ReviewThe need for cost-effectiveness analyses of antimicrobial stewardship programmes: A structured review
Introduction
Use of antimicrobial agents to both treat and prevent infections is an essential component of medical care. Indeed, many advances in critical care medicine, surgery and transplantation would not be possible without the use of effective antimicrobials. Whilst antimicrobials benefit the individual patient, the emergence of resistance has consequences to all of society. In 2014, the World Health Organization (WHO) urged all countries to work together to improve surveillance and to address the issue of antimicrobial resistance (http://www.who.int/drugresistance/documents/surveillancereport/en).
An effective approach to improving antimicrobial use in hospitals may be achieved by an organised antimicrobial management programme known as antimicrobial stewardship (AMS). The overarching goals of an AMS programme are to optimise clinical outcomes while minimising unintended consequences of antimicrobial use, including toxicity, the selection of opportunistic pathogens (such as Clostridium difficile) and the emergence of antimicrobial resistance [1]. AMS interventions have been reported to reduce antimicrobial consumption by 22–36% and lead to a cost reduction of US$200 000–900 000 per annum in some hospitals in the USA [2]. Despite this, it has been reported that it is difficult to attract adequate support for these activities as AMS is competing for resources against many other healthcare initiatives.
Whilst there are many combinations of strategies available for the development of an AMS programme, it is unclear which are optimal. In evaluating the cost effectiveness of AMS interventions, all relevant changes to costs as well as health benefits achieved must be quantified and compared in order to understand whether the intervention offers value for money. Whilst there have been some studies that have reported AMS results in cost savings in terms of reducing drug acquisition costs, these do not include costs of AMS staff and other implementation activities, thus they may underestimate the cost of the intervention [3], [4], [5], [6], [7], [8], [9], [10]. It is not clear whether the cost effectiveness of these programmes has been assessed fully. Such information is essential for making credible arguments to decision-makers about the value of funding these programmes.
The aim of this structured review was to synthesise the existing literature on the cost effectiveness of AMS programmes. We report the costs and health outcomes assessed, the economic evaluation methods used and the overall findings of this body of research, including important knowledge gaps in this area.
Section snippets
Literature search
A search for economic evaluations of AMS interventions was undertaken in the databases Embase, PubMed, Scopus, Web of Science, ProQuest, CINAHL and EconLit up to June 2014. Search terms used included the Mesh term ‘Anti Infective’ in conjunction with Stewardship, and search terms ‘Antimicrobial Stewardship’ AND ‘cost*’; ‘Antimicrobial Stewardship’ AND ‘cost effectiveness’; and ‘Antimicrobial Stewardship’ AND ‘economic*’.
Inclusion and exclusion criteria
The inclusion criteria for critical assessment of studies on AMS cost
Results
The final review included 36 studies [3], [4], [5], [6], [8], [9], [10], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38], [39], [40] conducted in the USA (22), UK (2), Canada (2), France (2), Spain (2) Japan (2), Israel (1), Slovenia (1), Belgium (1) and Germany (1). The most common AMS strategy implemented was prospective audit with intervention and feedback (PAIF), followed by
Discussion
The majority of existing work evaluating AMS programmes has focused on clinical effectiveness. However, in the current economic climate, governments need to identify the optimal allocation of health resources to maximise health outcomes. A well performed CEA can provide valuable information on the gains in health relative to the cost of different health interventions. This will enable comparisons to be made to assess the value for money of strategies that are implemented. CEAs are currently
Funding
This study was funded by the National Health & Medical Research Council Centre of Research Excellence in Reducing Healthcare Associated Infections [1030103] and the Queensland Government, Australia.
Competing interests
None declared.
Ethical approval
Not required.
Acknowledgement
The authors thank Danielle Herbert for proof-reading the article.
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