JAC Advance Access published online on June 7, 2007
Journal of Antimicrobial Chemotherapy, doi:10.1093/jac/dkm196
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Economic evaluation of targeted treatments of invasive aspergillosis in adult haematopoietic stem cell transplant recipients in the Netherlands: a modelling approach
1 Department of Health Organization Policy and Economics (HOPE), Faculty of Health Sciences, Maastricht University, PO Box 616, 6200 MD Maastricht, The Netherlands 2 Department of Medical Microbiology, University Medical Center Nijmegen, PO Box 9101, 6500 HB Nijmegen, The Netherlands 3 Department of Pediatrics, University Medical Center Nijmegen, PO Box 9101, 6500 HB Nijmegen, The Netherlands 4 Department of Internal Medicine, University Medical Center Nijmegen, PO Box 9101, 6500 HB Nijmegen, The Netherlands 5 Department of Haematology, University Medical Center Nijmegen, PO Box 9101, 6500 HB Nijmegen, The Netherlands 6 Department of General Internal Medicine, Bronovo Hospital, PO Box 96900, 2509 JH The Hague, The Netherlands 7 Department of Clinical Epidemiology and Medical Technology Assessment, University Medical Center Maastricht, PO Box 5800, 6202 AZ Maastricht, The Netherlands
Received 30 October 2006; returned 10 December 2006; revised 24 April 2007; accepted 6 May 2007
* Corresponding author. Tel: +31-43-38-81723/81727; Fax: +31-43-36-70-960; E-mail: a.ament{at}beoz.unimaas.nl
Objectives: The aim of this study was to assess the cost-effectiveness of a targeted treatment model of antifungal treatment strategies for adult haematopoietic stem cell transplant (HSCT) recipients in the Netherlands from a hospital perspective, using a decision analytic modelling approach.
Methods: The economic evaluation of desoxycholate amphotericin B, liposomal amphotericin B, voriconazole and caspofungin was undertaken. These drugs could be used alone, in various combinations or sequentially. In our model, first-line therapy consisted of either voriconazole or liposomal amphotericin B. If necessary, treatment was switched to a second-line treatment, including combination antifungal therapy. The theoretical population in this model consisted of adult HSCT recipients with proven or probable invasive aspergillosis (IA). Long-term survival was extrapolated from survival after 12 weeks of treatment and life expectancy.
Results: First-line antifungal treatment strategies with voriconazole were both more effective and less costly over first-line strategies employing liposomal amphotericin B at a dosage of 4 mg/kg/day. The strategy of voriconazole followed by caspofungin (voriconazole/caspofungin) was dominant over the strategies of voriconazole followed by liposomal amphotericin B (voriconazole/liposomal amphotericin B) or desoxycholate amphotericin B (voriconazole/desoxycholate amphotericin B). However, the voriconazole followed by the combination of liposomal amphotericin B and caspofungin strategy (voriconazole/liposomal amphotericin B + caspofungin) was more effective though more expensive than the voriconazole/caspofungin strategy resulting in an incremental cost-effectiveness ratio (ICER) of about 
107 000 for a life-year saved. At a dosage of 1 mg/kg/day of liposomal amphotericin B, the voriconazole/caspofungin strategy was more effective but more costly than the voriconazole/desoxycholate amphotericin B strategy with an ICER of 10 000 for each extra life-year saved. Between the voriconazole/liposomal amphotericin B + caspofungin and the voriconazole/caspofungin strategies, the ICER was 40 000.
Conclusions: Probabilistic analyses on net monetary benefit showed that the voriconazole/caspofungin strategy had the highest probability of being the most cost-effective strategy.
Key Words: antifungal treatment , cost-effectiveness , probabilistic sensitivity analysis