Cost-Benefit Analysis for <i>C Difficile</i> Infection Therapies

Peter Salgo, MD: Let me put something else on the table. Let’s take a look beyond the cost for a single course of any antibiotic—fidaxomicin is just 1 example. Don’t you have to look at the whole global picture? In other words, you’ve got a more expensive drug, but the recurrence rate is lower. So the total cost of this disease to the system, to that patient, may be lower. Don’t they take that into consideration at all?

Darrell S. Pardi, MD: Again, it depends who’s paying the bills.

Peter Salgo, MD: Well, even if somebody is paying the bill at the hospital, you could say, “Look, the recurrence rate is lower. They’re going to come back in. They’re going to require more therapy. It’s going to be more expensive. If we do it right the first time, then it’s going to be cheaper in the long run.”

Darrell S. Pardi, MD: We actually know that’s true. There’s modeling that shows that, and there’s actually emerging real-world cost data showing that’s true. But if you’re a pharmacy manager in the hospital and you get to pay $2000 for a drug that’s going to save the insurance company outpatient costs when the patient recurs, that’s a difficult equation to justify.

Peter Salgo, MD: So we’ve got a silo issue?

Darrell S. Pardi, MD: Yes.

Peter Salgo, MD: We’ve seen this in lots of other portions of the health care spectrum. “My bill’s here. Your bill’s here. Never the twain shall cooperate.”

Darrell S. Pardi, MD: Right.

Yoav Golan, MD: I think that the silo is largely conceptual and is not realistic. What Darrell is saying is, why would a hospital invest money for payers, then, to save money or for society to save money? But hospitals are now measured by how much Clostridium difficile (C. diff) they have. A lot of the C. diff that they have is actually the result of recurrence. You have to remember that every time you have a patient with recurrent C. diff in your hospital, they are secondary cases. So it produces more C. diff in the hospital. Many of those patients get readmitted within 30 days. If hospitals really looked into their economics in detail, they would find that it’s an investment worth doing.

Peter Salgo, MD: I don’t want to lose what you just said. They’re readmitted within 30 days. They don’t get compensated?

Yoav Golan, MD: Well, right now they do get compensated for readmissions, unless it’s for one of several initial admissions. But this is going to be further expended by CMS and so forth. There is a comparison of hospitals that’s put on the public domain. You’re going to a hospital to have removal of your gallbladder or cataract surgery. How likely are you to get C. diff? That’s a reputation, and there’s a reputation cost to hospitals. You were thinking that maybe 30% of our use of fidaxomicin is low. I would argue that it’s among the highest that I’ve ever heard.

We are sensitive to economics as well. But we find that we only have to give patients 3 or 4 days of treatment, on average. They get the rest in an outpatient pharmacy. So, we’re not making the investment for the entire....

Peter Salgo, MD: That’s somebody else’s silo, again.

Yoav Golan, MD: Very often, the outpatient pharmacy is our own hospital pharmacy. And so at the end of the day, we found that we’re actually not losing any money over providing the best care for our patients.

Peter Salgo, MD: You’re right. I was surprised. That 30% was low. Call me naïve, but I hear that we have a drug that works. It works better. The recurrence rate is lower. It’s simple to give. Why don’t we use it? The answer, whenever I ask that kind of a question, is that it always comes back to dollars and cents.

Darrell S. Pardi, MD: The other part of that answer is, it’s not always our decision. It’s the hospital P&T [pharmacy and therapeutics] committee or the outpatient prescription carrier. More often than not, if I try to prescribe fidaxomicin, it’s denied by insurance. They say that I have to try metronidazole or vancomycin first.

Peter Salgo, MD: He says, “Don’t do that.”

Darrell S. Pardi, MD: Well, new guidelines will hopefully change insurance company practice.

Dale N. Gerding, MD: With the new guidelines, it will be interesting to see what insurers and third-party payers do with the metronidazole treatment recommendation. The basis of coverage for C. diff has been that you need to try metronidazole first.

Peter Salgo, MD: There’s an example of the medical philosophy of “For every complicated problem, there’s a straightforward, inexpensive, logical solution.” That’s just wrong.

Dale N. Gerding, MD: Right.

Yoav Golan, MD: But I think that the situation of metronidazole being the only available drug is kind of declining in superiority now. There are new preparations of vancomycin, particularly one that is not going to be more expensive than $150 for the entire course. This is available. So I think that there will be little excuse to use metronidazole in first-line anymore.

Peter Salgo, MD: OK.

Darrell S. Pardi, MD: The other point we should make for the audience is that for outpatients who are having trouble paying the co-pay, there are patient assistance programs that can make it almost free.

Peter Salgo, MD: OK.

Transcript edited for clarity.