Cost-Effectiveness of Metoclopramide, Paracetamol, and Ceftriaxone for the Prevention of Infections and Fever in Elderly Patients with Acute Stroke

Objective. Infections and fever after stroke are associated with poor functional outcome and death. We compared the cost-effectiveness of prophylactic metoclopramide, paracetamol, and ceftriaxone, either as monotherapies or in combination, with standard of care for reducing complications in older patients with acute stroke. Methods. We conducted a model-based analysis estimating expected lifetime costs, quality-adjusted life-years (QALYs), and net monetary benefit (NMB) from a Dutch health care perspective, given a willingness-to-pay threshold of 50,000 euros per QALY gained. The model synthesized patient-level data from the PREvention of Complications to Improve OUtcome in older patients with acute Stroke (PRECIOUS) trial with data from long-term observational studies. We conducted a value-of-information analysis to quantify the expected value of reducing decision uncertainty through additional data collection on key input parameters. Results. Combination therapy with metoclopramide, ceftriaxone, and paracetamol yielded the highest expected NMB and was the most cost-effective treatment option. When compared with standard care, this treatment option decreased costs by €6,438 and increased QALYs by 0.10, resulting in an incremental NMB of €11,721. The value-of-information analysis indicated that decision uncertainty was driven by uncertainty about the treatment effects on poststroke disability, measured by the modified Rankin Scale (mRS). Moreover, the analysis suggested that the expected value of reducing uncertainty through additional data collection on acute phase mRS scores far exceeds the expected costs. Conclusion. Our economic evaluation suggests that combination therapy with metoclopramide, paracetamol, and ceftriaxone may be the most cost-effective option for treating older patients with stroke in the Netherlands. However, there is likely great value in reducing uncertainty by conducting a new study that collects additional data on acute phase mRS scores. Highlights: Prophylactic combination therapy with metoclopramide, paracetamol, and ceftriaxone may be the most cost-effective strategy for preventing infections and fever in elderly patients with acute stroke. There is substantial decision uncertainty, primarily driven by uncertainty regarding the treatment effects on functional outcome (modified Rankin Scale, mRS). Value-of-information analysis indicates that the value of reducing uncertainty through a new study on acute phase mRS scores is very high.