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Rutledge SM, Zheng H, Li DK, Chung RT. No evidence for higher rates of hepatocellular carcinoma after direct-acting antiviral treatment: a meta-analysis. ACTA ACUST UNITED AC 2019; 5. [PMID: 31453368 PMCID: PMC6709867 DOI: 10.20517/2394-5079.2019.19] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Aim: Hepatitis C virus (HCV) is the leading cause of hepatocellular carcinoma (HCC) in the United States. Achieving sustained viral response with interferon (IFN) treatment reduces the risk from 3%-5% to 0.5%-1% annually. Several studies reported unexpectedly high rates of HCC after treatment with direct-acting antivirals (DAAs). The aim of our study was to compare HCC rates in DAA-, IFN-treated and untreated populations. Methods: A literature search was conducted using ScienceDirect, Ovid®, Web of Science and MEDLINE through January 2019. Studies were included if they measured rates of de novo or recurrent HCC (following curative treatment) in HCV-infected persons. We included 138 studies (n = 177,512). Simple pooling of data and meta-analysis were performed, using the random effects method. Results: Mean age was higher in the DAA-treated vs. IFN-treated group (58.4 years vs. 52.6 years; P = 0.0073), as were diabetes prevalence (34.5% vs. 11.7%; P ≤ 0.001) and incident cirrhosis (47.8% vs. 34.2%, P = 0.0017). The incidence rate of de novo HCC was 2.01/100 person-years (py) (95%CI: 1.38, 2.67) in the DAA group and 1.45/100py (95%CI: 0.98, 1.94) in the IFN-treated group. HCC recurred at 16.76/100py (95%CI: 10.75, 22.91) in the DAA-treated group vs. 20.04/100py (95%CI: 2.58, 45.21) after IFN. After adjusting for factors such as age and cirrhosis, the hazard ratio was 0.58 (95%CI: 0.20, 1.07) for HCC occurrence and 0.59 (95%CI: 0.24, 1.03) for HCC recurrence after DAA treatment compared to IFN-based treatment. Conclusion: We did not find evidence for increased rates of HCC in DAA-treated compared with IFN-treated patients. Compared to those treated with IFN, older patients with additional risk factors for HCC were treated with DAAs. This imbalance appears to explain the higher numerical incidence of HCC among DAA-treated patients.
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Affiliation(s)
- Stephanie M Rutledge
- Department of Medicine, Massachusetts General Hospital, Gastroenterology Unit/Warren 10, Boston, MA02114, USA.,Liver Center, Gastrointestinal Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Hui Zheng
- Liver Center, Gastrointestinal Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Darrick K Li
- Department of Medicine, Massachusetts General Hospital, Gastroenterology Unit/Warren 10, Boston, MA02114, USA.,Liver Center, Gastrointestinal Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Raymond T Chung
- Department of Medicine, Massachusetts General Hospital, Gastroenterology Unit/Warren 10, Boston, MA02114, USA.,Liver Center, Gastrointestinal Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
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2
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Jena AB, Snider JT, Diaz Espinosa O, Ingram A, Sanchez Gonzalez Y, Lakdawalla D. How Does Treating Chronic Hepatitis C Affect Individuals in Need of Organ Transplants in the United Kingdom? VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2019; 22:669-676. [PMID: 31198184 DOI: 10.1016/j.jval.2018.09.2923] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 07/31/2018] [Accepted: 09/10/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVES To estimate the impact of cures for chronic hepatitis C (CHC) infection on organ donation in the United Kingdom. Curing CHC infection reduces the need for liver transplants and enables cured individuals to donate organs of all types. METHODS We adapted a double-queuing model of organ allocation to estimate the effects of CHC infection cures on liver, lung, heart, and kidney transplants in the United Kingdom. We assumed that cured individuals would donate organs at similar rates as the general population and no longer require liver transplants because of CHC infection. We estimated how curing CHC infection influences waitlist lengths for each organ and the annual net present value to society on the basis of quality-adjusted life-years gained through additional transplants under opt-in and opt-out organ donation policies. RESULTS Curing CHC generates the most value for patients on the liver waitlist, because it increases the number of transplantable livers and reduces the need for transplants. Under the current opt-in policy, liver waitlist length falls by 24%, generating £34.3 million of annual net present value. Growth in the number of uninfected lungs, hearts, and kidneys generates an additional £19.2 million annually, with £18.7 million from kidneys. Implementing the opt-out policy, liver waitlist length would decrease by 75%, implying that treating CHC eliminates one-third of the excess liver waitlist due to an opt-in policy. CONCLUSIONS Treating CHC has large positive spillovers to uninfected individuals by reducing the need for liver transplants and allowing cured individuals to donate organs. These spillovers have not been included in traditional value assessments of CHC treatment.
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Borba HHL, Rochau U, Wiens A, Sroczynski G, Siebert U, Ferreira VL, Minowa E, Pontarolo R. Effectiveness and Cost-Effectiveness of Triple Therapy With Telaprevir and Boceprevir for Chronic Hepatitis C: A Decision Analysis From the Brazilian Public Health System Perspective. Value Health Reg Issues 2019; 20:95-102. [PMID: 31108456 DOI: 10.1016/j.vhri.2019.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 01/15/2019] [Accepted: 02/19/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Because of the lack of evidence regarding long-term effectiveness and cost-effectiveness of first-generation direct-acting antivirals for chronic hepatitis C (CHC) treatment in Brazil, we performed a cost-utility analysis comparing standard dual therapy (peginterferon plus ribavirin [pegIFN/RBV]), boceprevir, and telaprevir for CHC patients. METHODS We developed a state-transition Markov model simulating the progression of CHC. Long-term outcomes included remaining life expectancy in life-years (LYs), quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio (ICER). Short-term outcomes included sustained virological response rates (SVR). Direct medical costs were obtained from Brazilian databases. A lifelong time horizon was considered and a 5% annual discount rate was applied for costs and clinical outcomes. A willingness-to-pay threshold of approximately $20 000 per QALY was used. We performed multiple sensitivity analyses. RESULTS For short- and long-term scenarios, therapy with boceprevir was dominated by telaprevir, which was more effective than standard dual therapy (75.0% vs 40.4% SVR rate, 13.47 vs 12.59 LYs, and 9.74 vs 8.49 QALYs, respectively) and was also more expensive ($15 742 vs $5413). The corresponding ICERs were $29 854/SVR, $11 803/LY, and $8277/QALY. Based on our model, triple therapy with telaprevir was the most cost-effective treatment for the Brazilian health system. Despite a lack of data regarding the Brazilian population, we incorporated as many applicable parameters as possible. CONCLUSIONS Telaprevir is more effective and cost-effective than boceprevir. Our model may be applied for other settings with a few adjustments in the input parameters.
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Affiliation(s)
- Helena H L Borba
- Department of Pharmacy, Federal University of Paraná, Curitiba, Brazil
| | - Ursula Rochau
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
| | - Astrid Wiens
- Department of Pharmacy, Federal University of Paraná, Curitiba, Brazil
| | - Gaby Sroczynski
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
| | - Uwe Siebert
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria; Division of Health Technology Assessment, ONCOTYROL-Center for Personalized Cancer Medicine, Innsbruck, Austria; Center for Health Decision Science, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Institute for Technology Assessment and Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Eimy Minowa
- Universidade de São Paulo, São Paulo, Brazil
| | - Roberto Pontarolo
- Department of Pharmacy, Federal University of Paraná, Curitiba, Brazil.
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Iida H, Osaki R, Fujimoto T, Maehira H, Mori H, Kitamura N, Andoh A, Tani M. Interval between hepatocellular carcinoma treatment and interferon-free direct-acting antiviral agents against hepatitis C is necessary to suppress tumor recurrence. Mol Clin Oncol 2019; 11:99-105. [PMID: 31289685 DOI: 10.3892/mco.2019.1847] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Accepted: 04/17/2019] [Indexed: 12/15/2022] Open
Abstract
Interferon (IFN) has been identified to suppress carcinogenesis when used for treating hepatitis C virus (HCV) infections. Treatment with IFN-free direct-acting antiviral agents (DAAs) is an acceptable alternative, even in elderly patients or patients who have been treated for hepatocellular carcinoma (HCC), because it has a lower incidence of side effects and higher sustained virological response (SVR) rate compared with IFN treatment. However, the suppression of carcinogenesis by DAAs is unclear. In the present study, 19 patients who underwent DAA treatment following treatment for HCC between January 2015 and March 2017 were retrospectively investigated. The clinical data were compared between 9 patients with HCC recurrence following DAA treatment (recurrence group) and 10 patients without HCC recurrence (no-recurrence group). The 1-year cumulative recurrence rate of HCC following SVR was as high as 50.2%. Age and sex did not significantly differ between the two groups, and the average number of HCC treatments prior to DAA treatment was also not significantly different between the recurrence and no-recurrence groups (3.2 and 2.2, respectively). The median interval between the final HCC treatment and the commencement of DAA treatment was 88 days in the recurrence group, which was significantly less compared with 790 days in the no-recurrence group (P=0.018). An interval of 120 days or more from final HCC treatment to the commencement of DAA treatment was a significant independent factor of no HCC recurrence following DAA treatment (P=0.028). A high HCC recurrence rate was identified following DAA treatment in patients with a history of HCC treatment. Therefore, there should be at least a 4-month interval from the final HCC treatment to the commencement of DAA treatment to ensure no HCC recurrence.
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Affiliation(s)
- Hiroya Iida
- Department of Surgery, Shiga University of Medical Science, Otsu, Shiga 520-2192, Japan
| | - Rie Osaki
- Department of Internal Medicine, Shiga University of Medical Science, Otsu, Shiga 520-2192, Japan
| | - Takehide Fujimoto
- Department of Internal Medicine, Shiga University of Medical Science, Otsu, Shiga 520-2192, Japan
| | - Hiromitsu Maehira
- Department of Surgery, Shiga University of Medical Science, Otsu, Shiga 520-2192, Japan
| | - Haruki Mori
- Department of Surgery, Shiga University of Medical Science, Otsu, Shiga 520-2192, Japan
| | - Naomi Kitamura
- Department of Surgery, Shiga University of Medical Science, Otsu, Shiga 520-2192, Japan
| | - Akira Andoh
- Department of Internal Medicine, Shiga University of Medical Science, Otsu, Shiga 520-2192, Japan
| | - Masaji Tani
- Department of Surgery, Shiga University of Medical Science, Otsu, Shiga 520-2192, Japan
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Umezaki N, Nakagawa S, Yamashita YI, Kitano Y, Arima K, Miyata T, Hiyoshi Y, Okabe H, Nitta H, Hayashi H, Imai K, Chikamoto A, Baba H. Lysyl oxidase induces epithelial-mesenchymal transition and predicts intrahepatic metastasis of hepatocellular carcinoma. Cancer Sci 2019; 110:2033-2043. [PMID: 30919528 PMCID: PMC6550133 DOI: 10.1111/cas.14010] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 03/24/2019] [Accepted: 03/25/2019] [Indexed: 12/27/2022] Open
Abstract
Hepatocellular carcinoma (HCC) has high recurrence rates even after curative hepatectomy. Drug therapy for recurrence of HCC is still limited; therefore, identifying new therapeutic targets is urgently needed. We searched for genes that would predict HCC recurrence from intrahepatic metastasis in an exhaustive DNA microarray database by searching genes associated with high early recurrence rate and having higher expression in the tumor area compared to background liver. We detected lysyl oxidase (LOX) and validated the clinical significance of LOX in 358 patients who underwent hepatectomy. Expression of LOX was evaluated by qRT‐ PCR, and immunohistochemical (IHC) staining. High LOX expression group had a significantly higher recurrence rate than the low LOX expression group (2‐year recurrence rate was 64.0% vs 24.2%, P < .0001 for IHC) and poorer survival rate (5‐year rate was 60.1% vs 86.2%, P < .0001 for IHC). Multivariate analysis showed that high LOX expression was an independent risk factor for early recurrence (IHC: HR, 2.52; P < .0001). Bioinformatic analysis showed that LOX expression was associated with hypoxia‐inducible factor‐1α (HIF‐1α) and the hypoxia cascade, suggesting that HIF‐1α or hypoxia regulates LOX expression and induces epithelial‐mesenchymal transition (EMT). In vitro, LOX and HIF‐1α were involved in migration and invasion capability. High LOX expression is associated with EMT markers and predicts early recurrence and poor survival in patients with HCC. These findings indicate that lysyl oxidase could be a potential therapeutic target for early recurrence of HCC.
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Affiliation(s)
- Naoki Umezaki
- Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Shigeki Nakagawa
- Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Yo-Ichi Yamashita
- Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Yuki Kitano
- Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Kota Arima
- Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Tatsunori Miyata
- Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Yukiharu Hiyoshi
- Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Hirohisa Okabe
- Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Hidetoshi Nitta
- Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Hiromitsu Hayashi
- Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Katsunori Imai
- Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Akira Chikamoto
- Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Hideo Baba
- Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, Kumamoto, Japan
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Luma HN, Eloumou SA, Noah DN, Eyenga BA, Nko’Ayissi G, Taku TS, Malongue A, Donfack-Sontsa O, Ditah IC. Hepatitis C Continuum of Care in a Treatment Center in Sub-Saharan Africa. J Clin Exp Hepatol 2018; 8:335-341. [PMID: 30563994 PMCID: PMC6286429 DOI: 10.1016/j.jceh.2018.01.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 01/07/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Hepatitis C virus (HCV) infection is a major public health challenge in Cameroon with over three million people infected. Government efforts to improve care and treatment are unsatisfactory and need to be assessed. We aimed at studying the several steps along the HCV continuum of care in one of two hepatitis treatment centers in Cameroon. METHODS We undertook a retrospective chart review of anti-HCV positive individuals, who attended the Douala general hospital between 2008 and 2015. We defined the HCV treatment cascade as follows: step 1-HCV RNA testing, step 2-complete pre-therapeutic evaluation (genotyping and liver fibrosis markers), step 3-initiation of treatment, step 4-treatment completion, and step 5-sustained virological response (SRV). Each successive step in the HCV care continuum was dependent on passing through the previous step. RESULTS The mean age of the 669 anti-HCV antibody positive individuals was 57 (sd: ±13) years. Females were 52.8% of the study population. 410 (61.3%) were tested for HCV RNA. Three hundred and sixty-six (54.7%) were confirmed to have viral replication (HCV RNA positive). One hundred and eighty (26.9%) did a complete pre-therapeutic evaluation (both HCV genotyping and liver fibrosis assessment included). Eighty-one (12.1%) initiated treatment with pegylated interferon/ribavirin. Seventy-two (10.8%) completed treatment and 44 (6.6%) had SVR. Sociodemographic characteristics including age, gender, marital status, having medical insurance, and profession were associated with attaining later steps in the care cascade. CONCLUSION This study shows that HCV continuum of care and treatment is less optimal at the Douala general hospital and is highly impacted by socio-economic factors. Continued efforts are needed to improve HCV care.
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Affiliation(s)
- Henry N. Luma
- Douala General Hospital, Douala, Cameroon
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé 1, Yaoundé, Cameroon
- Address for correspondence: Henry Namme Luma, P.O. Box 4856, Douala, Cameroon. Fax: +237 243 37 01 46.
| | - Servais A.F.B. Eloumou
- Douala General Hospital, Douala, Cameroon
- Faculty of Medicine and Pharmaceutical Sciences, University of Douala, Douala, Cameroon
| | - Dominique N. Noah
- Faculty of Medicine and Pharmaceutical Sciences, University of Douala, Douala, Cameroon
| | - B. Aude Eyenga
- Faculty of Medicine and Pharmaceutical Sciences, University of Douala, Douala, Cameroon
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Kiberd BA, Doucette K, Vinson AJ, Tennankore KK. Hepatitis C virus-infected kidney waitlist patients: Treat now or treat later? Am J Transplant 2018; 18:2443-2450. [PMID: 29687948 DOI: 10.1111/ajt.14891] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 03/23/2018] [Accepted: 04/15/2018] [Indexed: 01/25/2023]
Abstract
Currently many but not all centers transplant hepatitis C virus (HCV) viremic positive (+) donor kidneys into HCV+ recipients. Directed donation of HCV+ organs reduces the wait time to transplantation for HCV+ patients. Direct-acting antiviral (DAA) therapy can cure HCV in virtually all who are infected. Some have suggested that treatment of HCV+ waitlisted patients be deferred with the hope that earlier transplantation will provide better outcomes than early DAA therapy. However, there are not enough organs to guarantee prompt transplantation for the current waitlist of infected candidates. A Markov medical decision analysis model was created to compare the overall outcomes of delayed DAA therapy (Option 1) to immediate DAA therapy (Option 2) in waitlisted HCV+ patients. Option 1 patients were modeled to be transplanted 1 year earlier, with a higher cumulative transplant incidence (54% at 5 years post-listing vs 45% for Option 2). Despite this, Option 2 provided 0.43 (95% confidence interval [CI] 0.38-0.49) more life years than Option 1. However, Option 1 was preferred for regions with much greater access to HCV+ organs or in patients with very low HCV+-associated mortality. The best option from an individual patient's perspective will differ by region and candidate.
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Affiliation(s)
- B A Kiberd
- Departments of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - K Doucette
- University of Alberta, Edmonton, Alberta, Canada
| | - A J Vinson
- Departments of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - K K Tennankore
- Departments of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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Castro R, Crathorne L, Perazzo H, Silva J, Cooper C, Varley-Campbell J, Marinho DS, Haasova M, Veloso VG, Anderson R, Hyde C. Cost-effectiveness of diagnostic and therapeutic interventions for chronic hepatitis C: a systematic review of model-based analyses. BMC Med Res Methodol 2018; 18:53. [PMID: 29895281 PMCID: PMC5998601 DOI: 10.1186/s12874-018-0515-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 05/31/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Decisions about which subgroup of chronic hepatitis C (CHC) patients should be treated with direct acting anti-viral agents (DAAs) have economic importance due to high drug prices. Treat-all DAA strategies for CHC have gained acceptance despite high drug acquisition costs. However, there are also costs associated with the surveillance of CHC to determine a subgroup of patients with significant impairment. The aim of this systematic review was to describe the modelling methods used and summarise results in cost-effectiveness analyses (CEAs) of both CHC treatment with DAAs and surveillance of liver disease. METHODS Electronic databases including Embase and Medline were searched from inception to May 2015. Eligible studies included models predicting costs and/or outcomes for interventions, surveillance, or management of people with CHC. Narrative and quantitative synthesis were conducted. Quality appraisal was conducted using validated checklists. The review was conducted following principles published by NHS Centre for Research and Dissemination. RESULTS Forty-one CEAs met the eligibility criteria for the review; 37 evaluated an intervention and four evaluated surveillance strategies for targeting DAA treatment to those likely to gain most benefit. Included studies were of variable quality mostly due to reporting omissions. Of the 37 CEAs, eight models that enabled comparative analysis were fully appraised and synthesized. These models provided non-unique cost-effectiveness estimates in a specific DAA comparison in a specific population defined in terms of genotype, prior treatment status, and presence or absence of cirrhosis. Marked heterogeneity in cost-effectiveness estimates was observed despite this stratification. Approximately half of the estimates suggested that DAAs were cost-effective considering a threshold of US$30,000 and 73% with threshold of US$50,000. Two models evaluating surveillance strategies suggested that treating all CHC patients regardless of the staging of liver disease could be cost-effective. CONCLUSIONS CEAs of CHC treatments need to better account for variability in their estimates. This analysis suggested that there are still circumstances where DAAs are not cost-effective. Surveillance in place of a treat-all strategy may still need to be considered as an option for deploying DAAs, particularly where acquisition cost is at the limit of affordability for a given health system.
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Affiliation(s)
- Rodolfo Castro
- Fundação Oswaldo Cruz, FIOCRUZ, Instituto Nacional de Infectologia Evandro Chagas, INI, Avenida Brasil, 4365, 21040-900, Manguinhos, Rio de Janeiro, Brazil
- Universidade Federal do Estado do Rio de Janeiro, UNIRIO, Instituto de Saúde Coletiva, Rio de Janeiro, Brazil
| | - Louise Crathorne
- University of Exeter Medical School, Evidence Synthesis & Modelling for Health Improvement, ESMI, Peninsula Technology Assessment Group, PenTAG, Exeter, UK
| | - Hugo Perazzo
- Fundação Oswaldo Cruz, FIOCRUZ, Instituto Nacional de Infectologia Evandro Chagas, INI, Avenida Brasil, 4365, 21040-900, Manguinhos, Rio de Janeiro, Brazil
| | - Julio Silva
- Fundação Oswaldo Cruz, FIOCRUZ, Instituto Nacional de Infectologia Evandro Chagas, INI, Avenida Brasil, 4365, 21040-900, Manguinhos, Rio de Janeiro, Brazil
| | - Chris Cooper
- University of Exeter Medical School, Evidence Synthesis & Modelling for Health Improvement, ESMI, Peninsula Technology Assessment Group, PenTAG, Exeter, UK
| | - Jo Varley-Campbell
- University of Exeter Medical School, Evidence Synthesis & Modelling for Health Improvement, ESMI, Peninsula Technology Assessment Group, PenTAG, Exeter, UK
| | - Daniel Savignon Marinho
- Fundação Oswaldo Cruz, FIOCRUZ, Centro de Desenvolvimento Tecnológico em Saúde, CDTS, Rio de Janeiro, Brazil
| | - Marcela Haasova
- University of Exeter Medical School, Evidence Synthesis & Modelling for Health Improvement, ESMI, Peninsula Technology Assessment Group, PenTAG, Exeter, UK
| | - Valdilea G. Veloso
- Fundação Oswaldo Cruz, FIOCRUZ, Instituto Nacional de Infectologia Evandro Chagas, INI, Avenida Brasil, 4365, 21040-900, Manguinhos, Rio de Janeiro, Brazil
| | - Rob Anderson
- University of Exeter Medical School, Evidence Synthesis & Modelling for Health Improvement, ESMI, Peninsula Technology Assessment Group, PenTAG, Exeter, UK
| | - Chris Hyde
- University of Exeter Medical School, Evidence Synthesis & Modelling for Health Improvement, ESMI, Peninsula Technology Assessment Group, PenTAG, Exeter, UK
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9
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Sackey B, Shults JG, Moore TA, Rogers R, Mehvar M, King JG. Evaluating psychiatric outcomes associated with direct-acting antiviral treatment in veterans with hepatitis C infection. Ment Health Clin 2018; 8:116-121. [PMID: 29955556 PMCID: PMC6007636 DOI: 10.9740/mhc.2018.05.116] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Introduction: Approximately 70% of veterans with hepatitis C virus infection have at least one psychiatric illness. The advent of direct-acting antiviral (DAA) therapy provided an alternative to interferon-alpha regimens and revolutionized treatment, however, the extent of psychiatric effects attributed to these agents are unclear. The primary objective of this pilot study was to prospectively analyze psychiatric outcomes, specifically depression, in veterans with hepatitis C virus infection who are initiated on DAA therapy. Methods: In this single center, prospective cohort study, psychiatric outcomes were analyzed using Patient Health Questionnaire assessments at baseline and weeks 4, 8, and 12 of complete DAA treatment. Outcome analysis were stratified based on specific DAA therapy and preexisting mental illness (mental health [MH] subjects and non-MH subjects), with a sub-analysis of major depressive disorder patients. Results: Analysis included 48 patients, majority males (96%), with a mean age of 59.4 years (±8.0). Twenty-four (50%) patients had a preexisting MH diagnosis, with major depressive disorder being the most common MH diagnosis (50%, n = 12). Despite a trend toward improvement, no significant changes in questionnaire scores after 12 weeks of DAA therapy were observed for all patient groups (P > .05). Neither MH subjects nor non-MH subjects displayed a significant change in questionnaire scores from baseline to end of treatment (P > .05). No patients required acute psychiatric interventions during DAA treatment. Discussion: Treatment with DAA therapy was not associated with psychiatric decompensation. Data from this pilot study supports the safe utilization of DAA therapy in hepatitis C virus patients with preexisting MH illness as it appears to be devoid of depressive and psychiatric side effects.
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Affiliation(s)
- Bryan Sackey
- Mental Health Clinical Pharmacy Specialist, Pharmacy Department, South Texas Veterans Healthcare System, San Antonio, Texas; Adjoint Assistant Professor, Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, Texas,
| | - Jana G Shults
- Mental Health Clinical Pharmacy Specialist, Pharmacy Department, South Texas Veterans Healthcare System, San Antonio, Texas
| | - Troy A Moore
- Clinical Pharmacy Specialist-Psychiatry, Pharmacy Department, South Texas Veterans Healthcare System, San Antonio, Texas; Director, American Society of Health-System Pharmacists-Accredited Postgraduate Year 2 Psychiatric Pharmacy Residency Program, San Antonio, Texas; Assistant Professor, Division of Community Recovery, Research and Training, Department of Psychiatry, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Rachel Rogers
- Infectious Disease Clinical Pharmacy Specialist, South Texas Veterans Healthcare System, San Antonio, Texas
| | - Mina Mehvar
- Mental Health Clinical Pharmacy Specialist, South Texas Veterans Healthcare System, San Antonio, Texas
| | - Joshua G King
- Mental Health Clinical Pharmacy Specialist, Pharmacy Department, South Texas Veterans Healthcare System, San Antonio, Texas; Adjoint Assistant Professor, Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, Texas, .,Mental Health Clinical Pharmacy Specialist, Pharmacy Department, South Texas Veterans Healthcare System, San Antonio, Texas.,Clinical Pharmacy Specialist-Psychiatry, Pharmacy Department, South Texas Veterans Healthcare System, San Antonio, Texas; Director, American Society of Health-System Pharmacists-Accredited Postgraduate Year 2 Psychiatric Pharmacy Residency Program, San Antonio, Texas; Assistant Professor, Division of Community Recovery, Research and Training, Department of Psychiatry, University of Texas Health Science Center at San Antonio, San Antonio, Texas.,Infectious Disease Clinical Pharmacy Specialist, South Texas Veterans Healthcare System, San Antonio, Texas.,Mental Health Clinical Pharmacy Specialist, South Texas Veterans Healthcare System, San Antonio, Texas.,Mental Health Clinical Pharmacy Specialist, South Texas Veterans Healthcare System, San Antonio, Texas
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Lobato CMDO, Balassiano N, Hyppolito EB, Sanchez-Lermen RLP, Signorelli IV, Nicacio MYT, Firmino Filho AP, Andrade TGD, Lima JMDC, Arruda TAD, Coutinho FS, Araujo EFDV, Esmeraldo TM, Cortez E, Capeli RLA, Matos MBMD, Pessoa FSR, Oliveira HCD, Arruda ÉAGD, Gonçalves PL, Araújo Filho AH, Esberard EBC, Souto FJD. Effectiveness of first-wave protease inhibitors in hepatitis C virus genotype 1 infection: a multicenter study in Brazil. Rev Soc Bras Med Trop 2018. [PMID: 29513836 DOI: 10.1590/0037-8682-0279-2017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
INTRODUCTION In 2013, combination therapy using peginterferon, ribavirin, and boceprevir or telaprevir was introduced to treat hepatitis C virus genotype 1 infection in Brazil. The effectiveness of this therapy in four Brazilian regions was evaluated. METHODS Clinical and virological data were obtained from patients of public health institutions in five cities, including sustained virological response (SVR) and side effects. Patients with advanced fibrosis (F3/4), moderate fibrosis (F2) for > 3 years, or extra-hepatic manifestations were treated according to Ministry of Health protocol. Treatment effectiveness was verified by using bivariate and multivariate analysis; p-values of < 0.05 were considered significant. RESULTS Of 275 patients (64.7% men; average age, 57 years old), most (61.8%) were treatment-experienced; 53.9% had subgenotype 1a infection, 85.1% had advanced fibrosis, and 85.5% were treated with telaprevir. SVR was observed in 54.2%. Rapid virological response (RVR) was observed in 54.6% of patients (data available for 251 patients). Overall, 87.5% reported side effects and 42.5% did not complete treatment. Skin rash, severe infection, and death occurred in 17.8%, 2.5%, and death in 1.4% of cases, respectively. SVR was associated with treatment completion, RVR, and anemia. CONCLUSIONS The effectiveness of hepatitis C virus triple therapy was lower than that reported in phase III clinical trials, possibly owing to the prioritized treatment of patients with advanced liver fibrosis. The high frequency of side effects and treatment interruptions observed supported the decision of the Brazilian authorities to suspend its use when safer and more effective drugs became available in 2015.
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Affiliation(s)
| | - Natalia Balassiano
- Hospital Universitário Antonio Pedro, Universidade Federal Fluminense, Niterói, RJ, Brasil
| | - Elodie Bomfim Hyppolito
- Hospital Universitário Walter Cantídio, Universidade Federal do Ceará, Fortaleza, CE, Brasil.,Hospital São José, Fortaleza, CE, Brasil
| | | | | | | | | | | | | | - Talita Amorim de Arruda
- Hospital Universitário Júlio Muller, Universidade Federal de Mato Grosso, Cuiabá, MT, Brasil
| | - Fernanda Schwanz Coutinho
- Hospital Universitário Cassiano Antonio de Moraes, Universidade Federal do Espírito Santo, Vitória, ES, Brasil
| | | | | | - Erlon Cortez
- Hospital Universitário Júlio Muller, Universidade Federal de Mato Grosso, Cuiabá, MT, Brasil
| | | | | | | | | | | | - Patrícia Lofêgo Gonçalves
- Hospital Universitário Cassiano Antonio de Moraes, Universidade Federal do Espírito Santo, Vitória, ES, Brasil
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Shahid I, AlMalki WH, Hassan S, Hafeez MH. Real-world challenges for hepatitis C virus medications: a critical overview. Crit Rev Microbiol 2017; 44:143-160. [PMID: 28539069 DOI: 10.1080/1040841x.2017.1329277] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
From 2010, the landscape of hepatitis C therapeutics has been changed rapidly, and today we are standing at a cusp of a pharmacological revolution where highly effective and interferon (IFN)-free direct acting antivirals (DAAs) are already on the market. Such treatment paradigms attain 90-95% sustained virologic response (SVR; undetectable viral load at week 12 or 24 at the end of therapy) rates in treated individuals compared to 50-70% with treatment completion of dual-therapy-pegylated interferon (PEG-IFN) and ribavirin (RBV). As the major goal now for the hepatologists, clinicians, physicians, and health care workers is likely to eradicate hepatitis C infection in parallel to treatment, the demand is for a one-size-fits-all pill that could be prescribed beyond the limitations of hepatitis C genotype, viral load, previous treatment history, advanced hepatic manifestations (fibrosis, cirrhosis) and antiviral drug resistance. Although the new treatment strategies have shown high cure rates in clinical trials, such treatment paradigms are posing dilemmas too in real-world clinical practice. Therapy cost, treatment access to low and middle-income countries, treatment-emergent adverse events, lack of effective viral screening and disease progression simulation models are potential challenges in this prospect. This review article deeply overviews the challenges encountered while surmounting the burden of hepatitis C around the world.
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Affiliation(s)
- Imran Shahid
- a Department of Pharmacology and Toxicology, College of Pharmacy , Umm Al Qura University , Al-Abidiyah , Makkah , Saudi Arabia.,c Applied and Functional Genomics Laboratory, Centre of Excellence in Molecular Biology , University of the Punjab , Lahore , Pakistan
| | - Waleed Hassan AlMalki
- a Department of Pharmacology and Toxicology, College of Pharmacy , Umm Al Qura University , Al-Abidiyah , Makkah , Saudi Arabia
| | - Sajida Hassan
- b Viral Hepatitis Program, Laboratory of Medicine , University of Washington , Seattle , WA , USA.,c Applied and Functional Genomics Laboratory, Centre of Excellence in Molecular Biology , University of the Punjab , Lahore , Pakistan
| | - Muhammad Hassan Hafeez
- d Department of Gastroenterology and Hepatology , Fatima Memorial College of Medicine and Dentistry , Shadman , Lahore , Pakistan
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12
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Yang S, Britt RB, Hashem MG, Brown JN. Outcomes of Pharmacy-Led Hepatitis C Direct-Acting Antiviral Utilization Management at a Veterans Affairs Medical Center. J Manag Care Spec Pharm 2017; 23:364-369. [PMID: 28230455 PMCID: PMC10397608 DOI: 10.18553/jmcp.2017.23.3.364] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The Veterans Affairs Health (VA) Administration has reported hepatitis C virus (HCV) infection rates among veterans to be twice that of the general U.S population. New HCV direct-acting antiviral (DAA) treatment options offer superior sustained virologic response (SVR) rates, improved side-effect profiles, and shortened treatment courses; yet, these new HCV DAAs are expensive, and utilization management strategies are needed to optimize use and improve clinical outcomes. A VA medical center uses pharmacist-led HCV DAA utilization management strategies that includes clinical guidance, optimizing operational flow, budget tracking and forecasting, and patient outcomes tracking. OBJECTIVE To assess the economic and clinical outcomes of pharmacy-led HCV DAA utilization management in a VA medical center. METHODS This was a single-center, retrospective cohort study. Patient electronic health records and the hepatitis C DAA outcomes tracking database were reviewed at a VA medical center. Patients with an HCV DAA prior authorization drug request and therapy initiated between October 1, 2014, and September 30, 2015, were included. The primary endpoint was the ratio of drug spend to cure rate calculated as the total dollars spent to the number of patients achieving SVR at least 12 weeks from end of treatment. Secondary endpoints included economic, clinical, and safety outcomes. RESULTS A total of 372 patients were included in the study. The overall cost ratio of total drug spend to cure rate was $40,135.22. The overall cure rate was 94.1%, with no discontinuations due to treatment failure. The ratio of drug spend to cure rate was $41,907.35 and $38,430.77 in cirrhotic and noncirrhotic patients, respectively, and $39,481.62 and $39,178.74 in treatment-experienced and naive patients, respectively. Ten patients discontinued therapy because of the adverse effects of anemia, nausea, vomiting, and anxiety. The medication possession ratio was 98.7% (± 0.13) for all patients included in the study. CONCLUSIONS This study suggests that pharmacist-led HCV DAA utilization management is an important factor in costs and cure rates. Utilization management strategies are valuable to help adequately manage patients with chronic hepatitis C (CHC) and may allow practitioners to maximize available funding for CHC, while maintaining high efficacy and safety. DISCLOSURES No outside funding supported this research. The authors have no conflicts of interest to report. Study concept and design were contributed primarily by Britt, along with Hashem, Brown, and Yang. Yang took the lead in data collection, along with Britt, and data interpretation was performed by all the authors. The manuscript was written and revised by Yang, Britt, Brown, and Hashem.
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13
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Goodkin DA, Bieber B, Jadoul M, Martin P, Kanda E, Pisoni RL. Mortality, Hospitalization, and Quality of Life among Patients with Hepatitis C Infection on Hemodialysis. Clin J Am Soc Nephrol 2017; 12:287-297. [PMID: 27908905 PMCID: PMC5293341 DOI: 10.2215/cjn.07940716] [Citation(s) in RCA: 110] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 10/19/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND OBJECTIVES Hepatitis C virus (HCV) infection is widely prevalent among patients on hemodialysis (HD), but very rarely treated. The aim of our study is to evaluate the burdens of HCV suffered by patients on HD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The Dialysis Outcomes and Practice Patterns Study is an international, prospective, cohort study of patients on HD. We reviewed the HCV status of 76,689 adults enrolled between 1996 and 2015. We compared HCV-positive (HCV+) with HCV-negative (HCV-) patients for risk of mortality, hospitalization, decline in hemoglobin concentration <8.5 g/dl, and red blood cell transfusion. We also compared health-related quality of life scores using the Kidney Disease Quality of Life instrument and the Center for Epidemiologic Studies Short Depression Scale. We adjusted for age, sex, race, years on dialysis, 14 comorbid conditions (including hepatitis B infection), and serum albumin, phosphorus, and creatinine concentrations. RESULTS A total of 7.5% of patients were HCV+ at enrollment. Serum concentrations of alanine aminotransferase and aspartate aminotransferase were not markedly elevated in HCV+ patients on HD; the mean concentrations were only 22.6 and 21.8 U/L, respectively. Median follow-up was 1.4 years. Case-mix adjusted hazard ratios (95% confidence intervals) for HCV+ versus HCV- patients were 1.12 (1.05 to 1.20) for all-cause mortality, 5.90 (3.67 to 9.50) for hepatic-related mortality, 1.09 (1.04 to 1.13) for all-cause hospitalization, and 4.40 (3.14 to 6.15) for hepatic-related hospitalization. Quality of life measures indicated significantly worse scores for physical function, pain, vitality, mental health, depression, pruritus, and anorexia among HCV+ patients. The adjusted hazard ratio for transfusion was 1.36 (95% CI, 1.20 to 1.55) and incidence of hemoglobin concentration <8.5 g/dl was 1.12 (95% CI, 1.03 to 1.21). Only 1.5% of HCV+ patients received antiviral medication. CONCLUSIONS HCV infection among patients on HD is associated with higher risk of death, hospitalization, and anemic complications, and worse quality of life scores. Internationally, HCV infection is almost never treated in patients on HD. Our data provide a rationale for more frequent treatment of HCV in this population.
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Affiliation(s)
| | - Brian Bieber
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Michel Jadoul
- Division of Nephrology, Cliniques Universitaires St-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Paul Martin
- Division of Hepatology, University of Miami, Miami, Florida; and
| | - Eiichiro Kanda
- Department of Nephrology, Tokyo Kyosai Hospital, Tokyo, Japan
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14
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A clinician's guide to the cost and health benefits of hepatitis C cure assessed from the individual patient perspective. Eur J Gastroenterol Hepatol 2017; 29:208-214. [PMID: 27832039 DOI: 10.1097/meg.0000000000000773] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS The hepatitis C virus (HCV) remains a considerable public health challenge. Novel direct-acting antiviral (DAA) regimens offer high cure rates and the promise of reduced HCV incidence and prevalence following the up-scaling of treatment. This has focused attention towards affordability. This study aimed to estimate the economic value of cure to evaluate the treatment costs justifiable from the patient perspective. PATIENTS AND METHODS A published, validated HCV model was utilized to contrast clinical and cost outcomes for patients aged 30-70 years, stratified by METAVIR F0-F4, for (i) no treatment and (ii) successful treatment [i.e. sustained virologic response (SVR)] ignoring the cost of treatment. Regression equations were fitted and used to determine the financial expenditure justifiable to achieve a cost-neutral or a cost-effective [£20 000 per quality-adjusted life-year (QALY)] cure. Model inputs were derived from UK literature; costs and utilities were discounted at 3.5% over a lifetime horizon. RESULTS To achieve cost-neutrality, the maximum discounted expenditure justifiable for SVR was £3774-43 607 across ages and fibrosis stages. Spending between £19 745 (70 years, F0) and £188 420 (30 years, F4) on SVR is expected to be cost-effective at £20 000/QALY willingness-to-pay threshold. CONCLUSION Heterogeneity across HCV patients is considerable, which can obscure the relevance of conventional cohort-based economic models evaluated at the mean, particularly when considering the value of treatment at the individual patient level. By quantifying the full exposition of HCV cost-savings and health benefits realizable following HCV cure, this study provides insight into the economic value of successful treatment from the patient perspective.
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15
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Leidner AJ, Chesson HW, Spradling PR, Holmberg SD. Assessing the Effect of Potential Reductions in Non-Hepatic Mortality on the Estimated Cost-Effectiveness of Hepatitis C Treatment in Early Stages of Liver Disease. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2017; 15:65-74. [PMID: 27480538 PMCID: PMC5802335 DOI: 10.1007/s40258-016-0261-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND Most cost-effectiveness analyses of hepatitis C (HCV) therapy focus on the benefits of reducing liver-related morbidity and mortality. OBJECTIVES Our objective was to assess how cost-effectiveness estimates of HCV therapy can vary depending on assumptions regarding the potential impact of HCV therapy on non-hepatic mortality. METHODS We adapted a state-transition model to include potential effects of HCV therapy on non-hepatic mortality. We assumed successful treatment could reduce non-hepatic mortality by as little as 0 % to as much as 100 %. Incremental cost-effectiveness ratios were computed comparing immediate treatment versus delayed treatment and comparing immediate treatment versus non-treatment. RESULTS Comparing immediate treatment versus delayed treatment, when we included a 44 % reduction in non-hepatic mortality following successful HCV treatment, the incremental cost per quality-adjusted life year (QALY) gained by HCV treatment fell by 76 % (from US$314,100 to US$76,900) for patients with no fibrosis and by 43 % (from US$62,500 to US$35,800) for patients with moderate fibrosis. Comparing immediate treatment versus non-treatment, assuming a 44 % reduction in non-hepatic mortality following successful HCV treatment, the incremental cost per QALY gained by HCV treatment fell by 64 % (from US$186,700 to US$67,300) for patients with no fibrosis and by 27 % (from US$35,000 to US$25,500) for patients with moderate fibrosis. CONCLUSION Including reductions in non-hepatic mortality from HCV treatment can have substantial effects on the estimated cost-effectiveness of treatment.
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Affiliation(s)
- Andrew J Leidner
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop G-37, Atlanta, GA, 30333, USA.
| | - Harrell W Chesson
- Division of Sexually Transmitted Disease Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Philip R Spradling
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop G-37, Atlanta, GA, 30333, USA
| | - Scott D Holmberg
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop G-37, Atlanta, GA, 30333, USA
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16
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McElroy HJ, Roberts SK, Thompson AJ, Angus PW, McKenna SJ, Warren E, Musgrave S. Medical resource utilization and costs among Australian patients with genotype 1 chronic hepatitis C: results of a retrospective observational study. J Med Econ 2017; 20:72-81. [PMID: 27552282 DOI: 10.1080/13696998.2016.1227827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To evaluate medical resource utilization (MRU) and associated costs among Australian patients with genotype 1 chronic hepatitis C (GT1 CHC), including both untreated patients and those receiving treatment with first-generation protease inhibitor-based regimens (telaprevir, boceprevir with pegylated interferon and ribavirin). METHODS Medical records were reviewed for a stratified random sample of GT1 CHC patients first attending two liver clinics between 2011-2013 (principal population; PP), supplemented by all GT1 CHC patients attending one transplant clinic in the same period (transplant population; TP). CHC-related MRU and associated costs are reported for the PP by treatment status (treated/not treated) stratified by baseline fibrosis grade; and for the TP for the pre-transplant, year of transplant and post-transplant periods. RESULTS A total 1636 patients were screened and 590 patients (36.1%) were included. Comprehensive MRU data were collected for 276 PP patients (F0-1 n = 59, F2 n = 58, F3 n = 53, F4 n = 106; mean follow-up = 17.3 months). Thirty-eight (13.8%) were treatment-experienced prior to enrolment; 55 (19.9%) received triple therapy during the study. Data were collected for 112 TP patients (mean follow-up = 29.9 months), 33 (29.5%) received a transplant during the study, and 51 (45.5%) beforehand. The annual direct medical costs, excluding drug costs, were higher among treated PP vs untreated PP (AU$: $1,954 vs $1,202); and year of transplant TP vs pre-/post-transplant TP (AU$: pre-transplant $32,407, transplant $155,138, post-transplant $7,358). LIMITATIONS To aid interpretation of results, note that only patients with GT1 CHC who are actively managed are included, and MRU data were collected specifically from liver outpatient clinics. That said, movement of patients between hospitals is rare, and any uncaptured MRU is expected to be minimal. CONCLUSIONS CHC-related MRU increases substantially with disease severity. These real-world MRU data for GT1 CHC will be valuable in assessing the impact of new hepatitis C treatments.
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Affiliation(s)
| | - Stuart K Roberts
- b The Alfred Hospital and Monash University , Melbourne , Vic , Australia
| | - Alex J Thompson
- c St Vincent's Hospital and the University of Melbourne , Melbourne , Vic , Australia
| | - Peter W Angus
- d Austin Health and the University of Melbourne , Melbourne , Vic , Australia
| | | | - Emma Warren
- f HERA Consulting , Sydney , NSW , Australia
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Dusheiko G. The impact of antiviral therapy for hepatitis C on the quality of life: a perspective. Liver Int 2017; 37 Suppl 1:7-12. [PMID: 28052638 DOI: 10.1111/liv.13292] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 10/27/2016] [Indexed: 12/12/2022]
Abstract
Instruments to assess the impact of hepatitis C virus infection on health and measurements of reported outcomes in patients (health-related quality of life [HRQOL]) are not frequently used to assign priority for treatment. Several systematic reviews have been performed that provide a comprehensive analysis to help understand patient reported outcomes (PROs) with direct acting antiviral treatment. Clinical trials with direct acting antivirals (DAAs) provide an important opportunity to assess PROs without interferon or ribavirin. Significant improvement in quality of life parameters have been noted with DAA therapy. The results show improvement in HRQOL indices when interferon-free and particularly interferon and ribavirin-free treatments are compared to interferon and ribavirin treatment. Improvements in HRQOL indices are an encouraging aspect of the cure of chronic hepatitis C. It is unclear whether these measurable HRQOL improvements can be translated into a net benefit improvement in work productivity and a social dimension that is significant enough to convince payers of the added value of early and more widespread treatment.
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Affiliation(s)
- Geoffrey Dusheiko
- UCL Institute of Liver and Digestive Health, University College London Medical School, Kings College Hospital, London, UK
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18
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Nuño Solinís R, Arratibel Ugarte P, Rojo A, Sanchez Gonzalez Y. Value of Treating All Stages of Chronic Hepatitis C: A Comprehensive Review of Clinical and Economic Evidence. Infect Dis Ther 2016; 5:491-508. [PMID: 27783223 PMCID: PMC5125137 DOI: 10.1007/s40121-016-0134-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION The goal of chronic hepatitis C (CHC) treatment is to achieve a sustained virologic response (SVR). The new generation of direct-acting antivirals (DAAs) offers 90-100% SVR rates. However, access to these treatments is generally limited to patients with advanced liver disease. The aim of this review is to provide an overview of the clinical and economic benefits of achieving SVR and to better understand the full value of CHC treatment in all stages of liver disease. METHODS A comprehensive literature review was performed using the PubMed, Embase, and Cochrane library databases to identify articles examining the clinical, economic, and quality of life benefits associated with SVR. Articles were limited to those published in English language from January 2006 through January 2016. Inclusion criteria were (1) patients with CHC, (2) retrospective and prospective studies, (3) reporting of mortality, liver morbidity, extrahepatic manifestations (EHMs), and economic outcomes and, (4) availability of an abstract or full-text publication. RESULTS Overall this review identified 354 studies involving more than 500,000 CHC patients worldwide. Evidence from 38 studies (n = 73,861) shows a significant mortality benefit of achieving SVR in patients with all stages of fibrosis. Long-term studies with follow-up of 5-12 years suggest that, particularly among non-cirrhotic patients, there is a significant decrease in mortality in SVR versus non-SVR groups. Ninety-nine studies conducted in 235,891 CHC patients in all stages of fibrosis show that SVR reduces liver-related mortality, incidence of hepatocellular carcinoma (HCC), and decompensation. A total of 233 studies show that chronic HCV infection is associated with several serious EHMs, some of which can have high mortality. Evidence from four modeling studies shows that delaying treatment to CHC patient populations could significantly increase mortality, morbidity, and medical costs. CONCLUSIONS There is a robust body of evidence demonstrating diverse sources of value from achieving SVR in all stages of liver disease. While access to treatment is generally limited to late-stage patients, less restrictive treatment strategies that target HCV eradication have the potential to abate the burdens of mortality, liver morbidity and extrahepatic manifestations, and the associated healthcare costs.
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Affiliation(s)
- Roberto Nuño Solinís
- Deusto Business School Health, University of Deusto, Bilbao, Basque Country, Spain
| | | | - Ander Rojo
- Deusto Business School Health, University of Deusto, Bilbao, Basque Country, Spain
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Loftfield E, O’Brien TR, Pfeiffer RM, Howell CD, Horst R, Prokunina-Olsson L, Weinstein SJ, Albanes D, Morgan TR, Freedman ND. Vitamin D Status and Virologic Response to HCV Therapy in the HALT-C and VIRAHEP-C Trials. PLoS One 2016; 11:e0166036. [PMID: 27832143 PMCID: PMC5104464 DOI: 10.1371/journal.pone.0166036] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 10/11/2016] [Indexed: 12/17/2022] Open
Abstract
More than 150 million people worldwide are chronically infected with hepatitis C virus (HCV) and face higher risk of cirrhosis and hepatocellular carcinoma. Highly effective HCV treatments have recently been developed; however, they are costly and therefore poorly suited for application in resource-limited settings where HCV burden is high. Pegylated-interferon alpha (PEG-IFNα) and ribavirin (RBV) therapy is far less costly, but also less effective. Vitamin D supplementation has been proposed as an inexpensive adjuvant to treatment, however, prior epidemiological evidence on its effectiveness is inconsistent, with little data available among African Americans who naturally have lower vitamin D concentrations. We thus evaluated associations between baseline vitamin D status, measured by circulating 25-hydroxyvitamin D (25(OH)D), which is considered to be the best marker of vitamin D status in humans, and subsequent response to PEG-IFNα/RBV therapy in two large clinical trials that together included 1292 patients infected with HCV genotype 1. We used race-stratified logistic regression models to evaluate multivariable-adjusted associations of 25(OH)D with early virologic response (EVR; 2-log10 HCV RNA decline at week 12) and sustained virologic response (SVR). Among African Americans, we saw no associations. Among European Americans, we saw no association with low vitamin D (≤20 ng/mL) versus sufficient concentrations (20-<30 ng/mL). However, patients with 25(OH)D ≥30 ng/mL were actually less likely to attain EVR (OR = 0.64, 95% CI = 0.43–0.94) than those with sufficient concentrations, with a similar but non-significant association observed for SVR (OR = 0.49, 95% CI = 0.20–1.17).
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Affiliation(s)
- Erikka Loftfield
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD, United States of America
- * E-mail:
| | - Thomas R. O’Brien
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD, United States of America
| | - Ruth M. Pfeiffer
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD, United States of America
| | - Charles D. Howell
- Department of Medicine, Howard University College of Medicine, Washington, DC, United States of America
| | - Ron Horst
- Heartland Assays, Ames, IA, United States of America
| | - Ludmila Prokunina-Olsson
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD, United States of America
| | - Stephanie J. Weinstein
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD, United States of America
| | - Demetrius Albanes
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD, United States of America
| | - Timothy R. Morgan
- VA Long Beach Healthcare System, Long Beach, CA, United States of America
| | - Neal D. Freedman
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD, United States of America
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Liu S, Barnett PG, Holodniy M, Lo J, Joyce VR, Gidwani R, Asch SM, Owens DK, Goldhaber-Fiebert JD. Cost-Effectiveness of Treatments for Genotype 1 Hepatitis C Virus Infection in non-VA and VA Populations. MDM Policy Pract 2016; 1. [PMID: 29756049 PMCID: PMC5942888 DOI: 10.1177/2381468316671946] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background: Chronic hepatitis C viral (HCV) infection affects
millions of Americans. Health care systems face complex choices between highly
efficacious, costly treatments. This study assessed the cost-effectiveness of
treatments for chronic, genotype 1 HCV monoinfected, treatment-naïve individuals
in the Department of Veterans Affairs (VA) and general US health care systems.
Methods: The study used a decision-analytic Markov model,
employing appropriate payer perspectives and time horizons, and discounting
benefits and costs at 3% annually. Interventions included the following:
sofosbuvir/ledipasvir (SOF-LDV); ombitasvir/paritaprevir/ritonavir/dasabuvir
(3D); sofosbuvir/simeprevir (SOF-SMV); sofosbuvir/pegylated interferon/ribavirin
(SOF-RBV-PEG); boceprevir/pegylated interferon/ribavirin (BOC-RBV-PEG); and
pegylated interferon/ribavirin (PEG-RBV). Outcomes were sustained virologic
response (SVR), advanced liver disease, costs, quality adjusted life years
(QALYs), and incremental cost-effectiveness. Results: SOF-LDV and
3D achieve high SVR rates, reducing advanced liver disease (>20% relative to
no treatment), and increasing QALYs by >2 years per person. For the non-VA
population, at current prices ($5040 per week for SOF-LDV; $4796 per week for
3D), SOF-LDV’s lifetime cost ($293,370) is $18,000 lower than 3D’s because of
its shorter duration in subgroups. SOF-LDV costs $17,100 per QALY gained
relative to no treatment. 3D costs $208,000 per QALY gained relative to SOF-LDV.
Both dominate other treatments and are even more cost-effective for the VA,
though VA aggregate treatment costs still exceed $4 billion at SOF-LDV prices of
$3308 per week. Drug prices strongly determine relative cost-effectiveness for
SOF-LDV and 3D; with price reductions of 20% to 30% depending on health system,
3D could be cost-effective relative to SOF-LDV. We currently lack head-to-head
regimen effectiveness trials. Conclusions: New HCV treatments are
cost-effective in multiple health care systems if trial-estimated efficacy is
achieved in practice, though, at current prices, total expenditures could
present substantial challenges.
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Affiliation(s)
- Shan Liu
- Department of Industrial and Systems Engineering, University of Washington, Seattle, WA
| | - Paul G Barnett
- VA Center for Innovation to Implementation, Menlo Park, CA.,VA Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, CA.,Department of Health Research and Policy, Stanford University, Stanford, CA
| | - Mark Holodniy
- AIDS Research Center, VA Palo Alto Health Care System, Menlo Park, CA.,Division of Infectious Diseases, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Jeanie Lo
- VA Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, CA
| | - Vilija R Joyce
- VA Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, CA
| | - Risha Gidwani
- VA Center for Innovation to Implementation, Menlo Park, CA.,VA Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, CA.,Division of General Medical Disciplines, Department of Medicine, Stanford University School of Medicine, Stanford, CA.,Stanford Health Policy, Centers for Health Policy and Primary Care and Outcomes Research, Stanford University, Stanford, CA
| | - Steven M Asch
- VA Center for Innovation to Implementation, Menlo Park, CA.,Health Services Research, VA Palo Alto Health Care System, Palo Alto, CA.,Division of General Medical Disciplines, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Douglas K Owens
- VA Center for Innovation to Implementation, Menlo Park, CA.,Stanford Health Policy, Centers for Health Policy and Primary Care and Outcomes Research, Stanford University, Stanford, CA
| | - Jeremy D Goldhaber-Fiebert
- Stanford Health Policy, Centers for Health Policy and Primary Care and Outcomes Research, Stanford University, Stanford, CA
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Groessl EJ, Sklar M, Laurent DD, Lorig K, Ganiats TG, Ho SB. Cost-Effectiveness of the Hepatitis C Self-Management Program. HEALTH EDUCATION & BEHAVIOR 2016; 44:113-122. [PMID: 27206463 DOI: 10.1177/1090198116639239] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Despite the emergence of new hepatitis C virus (HCV) antiviral medications, many people with chronic HCV know little about their disease, are at risk for transmitting HCV to others, and/or are not considered good treatment candidates. Self-management interventions can educate HCV-infected persons, improve their quality of life, and prepare them for treatment. PURPOSE A cost-effectiveness analysis of the HCV Self-Management Program is presented. METHOD Effectiveness data in quality-adjusted life years (QALYs) were derived from the previously published prospective, randomized controlled trial ( n = 134). Health care utilization was abstracted from medical records in 2011 for the 12 months before and after study enrollment. Intervention costs were tracked from the payer's perspective and combined with health care costs. Sensitivity analyses were used to examine assumptions. Data were analyzed in 2014. RESULTS Estimated intervention costs including organizational overhead were $1,760 per 6-week workshop, or $229/person. Health care costs were $815 lower/person for self-management participants, resulting in a cost savings of $586/person. Self-management participants had an average net gain of 0.02975 QALYs after 1 year. When removing inpatient substance use treatment days from analyses, costs were similar between groups, producing an incremental cost-effectiveness ratio of $6,218/QALY. Sensitivity analyses showed that the results and conclusions change little when assumptions were varied. CONCLUSIONS When compared to information-only, the HCV Self-Management Program led to more QALYs and cost savings in the randomized controlled trial. Independent of health care costs, the intervention is low-cost and educates HCV-infected individuals about antiviral treatment and avoiding viral transmission. Low-cost interventions that can enhance the outcomes derived from expensive antiviral treatments should be studied further.
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Affiliation(s)
- Erik J Groessl
- 1 VA San Diego Healthcare System, San Diego, CA, USA.,2 University of California, San Diego, CA, USA
| | - Marisa Sklar
- 3 SDSU/UCSD Joint Doctoral Program in Clinical Psychology, San Diego, CA, USA
| | | | - Kate Lorig
- 4 Stanford University School of Medicine, Stanford, CA, USA
| | | | - Samuel B Ho
- 1 VA San Diego Healthcare System, San Diego, CA, USA.,2 University of California, San Diego, CA, USA
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22
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Chhatwal J, He T, Lopez-Olivo MA. Systematic Review of Modelling Approaches for the Cost Effectiveness of Hepatitis C Treatment with Direct-Acting Antivirals. PHARMACOECONOMICS 2016; 34:551-67. [PMID: 26748919 DOI: 10.1007/s40273-015-0373-9] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
BACKGROUND New direct-acting antivirals (DAAs) are highly effective for hepatitis C virus (HCV) treatment. However, their prices have been widely debated. Decision-analytic models can project the long-term value of HCV treatment. Therefore, understanding of the methods used in these models and how they could influence results is important. OBJECTIVE Our objective was to describe and systematically review the methodological approaches in published cost-effectiveness models of chronic HCV treatment with DAAs. DATA SOURCES We searched several electronic databases, including Medline, Embase and EconLit, from 2011 to 2015. STUDY ELIGIBILITY Study selection was performed by two reviewers independently. We included any cost-effectiveness analysis comparing DAAs with the old standard of care for HCV treatment. We excluded non-English-language studies and studies not reporting quality-adjusted life-years. STUDY APPRAISAL AND SYNTHESIS METHOD One reviewer collected data and assessed the quality of reporting, using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement. Another reviewer crosschecked the abstracted information. The development methods of the included studies were synthetized on the basis of good modelling practice recommendations. RESULTS Review of 304 citations revealed 36 cost-effectiveness analyses. The reporting quality scores of most articles were rated as acceptable, between 67 and 100 %. The majority of the studies were conducted in Europe (50 %), followed by the USA (44 %). Fifty-six percent of the 36 studies evaluated the cost effectiveness of HCV treatment in both treatment-naive and treatment-experienced patients, 97 % included genotype 1 patients and 53 % evaluated the cost effectiveness of second-generation or oral DAAs in comparison with the previous standard of care or other DAAs. Twenty-one models defined health states in terms of METAVIR fibrosis scores. Only one study used a discrete-event simulation approach, and the remainder used state-transition models. The time horizons varied; however, 89 % of studies used a lifetime horizon. One study was conducted from a societal perspective. Thirty-three percent of studies did not conduct any model validation. We also noted that none of the studies modelled HCV treatment as a prevention strategy, 86 % of models did not consider the possibility of re-infection with HCV after successful treatment, 97 % of studies did not consider indirect economic benefits resulting from HCV treatment and none of the studies evaluating oral DAAs used real-world data. LIMITATIONS The search was limited by date (from 1 January 2011 to 8 September 2015) and was also limited to English-language and published reports. CONCLUSIONS Most modelling studies used a similar modelling structure and could have underestimated the value of HCV treatment. Future modelling efforts should consider the benefits of HCV treatment in preventing transmission, extra-hepatic and indirect economic benefits of HCV treatment, real-world cost-effectiveness analysis and cost effectiveness of HCV treatment in low- and middle-income countries.
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Affiliation(s)
- Jagpreet Chhatwal
- Institute for Technology Assessment, Massachusetts General Hospital, Harvard Medical School, 101 Merrimac Street, 10th Floor, Boston, MA, 02114, USA.
| | - Tianhua He
- Tsinghua University School of Medicine, Beijing, China
| | - Maria A Lopez-Olivo
- Department of General Internal Medicine, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
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23
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Fukuhara T, Ono C, Puig-Basagoiti F, Matsuura Y. Roles of Lipoproteins and Apolipoproteins in Particle Formation of Hepatitis C Virus. Trends Microbiol 2016; 23:618-629. [PMID: 26433694 DOI: 10.1016/j.tim.2015.07.007] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Revised: 07/07/2015] [Accepted: 07/20/2015] [Indexed: 02/06/2023]
Abstract
More than 160 million people worldwide are infected with hepatitis C virus (HCV), and cirrhosis and hepatocellular carcinoma induced by HCV infection are life-threatening diseases. HCV takes advantage of many aspects of lipid metabolism for an efficient propagation in hepatocytes. Due to the morphological and physiological similarities of HCV particles to lipoproteins, lipid-associated HCV particles are named lipoviroparticles. Recent analyses have revealed that exchangeable apolipoproteins directly interact with the viral membrane to generate infectious HCV particles. In this review, we summarize the roles of lipid metabolism in the life cycle of HCV.
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Affiliation(s)
- Takasuke Fukuhara
- Department of Molecular Virology, Research Institute for Microbial Diseases, Osaka University, Osaka, Japan
| | - Chikako Ono
- Department of Molecular Virology, Research Institute for Microbial Diseases, Osaka University, Osaka, Japan
| | - Francesc Puig-Basagoiti
- Department of Molecular Virology, Research Institute for Microbial Diseases, Osaka University, Osaka, Japan
| | - Yoshiharu Matsuura
- Department of Molecular Virology, Research Institute for Microbial Diseases, Osaka University, Osaka, Japan.
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24
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Rein DB, Borton J, Liffmann DK, Wittenborn JS. The burden of hepatitis C to the United States Medicare system in 2009: Descriptive and economic characteristics. Hepatology 2016; 63:1135-44. [PMID: 26707033 DOI: 10.1002/hep.28430] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 12/23/2015] [Indexed: 01/23/2023]
Abstract
UNLABELLED The aim of this work was to estimate and describe the Medicare beneficiaries diagnosed with hepatitis C virus (HCV) in 2009, incremental annual costs by disease stage, incremental total Medicare HCV payments in 2009 using the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data covering the years 2002 to 2009. We weighted the 2009 SEER-Medicare data to create estimates of the number of patients with an HCV diagnosis, used an inverse probability-weighted two-part, probit, and generalized linear model to estimate incremental per patient per month costs, and used simulation to estimate annual 2009 Medicare burden, presented in 2014 dollars. We summarized patient characteristics, diagnoses, and costs from SEER-Medicare files into a person-year panel data set. We estimated there were 407,786 patients with diagnosed HCV in 2009, of whom 61.4% had one or more comorbidities defined by the study. In 2009, 68% of patients were diagnosed with chronic HCV only, 9% with cirrhosis, 12% with decompensated cirrhosis (DCC), 2% with liver cancer, 2% with a history of transplant, and 8% who died. Annual costs for patients with chronic infection only and DCC were higher than the values used in many previous cost-effectiveness studies, and treatment of DCC accounted for 63.9% of total Medicare's HCV expenditures. Medicare paid $2.7 billion (credible interval: $0.7-$4.6 billion) in incremental costs for HCV in 2009. CONCLUSIONS The costs of HCV to Medicare in 2009 were substantial and expected to increase over the next decade. Annual costs for patients with chronic infection only and DCC were higher than values used in many cost-effectiveness analyses.
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25
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Attar BM, Van Thiel DH. Hepatitis C virus: A time for decisions. Who should be treated and when? World J Gastrointest Pharmacol Ther 2016; 7:33-40. [PMID: 26855810 PMCID: PMC4734952 DOI: 10.4292/wjgpt.v7.i1.33] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 09/09/2015] [Accepted: 11/17/2015] [Indexed: 02/06/2023] Open
Abstract
Cirrhosis is the most important risk factor for hepatocellular carcinoma (HCC) regardless of the etiology of cirrhosis. Compared to individuals who are anti-hepatitis C virus (HCV) seronegative, anti-HCV seropositive individuals have a greater mortality from both hepatic as well as nonhepatic disease processes. The aim of this paper is do describe the burden of HCV infection and consider treatment strategies to reduce HCV-related morbidity and mortality. The newly developed direct acting antiviral (DAA) therapies are associated with greater rates of drug compliance, fewer adverse effects, and appear not to be limited by the presence of a variety of factors that adversely affect the outcome of interferon-based therapies. Because of the cost of the current DAA, their use has been severely rationed by insurers as well as state and federal agencies to those with advanced fibrotic liver disease (Metavir fibrosis stage F3-F4). The rationale for such rationing is that many of those recognized as having the disease progress slowly over many years and will not develop advanced liver disease manifested as chronic hepatitis C, cirrhosis, and experience any of the multiple complications of liver disease to include HCC. This mitigation has a short sided view of the cost of treatment of hepatitis C related disease processes and ignores the long-term expenses of hepatitis C treatment consisting of the cost of treatment of hepatitis C, the management of cirrhosis with or without decompensation as well as the cost of treatment of HCC and liver transplantation. We believe that treatment should include all HCV infected patients including those with stage F0-F2 fibrosis with or without evidence of coexisting liver disease. Specifically, interferon (IFN)-free regimens with the current effective DAAs without liver staging requirements and including those without evidence of hepatic diseases but having recognized extrahepatic manifestations of HCV infection is projected to be the most cost-effective approach for treating HCV in all of its varied presentations. Early rather than later therapy of HCV infected individuals would be even more efficacious than waiting particularly if it includes all cases from F0-F4 hepatic disease. Timely therapy will reduce the number of individuals developing advanced liver disease, reduce the cost of treating these cases and more importantly, reduce the lifetime cost of treatment of those with any form of HCV related disease as well as HCV associated all - cause mortality. Importantly, HCV treatment regimens without any restrictions would result in a substantial reduction in health care expenditure and simultaneously reduce the number of infected individuals who are infecting others.
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26
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Chidi AP, Rogal S, Bryce CL, Fine MJ, Good CB, Myaskovsky L, Rustgi VK, Tsung A, Smith KJ. Cost-effectiveness of new antiviral regimens for treatment-naïve U.S. veterans with hepatitis C. Hepatology 2016; 63:428-36. [PMID: 26524695 PMCID: PMC4718749 DOI: 10.1002/hep.28327] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 10/30/2015] [Indexed: 12/17/2022]
Abstract
UNLABELLED Recently approved, interferon-free medication regimens for treating hepatitis C are highly effective, but extremely costly. We aimed to identify cost-effective strategies for managing treatment-naïve U.S. veterans with new hepatitis C medication regimens. We developed a Markov model with 1-year cycle length for a cohort of 60-year-old veterans with untreated genotype 1 hepatitis C seeking treatment in a typical year. We compared using sofosbuvir/ledipasvir or ombitasvir/ritonavir/paritaprevir/dasabuvir to treat: (1) any patient seeking treatment; (2) only patients with advanced fibrosis or cirrhosis; or (3) patients with advanced disease first and healthier patients 1 year later. The previous standard of care, sofosbuvir/simeprevir or sofosbuvir/pegylated interferon/ribavirin, was included for comparison. Patients could develop progressive fibrosis, cirrhosis, or hepatocellular carcinoma, undergo transplantation, or die. Complications were less likely after sustained virological response. We calculated the incremental cost per quality-adjusted life year (QALY) and varied model inputs in one-way and probabilistic sensitivity analyses. We used the Veterans Health Administration perspective with a lifetime time horizon and 3% annual discounting. Treating any patient with ombitasvir-based therapy was the preferred strategy ($35,560; 14.0 QALYs). All other strategies were dominated (greater costs/QALY gained than more effective strategies). Varying treatment efficacy, price, and/or duration changed the preferred strategy. In probabilistic sensitivity analysis, treating any patient with ombitasvir-based therapy was cost-effective in 70% of iterations at a $50,000/QALY threshold and 65% of iterations at a $100,000/QALY threshold. CONCLUSION Managing any treatment-naïve genotype 1 hepatitis C patient with ombitasvir-based therapy is the most economically efficient strategy, although price and efficacy can impact cost-effectiveness. It is economically unfavorable to restrict treatment to patients with advanced disease or use a staged treatment strategy. (Hepatology 2016;63:428-436).
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Affiliation(s)
- Alexis P. Chidi
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Hines, IL,VA Center for Health Equity Research & Promotion, VA Pittsburgh Healthcare System, Hines, IL
| | - Shari Rogal
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Hines, IL,VA Center for Health Equity Research & Promotion, VA Pittsburgh Healthcare System, Hines, IL
| | - Cindy L. Bryce
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Hines, IL,Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Hines, IL
| | - Michael J. Fine
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Hines, IL,VA Center for Health Equity Research & Promotion, VA Pittsburgh Healthcare System, Hines, IL
| | - Chester B. Good
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Hines, IL,VA Center for Health Equity Research & Promotion, VA Pittsburgh Healthcare System, Hines, IL,VA Center for Medication Safety, Department of Veterans Affairs, Hines, IL
| | - Larissa Myaskovsky
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Hines, IL,VA Center for Health Equity Research & Promotion, VA Pittsburgh Healthcare System, Hines, IL
| | - Vinod K. Rustgi
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Allan Tsung
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Kenneth J. Smith
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Hines, IL,VA Center for Health Equity Research & Promotion, VA Pittsburgh Healthcare System, Hines, IL
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Ho SB, Bräu N, Cheung R, Liu L, Sanchez C, Sklar M, Phelps TE, Marcus SG, Wasil MM, Tisi A, Huynh L, Robinson SK, Gifford AL, Asch SM, Groessl EJ. Integrated Care Increases Treatment and Improves Outcomes of Patients With Chronic Hepatitis C Virus Infection and Psychiatric Illness or Substance Abuse. Clin Gastroenterol Hepatol 2015; 13:2005-14.e1-3. [PMID: 25724704 DOI: 10.1016/j.cgh.2015.02.022] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Revised: 12/22/2014] [Accepted: 02/06/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients with hepatitis C virus (HCV) infection with psychiatric disorders and/or substance abuse face significant barriers to antiviral treatment. New strategies are needed to improve treatment rates and outcomes. We investigated whether an integrated care (IC) protocol, which includes multidisciplinary care coordination and patient case management, could increase the proportion of patients with chronic HCV infection who receive antiviral treatment (a combination of interferon-based and direct-acting antiviral agents) and achieve a sustained virologic response (SVR). METHODS We performed a prospective randomized trial at 3 medical centers in the United States. Participants (n = 363 patients attending HCV clinics) had been screened and tested positive for depression, post-traumatic stress disorder, and/or substance use; they were assigned randomly to groups that received IC or usual care (controls) from March 2009 through February 2011. A midlevel mental health practitioner was placed at each HCV clinic to provide IC with brief mental health interventions and case management, according to formal protocol. The primary end point was SVR. RESULTS Of the study participants, 63% were non-white, 51% were homeless in the past 5 years, 64% had psychiatric illness, 65% were substance abusers within 1 year before enrollment, 57% were at risk for post-traumatic stress disorder, 71% had active depression, 80% were infected with HCV genotype 1, and 23% had advanced fibrosis. Over a mean follow-up period of 28 months, a greater proportion of patients in the IC group began receiving antiviral therapy (31.9% vs 18.8% for controls; P = .005) and achieved a SVR (15.9% vs 7.7% of controls; odds ratio, 2.26; 95% confidence interval, 1.15-4.44; P = .018). There were no differences in serious adverse events between groups. CONCLUSIONS Integrated care increases the proportion of patients with HCV infection and psychiatric illness and/or substance abuse who begin antiviral therapy and achieve SVRs, without serious adverse events. ClinicalTrials.gov # NCT00722423.
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Affiliation(s)
- Samuel B Ho
- Gastroenterology Section, Medicine Service, VA San Diego Healthcare System, San Diego, California; Division of Gastroenterology, Department of Medicine, University of California, San Diego, San Diego, California.
| | - Norbert Bräu
- Infectious Disease Section, James J. Peters VA Medical Center, Bronx, New York; Divisions of Infectious Disease and Liver Disease, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ramsey Cheung
- Gastroenterology Section, Medicine Service, VA Palo Alto Healthcare System, Palo Alto, California; Division of Gastroenterology and Hepatology, Stanford University, Stanford, California
| | - Lin Liu
- Division of Biostatistics, Department of Family Medicine and Public Health, University of California, San Diego, San Diego, California
| | - Courtney Sanchez
- Research Service, VA San Diego Healthcare System, San Diego, California
| | - Marisa Sklar
- Research Service, VA San Diego Healthcare System, San Diego, California
| | - Tyler E Phelps
- Gastroenterology Section, Medicine Service, VA Palo Alto Healthcare System, Palo Alto, California
| | - Sonja G Marcus
- Research Service, James J. Peters VA Medical Center, Bronx, New York
| | - Michelene M Wasil
- Research Service, VA San Diego Healthcare System, San Diego, California
| | - Amelia Tisi
- Research Service, James J. Peters VA Medical Center, Bronx, New York
| | - Lia Huynh
- Research Service, VA Palo Alto Healthcare System, Palo Alto, California
| | - Shannon K Robinson
- Department of Psychiatry, VA San Diego Healthcare System, San Diego, California; Department of Psychiatry, University of California, San Diego, San Diego, California
| | - Allen L Gifford
- Infectious Disease Section, Medicine Service, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts; Departments of Health Policy and Management and Medicine, Boston University, Boston, Massachusetts
| | - Steven M Asch
- Research Service, VA Palo Alto Healthcare System, Palo Alto, California; Division of General Medical Disciplines, Department of Medicine, Stanford University, Stanford, California
| | - Erik J Groessl
- Division of Health Services Research & Development, Research Service, VA San Diego Healthcare System, San Diego, California; Division of Behavioral Medicine, Department of Family Medicine and Public Health, University of California, San Diego, San Diego, California
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28
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Chhatwal J, Chen Q, Kanwal F. Why We Should Be Willing to Pay for Hepatitis C Treatment. Clin Gastroenterol Hepatol 2015; 13:1711-3. [PMID: 26091736 PMCID: PMC4575858 DOI: 10.1016/j.cgh.2015.06.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Revised: 06/06/2015] [Accepted: 06/09/2015] [Indexed: 12/23/2022]
Affiliation(s)
- Jagpreet Chhatwal
- Institute for Technology Assessment, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Qiushi Chen
- Department of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, GA USA
| | - Fasiha Kanwal
- Houston Veterans Affairs Health Services Research and Development Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center,Department of Medicine, Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX USA
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29
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San Miguel R, Gimeno-Ballester V, Blázquez A, Mar J. Cost-effectiveness analysis of sofosbuvir-based regimens for chronic hepatitis C. Gut 2015; 64:1277-88. [PMID: 25311032 DOI: 10.1136/gutjnl-2014-307772] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Accepted: 09/18/2014] [Indexed: 12/19/2022]
Abstract
BACKGROUND A new scenario of therapy for chronic hepatitis C (CHC) is being established with the approval of sofosbuvir (SOF). OBJECTIVE To estimate the cost-effectiveness of SOF-based regimens approved in the Summary of Product Characteristics (SmPC) versus the standard of care for different genotypes and patient populations (naive or pretreated). METHODS A Markov model simulating CHC progression was used to estimate disease treatment costs and effects over patients' lifetimes, from the Spanish National Public Healthcare System perspective. Different therapeutic options were analysed for genotypes 1, 2 and 3 in naive population and for genotype 2 and 3 pretreated patients, according to data obtained from clinical trials. A one-way sensitivity analysis was performed to evaluate the uncertainty of certain parameters: treatment starting age, transition probabilities, drug costs and discount rate. A probabilistic sensitivity analysis was also carried out. RESULTS For the naive population, the option SOF+pegylated-interferon-α (pIFN)+ribavirin (RBV) for 12 weeks recorded in SmPC for genotype 1 and 3 versus pIFN+RBV for 24 weeks estimated an incremental cost-effectiveness ratio (ICER) below the €40,000/quality-adjusted life-year (QALY) benchmark. For the pretreated population, SOF triple therapy reached an ICER on the threshold limit for genotype 3. Other options included in SmPC for different genotypes exceeded the accepted efficiency limit in our setting. CONCLUSIONS The options that included SOF+RBV+pIFN in a 12-week course regimen fell below the efficiency threshold considered in our setting. IFN-free regimens administered for 24 weeks reached figures over the benchmark of €40,000/QALY.
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Affiliation(s)
- Ramón San Miguel
- Department of Pharmacy, Complejo Hospitalario de Navarra, Pamplona, Spain
| | | | - Antonio Blázquez
- Department of Medicines for Human Use, Agencia Española de Medicamentos y Productos Sanitarios, Madrid, Spain
| | - Javier Mar
- Clinical Management Service, Hospital Alto Deba, Mondragon, Spain
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30
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Soden SE, Saunders CJ, Willig LK, Farrow EG, Smith LD, Petrikin JE, LePichon JB, Miller NA, Thiffault I, Dinwiddie DL, Twist G, Noll A, Heese BA, Zellmer L, Atherton AM, Abdelmoity AT, Safina N, Nyp SS, Zuccarelli B, Larson IA, Modrcin A, Herd S, Creed M, Ye Z, Yuan X, Brodsky RA, Kingsmore SF. Effectiveness of exome and genome sequencing guided by acuity of illness for diagnosis of neurodevelopmental disorders. Sci Transl Med 2015; 6:265ra168. [PMID: 25473036 DOI: 10.1126/scitranslmed.3010076] [Citation(s) in RCA: 386] [Impact Index Per Article: 42.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Neurodevelopmental disorders (NDDs) affect more than 3% of children and are attributable to single-gene mutations at more than 1000 loci. Traditional methods yield molecular diagnoses in less than one-half of children with NDD. Whole-genome sequencing (WGS) and whole-exome sequencing (WES) can enable diagnosis of NDD, but their clinical and cost-effectiveness are unknown. One hundred families with 119 children affected by NDD received diagnostic WGS and/or WES of parent-child trios, wherein the sequencing approach was guided by acuity of illness. Forty-five percent received molecular diagnoses. An accelerated sequencing modality, rapid WGS, yielded diagnoses in 73% of families with acutely ill children (11 of 15). Forty percent of families with children with nonacute NDD, followed in ambulatory care clinics (34 of 85), received diagnoses: 33 by WES and 1 by staged WES then WGS. The cost of prior negative tests in the nonacute patients was $19,100 per family, suggesting sequencing to be cost-effective at up to $7640 per family. A change in clinical care or impression of the pathophysiology was reported in 49% of newly diagnosed families. If WES or WGS had been performed at symptom onset, genomic diagnoses may have been made 77 months earlier than occurred in this study. It is suggested that initial diagnostic evaluation of children with NDD should include trio WGS or WES, with extension of accelerated sequencing modalities to high-acuity patients.
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Affiliation(s)
- Sarah E Soden
- Center for Pediatric Genomic Medicine, Children's Mercy-Kansas City, Kansas City, MO 64108, USA. Department of Pediatrics, Children's Mercy-Kansas City, Kansas City, MO 64108, USA. School of Medicine, University of Missouri-Kansas City, Kansas City, MO 64108, USA.
| | - Carol J Saunders
- Center for Pediatric Genomic Medicine, Children's Mercy-Kansas City, Kansas City, MO 64108, USA. Department of Pediatrics, Children's Mercy-Kansas City, Kansas City, MO 64108, USA. School of Medicine, University of Missouri-Kansas City, Kansas City, MO 64108, USA. Department of Pathology, Children's Mercy-Kansas City, Kansas City, MO 64108, USA
| | - Laurel K Willig
- Center for Pediatric Genomic Medicine, Children's Mercy-Kansas City, Kansas City, MO 64108, USA. Department of Pediatrics, Children's Mercy-Kansas City, Kansas City, MO 64108, USA. School of Medicine, University of Missouri-Kansas City, Kansas City, MO 64108, USA
| | - Emily G Farrow
- Center for Pediatric Genomic Medicine, Children's Mercy-Kansas City, Kansas City, MO 64108, USA. Department of Pediatrics, Children's Mercy-Kansas City, Kansas City, MO 64108, USA. School of Medicine, University of Missouri-Kansas City, Kansas City, MO 64108, USA. Department of Pathology, Children's Mercy-Kansas City, Kansas City, MO 64108, USA
| | - Laurie D Smith
- Center for Pediatric Genomic Medicine, Children's Mercy-Kansas City, Kansas City, MO 64108, USA. Department of Pediatrics, Children's Mercy-Kansas City, Kansas City, MO 64108, USA. School of Medicine, University of Missouri-Kansas City, Kansas City, MO 64108, USA
| | - Josh E Petrikin
- Center for Pediatric Genomic Medicine, Children's Mercy-Kansas City, Kansas City, MO 64108, USA. Department of Pediatrics, Children's Mercy-Kansas City, Kansas City, MO 64108, USA. School of Medicine, University of Missouri-Kansas City, Kansas City, MO 64108, USA
| | - Jean-Baptiste LePichon
- Center for Pediatric Genomic Medicine, Children's Mercy-Kansas City, Kansas City, MO 64108, USA. Department of Pediatrics, Children's Mercy-Kansas City, Kansas City, MO 64108, USA. School of Medicine, University of Missouri-Kansas City, Kansas City, MO 64108, USA
| | - Neil A Miller
- Center for Pediatric Genomic Medicine, Children's Mercy-Kansas City, Kansas City, MO 64108, USA. Department of Pediatrics, Children's Mercy-Kansas City, Kansas City, MO 64108, USA
| | - Isabelle Thiffault
- Center for Pediatric Genomic Medicine, Children's Mercy-Kansas City, Kansas City, MO 64108, USA. School of Medicine, University of Missouri-Kansas City, Kansas City, MO 64108, USA. Department of Pathology, Children's Mercy-Kansas City, Kansas City, MO 64108, USA
| | - Darrell L Dinwiddie
- Department of Pediatrics, University of New Mexico Health Sciences Center, Albuquerque, NM 87131, USA. Clinical and Translational Science Center, University of New Mexico Health Sciences Center, Albuquerque, NM 87131, USA
| | - Greyson Twist
- Center for Pediatric Genomic Medicine, Children's Mercy-Kansas City, Kansas City, MO 64108, USA
| | - Aaron Noll
- Center for Pediatric Genomic Medicine, Children's Mercy-Kansas City, Kansas City, MO 64108, USA
| | - Bryce A Heese
- Department of Pediatrics, Children's Mercy-Kansas City, Kansas City, MO 64108, USA. School of Medicine, University of Missouri-Kansas City, Kansas City, MO 64108, USA
| | - Lee Zellmer
- Center for Pediatric Genomic Medicine, Children's Mercy-Kansas City, Kansas City, MO 64108, USA. Department of Pathology, Children's Mercy-Kansas City, Kansas City, MO 64108, USA
| | - Andrea M Atherton
- Center for Pediatric Genomic Medicine, Children's Mercy-Kansas City, Kansas City, MO 64108, USA. Department of Pediatrics, Children's Mercy-Kansas City, Kansas City, MO 64108, USA. School of Medicine, University of Missouri-Kansas City, Kansas City, MO 64108, USA
| | - Ahmed T Abdelmoity
- Department of Pediatrics, Children's Mercy-Kansas City, Kansas City, MO 64108, USA. School of Medicine, University of Missouri-Kansas City, Kansas City, MO 64108, USA
| | - Nicole Safina
- Department of Pediatrics, Children's Mercy-Kansas City, Kansas City, MO 64108, USA. School of Medicine, University of Missouri-Kansas City, Kansas City, MO 64108, USA
| | - Sarah S Nyp
- Department of Pediatrics, Children's Mercy-Kansas City, Kansas City, MO 64108, USA
| | - Britton Zuccarelli
- Department of Pediatrics, Children's Mercy-Kansas City, Kansas City, MO 64108, USA
| | - Ingrid A Larson
- Center for Pediatric Genomic Medicine, Children's Mercy-Kansas City, Kansas City, MO 64108, USA. Department of Pediatrics, Children's Mercy-Kansas City, Kansas City, MO 64108, USA
| | - Ann Modrcin
- Department of Pediatrics, Children's Mercy-Kansas City, Kansas City, MO 64108, USA. School of Medicine, University of Missouri-Kansas City, Kansas City, MO 64108, USA
| | - Suzanne Herd
- Center for Pediatric Genomic Medicine, Children's Mercy-Kansas City, Kansas City, MO 64108, USA. Department of Pediatrics, Children's Mercy-Kansas City, Kansas City, MO 64108, USA
| | - Mitchell Creed
- Center for Pediatric Genomic Medicine, Children's Mercy-Kansas City, Kansas City, MO 64108, USA
| | - Zhaohui Ye
- Department of Medicine, Johns Hopkins University, Baltimore, MD 21205, USA
| | - Xuan Yuan
- Department of Medicine, Johns Hopkins University, Baltimore, MD 21205, USA
| | - Robert A Brodsky
- Department of Medicine, Johns Hopkins University, Baltimore, MD 21205, USA
| | - Stephen F Kingsmore
- Center for Pediatric Genomic Medicine, Children's Mercy-Kansas City, Kansas City, MO 64108, USA. Department of Pediatrics, Children's Mercy-Kansas City, Kansas City, MO 64108, USA. School of Medicine, University of Missouri-Kansas City, Kansas City, MO 64108, USA. Department of Pathology, Children's Mercy-Kansas City, Kansas City, MO 64108, USA
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Rein DB, Wittenborn JS, Smith BD, Liffmann DK, Ward JW. The cost-effectiveness, health benefits, and financial costs of new antiviral treatments for hepatitis C virus. Clin Infect Dis 2015; 61:157-68. [PMID: 25778747 PMCID: PMC5759765 DOI: 10.1093/cid/civ220] [Citation(s) in RCA: 119] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 01/13/2015] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND New hepatitis C virus (HCV) treatments deliver higher cure rates with fewer contraindications, increasing demand for treatment and healthcare costs. The cost-effectiveness of new treatments is unknown. METHODS We conducted a microsimulation of guideline testing followed by alternative treatment regimens for HCV among the US population aged 20 and older to estimate cases identified, treated, sustained viral response, deaths, medical costs, quality-adjusted life-years (QALYs), and the incremental cost-effectiveness ratio (ICER) of different treatment options expressed as discounted lifetime costs and benefits from the healthcare perspective. RESULTS Compared to treatment with pegylated interferon and ribavirin (PR), and a protease inhibitor for HCV genotype (G) 1 and PR alone for G2/3, treatment with PR and Sofosbuvir (PRS) for G1/4 and treatment with Sofosbuvir and ribavirin (SR) for G2/3 increased QALYs by 555 226, reduced deaths by 80 682, and increased costs by $26.2 billion at an ICER of $47 304 per QALY gained. As compared to PRS/SR, treating with an all oral regimen of Sofosbuvir and Simeprevir (SS) for G1/4 and SR for G2/3, increased QALYs by 1 110 451 and reduced deaths by an additional 164 540 at an incremental cost of $80.1 billion and an ICER of $72 169. In sensitivity analysis, where treatment with SS effectiveness was set to the list price of Viekira Pak and then Harvoni, treatment cost $24 921 and $25 405 per QALY gained as compared to PRS/SR. CONCLUSIONS New treatments are cost-effectiveness per person treated, but pent-up demand for treatment may create challenges for financing.
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Affiliation(s)
- David B. Rein
- Public Health Department, NORC at the University of Chicago, Atlanta, Georgia
| | - John S. Wittenborn
- Public Health Department, NORC at the University of Chicago, Atlanta, Georgia
| | - Bryce D. Smith
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - John W. Ward
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia
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The effects of pegylated interferon-α and ribavirin on liver and serum concentrations of activin-A and follistatin in normal Wistar rat: a preliminary report. BMC Res Notes 2015; 8:265. [PMID: 26112013 PMCID: PMC4481076 DOI: 10.1186/s13104-015-1253-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Accepted: 06/18/2015] [Indexed: 12/22/2022] Open
Abstract
Background Activin-A and follistatin regulate the liver and the immune system. Aims To measure the effects of treatment with pegylated-interferon-α (Peg-IFN-α) and ribavirin on the concentrations of mature activin-A and follistatin in serum and liver tissue homogenates in rats. Methods A total of 28 male Wistar rats were divided equally into four groups as follow: ‘Control group’ (n = 7), ‘PEG only group’ consisted of those that only received a weekly injection of Peg-IFN-α (6 µg/rat) for 4 weeks, ‘RBV only group’ received ribavirin only (4 mg/rat/day) orally for 35 days and the last group received both Peg-IFN-α and ribavirin ‘PEG & RBV group’. The concentrations of candidate proteins in serum and liver samples were measured using ELISA. Results Pegylated-interferon-α decreased activin-A and increased follistatin significantly in serum and liver of ‘PEG only’ and ‘PEG & RBV’ groups compared with the ‘Control’ and ‘RBV only’ groups (P < 0.05). There was no significant difference between the ‘RBV only’ and ‘Control’ groups (P > 0.05) in the concentrations of candidate proteins. A significant positive correlations between serum and liver activin-A (r = 0.727; P = 0.02 × 10−3) and follistatin (r = 0.540; P = 0.01) was also detected. Conclusion Pegylated-interferon-α modulates the production of activin-A and follistatin by the liver, which is reflected and can be detected at the serum level. Further studies are needed to explore the role of Peg-IFN-α based therapy on the production of activins and follistatin by the liver and immune cells.
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Leidner AJ, Chesson HW, Xu F, Ward JW, Spradling PR, Holmberg SD. Cost-effectiveness of hepatitis C treatment for patients in early stages of liver disease. Hepatology 2015; 61:1860-9. [PMID: 25677072 PMCID: PMC5802336 DOI: 10.1002/hep.27736] [Citation(s) in RCA: 89] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 01/30/2015] [Indexed: 12/31/2022]
Abstract
UNLABELLED New treatments for hepatitis C virus (HCV) may be highly effective but are associated with substantial costs that may compel clinicians and patients to consider delaying treatment. This study investigated the cost-effectiveness of these treatments with a focus on patients in early stages of liver disease. We developed a state-transition (or Markov) model to calculate costs incurred and quality-adjusted life-years (QALYs) gained following HCV treatment, and we computed incremental cost-effectiveness ratios (cost per QALY gained, in 2012 US dollars) for treatment at different stages of liver disease versus delaying treatment until the subsequent liver disease stage. Our analysis did not include the potential treatment benefits associated with reduced non-liver-related mortality or preventing HCV transmission. All parameter values, particularly treatment cost, were varied in sensitivity analyses. The base case scenario represented a 55-year-old patient with genotype 1 HCV infection with a treatment cost of $100,000 and treatment effectiveness of 90%. In this scenario, for a 55-year-old patient with moderate liver fibrosis (Metavir stage F2), the cost-effectiveness of immediately initiating treatment at F2 (versus delaying treatment until F3) was $37,300/QALY. For patients immediately treated at F0 (versus delaying treatment until F1), the threshold of treatment costs that yielded $50,000/QALY and $100,000/QALY cost-effectiveness ratios were $22,200 and $42,400, respectively. CONCLUSION Immediate treatment of HCV-infected patients with moderate and advanced fibrosis appears to be cost-effective, and immediate treatment of patients with minimal or no fibrosis can be cost-effective as well, particularly when lower treatment costs are assumed.
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Affiliation(s)
- Andrew J. Leidner
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, GA
| | - Harrell W. Chesson
- Division of Sexually Transmitted Disease Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Fujie Xu
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, GA
| | - John W. Ward
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, GA
| | - Philip R. Spradling
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, GA
| | - Scott D. Holmberg
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, GA
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Refaat B, Ashshi AM, El-Shemi AG, Azhar E. Activins and Follistatin in Chronic Hepatitis C and Its Treatment with Pegylated-Interferon-α Based Therapy. Mediators Inflamm 2015; 2015:287640. [PMID: 25969625 PMCID: PMC4417604 DOI: 10.1155/2015/287640] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2015] [Revised: 02/27/2015] [Accepted: 02/27/2015] [Indexed: 12/12/2022] Open
Abstract
Pegylated-interferon-α based therapy for the treatment of chronic hepatitis C (CHC) is considered suboptimal as not all patients respond to the treatment and it is associated with several side effects that could lead to dose reduction and/or termination of therapy. The currently used markers to monitor the response to treatment are based on viral kinetics and their performance in the prediction of treatment outcome is moderate and does not combine accuracy and their values have several limitations. Hence, the development of new sensitive and specific predictor markers could provide a useful tool for the clinicians and healthcare providers, especially in the new era of interferon-free therapy, for the classification of patients according to their response to the standard therapy and only subscribing the novel directly acting antiviral drugs to those who are anticipated not to respond to the conventional therapy and/or have absolute contraindications for its use. The importance of activins and follistatin in the regulation of immune system, liver biology, and pathology has recently emerged. This review appraises the up-to-date knowledge regarding the role of activins and follistatin in liver biology and immune system and their role in the pathophysiology of CHC.
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Affiliation(s)
- Bassem Refaat
- Laboratory Medicine Department, Faculty of Applied Medical Sciences, Umm Al-Qura University, Al-'Abdiyah Campus, P. O. Box 7607, Makkah, Saudi Arabia
| | - Ahmed Mohamed Ashshi
- Laboratory Medicine Department, Faculty of Applied Medical Sciences, Umm Al-Qura University, Al-'Abdiyah Campus, P. O. Box 7607, Makkah, Saudi Arabia
| | - Adel Galal El-Shemi
- Laboratory Medicine Department, Faculty of Applied Medical Sciences, Umm Al-Qura University, Al-'Abdiyah Campus, P. O. Box 7607, Makkah, Saudi Arabia
- Department of Pharmacology, Faculty of Medicine, Assiut University, Assiut 6515, Egypt
| | - Esam Azhar
- Special Infectious Agents Unit, King Fahd Medical Research Center, King Abdulaziz University, P.O. Box 80216, Jeddah 21589, Saudi Arabia
- Department of Medical Laboratory Technology, Faculty of Applied Medical Sciences, King Abdulaziz University, P.O. Box 80216, Jeddah 21589, Saudi Arabia
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Impact of provider type on hepatitis C outcomes with boceprevir-based and telaprevir-based regimens. J Clin Gastroenterol 2015; 49:329-35. [PMID: 24667591 DOI: 10.1097/mcg.0000000000000124] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
GOALS To examine the effect of provider type on outcomes and safety in a large hepatitis C virus (HCV)-infected cohort treated in routine medical practice. BACKGROUND Nonphysician providers (NPP) are uniquely positioned to expand health care infrastructure to meet HCV treatment demands. STUDY Retrospective, observational cohort analysis of 820 HCV genotype 1-infected veterans initiated on peginterferon/ribavirin and boceprevir or telaprevir in routine medical practice at 94 VA facilities before January 1, 2012 and followed through July 30, 2013. Provider type was determined from prescription records and included physicians (MD) or NPPs (ie, nurse practitioners, physician assistants, and pharmacists). Inverse probability-of-treatment weighting and unweighted logistic regression analysis was used for comparison of sustained virologic response (SVR), treatment discontinuation rates, and adverse hematologic events. RESULTS There was no significant difference in SVR by provider type overall (NPPs 52% vs. MDs 49%, P=0.33) and within patient subgroups, or in treatment discontinuation rates. In multivariate analyses, provider type was not associated with any significant difference in the odds of achieving SVR (NPP vs. MD; odds ratio 1.17; 95% confidence interval, 0.84-1.63; P=0.37 inverse probability of treatment weighting; odds ration 1.16, 95% confidence interval, 0.84-1.59, P=0.38 unweighted). Hematologic adverse event rates were similar: anemia: 57% NPP, 62% MD; thrombocytopenia: 43% NPP, 40% MD; neutropenia: 40% NPP, 39% MD. CONCLUSIONS Treatment prescribed by NPPs was as likely to result in SVR as treatment prescribed by MDs, even after accounting for patient differences. Engaging more NPPs as HCV treatment providers may allow wider access to HCV treatment.
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Najafzadeh M, Andersson K, Shrank WH, Krumme AA, Matlin OS, Brennan T, Avorn J, Choudhry NK, Ho SB. Cost-effectiveness of novel regimens for the treatment of hepatitis C virus. Ann Intern Med 2015; 162:407-19. [PMID: 25775313 DOI: 10.7326/m14-1152] [Citation(s) in RCA: 165] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND New regimens for hepatitis C virus (HCV) have shorter treatment durations and increased rates of sustained virologic response compared with existing therapies but are extremely expensive. OBJECTIVE To evaluate the cost-effectiveness of these treatments under different assumptions about their price and efficacy. DESIGN Discrete-event simulation. DATA SOURCES Published literature. TARGET POPULATION Treatment-naive patients infected with chronic HCV genotype 1, 2, or 3. TIME HORIZON Lifetime. PERSPECTIVE Societal. INTERVENTION Usual care (boceprevir-ribavirin-pegylated interferon [PEG]) was compared with sofosbuvir-ribavirin-PEG and 3 PEG-free regimens: sofosbuvir-simeprevir, sofosbuvir-daclatasvir, and sofosbuvir-ledipasvir. For genotypes 2 and 3, usual care (ribavirin-PEG) was compared with sofosbuvir-ribavirin, sofosbuvir-daclatasvir, and sofosbuvir-ledipasvir-ribavirin (genotype 3 only). OUTCOME MEASURES Discounted costs (in 2014 U.S. dollars), quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios. RESULTS OF BASE-CASE ANALYSIS Assuming sofosbuvir, simeprevir, daclatasvir, and ledipasvir cost $7000, $5500, $5500, and $875 per week, respectively, sofosbuvir-ledipasvir was cost-effective for genotype 1 and cost $12 825 more per QALY than usual care. For genotype 2, sofosbuvir-ribavirin and sofosbuvir-daclatasvir cost $110 000 and $691 000 per QALY, respectively. For genotype 3, sofosbuvir-ledipasvir-ribavirin cost $73 000 per QALY, sofosbuvir-ribavirin was more costly and less effective than usual care, and sofosbuvir-daclatasvir cost more than $396 000 per QALY at assumed prices. RESULTS OF SENSITIVITY ANALYSIS Sofosbuvir-ledipasvir was the optimal strategy in most simulations for genotype 1 and would be cost-saving if sofosbuvir cost less than $5500. For genotype 2, sofosbuvir-ribavirin-PEG would be cost-saving if sofosbuvir cost less than $2250 per week. For genotype 3, sofosbuvir-ledipasvir-ribavirin would be cost-saving if sofosbuvir cost less than $1500 per week. LIMITATION Data are lacking on real-world effectiveness of new treatments and some prices. CONCLUSION From a societal perspective, novel treatments for HCV are cost-effective compared with usual care for genotype 1 and probably genotype 3 but not for genotype 2. PRIMARY FUNDING SOURCE CVS Health.
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Affiliation(s)
- Mehdi Najafzadeh
- From Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, and Massachusetts General Hospital, Boston, Massachusetts, and CVS Health, Woonsocket, Rhode Island
| | - Karin Andersson
- From Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, and Massachusetts General Hospital, Boston, Massachusetts, and CVS Health, Woonsocket, Rhode Island
| | - William H. Shrank
- From Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, and Massachusetts General Hospital, Boston, Massachusetts, and CVS Health, Woonsocket, Rhode Island
| | - Alexis A. Krumme
- From Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, and Massachusetts General Hospital, Boston, Massachusetts, and CVS Health, Woonsocket, Rhode Island
| | - Olga S. Matlin
- From Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, and Massachusetts General Hospital, Boston, Massachusetts, and CVS Health, Woonsocket, Rhode Island
| | - Troyen Brennan
- From Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, and Massachusetts General Hospital, Boston, Massachusetts, and CVS Health, Woonsocket, Rhode Island
| | - Jerry Avorn
- From Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, and Massachusetts General Hospital, Boston, Massachusetts, and CVS Health, Woonsocket, Rhode Island
| | - Niteesh K. Choudhry
- From Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, and Massachusetts General Hospital, Boston, Massachusetts, and CVS Health, Woonsocket, Rhode Island
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Abstract
Although chronic infection of hepatitis C virus (HCV) induces disorders of lipid metabolism, HCV is known to utilize lipid metabolism for efficient propagation in the liver. Due to the morphological and physiological similarities of HCV particles to lipoproteins, lipid-associated HCV particles are named lipoviroparticles. Previous reports have shown that lipoprotein receptors or cholesterol transporter participate in the entry of lipoviroparticles. In addition, recent analyses revealed that exchangeable apolipoproteins directly interact with the viral membrane to generate infectious HCV particles. In this review, we would like to discuss about involvement of lipoprotein and apolipoprotein in HCV lifecycle.
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Affiliation(s)
- Takasuke Fukuhara
- Department of Molecular Virology, Research Institute for Microbial Diseases, Osaka University
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Halfon P, Ouzan D, Asselah T, Renou C, Allègre T, Delasalle P, Lafeuillade A, Cadranel JF, Haddad N, Khiri H, Pénaranda G, Bourlière M. Impact of IL28B on the treatment decision in naïve and experienced patients with genotype 1 and 4 chronic hepatitis C in real-life clinical practice: a prospective multicenter cohort. Clin Res Hepatol Gastroenterol 2014; 38:720-6. [PMID: 25034356 DOI: 10.1016/j.clinre.2014.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 04/03/2014] [Accepted: 06/02/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND The impact of the IL28B genotype on the real-life treatment decisions for patients infected with the hepatitis C virus (HCV) is unknown. OBJECTIVE To prospectively analyze the impact of IL28B genotype in HCV genotype 1 (G1)- or 4 (G4)-infected patients using buccal epithelial cell samples in real-life clinical practices. PATIENTS AND METHODS From October 2011 to March 2013, 1007 CHC patients were included among 127 French clinical centers. RESULTS The IL28B CC, CT, and TT genotype distribution was 252 (25%), 576 (57%), and 177 (18%), respectively. The treatment decisions were recorded and matched with the initial intentions for 433 patients. Multivariate analysis on intention to start treatment showed that patients with HCV G4 were less likely to be intended to be treated than HCV G1 patients (odds ratio [OR]=0.43 [95% CI 0.19-0.97], P=0.04); similarly HIV-HCV coinfected patients were less likely to be intended to be treated than HCV monoinfected patients (OR=0.20 [0.09-0.41], P<.0001); conversely, F3-F4 patients were more likely to be intended to be treated than F0-F2 patients (OR=2.24 [1.29-3.89], P=0.004). Multivariate analysis on final decision to treat showed that Patients with F3-F4 were more likely to be treated than others (OR=2.06 [1.26-3.38], P=0.004). Conversely, although P-values are not significant, patients recruited in public hospitals tended to be less treated (OR=0.65 [0.40-1.04], P=0.069), similarly to HIV-HCV coinfected patients (OR=0.55 [0.28-1.11], P=0.095). CONCLUSION Our study showed that the IL28B genotype is used for the management of HCV-infected patients. In the context of future treatments, IL28B genotyping may remain useful if it can be used to develop individualized treatment strategies, identifying patients who can be successfully treated with shorter, simpler, or cheaper regimens.
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Affiliation(s)
| | - Denis Ouzan
- Institut Arnault-Tzanck, Saint-Laurent-du-Var, France
| | | | | | | | | | | | | | | | - Hacène Khiri
- Association Génovir - Laboratoire Alphabio, Marseille, France
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Bichoupan K, Martel-Laferriere V, Sachs D, Ng M, Schonfeld EA, Pappas A, Crismale J, Stivala A, Khaitova V, Gardenier D, Linderman M, Perumalswami PV, Schiano TD, Odin JA, Liu L, Moskowitz AJ, Dieterich DT, Branch AD. Costs of telaprevir-based triple therapy for hepatitis C: $189,000 per sustained virological response. Hepatology 2014; 60:1187-95. [PMID: 25065814 PMCID: PMC4190678 DOI: 10.1002/hep.27340] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Revised: 06/11/2014] [Accepted: 07/24/2014] [Indexed: 12/15/2022]
Abstract
UNLABELLED In registration trials, triple therapy with telaprevir (TVR), pegylated interferon (Peg-IFN), and ribavirin (RBV) achieved sustained virological response (SVR) rates between 64% and 75%, but the clinical effectiveness and economic burdens of this treatment in real-world practice remain to be determined. Records of 147 patients who initiated TVR-based triple therapy at the Mount Sinai Medical Center (May-December 2011) were reviewed. Direct medical costs for pretreatment, on-treatment, and posttreatment care were calculated using data from Medicare reimbursement databases, RED Book, and the Healthcare Cost and Utilization Project database. Costs are presented in 2012 U.S. dollars. SVR (undetectable hepatitis C virus [HCV] RNA 24 weeks after the end of treatment) was determined on an intention-to-treat basis. Cost per SVR was calculated by dividing the median cost by the SVR rate. Median age of the 147 patients was 56 years (interquartile range [IQR] = 51-61), 68% were male, 19% were black, 11% had human immunodeficiency virus/HCV coinfection, 36% had advanced fibrosis/cirrhosis (FIB-4 scores ≥3.25), and 44% achieved an SVR. The total cost of care was $11.56 million. Median cost of care was $83,721 per patient (IQR = $66,652-$98,102). The median cost per SVR was $189,338 (IQR = $150,735-$221,860). Total costs were TVR (61%), IFN (24%), RBV (4%), adverse event management (8%), professional fees (2%), and laboratory tests (1%). CONCLUSIONS TVR and Peg-IFN accounted for 85% of costs. Pharmaceutical prices and the low (44%) SVR rate, in this real-world study, were major contributors to the high cost per SVR.
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Affiliation(s)
- Kian Bichoupan
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - David Sachs
- Genetics and Genomics, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Michel Ng
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Alexis Pappas
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY
| | - James Crismale
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Alicia Stivala
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Viktoriya Khaitova
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Donald Gardenier
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Michael Linderman
- Genetics and Genomics, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Thomas D. Schiano
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Joseph A. Odin
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Lawrence Liu
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Alan J. Moskowitz
- Health Evidence and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Douglas T. Dieterich
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Andrea D. Branch
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY
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Strazzulla A, Costa C, Pisani V, De Maria V, Giancotti F, Di Salvo S, Parisi SG, Basso M, Franzetti MM, Marascio N, Liberto MC, Barreca GS, Lamberti AG, Zicca E, Postorino MC, Matera G, Focà A, Torti C. Present, old and future strategies for anti-HCV treatment in patients infected by genotype-1: estimation of the drug costs in the Calabria Region in the era of the directly acting antivirals. BMC Infect Dis 2014; 14 Suppl 5:S3. [PMID: 25236374 PMCID: PMC4160897 DOI: 10.1186/1471-2334-14-s5-s3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND In Italy, anti-HCV drugs are provided free of charge by the National Health System. Since 2011, three drug regimens including a directly acting antiviral (DAA) are considered the gold standard for HCV treatment. However, these drugs add a significant cost (roughly €26,000) to the combination of pegylated-interferon-α/ribavirin (PEG-IFN/RBV), which before DAA represented the unique treatment. To provide the National Health System potential useful information, we estimated costs to provide anti-HCV drugs to treat a population experienced for PEG-INF/RBV. METHODS Genotype 1 HCV mono-infected or HIV/HCV co-infected individuals who were treated with PEG-IFN/RBV between 2008 and 2013 were included. The cost to treat these patients with PEG-IFN/RBV was calculated (cost 1). We also estimated costs if we had to treat these patients with a lead-in period of PEG-INF/RBV followed by PEG-IFN/RBV and a DAA in naïves (cost 2), in addition to cost 1 plus the estimated cost to re-treat with PEG-IFN/RBV and a DAA patients who had a relapse or a non response (cost 3). Moreover, all costs were normalized by SVR. Rates of foreseen response with DAA were obtained from literature data. RESULTS The overall study population consisted of 104 patients. The rate of sustained virological response (SVR) was 55%, while it was estimated that SVR would be obtained in 75% of patients with a lead-in period with PEG-IFN/RBV followed by a DAA combination, and in 78% if this treatment is used to re-treat experienced patients with a DAA. Drug costs associated with these treatments were: €1,214,283 for cost 1, €3,474,977 for cost 2 and €3,002,095 for cost 3. Costs per SVR achieved were: €22,284 for cost 1, €44,643 for cost 2 and €38,322 for cost 3. CONCLUSIONS Treatments including DAAs achieve a SVR in more patients than PEG-IFN/RBV but they cost around three times more than PEG-IFN/RBV alone regimens. Also, cost per SVR is almost twofold greater than PEG-IFN/RBV regimens. Therefore, it is mandatory to implement use of DAA in clinical practice, but the National Health System should allocate adequate resources to provide drugs, which challenges sustainability. Cost reduction for anti-HCV drugs should be pursued.
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Stepanova M, Nader F, Cure S, Bourhis F, Hunt S, Younossi ZM. Patients' preferences and health utility assessment with SF-6D and EQ-5D in patients with chronic hepatitis C treated with sofosbuvir regimens. Aliment Pharmacol Ther 2014; 40:676-85. [PMID: 25040192 DOI: 10.1111/apt.12880] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 05/29/2014] [Accepted: 06/27/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Health utilities measure patients' preferences for a health state. AIM To assess health utilities for sofosbuvir-containing therapy for chronic hepatitis C. METHODS The SF-6D utility scores were derived from the SF-36 instrument administered at baseline, during and post-treatment to participants of the previously reported clinical trials of sofosbuvir. EQ-5D utility scores were also approximated from the SF-36 using a regression model. RESULTS Nine hundred and ninety-four patients were enrolled. Baseline SF-6D and EQ-5D scores were 0.66 ± 0.13 and 0.71 ± 0.22, respectively (the POSITRON trial), 0.71 ± 0.16 and 0.76 ± 0.23 (FISSION), 0.70 ± 0.14 and 0.75 ± 0.22 (FUSION), 0.72 ± 0.15 and 0.79 ± 0.22 (NEUTRINO). In all studies, SF-6D and EQ-5D scores were highly correlated with each other. (r = 0.83-0.87, P < 0.0001). After 12 weeks, patients receiving sofosbuvir + ribavirin (POSITRON) had similar utility scores to placebo (P > 0.05). Patients receiving 12 and 16 weeks of sofosbuvir + ribavirin (FUSION) had similar utility scores (P > 0.05). In FISSION, patients receiving sofosbuvir + ribavirin had significantly better utilities compared to patients receiving interferon + ribavirin (P < 0.001). Patients receiving sofosbuvir + ribavirin + interferon (NEUTRINO) had a decrease in utilities during treatment (SF-6D: from 0.72 to 0.62, EQ-5D: 0.79 to 0.65; P < 0.0001) similar to that observed in patients receiving pegylated interferon + ribavirin for 24 weeks in FISSION (0.72 to 0.62 and 0.77 to 0.65, respectively, P < 0.0001). After 12 weeks post-treatment, patients with SVR (FUSION) had improvement in SF-6D (+0.026 from baseline, P = 0.013) and EQ-5D (+0.043, P = 0.013). In multivariate analyses, baseline depression, anxiety, fatigue, insomnia and treatment-related anaemia were the most consistent predictors of utilities. CONCLUSIONS Patients' health utilities are minimally impacted by sofosbuvir + ribavirin treatment, as compared to interferon-based, therapy regardless of treatment duration. Clinical trials' numbers: NCT01542788 (POSITRON), NCT01497366 (FISSION), NCT01604850 (FUSION), NCT01641640 (NEUTRINO).
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Affiliation(s)
- M Stepanova
- Department of Medicine, Center for Liver Diseases, Inova Fairfax Hospital, Falls Church, VA, USA
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Edlin BR, Winkelstein ER. Can hepatitis C be eradicated in the United States? Antiviral Res 2014; 110:79-93. [PMID: 25110202 DOI: 10.1016/j.antiviral.2014.07.015] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Revised: 07/18/2014] [Accepted: 07/27/2014] [Indexed: 12/11/2022]
Abstract
The advent of highly effective antiviral regimens will make the eradication of hepatitis C in high-income countries such as the United States technically feasible. But eradicating hepatitis C will require escalating our response to the epidemic in key domains, including surveillance and epidemiology, prevention, screening, care and treatment, policy, research, and advocacy. Surveillance must be nimble enough to quickly assess the magnitude of new transmission patterns as they emerge. Basic prevention strategies - community-based outreach and education, testing and counseling, and access to sterile injection equipment and opioid substitution therapies - must be scaled up and adapted to target groups in which new epidemics are emerging. All adults should be screened for hepatitis C, but special efforts must focus on groups with increased prevalence through community outreach and rapid testing. Government, industry, and payers must work together to assure full access to health services and antiviral drugs for everyone who is infected. Access to the new regimens must not be compromised by excessively high prices or arbitrary payer restrictions. Partnerships must be forged between hepatitis providers and programs that serve people who inject illicit drugs. Healthcare providers and systems, especially primary care practitioners, need education and training in treating hepatitis C and caring for substance-using populations. Services must be provided to the disadvantaged and stigmatized members of society who bear a disproportionate burden of the epidemic. Environments must be created where people who use drugs can receive prevention and treatment services without shame or stigma. Action is needed to end the policy of mass incarceration of people who use drugs, reduce the stigma associated with substance use, support the human rights of people who use drugs, expand social safety net services for the poor and the homeless, remove the legal barriers to hepatitis C prevention, and build public health infrastructure to reach, engage, and serve marginalized populations. Governments must take action to bring about these changes. Public health agencies must work with penal institutions to provide prevention and treatment services, including antiviral therapy, to those in need in jails and prisons or on probation or parole. Research is needed to guide efforts in each of these domains. Strong and sustained political advocacy will be needed to build and sustain support for these measures. Leadership must be provided by physicians, scientists, and the public health community in partnership with community advocates and people living with or at risk for hepatitis C. Eliminating hepatitis C from the United States is possible, but will require a sustained national commitment to reach, test, treat, cure, and prevent every case. With strong political leadership, societal commitment, and community support, hepatitis C can be eradicated in the United States. If this is to happen in our lifetimes, the time for action is now. This article forms part of a symposium in Antiviral Research on "Hepatitis C: next steps toward global eradication."
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Affiliation(s)
- Brian R Edlin
- Weill Cornell Medical College, New York, NY 10065, United States; National Development and Research Institutes, 71 West 23rd St., 4th floor, New York, NY 10010, United States.
| | - Emily R Winkelstein
- National Development and Research Institutes, 71 West 23rd St., 4th floor, New York, NY 10010, United States.
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The treatment cascade for chronic hepatitis C virus infection in the United States: a systematic review and meta-analysis. PLoS One 2014; 9:e101554. [PMID: 24988388 PMCID: PMC4079454 DOI: 10.1371/journal.pone.0101554] [Citation(s) in RCA: 341] [Impact Index Per Article: 34.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Accepted: 06/09/2014] [Indexed: 12/17/2022] Open
Abstract
Background Identifying gaps in care for people with chronic hepatitis C virus (HCV) infection is important to clinicians, public health officials, and federal agencies. The objective of this study was to systematically review the literature to provide estimates of the proportion of chronic HCV-infected persons in the United States (U.S.) completing each step along a proposed HCV treatment cascade: (1) infected with chronic HCV; (2) diagnosed and aware of their infection; (3) with access to outpatient care; (4) HCV RNA confirmed; (5) liver fibrosis staged by biopsy; (6) prescribed HCV treatment; and (7) achieved sustained virologic response (SVR). Methods We searched MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews for articles published between January 2003 and July 2013. Two reviewers independently identified articles addressing each step in the cascade. Studies were excluded if they focused on specific populations, did not present original data, involved only a single site, were conducted outside of the U.S., or only included data collected prior to 2000. Results 9,581 articles were identified, 117 were retrieved for full text review, and 10 were included. Overall, 3.5 million people were estimated to have chronic HCV in the U.S. Fifty percent (95% CI 43–57%) were diagnosed and aware of their infection, 43% (CI 40–47%) had access to outpatient care, 27% (CI 27–28%) had HCV RNA confirmed, 17% (CI 16–17%) underwent liver fibrosis staging, 16% (CI 15–16%) were prescribed treatment, and 9% (CI 9–10%) achieved SVR. Conclusions Continued efforts are needed to improve HCV care in the U.S. The proposed HCV treatment cascade provides a framework for evaluating the delivery of HCV care over time and within subgroups, and will be useful in monitoring the impact of new screening efforts and advances in antiviral therapy.
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Linas BP, Barter DM, Leff JA, Assoumou SA, Salomon JA, Weinstein MC, Kim AY, Schackman BR. The hepatitis C cascade of care: identifying priorities to improve clinical outcomes. PLoS One 2014; 9:e97317. [PMID: 24842841 PMCID: PMC4026319 DOI: 10.1371/journal.pone.0097317] [Citation(s) in RCA: 107] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Accepted: 04/17/2014] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND As highly effective hepatitis C virus (HCV) therapies emerge, data are needed to inform the development of interventions to improve HCV treatment rates. We used simulation modeling to estimate the impact of loss to follow-up on HCV treatment outcomes and to identify intervention strategies likely to provide good value for the resources invested in them. METHODS We used a Monte Carlo state-transition model to simulate a hypothetical cohort of chronically HCV-infected individuals recently screened positive for serum HCV antibody. We simulated four hypothetical intervention strategies (linkage to care; treatment initiation; integrated case management; peer navigator) to improve HCV treatment rates, varying efficacies and costs, and identified strategies that would most likely result in the best value for the resources required for implementation. MAIN MEASURES Sustained virologic responses (SVRs), life expectancy, quality-adjusted life expectancy (QALE), costs from health system and program implementation perspectives, and incremental cost-effectiveness ratios (ICERs). RESULTS We estimate that imperfect follow-up reduces the real-world effectiveness of HCV therapies by approximately 75%. In the base case, a modestly effective hypothetical peer navigator program maximized the number of SVRs and QALE, with an ICER compared to the next best intervention of $48,700/quality-adjusted life year. Hypothetical interventions that simultaneously addressed multiple points along the cascade provided better outcomes and more value for money than less costly interventions targeting single steps. The 5-year program cost of the hypothetical peer navigator intervention was $14.5 million per 10,000 newly diagnosed individuals. CONCLUSIONS We estimate that imperfect follow-up during the HCV cascade of care greatly reduces the real-world effectiveness of HCV therapy. Our mathematical model shows that modestly effective interventions to improve follow-up would likely be cost-effective. Priority should be given to developing and evaluating interventions addressing multiple points along the cascade rather than options focusing solely on single points.
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Affiliation(s)
- Benjamin P. Linas
- HIV Epidemiology and Outcomes Research Unit, Section of Infectious Diseases, Boston Medical Center, Boston, Massachusetts, United States of America
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Devra M. Barter
- HIV Epidemiology and Outcomes Research Unit, Section of Infectious Diseases, Boston Medical Center, Boston, Massachusetts, United States of America
| | - Jared A. Leff
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, New York, United States of America
| | - Sabrina A. Assoumou
- HIV Epidemiology and Outcomes Research Unit, Section of Infectious Diseases, Boston Medical Center, Boston, Massachusetts, United States of America
| | - Joshua A. Salomon
- Department of Global Health and Population, Harvard School of Public Health, Boston, Massachusetts, United States of America
| | - Milton C. Weinstein
- Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts, United States of America
| | - Arthur Y. Kim
- Massachusetts General Hospital Boston, Massachusetts, United States of America
| | - Bruce R. Schackman
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, New York, United States of America
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Hunyady B, Gervain J, Horváth G, Makara M, Pár A, Szalay F, Telegdy L, Tornai I. [Diagnosis, treatment, and follow-up of hepatitis C-virus related liver disease. Hungarian national consensus guideline]. Orv Hetil 2014; 155 Suppl:3-24. [PMID: 24631886 DOI: 10.1556/oh.2013.29893] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Approximately 70 000 people are infected with hepatitis C virus in Hungary, more than half of whom are not aware of their infection. Early recognition and effective treatment of related liver injury may prevent consequent advanced liver diseases (liver cirrhosis and liver cancer) and its complications. In addition, it may increase work productivity and life expectancy of infected individual, and can prevent further viral transmission. Early recognition can substantially reduce the long term financial burden of related morbidity from socioeconomic point of view. Pegylated interferon + ribavirin dual therapy, which is available in Hungary since 2003, can kill the virus in 40-45% of previously not treated (naïve), and in 5-21% of previous treatment-failure patients. Addition of two direct acting first generation protease inhibitor drugs (boceprevir and telaprevir) to the dual therapy increased the chance of sustained clearance of virus to 63-75% and 59-66%, respectively. These two protease inhibitor drugs are available and financed for a segment of Hungarian patients since May 2013. Indication of therapy includes exclusion of contraindications to the drugs and demonstration of viral replication with consequent liver injury, i.e., inflammation and/or fibrosis in the liver. For initiation of treatment as well as for on-treatment decisions accurate and timely molecular biology tests are mandatory. Staging of liver damage (fibrosis) non-invasive methods (transient elastography and biochemical methods) are acceptable to avoid concerns of patients related to liver biopsy. Professional decision for treatment is balanced against budget limitations in Hungary, and priority is given to those with urgent need using a national Priority Index system reflecting stage of liver disease as well as additional factors (activity and progression of liver disease, predictive factors and other special circumstances). All naïve patients are given a first chance with dual therapy. Those with genotype 1 infection and with on-treatment or historic failure to dual therapy are eligible to receive protease inhibitor based triple therapy provided, they reach financial cutoff eligibility based on Priority Index. Duration of therapy is usually 48 weeks in genotype 1 with a response-guided potential to reduce duration for non-cirrhotic patients. Patients with non-1 genotypes are treated with dual therapy (without protease inhibitors) for a genotype and response driven duration of 16, 24, 48, or 72 week. Careful monitoring for early recognition and management of side-effects as well as viral response and potential breakthrough during protease-inhibitor therapy are recommended.
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Affiliation(s)
- Béla Hunyady
- Somogy Megyei Kaposi Mór Oktató Kórház Belgyógyászati Osztály Kaposvár Tallián Gyula u. 20-32. 7400 Pécsi Tudományegyetem, Általános Orvostudományi Kar I. Belgyógyászati Klinika Pécs
| | - Judit Gervain
- Szent György Egyetemi Oktató Kórház I. Belgyógyászat és Molekuláris Diagnosztikai Laboratórium Székesfehérvár
| | - Gábor Horváth
- Szent János Kórház és Észak-budai Egyesített Kórházak Hepatológiai Szakrendelés Budapest
| | - Mihály Makara
- Egyesített Szent István és Szent László Kórház Budapest
| | - Alajos Pár
- Pécsi Tudományegyetem, Általános Orvostudományi Kar I. Belgyógyászati Klinika Pécs
| | - Ferenc Szalay
- Semmelweis Egyetem, Általános Orvostudományi Kar I. Belgyógyászati Klinika Budapest
| | | | - István Tornai
- Debreceni Egyetem, Általános Orvostudományi Kar, Orvos- és Egészségtudományi Centrum Belgyógyászati Intézet Debrecen
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Abstract
PURPOSE OF REVIEW This article examines recent health services and policy research studies in hepatology and liver transplantation. RECENT FINDINGS Critical issues include access to medical care, timeliness of referral and consultation, resource utilization in clinical practice, comparative effectiveness research, and the evaluation of care delivery models. Despite policymaking efforts, there continues to be unwarranted variation in access to subspecialty care and liver transplantation services based on race and geographic location. Variations in primary care and specialist awareness of practice guidelines for liver disease contribute to disparities in appropriateness and timeliness of treatments. Defining the cost-effectiveness of increased resource utilization for novel antiviral therapies and liver transplantation continues to stimulate controversy. Few comparative effectiveness studies in hepatology exist to date, yet a growing number of analyses using national datasets will help inform policy in this arena. Identifying care delivery models that demonstrate high value for populations with chronic liver disease is critical in the context of recent healthcare reform efforts. SUMMARY Health services and policy research is a growing field of investigation in hepatology and liver transplantation. Further emphasis on research training and workforce development in this area will be critical for understanding and improving patient-centered outcomes for this population.
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San Miguel R, Gimeno-Ballester V, Mar J. Cost-effectiveness of protease inhibitor based regimens for chronic hepatitis C: a systematic review of published literature. Expert Rev Pharmacoecon Outcomes Res 2014; 14:387-402. [DOI: 10.1586/14737167.2014.906307] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Neoh CF, Kong DCM. The cost-effectiveness of boceprevir for hepatitis C. Expert Rev Pharmacoecon Outcomes Res 2014; 14:319-34. [DOI: 10.1586/14737167.2014.906306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Serum Activins and Follistatin during the Treatment of Chronic Hepatitis C Genotypes 1 and 4 and Their Correlations with Viral Load and Liver Enzymes: A Preliminary Report. Gastroenterol Res Pract 2014; 2014:628683. [PMID: 24799891 PMCID: PMC3995172 DOI: 10.1155/2014/628683] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Revised: 02/21/2014] [Accepted: 03/07/2014] [Indexed: 12/26/2022] Open
Abstract
Aims. To measure the effect of pegylated interferon-α therapy on serum activin-A, activin-B, and follistatin and their correlation with viral load and liver fibrosis in chronic hepatitis C (CHC). Methods. This study was cross-sectional and sera were collected from 165 participants classified into 7 groups: 40 healthy negative control, 33 treatment naïve patients as positive control, 19 patients at week 4, 22 at week 12, and 19 at week 24 of treatment initiation and 21 responders and 11 nonresponders at the end of 48-week treatment protocol. Serum candidate proteins were measured using ELISA and liver fibrosis was assessed by AST platelet ratio index (APRI). Results. CHC significantly increased activins and decreased follistatin compared to negative control (P < 0.05). Activin-A and follistatin levels returned to the levels of negative control group at weeks 4, 12, and 24 following treatment initiation and were significantly different from positive control (P < 0.05). Both proteins were significantly different between responders and nonresponders. Activin-A correlated positively and significantly with the viral load and APRI. Conclusion. CHC modulates serum activin-A and follistatin and they appear to be influenced by pegylated interferon-α therapy. Further studies are needed to explore the role of activins in CHC.
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Viral hepatitis: Cost-effectiveness of direct-acting antivirals for chronic hepatitis C. Nat Rev Gastroenterol Hepatol 2013; 10:572-4. [PMID: 23958602 DOI: 10.1038/nrgastro.2013.162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
A new study has reported the long-term effectiveness and cost-effectiveness of the direct-acting antivirals telaprevir and boceprevir for the treatment of chronic hepatitis C. These findings have the potential to be used to guide clinical and reimbursement decisions for treating populations with a high prevalence of HCV infection.
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