Impact of preemptive therapy for Cytomegalovirus on hospitalizations and cost after Hematopoietic Stem Cell Transplantation

Fang J, et al. Biol Blood Marrow Transplant 2020.


BACKGROUND: CMV viremia occurs in 40%-80% of CMV seropositive (R+) allogeneic hematopoietic stem cell (HCT) recipients. The preemptive therapy (PET) strategy has reduced the risk of CMV end-organ disease (EOD) and associated mortality but may lead to substantial healthcare resource utilization (HCRU) and cost. Real-world data on the economic impact of PET is relevant for the evaluation of alternative strategies for CMV management. We examined the impact of clinically significant CMV treated with PET on inpatient length of stay (LOS), number of readmissions and associated costs from day (D) 0 through D 180 post-HCT.

METHODS: A retrospective study of CMV seropositive (R+) adults who underwent peripheral blood or marrow allogeneic HCT from March 2013 through December 2017 at Memorial Sloan Kettering Cancer Center. Patients were routinely screened for CMV by quantitative PCR and received PET per institutional standards of care. Data was extracted from electronic medical records and hospital databases. Itemized cost data per patient was obtained from the Vizient database adjusted to 2017 dollars using inflation indices. Study outcomes included healthcare resource use (HCRU) evaluated by inpatient LOS and inpatient cost in patients who received PET for clinically significant CMV (PET group) compared to those who did not receive PET (no PET group); and frequency and cost of CMV-related compared to non-CMV-related readmissions. We utilized multivariable negative binomial and log-linked Gamma models to examine the incremental healthcare resource use and cost associated with PET controlling for other potential factors.

RESULTS: Of 357 patients included in the analyses, PET was initiated in 208 (56.5%) at a median of 35 days after HCT. By D180, 23 patients (6.4%) developed CMV EOD and three (0.8%) died of CMV. PET recipients had a longer LOS for HCT admission (p=0.0276) and total LOS by D 180 (p=0.0001), higher number of readmissions (p=0.0001), higher mean inpatient cost for HCT admission ($189,389 vs. $151,646, p=0.0133) and total inpatient cost by D180 ($297,563 vs. $205,815, p<0.0001) compared with no PET recipients. Among PET recipients, CMV-related readmissions were associated with higher mean cost per episode compared to non CMV-related readmissions ($165,455 vs. $89,419, p=0.005). CMV-related readmissions comprised of 40.6% of total all-cause readmissions and incurred 55.9% of total all-cause readmission cost in PET recipients.

CONCLUSIONS: HCT recipients who had CMV infection treated with the currently available PET had a greater inpatient HCRU including LOS and cost by D 180 compared with patients who did not receive PET. The cost of CMV-related readmissions accounted for 60% of total readmission cost among PET recipients. Future studies are needed to examine the cost-effectiveness of alternative strategies for CMV management.

PMID:32640313 | DOI:10.1016/j.bbmt.2020.06.025