Cytomegalovirus immune globulin after liver transplantation: a cost-effectiveness analysis

Objective: Cytomegalovirus (CMV) immune globulin (CMVIG) has been shown to significantly reduce severe CMV-associated disease complicating orthotopic liver transplant (OLT). We evaluated the economic impact of severe CMV-asso ciated disease and calculated the marginal cost-effectiveness (C/E) of rout ine prophylaxis with CMVIG after OLT. Design: C/E analysis. Setting: Four teaching hospitals in Boston. Patients: Patients who underwent OLT from January 1988 through June 1990. Measurements: We gathered actual cost data of hospital care for patients en rolled in a clinical trial of CMVIG prophylaxis in OLT. We calculated avera ge outpatient expenses from a separate group of patients undergoing OLT and developed a regression model to estimate costs during the first year post- transplant (R-2 = 0.77), Based on this model, we calculated variable costs (in 1999 US dollars) for all patients in the randomized trial. From the pub lished literature we obtained the probability of CMV outcomes and of long-t erm survival after OLT. We then developed a decision analytical model to determine an incremental C /E ratio, using a Markov simulation to estimate long-term survival and long -term costs. We discounted costs and life-years at 3% and 5% per yr. Results: Based on the efficacy rate of 54% in the controlled trial, we esti mate that CMVIG will increase life expectancy by 0.65 discounted years at a n additional cost of $11600, providing a marginal C/E ratio of $17900/yr li fe saved. Examining the confidence limits of efficacy, we estimate that CMV IG will have a marginal C/E ratio of $66200 gained/yr at an efficacy of 11% and $14000 gained/yr at an efficacy of 83%. Conclusion: After OLT, prophylactic CMVIG has an incremental C/E ratio comp arable to that of other well-accepted medical therapies and should be used routinely in these patients.