Increasing patient access to faecal microbiota transplantation with remote delivery: a cost analysis of outpatient versus home-based treatment

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BACKGROUND: Faecal microbiota transplantation (FMT) for recurrent Clostridioides difficile infection (CDI) is used in less than 10% of the patients in Europe who meet the indication. Encapsulated FMT allows increased use for CDI because capsules can be safely shipped to local healthcare facilities and administered orally to patients without use of e.g. colonoscopy. The aim of this study was to calculate and compare the costs of alternative ways of delivering encapsulated FMT to patients with CDI in Denmark, including outpatient treatment at a specialised FMT centre, outpatient treatment at local hospitals including remote delivery to the Faroe Islands, and home-based care. METHODS: Applying a healthcare perspective, we used an activity-based costing approach, combining data from a pragmatic clinical randomised trial with the best available literature and expert input. Only relevant costs were included. The main outcome was the average cost of delivering outpatient, encapsulated FMT treatment at an FMT centre, at a local hospital, or in the patient's home, only including additional costs related to delivery. An 8-week time horizon was applied for the analysis. Probabilistic and deterministic sensitivity analyses were applied to evaluate decision uncertainty and the robustness of the results. RESULTS: In a pragmatic randomised trial including 217 patients with CDI, 135 patients received FMT. Analysing relevant costs in a base case analysis, local outpatient treatment (€145) was cost-saving compared with both treatment at the FMT centre (€209) and home-based treatment (€353). These differences remained robust across sensitivity analyses, including those accounting for patients' time costs. In the Faroe Islands case, shipment to remote locations added an average cost of €54 per FMT to the cost for the local outpatient treatment. CONCLUSION: Capsule-based FMT treatment has made it clinically and economically feasible to administer FMT in contextual settings outside of specialised hospitals. Our findings highlight the importance of local hospital-based treatment for increasing patient access to FMT, the ability to ship FMT to remote locations lacking a FMT centre, and the option of home-based treatment for a selected group of patients who may not tolerate transport to hospital.

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