title: Cost-Effectiveness of Antibody-Based Induction Therapy in Deceased Donor Kidney Transplantation in the United States.
abstract: Induction therapy in deceased donor kidney transplantation is costly, with wide discrepancy in utilization and a limited evidence base, particularly regarding cost-effectiveness.
  
  
  
  We linked the United States Renal Data System data set to Medicare claims to estimate cumulative costs, graft survival, and incremental cost-effectiveness ratio (ICER - cost per additional year of graft survival) within 3 years of transplantation in 19 450 deceased donor kidney transplantation recipients with Medicare as primary payer from 2000 to 2008. We divided the study cohort into high-risk (age > 60 years, panel-reactive antibody > 20%, African American race, Kidney Donor Profile Index > 50%, cold ischemia time > 24 hours) and low-risk (not having any risk factors, comprising approximately 15% of the cohort). After the elimination of dominated options, we estimated expected ICER among induction categories: no-induction, alemtuzumab, rabbit antithymocyte globulin (r-ATG), and interleukin-2 receptor-antagonist.
  
  
  
  No-induction was the least effective and most costly option in both risk groups. Depletional antibodies (r-ATG and alemtuzumab) were more cost-effective across all willingness-to-pay thresholds in the low-risk group. For the high-risk group and its subcategories, the ICER was very sensitive to the graft survival; overall both depletional antibodies were more cost-effective, mainly for higher willingness to pay threshold (US $100 000 and US $150 000). Rabbit ATG appears to achieve excellent cost-effectiveness acceptability curves (80% of the recipients) in both risk groups at US $50 000 threshold (except age > 60 years). In addition, only r-ATG was associated with graft survival benefit over no-induction category (hazard ratio, 0.91; 95% confidence interval, 0.84-0.99) in a multivariable Cox regression analysis.
  
  
  
  Antibody-based induction appears to offer substantial advantages in both cost and outcome compared with no-induction. Overall, depletional induction (preferably r-ATG) appears to offer the greatest benefits.
authors.affiliation: 1 Department of Engineering Management, Information, and Systems, Southern Methodist University, Dallas, TX. 2 Information Systems and Operations Management, University of Texas at Dallas, Dallas, TX. 3 Department of Computer Science and Engineering, Southern Methodist University, Dallas, TX. 4 Transplant Services, Methodist Dallas Medical Center, Dallas, TX. 5 Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL. 6 Division of Nephrology, UT Southwestern Medical Center, Dallas, TX.
authors.forename: Zahra
authors.initials: Z
authors.lastname: Gharibi
authors.forename: Mehmet U S
authors.initials: MUS
authors.lastname: Ayvaci
authors.forename: Michael
authors.initials: M
authors.lastname: Hahsler
authors.forename: Tracy
authors.initials: T
authors.lastname: Giacoma
authors.forename: Robert S
authors.initials: RS
authors.lastname: Gaston
authors.forename: Bekir
authors.initials: B
authors.lastname: Tanriover
mesh_terms: D000067575:Administrative Claims, Healthcare / Q000191:economics; D000074323:Alemtuzumab; D000906:Antibodies / Q000009:adverse effects / Q000191:economics* / Q000627:therapeutic use*; D061067:Antibodies, Monoclonal, Humanized / Q000191:economics / Q000627:therapeutic use; D000961:Antilymphocyte Serum / Q000191:economics / Q000627:therapeutic use; D002423:Cause of Death; D017046:Cost Savings; D003362:Cost-Benefit Analysis; D016208:Databases, Factual; D016527:Drug Costs; D005260:Female; D006084:Graft Rejection / Q000191:economics* / Q000276:immunology / Q000517:prevention & control*; D006085:Graft Survival / Q000187:drug effects; D006801:Humans; D007166:Immunosuppressive Agents / Q000009:adverse effects / Q000191:economics* / Q000627:therapeutic use*; D060828:Induction Chemotherapy / Q000009:adverse effects / Q000191:economics*; D053645:Interleukin-2 Receptor alpha Subunit / Q000037:antagonists & inhibitors / Q000276:immunology; D016030:Kidney Transplantation / Q000009:adverse effects / Q000191:economics* / Q000379:methods; D008297:Male; D006278:Medicare / Q000191:economics; D008875:Middle Aged; D018803:Models, Economic; D012189:Retrospective Studies; D013997:Time Factors; D014019:Tissue Donors; D016896:Treatment Outcome; D014481:United States
chemical_list: D000906:Antibodies; D061067:Antibodies, Monoclonal, Humanized; D000961:Antilymphocyte Serum; C508017:IL2RA protein, human; D007166:Immunosuppressive Agents; D053645:Interleukin-2 Receptor alpha Subunit; D000074323:Alemtuzumab; C512542:thymoglobulin