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Doxycycline Compared with Azithromycin for Treating Women with Genital Chlamydia trachomatis Infections: An Incremental Cost-Effectiveness Analysis

David Magid, MD; John M. Douglas Jr., MD; and J. Sanford Schwartz, MD
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From the Robert Wood Johnson Clinical Scholars Program, University of Washington, Seattle, Washington; Denver Department of Health, Denver, Colorado; and the University of Pennsylvania, Philadelphia, Pennsylvania. Disclaimer: The views expressed herein are those of the authors and are not necessarily those of the Robert Wood Johnson Foundation. Acknowledgments: The authors thank the following consultants, who served as volunteer members of our expert panel: Thomas A. Bell, MD, David A. Eschenbach, MD, Edward W. Hook III, MD, H. Hunter Handsfield, MD, Margaret R. Hammerschlag, MD, Susan Hillis, MD, Robert B. Jones, MD, PhD, Franklyn N. Judson, MD, James A. McGregor, MD, Thomas C. Quinn, MD, George P. Schmid, MD, Steven J. Sondheimer, MD, and A. Eugene Washington, MD, MSc. The authors also thank Thomas D. Koepsell, MD, MPH, and Virginia L. Golder, MS, for their editorial support. Grant Support: In part by an unrestricted investigator-initiated grant from Pfizer, Inc. All aspects of the study, including the design, analysis, and interpretation of the results of the study and the preparation of the manuscript, were done completely independently of Pfizer, Inc. Requests for Reprints: John M. Douglas Jr., MD, Disease Control Service, Denver Department of Public Health, 605 Bannock Street, Denver, CO 80204. Current Author Addresses: Dr. Magid: Robert Wood Johnson Clinical Scholars Program, University of Washington, 3747 15th Avenue NE, Room 203, Seattle, WA 98105.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1996;124(4):389-399. doi:10.7326/0003-4819-124-4-199602150-00002
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Objective: To compare the economic consequences of doxycycline therapy with those of azithromycin therapy for women with uncomplicated cervical chlamydial infections.

Design: Decision analysis in which the health outcomes, costs, and cost-effectiveness of two provider-administered treatment strategies for women with uncomplicated cervical chlamydial infections were compared: 1) initial therapy with doxycycline, 100 mg orally twice daily for 7 days [estimated cost, $5.51] and 2) initial therapy with azithromycin, 1 g orally administered as a single dose (estimated cost, $18.75).

Results: Under baseline assumptions, the azithromycin strategy incurred fewer major and minor complications and was less expensive overall than the doxycycline strategy despite a higher initial cost for acquiring antibiotic agents. In univariate sensitivity analyses, the azithromycin strategy prevented more major complications but was more expensive than the doxycycline strategy when doxycycline effectiveness was greater than 0.93. In a multivariate sensitivity analysis combining 11 parameter estimates selected so that the cost-effectiveness of the doxycycline strategy would be maximized relative to that of the azithromycin strategy, the azithromycin strategy resulted in fewer complications but was more costly. The incremental cost-effectiveness was $521 per additional major complication prevented. However, if the difference in the cost of azithromycin and doxycycline decreased to $9.80, the azithromycin strategy was less expensive and more effective, even under these extreme conditions.

Conclusions: On the basis of the best available data as derived from the literature and experts, the azithromycin strategy was more cost-effective than the doxycycline strategy for women with uncomplicated cervical chlamydial infections. Despite the dominance of the azithromycin strategy over the doxycycline strategy, the adoption of the azithromycin strategy may be limited by the practical financial constraints of our currently fragmented health care system, in which the costs and benefits of preventing chlamydia sequelae are often incurred by different components of the system.


Grahic Jump Location
Figure 1.
Decision tree for the azithromycin (AZI) and doxycycline (DOXY) treatment strategies.Chlamydia trachomatis

The □ at the left indicates the initial decision about treatment. The open ovals denote possible clinical events, and the solid squares indicate outcomes. CT = infection; PID = pelvic inflammatory disease.

Grahic Jump Location
Grahic Jump Location
Figure 2.
Incremental cost-effectiveness of the azithromycin (AZI) strategy compared with that of the doxycycline strategy, as the probability of the effectiveness of doxycycline is varied.

The x-axis shows the effectiveness of doxycycline (base-case estimate, 0.857). The y-axis shows the additional cost incurred or saved for each additional major complication prevented. The solid curve represents the incremental cost-effectiveness of the azithromycin strategy relative to the doxycycline strategy. At rates of doxycycline effectiveness less than 0.93 (intersection of the solid curve and dotted line), the azithromycin strategy is a dominant one because it prevents more major complications and results in lower overall cost than the doxycycline strategy. At rates of doxycycline effectiveness higher than 0.93, the azithromycin strategy prevents more major complications than the doxycycline strategy but at a higher cost. The shaded area (0.80 to 0.90) represents the plausible range of doxycycline effectiveness for the population as a whole.

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