1571. Cost-effectiveness analysis of duration of valganciclovir prophylaxis among CMV serology mismatched (donor+/recipient-) lung transplant recipients
Session: Poster Abstract Session: Viruses and Bacteria in Immunocompromised Patients
Friday, October 5, 2018
Room: S Poster Hall
Background: Cytomegalovirus (CMV) is the most common cause of opportunistic infection (OI) following lung transplant (LTx), with incidence of 30-90%. CMV is associated with direct morbidity and indirect effects (e.g. graft failure, development of OIs and graft rejection (ACR), etc.), all of which lead to poor outcomes. Donor CMV positive, recipient negative (D+/R-) patients (pts) have the highest risk of CMV infections, for which they typically receive prolonged durations (≥1 year) of valganciclovir prophylaxis (Px). Px is limited by toxicity and ganciclovir-resistance. We performed a cost effectiveness analysis of differing lengths of Px in CMV D+/R- LTx pts.

Methods: We built a Markov state transition model using month-long cycles over a five-year (yr) time horizon, a 3% discount rate, and taking a healthcare system perspective. Model health states included episodes of CMV viremia and disease, ACR, and death. Identical hypothetical cohorts of D+/R- pts received 1 to 2 yrs of Px. Event probabilities were drawn from national data and local data from patients seen at our center. Cost data (Px and treatment, treatment of side effects, CMV-associated OI, viral load monitoring, etc.) were based on national estimates. Sensitivity analyses were performed on CMV infection incidence while on Px and time on Px.

Results: Receiving 1 and 2 yrs of Px had average total direct medical care costs of $115,182 and $141,290, respectively. The average life-years gained for receiving 2 yrs and 1 yr of Px were 3.11 and 2.81, respectively, resulting in an incremental cost-effectiveness ratio (ICER) of $87,984 per life-year gained. A sensitivity analysis varying CMV infection incidence on Px showed that 1 yr dominates 2 yrs of Px only when this incidence is >50% annually (i.e. 1 yr of Px costs less and gains more life years). Real-world experience, however, shows that breakthrough CMV rate while on VGC Px is much less than 50% due to Px efficacy. If duration of Px is extended to 3 yrs, the ICER increases to $95,815/life-year (3.34 life-years gained) when compared to 1 yr.

Conclusion: A longer duration of Px is predicted to lead to higher overall costs but increased life expectancy for CMV D+/R- mismatch Ltx pts. Px duration > 1 yr for these pts may be economically reasonable.

Heather Tomko, MA1, Cornelius J. Clancy, M.D.2, Cynthia Bryce, PhD1, Mark Roberts, MD1, Kenneth Smith, MD1 and M. Hong Nguyen, MD3, (1)University of Pittsburgh, Pittsburgh, PA, (2)Infectious Diseases, University of Pittsburgh, Pittsburgh, PA, (3)Infectious Disease, University of Pittsburgh, Pittsburgh, PA

Disclosures:

H. Tomko, None

C. J. Clancy, Merck: Grant Investigator , Research grant . Astellas: Grant Investigator , Research grant .

C. Bryce, None

M. Roberts, None

K. Smith, None

M. H. Nguyen, Merck: Grant Investigator , Research grant . Astellas: Grant Investigator , Research grant .

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