title: Is a biomarker-based diagnostic strategy for invasive aspergillosis cost effective in high-risk haematology patients?
abstract: Empirical antifungal therapy is frequently used in hematology patients at high risk of invasive aspergillosis (IA), with substantial cost and toxicity. Biomarkers for IA aim for earlier and more accurate diagnosis and targeted treatment. However, data on the cost-effectiveness of a biomarker-based diagnostic strategy (BDS) are limited. We evaluated the cost effectiveness of BDS using results from a randomized controlled trial (RCT) and individual patient costing data. Data inputs derived from a published RCT were used to construct a decision-analytic model to compare BDS (Aspergillus galactomannan and PCR on blood) with standard diagnostic strategy (SDS) of culture and histology in terms of total costs, length of stay, IA incidence, mortality, and years of life saved. Costs were estimated for each patient using hospital costing data to day 180 and follow-up for survival was modeled to five years using a Gompertz survival model. Treatment costs were determined for 137 adults undergoing allogeneic hematopoietic stem cell transplant or receiving chemotherapy for acute leukemia in four Australian centers (2005-2009). Median total costs at 180 days were similar between groups (US$78,774 for SDS [IQR US$50,808-123,476] and US$81,279 for BDS [IQR US$59,221-123,242], P = .49). All-cause mortality was 14.7% (10/68) for SDS and 10.1% (7/69) for BDS, (P = .573). The costs per life-year saved were US$325,448, US$81,966, and US$3,670 at 180 days, one year and five years, respectively. BDS is not cost-sparing but is cost-effective if a survival benefit is maintained over several years. An individualized institutional approach to diagnostic strategies may maximize utility and cost-effectiveness.
authors.affiliation: Division of Infectious Diseases, Columbia University Medical Center, 161 Fort Washington Ave, New York, NY 10032, USA.|Department of Infectious Diseases, 145 Studley Rd, Heidelberg, VIC 3084, Australia.
authors.forename: N
authors.initials: N
authors.lastname: Macesic
authors.affiliation: Department of Infectious Diseases, 55 Commercial Rd, Prahran, VIC 3181, Australia.|Department of Infectious Diseases, Central Clinical School, Monash University, 55 Commercial Rd, Prahran, VIC 3181, Australia.
authors.forename: C O
authors.initials: CO
authors.lastname: Morrissey
authors.affiliation: School of Public Health and Preventive Medicine, Monash University, 40 Exhibition Walk, Clayton, VIC 3800, Australia.
authors.forename: D
authors.initials: D
authors.lastname: Liew
authors.affiliation: Melbourne EpiCentre, University of Melbourne, Level 7 East, 300 Grattan Street, Parkville, VIC 3052, Australia.
authors.forename: M A
authors.initials: MA
authors.lastname: Bohensky
authors.affiliation: Centre for Infectious Diseases and Microbiology Laboratory Services, Level 3, ICPMR, Westmead Hospital, Locked Bag 9001, Westmead, NSW 2145, Australia.
authors.forename: S C-A
authors.initials: SC
authors.lastname: Chen
authors.affiliation: Blood and Marrow Transplant Network, Agency for Clinical Innovation, 67 Albert Ave, Chatswood, NSW 2057, Australia.
authors.forename: N M
authors.initials: NM
authors.lastname: Gilroy
authors.affiliation: Department of Clinical Haematology and Bone Marrow Transplantation, St. Vincent's Hospital, Sydney, 390 Victoria St, Darlinghurst, NSW 2010, Australia.
authors.forename: S T
authors.initials: ST
authors.lastname: Milliken
authors.affiliation: Department of Clinical Haematology and Bone Marrow Transplant Service, Royal Melbourne Hospital, 300 Grattan St, Parkville, VIC 3050, Australia.
authors.forename: J
authors.initials: J
authors.lastname: Szer
authors.affiliation: Department of Infectious Diseases, Peter MacCallum Cancer Centre, 2 St Andrews Pl, East Melbourne, VIC 3002, Australia.|Victorian Infectious Diseases Service, The Doherty Institute for Infection and Immunity, 792 Elizabeth St, Melbourne, VIC 3000, Australia.
authors.forename: M A
authors.initials: MA
authors.lastname: Slavin
mesh_terms: D000328:Adult; D015415:Biomarkers / Q000032:analysis*; D003362:Cost-Benefit Analysis; D003955:Diagnostic Tests, Routine / Q000191:economics* / Q000379:methods*; D005260:Female; D019337:Hematologic Neoplasms / Q000150:complications; D006801:Humans; D055744:Invasive Pulmonary Aspergillosis / Q000175:diagnosis*; D008297:Male; D008875:Middle Aged
chemical_list: D015415:Biomarkers
keywords: antifungal therapy; aspergillosis; cost analysis; diagnosis; galactomannan; polymerase chain reaction (PCR)