Summarizing the Total Cost of Care for ABSSSI

FEBRUARY 27, 2019

A summarization of the total cost of care related to acute bacterial skin and skin structure infections (ABSSSI) is provided, particularly in light of hospitalization versus the outpatient setting.

Tom Lodise, PharmD, PhD: When summarizing the cost of care for skin, there are really 2 things to consider: inpatient cost as well as outpatient. As we discussed today, an inpatient admission is somewhere between $6,000 and $10,000, based on the duration of patients within the hospital. Even a 4- to 5-day length of stay really gets you at that lower threshold. My outpatient costs are considered to be low. It’s really dependent upon what is chosen as the site of care. So a lot of times, to ensure compliance, they’ll give IV [intravenous] antibiotics in either a hospital room or a physician suite. And in that scenario, a lot of drugs we use have low drug acquisition cost. Even with vancomycin, it’s probably $2,000 when one considers monitoring, cost of care, and coming back to the OPAT [outpatient parenteral antimicrobial therapy] setting every day; and it’s even more expensive for drugs like daptomycin, which can be upward of $4,000.

Again, when we think about outpatient cost, I think the other thing we need to consider is that about 1 in 5 patients are going to get readmitted. So that should also be factored in. Whether you want to consider that with the initial hospitalization cost or outpatient, in totality the overall cost of care 30 days after the hospital admission is priced somewhere between $10,000 and $15,000, with what our current approach is to care.

Joe Reilly, BS, PharmD, BCGP: I agree with what Tom said about when we look at the total cost of care. And I think the problem is that we tend to focus on the dollar signs that are right in front of us, more short-term than the big picture. When these patients come to the hospital, we decide to treat them, we use less expensive antibiotics. Whatever we use, the real outcome we’re concerned about here is if the patients get better. That’s what we’re concerned about. And I know costs are important, but really we want to ensure that the patients get better and the disease is cured, and hopefully they don’t come back with the same infection.

What we showed is, looking at older data and studies that have been done, there’s a significant reinfection rate and a significant failure rate. Patients often aren’t compliant with their medications. If cost wasn’t an issue, I can’t imagine why we wouldn’t want to use a single dose of anything to treat all infections. If somebody comes in with a skin infection, give them a single dose. If somebody comes in with a UTI [urinary tract infection], give them a single dose. We can remove the patient from the equation in determining whether there’s going to be a treatment failure or not. It’s just sensitivities. It could be 100% sensitive. For an E. coli infection or a UTI, it doesn’t matter if the patient doesn’t take it or if they might want to be compliant. But if they get an upset stomach or develop a rash or become itchy while they’re taking the medication, they’ll stop. We really don’t want that to happen.

What’s interesting in this case with oritavancin is the acquisition cost up front is higher than the competitors. But at the end of the day, the outcomes appear to be better, there’s a lower recurrence rate for infections, and the economic modeling and money saved by utilizing this drug that cost more up front…seems to favor the single-dose treatment.

Tom Lodise, PharmD, PhD: And I think it does favor not only overall costs but also patients’ out of pocket. So if someone gets admitted when they could otherwise be treated as an outpatient, Medicare pays 20% of that as a co-pay. If you continue outpatient OPAT, it’s another 20%. So even from a patient perspective, shifting their care is to their benefit.

Joe Reilly, BS, PharmD, BCGP: And I wonder, Tom—it would be difficult to do, but what if we looked at patients’ quality of life more? Can they go back to their normal activities? They can get back to work. They got their single dose. It’s over with, their treatment. Another thing that stands out, based on some of the data we talked about, is preventing disease progression. It may not be a specific pharmacology-related benefit. I think it’s more of a benefit that we’re giving you 10 days of IV antibiotics in a single dose, so we’ve ensured that you have a full treatment course for these patients, as opposed to whatever else is happening with alternative therapy.