Cost-effectiveness of a short-course antibiotic treatment strategy for the treatment of ventilator-associated pneumonia: an economic analysis of the REGARD-VAP trial

Abstract

Background: The REGARD-VAP trial showed that individualised shortened antibiotic therapy was non-inferior to usual care for mortality and pneumonia recurrence in patients with ventilator-associated pneumonia (VAP). We aimed to assess the cost-effectiveness of an individualised shortened antibiotic therapy approach in this planned economic analysis. Methods: REGARD-VAP was a phase 4, multicentre, open-label, randomised trial to assess a short-course antibiotic treatment strategy for treatment of VAP. In this planned economic analysis, we fitted a decision tree with data from the REGARD-VAP trial to estimate the cost-effectiveness of individualised short-course therapy for VAP, compared to usual care from the health system perspective, in Nepal, Singapore, and Thailand. Incremental cost-effectiveness ratios (ICERs) and incremental net monetary benefits with 95% uncertainty intervals (UIs) were reported against relevant willingness-to-pay thresholds. Parameter uncertainties were evaluated using scenario analyses. A value of information analysis was conducted. Findings: Adopting individualised short-course therapy was cost-effective for Nepal (ICER=US$1086; percentage cost-effectiveness=50·3%), Singapore (ICER=–$6069; percentage cost-effectiveness=55·2%), and Thailand (ICER=$263; percentage cost-effectiveness=60·5%). The associated incremental net monetary benefits were $41 (95% UI –2308 to 2390) in Nepal, $5156 (–45 805 to 56 117) in Singapore, and $804 (–6245 to 7852) in Thailand. Value of information analysis showed that reducing uncertainties for mortality probabilities, bed-day costs, and variable costs were valuable for decision making. Interpretation: We found that an individualised short-course antibiotics strategy in patients with VAP is likely to be cost-effective in high-income, middle-income, and low-income settings, although with evident uncertainty. Considered alongside the positive externalities of reduced antimicrobial use, our findings foster confidence in policy makers contemplating adoption of short-course antibiotics. Funding: UK Medical Research Council, Singapore National Medical Research Council, and Wellcome Trust.