Cost Effectiveness of Letermovir for Cytomegalovirus Prophylaxis Compared with Pre-Emptive Therapy in Allogeneic Hematopoietic Stem Cell Transplant Recipients in the United States

Aryana Sepassi; Ila M Saunders; Mark Bounthavong; Randy A Taplitz; Cathy Logan; Jonathan H Watanabe

doi:10.1007/s41669-023-00398-y

Cost Effectiveness of Letermovir for Cytomegalovirus Prophylaxis Compared with Pre-Emptive Therapy in Allogeneic Hematopoietic Stem Cell Transplant Recipients in the United States

Pharmacoecon Open. 2023 May;7(3):393-404. doi: 10.1007/s41669-023-00398-y. Epub 2023 Feb 25.

Authors

Aryana Sepassi¹, Ila M Saunders², Mark Bounthavong^{2

3}, Randy A Taplitz⁴, Cathy Logan⁵, Jonathan H Watanabe⁶

Affiliations

¹ Department of Clinical Pharmacy Practice, University of California, Irvine School of Pharmacy and Pharmaceutical Sciences, Irvine, CA, USA. asepassi@hs.uci.edu.
² Division of Clinical Pharmacy, University of California, San Diego Skaggs School of Pharmacy & Pharmaceutical Sciences, La Jolla, CA, USA.
³ Department of Veteran Affairs, Health Economic Resource Center, Menlo Park, CA, USA.
⁴ Department of Medicine, City of Hope, Duarte, CA, USA.
⁵ Division of Infectious Diseases and Global Health, University of California, San Diego, La Jolla, CA, USA.
⁶ Department of Clinical Pharmacy Practice, University of California, Irvine School of Pharmacy and Pharmaceutical Sciences, Irvine, CA, USA.

Abstract

Purpose: The aim of this study was to assess the cost effectiveness of letermovir prophylaxis with the option for subsequent pre-emptive therapy (PET) for the prevention of cytomegalovirus (CMV) infection compared with a PET-only scenario in adult allogeneic hematopoietic stem cell transplant (allo-HCT) recipients in the United States over a 10-year time horizon.

Materials and methods: A publicly available decision tree model was constructed using a commercial third-party payer perspective to simulate an allo-HCT recipient's clinical trajectory in the first-year post-transplant, followed by entry to a Markov model to simulate years 2 through 10. Clinical inputs and utility estimates were derived from published literature. Costs were derived from published literature and US Department of Veterans Affairs Federal Supply Schedule drug pricing. Outcomes assessed included life expectancy, quality-adjusted life-years (QALYs), direct medical costs, and the incremental cost-effectiveness ratio (ICER). One-way and probabilistic sensitivity analyses (PSA) were performed to test the robustness of the findings.

Results: Compared with PET alone, letermovir prophylaxis was projected to increase life-years per person (4.99 vs. 4.70 life-years), and increase QALYs (3.29 vs. 3.08) and costs (US$83.411 vs. US$70,698), yielding an ICER of US$59,356 per QALY gained. One-way sensitivity analyses indicated our model was sensitive to mortality (ICER: $164,771/QALY) and utility (letermovir ICER: $117,447/QALY; PET ICER: $107,290/QALY) in the first-year post-transplant. In 57.1% of the PSA simulations, letermovir was a cost-effective option using a willingness-to-pay threshold of US$100,000 per QALY.

Conclusions: Letermovir prophylaxis is cost effective compared with PET alone with a willingness-to-pay threshold of US$100,000 per QALY gained. Sensitivity analysis results indicate future research is required to understand the impact of mortality and quality of life in the first-year post-transplant to arrive at a conclusive decision on letermovir adoption.