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 elderly 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 healthcare 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 elderly 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 to 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 post-stroke 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 elderly 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.