Cost-effectiveness model of cytomegalovirus management strategies in renaltransplantation - Comparing valaciclovir prophylaxis with current practice

Background: Cytomegalovirus (CMV) disease may occur following renal transpl antation and has been shown to have health and cost consequences in this se tting. Objective: To compare the cost effectiveness of different CMV management st rategies for renal transplant patients: prophylaxis with (i) oral valaciclo vir or (ii) intravenous ganciclovir; viral testing for CMV followed by (iii ) pre-emptive therapy with intravenous ganciclovir or (iv) adjustment of im munosuppression and intensive monitoring; or (v) waiting to treat when CMV disease develops. Methods: A decision-tree model was constructed that included the different management strategies for the donor seropositive/recipient seronegative (DR-) population. Clinical outcomes for the D+R- population came from clinica l trials. Treatment algorithms and costs for CMV syndrome and tissue invasi ve disease were developed from published literature and UK physician interv iews. One- and 2-way sensitivity analyses were performed. Study Perspective: UK National Health Service. Results: Prophylaxis with either oral valaciclovir or intravenous ganciclov ir dominated (lower costs and fewer cases of CMV disease) the pre-emptive t reatment and wait-and-treat strategies. The cost per patient was from pound 157 to pound 438 higher with oral valaciclovir prophylaxis compared with i ntravenous ganciclovir prophylaxis and the incremental cost per case of CMV disease avoided with valaciclovir prophylaxis ranged from pound 2243 to po und 8111 (1996 values). These results are sensitive to the efficacy of intr avenous ganciclovir prophylaxis and CMV management costs. Conclusions: For D+R- renal transplant patients, prophylaxis is the dominan t (more effective and less costly) management strategy compared with pre-em ptive and wait-and-treat strategies. The cost per patient with oral valacic lovir prophylaxis compared with intravenous ganciclovir prophylaxis is slig htly higher in our base case scenario, but may be lower under reasonable al ternative assumptions.