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Published on: March 9, 2018
Cost-Effectiveness of Serum Galactomannan Surveillance during Mould-Active Antifungal Prophylaxis
Ai Leng Khoo1, Ying Jiao Zhao1, Glorijoy Shi En Tan2,3
1Pharmacy and Therapeutics Office, Group Health Informatics, National Healthcare Group, Singapore 138543, Singapore.
Abstract:
Serial galactomannan (GM) monitoring can aid the diagnosis of invasive aspergillosis (IA) and optimise treatment decisions. However, widespread adoption of mould-active prophylaxis has reduced the incidence of IA and challenged its use. We evaluated the cost-effectiveness of prophylaxis-biomarker strategies. A Markov model simulating high-risk patients undergoing routine GM surveillance with mould-active versus non-mould-active prophylaxis was constructed. The incremental cost for each additional quality-adjusted life-year (QALY) gained over a lifetime horizon was calculated. In 40- and 60-year-old patients receiving mould-active prophylaxis coupled with routine GM surveillance, the total cost accrued was the lowest at SGD 11,227 (USD 8255) and SGD 9234 (USD 6790), respectively, along with higher QALYs gained (5.3272 and 1.1693). This strategy, being less costly and more effective, dominated mould-active prophylaxis with no GM monitoring or GM surveillance during non-mould-active prophylaxis. The prescription of empiric antifungal treatment was influential in the cost-effectiveness. When the GM test sensitivity was reduced from 80% to 30%, as might be anticipated with the use of mould-active prophylactic agents, the conclusion remained unchanged. The likelihood of GM surveillance with concurrent mould-active prophylaxis being cost-effective was 77%. Routine GM surveillance remained cost-effective during mould-active prophylaxis despite lower IA breakthroughs. Cost-saving from reduced empirical antifungal treatment was an important contributing factor.
Insights
Routine galactomannan (GM) monitoring with mould-active prophylaxis is cost-effective for high-risk patients, even with reduced invasive aspergillosis (IA) incidence. This strategy offers better outcomes and lower costs compared to other approaches.
Area of Science:
- Medical Mycology
- Health Economics
- Clinical Decision Making
Background:
- Serial galactomannan (GM) monitoring aids invasive aspergillosis (IA) diagnosis and treatment optimization.
- Widespread mould-active prophylaxis has decreased IA incidence, questioning the utility of GM surveillance.
- Evaluating cost-effectiveness of prophylaxis-biomarker strategies is crucial for clinical practice.
Purpose of the Study:
- To assess the cost-effectiveness of prophylaxis-biomarker strategies in high-risk patients.
- To compare routine GM surveillance with mould-active versus non-mould-active prophylaxis.
- To determine the optimal strategy for managing IA in the context of evolving prophylaxis practices.
Main Methods:
- A Markov model was developed to simulate high-risk patients.
- The model incorporated routine GM surveillance alongside mould-active and non-mould-active prophylaxis.
- Cost-effectiveness analysis calculated incremental cost per quality-adjusted life-year (QALY) gained over a lifetime horizon.
Main Results:
- Mould-active prophylaxis combined with routine GM surveillance was the least costly and most effective strategy for 40- and 60-year-old patients.
- This strategy dominated alternatives, including no GM monitoring or GM surveillance during non-mould-active prophylaxis.
- Reduced empirical antifungal treatment significantly contributed to cost-effectiveness, persisting even with decreased GM test sensitivity.
Conclusions:
- Routine GM surveillance concurrent with mould-active prophylaxis is a cost-effective strategy for high-risk patients.
- This approach remains valuable despite lower IA breakthrough rates due to prophylaxis.
- Cost savings from reduced empirical antifungal use are a key factor in the favorable cost-effectiveness.
