Long-Term Cost Benefit in Treating ABSSSI Appropriately

Regarding economic data tied to acute bacterial skin and skin structure infection management, experts consider how the long-term cost of oritavancin supersedes acquisition costs.

Joe Reilly, PharmD, BS, BCGP: When we think about cost for the antibiotics when a drug like oritavancin comes out, people will ask initially, “Well, how much does it cost?” as they often do with all new drugs. And you hear it’s about $2900 for the cost of the drug. And you think in your head, “Well, vancomycin is relatively inexpensive, depending on where you look, less than $20 a day or maybe more.” If you include monitoring and things like that, of course, those costs go up. But from a pharmacy perspective, you’re thinking almost $3000 versus under $20, and then it doesn’t make sense. But we’ve spoken today about all the costs that are incurred and how we should get out of that silo mentality and think about, “Is our job to save the pharmacy money, or is our job to save the hospital money?”

Now, I’m not even mentioning what’s best for the patient. What’s best for the patient is they take all their antibiotics, or we can ensure that they get all their antibiotics. As we’ve demonstrated before based on Dr. Kristen Whitaker’s data and other posters and publications that are out there, spending a little money for a drug that ensures compliance and that the infection will respond is certainly the best way to go because we have better outcomes, decreased readmissions. And it’s been proved on different publications and pharmacoeconomic modeling to be less expensive.

Tom Lodise, PharmD, PhD: Yes, and I think Joe hammers on a lot of good points. I think this myopic silo approach of strictly looking at drug costs is really inconsistent. In health care right now, it’s quality and efficiency of care. And when we think about quality and efficiency of care, that includes the overall cost of care, both inpatient and outpatient. So, again, if you can shift the hospitalization, when a patient gets admitted for IV [intravenous] antibiotics, we’ll use vancomycin as a cheap generic, and you’re committing them to $5000 or $10,000 worth of cost. Because the length of stay is 4 to 5 days on average, those patients often consider IV therapy outpatient if that’s the decision with vancomycin. And there you have to talk about using vancomycin multiple times a day in the outpatient setting. So you have to consider both monitoring costs as well as drug administration costs.

So, again, we did a poster at the recent [Infectious Diseases Society of America] IDWeek meeting, and just looking at the Truven database, for people who got either oritavancin or vancomycin, what we found is that 30-day costs were similar, actually slightly lower in the oritavancin group compared with vancomycin. Our sample size really prohibited us from finding any sort of difference, but one thing we did see was in that vancomycin group, 15% or 16% had another 30-day readmission, where it was only 5% with oritavancin. So, again, I think if you take that initial myopic view, as Joe mentioned, why would you use a $3000 drug? But when I think about stewardship, the thing about stewardship is identifying therapies, most efficient therapies, and I think that’s part of site of care. So if you use the drug judiciously, targeting the right patients to avoid a hospitalization or create a shorter length of stay, it makes a lot of sense.

The other thing I mentioned—we have been mentioning this a lot—in addition to overall costs, I think we need to be a little bit more patient centric too. Rarely will you find a patient who says, “I want to be in a hospital longer.” And also, it hurts them in the wallet. With Medicare, you have a 20% deductible. So if you get admitted, that patient is paying 20% of that. If they get outpatient care in an OPAT [outpatient parenteral antibiotic therapy] setting, oral antibiotics, they pay 20% of that as well. So with oritavancin, even we think, from the patient perspective, if they’re on Medicare, it’s actually cheaper than IV vancomycin therapy within a hospital and subsequent discharge on an IV drug.

So it’s 2018. I appreciate that pharmacy has to be conscious of their budget, but I think in situations like this where we can operationalize care, anytime we standardize care, good things happen, a shift in care or a shortened hospitalization. For this to be successful for pharmacy, they have to get a little bit of reward, almost like a gold star. And I think some of the data by Whitaker said, “Yes, pharmacy incurred these costs. But this is what we did for the institution.” And I think that makes sense. I think just using drugs and not evaluating the subsequent outcomes is not good quality assurance. So when I do think about these more expensive modalities, I think these are some of the things we need to consider. I think that’s one of the most impressive parts of those Whitaker data.

Joe Reilly, PharmD, BS, BCGP: And for the hospital it becomes a best-quality initiative. So it’s not only best for the patients, but it’s best for the hospital economically, which is an unusual or not frequent combination. And, as Tom said, it’s focusing more on the patients, not just preventing consequences of untreated infection. As we showed in those data, some of the patients came back with bacteremia or even osteomyelitis, which now you’re committed to 6 weeks of outpatient parenteral antibiotics. Think of lost time from work, lost productivity. Many of these patients are living check to check. So now you don’t have to be in the hospital. You didn’t have disease progression, and you didn’t have a reinfection that requires more medical care and cost. So there are a lot of benefits and a lot of costs that we need to look at in the big picture and of course include, which is often overlooked, what’s best for the patients.

Tom Lodise, PharmD, PhD: Just 1 final point, Joe. When we think about someone presenting to the hospital, in their mind, it’s “I’m going to get antibiotics. I’m going to be better.” But what we’re finding with vancomycin, 1 in 6 comes back; 1 in 5 comes back. So, again, it’s just a hardship on the patient, not only from lost productivity but just going in and out of the hospital, the care. There are concerns. There are a lot more things we need to consider now, particularly in light of the Affordable Care Act.