OBJECTIVES

To compare the cost per cytomegalovirus-associated death averted in 100 days after allogeneic transplantation between ganciclovir and valganciclovir use as pre-emptive and treatment strategies from a societal perspective.

METHODS

Thai current practice showed 74% of recipients were treated with no specific pattern of anti-cytomegalovirus (CMV) drug, while the international guideline recommended pre-emptive strategy. Moreover, oral valganciclovir could reduce the direct non-medical and indirect costs, but valganciclovir costs were higher than intravenous ganciclovir. Cost-minimization using the decision tree was performed to estimate the costs and outcome. Thai costs were obtained from the survey, the national protocol and charge reimbursement. Effectiveness was estimated from literature review as the risk event. The Monte Carlo simulation, tornado diagram, and the scenario analysis was also analyzed for the parameter uncertainty.

RESULTS

The least costs per CMV-associated death averted from the deterministic analysis were the pre-emptive strategies of ganciclovir, IV-to-PO, and valganciclovir, 143,334, 168,200, and 200,413 THB, respectively. Whereas, the current practice, the treatment strategies of IV-to-PO, and valganciclovir were 1,524,851, 7,941,753, and 9,885,751 THB, respectively, but the probabilistic results showed the current practice as the most saving approach. The most influential parameters were the death of untreated CMV, viral load testing costs, and recipient wage loss. The scenario analysis of changing the untreated death probability illustrated the increasing probability of untreated death from 30% resulted in all costs per case averted of pre-emptive were less than the treatment strategies and if considering from more than 80%, the pre-emptive strategies could overcome the current practice.

CONCLUSIONS : Pre-emptive strategies generated the cost per CMV averted less than the treatment strategies. Using valganciclovir did not minimize the overall costs and the drug costs were not sensitive. The untreated CMV outcome should be studied more to verify the pre-emptive strategy could be a more valuable option than the current practice in Thailand.