Using a cost-utility model of a hypothetical group of symptomatic children aged younger than 2 years who were diagnosed with acute otitis media (AOM), investigators evaluated whether antimicrobial therapy reduces time to symptom resolution, overall symptom burden, and persistence of infection.
The model, which compared the cost per quality-adjusted life day (QALD) of 5 frequently used options for managing children with AOM, showed that in young children with no recent antibiotic exposure, immediate amoxicillin is the most cost-effective initial treatment. The 5 evaluated treatments were immediate amoxicillin/clavulanate, immediate amoxicillin, immediate cefdinir, watchful waiting, and delayed prescription for antibiotic.
Investigators used systematic reviews to obtain estimated values for most measures of clinical efficacy, 2015 Medicare reimbursement data for healthcare costs, and the 2015 Red Book: Pharmacy’s Fundamental Reference for medication costs. They compared QALDs across treatment options with a so-called utility approach, which assesses health-related quality of life at a particular point in time.
Immediate amoxicillin treatment was the most cost effective of the 5 strategies. Amoxicillin/clavulanate became the most cost-effective first-line treatment option only when the probability of symptom improvement with amoxicillin was projected to be quite low. Immediate treatment with cefdinir was the most-expensive strategy and was less effective than amoxicillin. The least-effective regimens were delayed prescription, followed by watchful waiting. The incremental cost-utility ratio of immediate amoxicillin compared with delayed prescription was $101.07 per QALD gained; for immediate amoxicillin/clavulanate compared with amoxicillin, this figure was $2331.28 (Shaikh N, et al. J Pediatr. 2017;189:54.e3-60.e3).
Thoughts from Dr. Burke
In this study, the authors are not seeking the most effective treatment regimen, but rather the most cost effective. They do this by using previous studies of effectiveness, layering on estimated costs for everything from return office visits and lost work days to diapers for diarrhea and antifungal creams for fungal diaper rashes. It’s an interesting exercise that tries to replicate the way you weigh otitis media treatment decisions every day.