title: Cost-effectiveness of Prophylaxis Against Pneumocystis jiroveci Pneumonia in Patients with Crohn's Disease.
abstract: BACKGROUND
  Emerging evidence suggests that Pneumocystis jiroveci pneumonia is occurring more frequently in Crohn's disease patients on immunosuppressive medications, especially corticosteroids. Considering its excess mortality and the efficacy of chemoprophylaxis in reducing P. jiroveci pneumonia in acquired immunodeficiency syndrome, there is debate without consensus on the need for chemoprophylaxis in Crohn's disease patients on corticosteroids.
  
  
  OBJECTIVE
  We sought to address this debate using insights from simulation modeling.
  
  
  METHODS
  We used a Markov microsimulation model to simulate the natural history of Crohn's disease in 1 million virtual patients receiving appropriate care and who faced P. jiroveci pneumonia risks that varied with corticosteroid use. We examined several chemoprophylaxis strategies and compared their population-level economic and clinical impact using various indices including costs, quality-adjusted life expectancy, and incremental cost-effectiveness ratios. We also performed several nested probabilistic sensitivity analyses to estimate the health and economic impact of chemoprophylaxis in patients on triple immunosuppressive therapy.
  
  
  RESULTS
  At the current PJP incidence, no PJP chemoprophylaxis was the preferred strategy from a population perspective. Considered chemoprophylactic strategies led to higher average costs and fewer P. jiroveci pneumonia cases. However, they also led to lower average quality-adjusted life expectancy and were thus dominated. Nevertheless, these alternative strategies became preferred with progressively higher risks of P. jiroveci pneumonia. Our results also suggest that PJP chemoprophylaxis may be cost-effective in patients on triple immunosuppressive therapy.
  
  
  CONCLUSIONS
  Our findings support a case-by-case consideration of P. jiroveci pneumonia chemoprophylaxis in Crohn's disease patients receiving corticosteroids.
authors.affiliation: Division of Gastroenterology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
authors.forename: Philip N
authors.initials: PN
authors.lastname: Okafor
authors.affiliation: Section of Gastroenterology, Boston Medical Center, Boston, MA, 02118, USA.
authors.forename: Francis A
authors.initials: FA
authors.lastname: Farraye
authors.affiliation: Department of Epidemiology, University of Minnesota School of Public Health, Minneapolis, MN, 55455, USA.
authors.forename: Adetoro T
authors.initials: AT
authors.lastname: Okafor
authors.affiliation: Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, 27599, USA. erim.daniel@unc.edu.
authors.forename: Daniel O
authors.initials: DO
authors.lastname: Erim
mesh_terms: D000305:Adrenal Cortex Hormones / Q000009:adverse effects; D000890:Anti-Infective Agents / Q000009:adverse effects / Q000191:economics / Q000494:pharmacology*; D003198:Computer Simulation; D003362:Cost-Benefit Analysis; D003424:Crohn Disease / Q000150:complications* / Q000191:economics; D006801:Humans; D016867:Immunocompromised Host; D008954:Models, Biological; D045363:Pneumocystis carinii; D011020:Pneumonia, Pneumocystis / Q000191:economics / Q000517:prevention & control*
chemical_list: D000305:Adrenal Cortex Hormones; D000890:Anti-Infective Agents
keywords: Decision analysis; Inflammatory bowel disease; Opportunistic infections