publisher	Public Library of Science (PLoS)
publishDate	2012
url	https://doaj.org/article/79df12c32dd0465b8e097284eb5ace99
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Cryptococcal meningitis treatment strategies in resource-limited settings: a cost-effectiveness analysis.

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