Routine Cryptococcal Antigen Screening in Solid Organ Transplant Recipients: Is it Time to Save Lives and Money?. (4th October 2017)

• Record Type: Journal Article
• Authors: George, Ige; Rajasingham, Radha; Powderly, William; Boulware, David
• Is Part Of: Open forum infectious diseases. Volume 4(2017)Supplement 1
• Page Start: S55
• Page End: S55
• Publication Date: 2017-10-04
• Subjects: Communicable diseases -- Periodicals; Medical microbiology -- Periodicals; Infection -- Periodicals; 616.9
• DOI: 10.1093/ofid/ofx162.128
• Languages: English
• ISSNs: 2328-8957

Abstract

Abstract: Background: Cryptococcosis affects 1 in 270 solid organ transplant (SOT) recipients with high mortality. In HIV-infected patients, cryptococcal antigen (CRAG) is detectable in blood weeks to months before symptomatic infection and screening is recommended. No screening guidelines exist for SOT recipients. Methods: We performed a cost-effectiveness analysis of CRAG screening amongst SOT recipients. We estimated costs of screening from Medicare reimbursement of $16.49 for CPT 87899 (Infectious agent antigen detection by immunoassay). We determined the number at risk from a large cohort of 42, 634 adult SOT recipients from ICD-9 CM billing data from HCUP State Inpatient Databases of Florida (2006–2012), New York (2006–2011), and California (2004–2010). Cost of screening was compared with the cost of inpatient hospitalization. Results: Among 42, 634 adult SOT recipients, 158 (0.37%) developed cryptococcosis at a median time of 15.5 months (range 0.1 -80) after transplant. During the 43 month follow-up, there was approximately 2.5% annual mortality. The estimated cost of hospital care for cryptococcal meningitis per person is approximately $70, 000 in 2016 with current explosive cost of flucytosine at ~$29, 000 per 2 weeks. Thus, the total estimated cost of hospital care in the cohort would be $11.0 million in 2016. In comparison, the cost to screen all 42, 634 SOT recipients every three months would be $8.8 million. If CRAG screening could detect 75% of asymptomatic cryptococcal antigenemia prior to symptomatic disease requiring prolonged hospitalization, it would be approximately cost neutral ($11.5 million), and even cost saving if above 80% of hospitalizations are averted. Alternatively stated, for every one hospitalization avoided, 4245 persons could be CRAG screened for similar cost and likely better outcome. Conclusion: Assuming the ability of routine screening to identify 75% of patients who would develop invasive cryptococcosis; CRAG screening every 3 months among SOT recipients likely would be at least cost neutral to the healthcare system. Antecedent duration of cryptococcal antigenemia prior to symptomatic disease in Non-HIV/SOT cohorts to inform optimal screening intervals should be further studied. Prospective SOT cohorts should validate this approach to save lives in a cost-effective manner. Disclosures: All authors: No reported disclosures.