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Prophylaxis against infective endocarditis. London: National Institute for Health and Care Excellence (NICE); 2015 Sep. (NICE Guideline Addendum, No. 64.1.)
P.1. Background
A team at the University of Sheffield conducted an economic analysis independtly of the guideline update and kindly provided the initial results of this analysis to the Committee. A presentation was provided along with a report containing the full details of the analysis. The full details of this analysis cannot be disclosed in the present document because it has not yet been published and is considered academic in confidence. The investigators have provided the following summary of their analysis.
P.2. The findings of this analysis in the final published version may differ to what is reported here.Abstract: the cost effectiveness of prophylactic antibiotics for patients at risk of infective endocarditis
Matthew Franklin1, Allan Wailoo1, Mark Dayer2, Simon Jones3, Martin Thornhill4.
- School of Health and Related Research, University of Sheffield
- Taunton and Somerset NHS Trust, Cardiology
- Department of Health Care Management and Policy, University of Surrey
- Oral and Maxillofacial Medicine and Surgery, University of Sheffield
P.2.1. Introduction
2008 guidance issued for the health services of England and Wales recommended that antibiotic prophylaxis before dental procedures for those considered at risk of infective endocarditis (IE) should cease. This study reports an economic evaluation of amoxicillin or clindamycin compared to no prophylaxis in this setting based on up-to-date estimates of their efficacy, adverse event profiles and the resource implications of infective endocarditis.
P.2.2. Methods
Costs, from a health service perspective, and health benefits measured in terms of Quality Adjusted Life Years, were estimated using a decision analytic model run over a time horizon spanning patients’ whole lifetime. Observed rates of IE pre and for up to 5 years post the 2008 guidance were used to estimate prophylactic efficacy. Adverse event rates came from recent analyses of UK datasets. Updated resource implications were based on HES data.
P.2.3. Results
The base case analysis suggests clindamycin is unlikely to be cost effective due to the relatively high probability of fatal adverse events which may outweigh the health benefits of reduced risk of IE. The incremental cost effectiveness ratio (ICER) for amoxicillin is £31k in the base case. This is sensitive to the drug acquisition cost, efficacy, and the rate of fatal adverse events. The ICER increases to £53k using less optimistic estimates of prophylactic efficacy. Both drugs are more cost effective if the baseline risk of IE is higher. Using a baseline risk for patients with prosthetic heart valves leads to estimates of £6.5k and £13k for amoxicillin and clindamycin respectively.
P.2.4. Conclusions
This study presents updated estimates of the cost effectiveness of two candidate antibiotics for prophylaxis in dental procedures in the UK health service. Base case estimates suggest amoxicillin may be cost effective whilst there is concern than clindamycin may generate more harms than health benefits for patients and is therefore dominated in terms of cost effectiveness. There does remain considerable uncertainty around these findings, driven in large part by the fact that there is no randomised controlled trial evidence on which to base estimates of antibiotic effectiveness or adverse event rates.