Pre-emptive virology screening in the pediatric hematopoietic stem cell transplant population: a cost effectiveness analysis.

BACKGROUND AND OBJECTIVES: Pediatric patients undergoing hematopoietic stem cell transplant (HSCT) are at a uniquely high risk of cytomegalovirus (CMV) and Epstein-Barr virus (EBV) infections. The pre-emptive treatment model whereby asymptomatic post-transplant patients are routinely screened with treatment initiated if found viremic has recently been shown to be superior in terms of patient mortality when compared to deferring laboratory assessment and treatment until symptoms emerge. This study analyzes the cost-effectiveness of the pre-emptive therapy model in patient care dollars per quality-adjusted life years (QALY). PATIENTS AND METHODS: Utilization and outcome data were compiled as a retrospective cohort study of 96 pediatric patients receiving HSCT at University of California Los Angeles Pediatric Hematology/Oncology Department between the years 2006 and 2010. Two-decision tree models were constructed for each the pre-emptive model and the deferred model wherein costs and probability assumptions were based on either previously published literature or calculated from this study cohort.
RESULTS: The pre-emptive model resulted in a five-year survival of 71%, during which time 4% of patients were found to be EBV viremic, while 33% were found to be CMV viremic. The average actual cost of EBV/CMV virology screening per patient in the cohort following the pre-emptive model was $9699 while the expected cost following the deferred model was $19,284. This results in an incremental cost effectiveness ratio illustrating pre-emptive model cost-savings of $2367/QALY.
CONCLUSION: These results support the financial viability and prudence of scheduled screening for subclinical viremia for achieving optimal outcomes in a cost-effective manner in the pediatric HSCT population.