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P242. Cost analysis of screening according to ECCO Guidelines for prevention of opportunistic infections in infliximab-treated IBD patients

A. Metz1, T.R. Elliott2, B. Hull2, J. Duncan2, M. Sastrillo2, M. Smith2, J. Sanderson2, P.M. Irving2

1Addenbrooke's Hospital, Cambridge, United Kingdom; 2Guys and St Thomas' NHS Foundation Trust, London, United Kingdom

Aim: We previously reported that our practice of screening for and prevention of opportunistic infections (OI's) in at risk IBD patients was not in line with ECCO recommendations [1,2]. We aimed firstly, to seek evidence of OI's in our historical cohort of infliximab (IFX)-treated patients who had not been screened according to recommendations and secondly, to analyse the cost-effectiveness of screening of, and prophylaxis as required for tuberculosis (TB) and hepatitis B (hep B) in IFX-treated patients.

Materials and Methods: A retrospective audit of consecutive patients treated with IFX (2005–2009) was conducted. Ocurrence of OIs and duration of IFX were recorded from patient records.

A cost-minimisation analysis was performed using clinical decision analytic modelling to assess cost outcome of screening and prevention versus not screening and prevention. Branch probabilities for the model were obtained from a Medline search. The cost perspective was the health sector. Hospital admissions were based on Healthcare Resource Group (HRG4) codes.

Results: There were no OI's identified in 92 IBD patients treated with a median duration of 21 months of IFX therapy.

For 1000 hypothetical Crohn's patients in a western European population, the model predicted 15 screened patients required isoniazid prophylaxis, with 0.5 unscreened patients admitted to hospital with TB. There was an incremental cost for screening of £39.50/patient for CXR alone, or £125.60 for CXR in combination with an interferon release assay. Conversely, there was a cost saving for screening in Southern Europe (£12/patient).

For Hepatitis B in the Western European population, the model predicted 35.7 screened patients required lamivudine prophylaxis, whereas in the unscreened group, 2 patients reactivated with hepatitis, 3 patients with liver failure, and one required a transplant. There was a cost saving of £32/patient for screening.

These results held when the model was varied over the range of costs and outcome probabilities quoted in the literature, indicating the study is robust.

Conclusions: There were no significant opportunistic infections identified in this audit of IFX-treated IBD patients despite failure to screen according to ECCO guidelines.

Due to the significant cost of Hepatitis B reactivation, the model demonstrates cost saving for hepatitis B screening. Due to the low risk of TB reactiviation in the western European population, there is an incremental cost for screening. This cost should be balanced against the risk of death, (reported in Southern but not Western Europe) [3]. Due to the higher rate of latent TB, there is a cost benefit for screening in southern European countries.

1. Rahier JF et al., Journal of Crohn's and Colitis, 3(2), 2009, p47.

2. Elliott TR et al., Journal of Crohn's and Colitis, 4(1), 2010, S63

3. Fonseca JE et al, Acta Reumatol Port. 2006;31(3):247–53.