title: Universal prophylaxis is cost effective in cytomegalovirus serology-positive kidney transplant patients.
abstract: BACKGROUND
  The economic merit of universal prophylaxis and preemptive therapy in the management of cytomegalovirus (CMV) infection for serology positive (R+) kidney transplant patients remains undefined. We performed cost effectiveness and cost utility modeling comparing these two approaches.
  
  
  METHODS
  The incidence of CMV infection under universal prophylaxis and preemptive therapy was determined among 653 R+ patients from our institution and 416 R+ patients from various clinic trials, respectively. Standardized decision tree analysis and Markov transitional models were used to calculate cost and quality-adjusted life years (QALYs) from the prototypical clinical data and published literature. Incremental cost effectiveness and cost utility were calculated as dollars for one case of infection avoided and one QALY gained over 10 years, respectively. One- and two-way sensitivity analyses were performed.
  
  
  RESULTS
  The incidence of CMV infection was 4.1% and 55.5% within the first year after transplant for universal prophylaxis and preemptive therapy, respectively. Compared with preemptive therapy, universal prophylaxis incurred $1464 more in direct cost while saving $7309 in indirect cost, and resulted in a net gain of 0.209 in QALYs per patient over a 10-year period. Thus, universal prophylaxis dominates over preemptive therapy with a cost saving of $27,967 for 1 QALY gained. This cost saving was sensitive to the variation in the rate of CMV infection and disease with each approach.
  
  
  CONCLUSIONS
  Universal prophylaxis in CMV R+ kidney transplant patients is clinically effective and cost saving. It should be considered as the preferred approach.
authors.affiliation: Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA. fluan@med.umich.edu
authors.forename: Fu L
authors.initials: FL
authors.lastname: Luan
authors.forename: Mallika
authors.initials: M
authors.lastname: Kommareddi
authors.forename: Akinlolu O
authors.initials: AO
authors.lastname: Ojo
mesh_terms: D000328:Adult; D000368:Aged; D000914:Antibodies, Viral / Q000097:blood; D000998:Antiviral Agents / Q000494:pharmacology; D003362:Cost-Benefit Analysis; D003587:Cytomegalovirus / Q000276:immunology; D003586:Cytomegalovirus Infections / Q000175:diagnosis / Q000191:economics / Q000209:etiology / Q000517:prevention & control*; D003663:Decision Trees; D015774:Ganciclovir / Q000031:analogs & derivatives / Q000494:pharmacology; D006801:Humans; D016030:Kidney Transplantation / Q000009:adverse effects* / Q000191:economics; D008390:Markov Chains; D008875:Middle Aged; D018803:Models, Economic; D019057:Quality-Adjusted Life Years; D012189:Retrospective Studies; D012698:Serologic Tests; D000077562:Valganciclovir
chemical_list: D000914:Antibodies, Viral; D000998:Antiviral Agents; D000077562:Valganciclovir; D015774:Ganciclovir