Cost-Effectiveness of Postoperative Drug Rehabilitation for Injection Drug Users

Abstract Background With the opioid crisis showing no sign of abating, strategies are needed to facilitate postoperative care for injection drug use (IDU)-related endocarditis. The current standard, six weeks of intravenous antibiotics, yields frequent reoperation and IDU relapse. We examined the cost-effectiveness of inpatient rehabilitation postoperatively to optimize outcomes and costs. Methods Two postoperative strategies were assessed: hospital-only care (HC) versus HC plus inpatient drug rehabilitation (DR). Monte-Carlo simulation evaluated effectiveness in quality adjusted life-years (QALY) and cost/patient calculated over a 20-year time horizon in 100,000 iterations. Willingness-to-pay (WTP) was set to $100,000/QALY. To determine probabilities of continued postoperative IDU, recurrent infection, and mortality, best available evidence was combined with institutional data from IDU patients. Baseline probability of postoperative IDU was set to 35% after DR vs 60% after HC, and the cost of inpatient rehabilitation to $30,000. Results Addition of inpatient drug rehabilitation to standard hospital care is the favorable strategy, with incremental per-patient cost of $36,920 and 0.93 QALYs gained over 20 years. Sensitivity analysis demonstrates DR is within our WTP of $100,000/QALY if post-operative IDU is reduced by at least 7% (from 60% to 53%). Conclusions Addition of postoperative inpatient drug rehabilitation for IDU-related endocarditis is cost-effective even if only a modest reduction in IDU is achieved. Collaboration between hospitals and payors to launch pilot programs that provide postoperative addiction treatment and intravenous antibiotics after cardiac surgery could dramatically improve endocarditis care. (234/250)