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Lam L, Carrieri P, Hejblum G, Bellet J, Bourlière M, Carrat F. Real-world economic burden of hepatitis C and impact of direct-acting antivirals in France: A nationwide claims data analysis. Liver Int 2024; 44:1233-1242. [PMID: 38375961 DOI: 10.1111/liv.15872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 01/04/2024] [Accepted: 02/08/2024] [Indexed: 02/21/2024]
Abstract
BACKGROUND AND AIMS The economic impact of managing patients with hepatitis C virus (HCV) infection remains unknown. This study aimed to assess the economic burden of chronic HCV infection from a national health insurance perspective and the impact of direct-acting antivirals (DAAs) using nationwide real-world data. METHODS Patients with chronic HCV infection were identified from the French Health Insurance Claims Databases (SNDS) and matched for age and sex to the general population. Health resource utilization and reimbursements were summarized according to healthcare expenditure items from 2012 to 2021. The economic burden attributable to chronic HCV infection was evaluated over a 10-year period. Finally, the impact of DAAs was estimated using economic data derived from the SNDS. RESULTS A total of 145 187 patients with chronic HCV infection were identified. Among the patients eligible for DAA therapy, 81.5% had received DAA by the end of 2021. Over a 10-year period, managing patients with chronic HCV infection resulted in an additional cost of €9.71 billion (95% confidence interval [CI]: €9.66-€9.78 billion) or €9191 (95% CI: €9134-€9252) per patient per year compared to the general population. After DAA therapy, patients with chronic HCV infection had a higher economic burden than the general population, with an additional cost of €5781 (95% CI: €5540-€6028) per patient at the fifth-year post-DAA therapy. CONCLUSIONS A significant economic burden persists among patients with HCV infection after DAA treatment. The high proportion of patients not treated with DAA therapy supports reinforcing policies for universal access.
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Affiliation(s)
- Laurent Lam
- INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique, IPLESP, Sorbonne Université, Paris, France
| | - Patrizia Carrieri
- INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, ISSPAM, Aix Marseille Univ, Marseille, France
| | - Gilles Hejblum
- INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique, IPLESP, Sorbonne Université, Paris, France
| | - Jonathan Bellet
- INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique, IPLESP, Sorbonne Université, Paris, France
| | - Marc Bourlière
- Department of Hepatology and Gastroenterology, Hôpital Saint Joseph, Marseille, France
- INSERM, UMR 1252 IRD SESSTIM, Aix Marseille Université, Marseille, France
| | - Fabrice Carrat
- INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique, IPLESP, Sorbonne Université, Paris, France
- Department of Public Health, Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, Sorbonne Université, Paris, France
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Calleja JL, Espin J, Kaushik A, Hernandez-Guerra M, Blissett R, Yehoshua A, Igloi-Nagy A. The Efficiency of Increased HCV Testing and Treatment Strategies in Spain to Achieve Elimination Goals. PHARMACOECONOMICS - OPEN 2024; 8:221-233. [PMID: 38100074 PMCID: PMC10884368 DOI: 10.1007/s41669-023-00458-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/22/2023] [Indexed: 02/23/2024]
Abstract
BACKGROUND In 2015, Spain launched a national eradication strategy for hepatitis C virus (HCV), resulting in the highest treatment rate in Europe and substantial reductions in HCV prevalence. However, to achieve the goal of HCV elimination, it is necessary to scale-up the diagnosis, treatment, and management of HCV infection. OBJECTIVE Our aim was to assess the prevalence, incidence, and cost effectiveness of scaling-up compared with status quo scenarios. METHODS A compartmental dynamic transmission model was developed comprising of a cascade of care and a liver progression module. Cost and quality-of-life inputs were sourced from the literature. Key outcomes were the prevalence and incidence of HCV and the incremental cost per quality-adjusted life-year (QALY) and per life-year (LY). Outcomes for a hypothetical elimination strategy were compared with the status quo. RESULTS The base-case analysis found that scaling-up testing and treatment reduced both the prevalence and incidence of HCV over time, resulting in incremental costs per QALY and LY of €13,291 and €12,285 respectively, compared with the status quo. The main drivers of the cost-effectiveness results included cost of diagnosis, cost of treatment, proportion of people who are unaware, percentage of population who inject drugs, and calibration parameters related to HCV infection prevalence. CONCLUSIONS This analysis demonstrated that scaling-up testing and treatment with direct-acting antivirals may be an efficient strategy for reducing the incidence and prevalence of HCV and may help achieve HCV elimination goals in Spain.
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Affiliation(s)
- Jose Luis Calleja
- Hospital Universitario Puerta de Hierro, Universidad Autónoma de Madrid, Madrid, Spain
| | - Jaime Espin
- Escuela Andaluza de Salud Pública, Granada, Spain
| | | | | | | | - Alon Yehoshua
- Formerly of Gilead Sciences, Inc., Foster City, CA, USA
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Zhou S, Qi K, Bersoff-Matcha SJ, Mishra P, Struble K. Sex-related difference analyses of efficacy and safety in clinical trials of direct-acting antivirals to treat chronic HCV genotype 1 and 3 infections. J Viral Hepat 2024; 31:78-87. [PMID: 38111976 DOI: 10.1111/jvh.13901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 11/19/2023] [Indexed: 12/20/2023]
Abstract
This study aims to identify clinically meaningful sex differences in efficacy and selected safety adverse events for the treatment of chronic hepatitis C virus infection (HCV) or HIV/HCV co-infection in those receiving combination direct-acting antiviral (DAA) regimens. Our assessment was based on adult trial participants treated at the approved DAA dosage and treatment duration from 40 phase 3 clinical trials submitted to the FDA. Female enrollment ranged from 11% to 54% (overall mean 38%). Females with HCV genotype (GT) 1 or 3 infection had statistically significant higher unadjusted or covariant-adjusted odds of achieving sustained virologic response at post-treatment Week 12 (SVR12) compared with males. Odds ratios favouring females were observed among Whites and those ≥40 years of age with HCV GT1 or 3 infections, and among those ≥50 years of age, non-cirrhotic and those with HCV GT3 infection who were treatment-experienced. These differences were not clinically relevant due to the high SVR12 rate achieved by females and males, overall or in subgroups. No differences were observed in SVR12 rates between HCV GT1 mono-infected and HCV GT1/ HIV-1 co-infected participants. Numerically, more females reported headache, fatigue and nausea compared to males, but the differences were small and predominately Grade 1 or 2 severity. Discontinuation rates for any reason or due to an adverse event were low and similar between the sexes. Our study demonstrated females successfully complete DAA regimens and achieve high SVR12 rates despite numerically higher adverse events for certain commonly reported events.
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Affiliation(s)
- Shuang Zhou
- Center for Drug Evaluation and Research, Division of Antivirals, FDA, Silver Spring, Maryland, USA
| | - Karen Qi
- Center for Drug Evaluation and Research, Office of Biostatistician, FDA, Silver Spring, Maryland, USA
| | | | - Poonam Mishra
- Center for Drug Evaluation and Research, Division of Antivirals, FDA, Silver Spring, Maryland, USA
| | - Kimberly Struble
- Center for Drug Evaluation and Research, Division of Antivirals, FDA, Silver Spring, Maryland, USA
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Giachello M, Leporatti L, Levaggi R, Montefiori M. The illness trap: The impact of disability benefits on willingness to receive HCV treatment. ECONOMICS AND HUMAN BIOLOGY 2024; 52:101352. [PMID: 38278057 DOI: 10.1016/j.ehb.2024.101352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 11/28/2023] [Accepted: 01/13/2024] [Indexed: 01/28/2024]
Abstract
Health care is assumed to be a primary good, implying that patients should always demand or accept treatments that may enhance their life expectancy and quality of life, especially if the risks associated with the treatment are low. We argue that, especially in countries with a well-developed welfare state, treating an invalidating condition may lead to opportunity costs in terms of reduced disability allowances that may represent a barrier to treatment for low-income individuals. We test this hypothesis by applying a recursive bivariate probit approach to population data from an ad hoc administrative database for Liguria (an Italian administrative region). The dataset includes data for more than 8 thousand people affected by hepatitis C Virus (HCV) infection between 2013 and 2020. After the discovery of new direct-acting antivirals (DAAs) in 2014, HCV eradication may now be possible. However, despite the national and international efforts, several patients diagnosed with HCV choose not to undergo drug therapy despite the adverse consequences for their personal health and relevant costs to the national health system. We show that five years after the implementation of the new drugs, approximately 41 % of the diagnosed population in Liguria remains untreated. This percentage increases to 64 % within the subgroup entitled to disability benefits and characterized by lower income levels. The "illness trap" effect is more substantial for older people but also low-income patients. Moreover, we find that this effect is higher in patients with an intermediate range of comorbidities; indeed, these patients are at a higher risk of losing economic benefits if they recover from HCV. These results suggest the need for healthcare policies addressing this distorting effect when designing benefit programs and granting financial benefits to patients.
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Affiliation(s)
- Marta Giachello
- Department of Economics (DIEC), Centro APHEC, University of Genoa, Via Vivaldi, 5, Genova, GE 16126, Italy
| | - Lucia Leporatti
- Department of Economics (DIEC), Centro APHEC, University of Genoa, Via Vivaldi, 5, Genova, GE 16126, Italy.
| | - Rosella Levaggi
- Department of Economics and Management, University of Brescia, via S. Faustino 74/B, Brescia, BS 25122, Italy
| | - Marcello Montefiori
- Department of Economics (DIEC), Centro APHEC, University of Genoa, Via Vivaldi, 5, Genova, GE 16126, Italy
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Lopez Bray C, Taylor R, Tamez N, Durkalski W, Litaker JR. Hepatitis C Virus Screening among Baby Boomers: The Positive Benefits of Health Education and Outreach during the COVID-19 Pandemic. Healthcare (Basel) 2023; 11:healthcare11030302. [PMID: 36766877 PMCID: PMC9914406 DOI: 10.3390/healthcare11030302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/13/2023] [Accepted: 01/18/2023] [Indexed: 01/20/2023] Open
Abstract
In 2019, 2020, and 2021, Sendero Health Plans, an ACA health insurance company, implemented Hepatitis C Virus (HCV) health education and outreach screening campaigns. Chi-square goodness-of-fit and tests of independence were performed to assess and compare the uptake of HCV screening among baby boomers in 2019, 2020, and 2021. In 2019, 2020, and 2021, 17.9% (308/1,718), 10.9% (93/852), and 8.5% (37/435) of eligible members were screened, respectively. Individuals were more likely to be screened for HCV in 2019 than in 2020 and 2021 (p < 0.0001). In 2019, 2020, and 2021, 39.9%, 26.9%, and 48.6% of annual screenings occurred during the health campaign months, respectively. Annual HCV screening rates were lower during the COVID-19 pandemic period than in the pre-pandemic cohort. However, screening rates during the months of outreach and education contributed to nearly 50% of annual screenings in the pandemic year 2021, thus representing a positive impact on preventive screening uptake despite the pandemic. Missed screening opportunities affect HCV transmission, diagnosis, and treatment. Yet, health education and outreach continue to work, even during a pandemic.
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Affiliation(s)
- Carlos Lopez Bray
- Office of Population Health, Sendero Health Plans, Inc., Austin, TX 78741, USA
| | - Richard Taylor
- Undergraduate Public Health Program, The University of Texas at Austin, Austin, TX 78712, USA
| | - Naomi Tamez
- Office of Population Health, Sendero Health Plans, Inc., Austin, TX 78741, USA
| | - Wesley Durkalski
- Former Chief Executive Officer, Sendero Health Plans, Inc., Austin, TX 78741, USA
| | - John R. Litaker
- Office of Population Health and Science, The Litaker Group, LLC, Austin, TX 78716, USA
- Correspondence:
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Pursuing Elimination of Hepatitis C in Egypt: Cost-Effectiveness and Economic Evaluation of a Country-Wide Program. Infect Dis Ther 2022; 11:1193-1203. [PMID: 35451742 PMCID: PMC9124269 DOI: 10.1007/s40121-022-00631-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 03/24/2022] [Indexed: 12/02/2022] Open
Abstract
Introduction Hepatitis C virus (HCV) is a global public health crisis. Egypt presents the highest HCV global prevalence. Recently, three different HCV screening/testing/therapy programs were implemented: In 2014 (wave 1), major decisions on HCV therapy were enacted, accompanied by a 99% discount for the HCV therapy sofosbuvir. In 2016 (wave 2), a first testing program was launched to identify patients for free treatment. In 2018 (wave 3), population-wide screening was conducted using a WHO-prequalified finger prick rapid diagnostic test (RDT) to identify/treat all Egyptians with HCV. The financial advantages of HCV screening programs (wave 1–3 results) were estimated vs a baseline period of limited Egyptian HCV testing/therapeutic intervention (2008–2014). Methods Using published evidence and model-based estimates from real-world data, we evaluated the direct costs of the different HCV programs, accompanied by a conservative simulation of major HCV health consequences (i.e., liver-related deaths/life years lost) and related indirect costs. Total economic consequences of each HCV program were compared to each other and baseline from a societal perspective. Future costs and health effects were discounted by 3.5% per year. Results Discounted total costs (in US dollars) were $1,057 billion (baseline), $913 million (wave 1), $457 million (wave 2), and $396 million (wave 3). Discounted HCV-related life years lost were 418,000 (baseline), 377,000 (wave 1), 142,000 (wave 2), and 62,000 (wave 3). With each successive Egyptian HCV screening/testing/therapy wave, total costs and HCV-related mortality were reduced. Conclusion Use of the community-applied, WHO-prequalified RDT was the most dominant approach to cost-effectiveness. These results provide rationale for worldwide scalability of similar HCV elimination programs.
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Exploring the Multicomponent Synergy Mechanism of Yinzhihuang Granule in Inhibiting Inflammation-Cancer Transformation of Hepar Based on Integrated Bioinformatics and Network Pharmacology. BIOMED RESEARCH INTERNATIONAL 2022; 2022:6213865. [PMID: 35342754 PMCID: PMC8956385 DOI: 10.1155/2022/6213865] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 02/12/2022] [Accepted: 02/28/2022] [Indexed: 12/21/2022]
Abstract
Background The Chinese patent drug Yinzhihuang granule (YZHG) is used to treat hepatitis B. This research is aimed at exploring the multicomponent synergistic mechanism of YZHG in the treatment of inflammation-cancer transformation of hepar and at providing new evidence and insights for its clinical application. Methods To retrieve the components and targets of Yinzhihuang granules. The differentially expressed genes (DEGs) of hepar inflammation-cancer transformation were obtained from TTD, PharmGKB, and GEO databases. Construct the compound-prediction target network and the key module network using Cytoscape 3.7.1. Results The results show that hepatitis B and hepatitis C shared a common target, MMP2. CDK1 and TOP2A may play an important role in the treatment with YZHG in hepatitis B inflammatory cancer transformation. KEGG pathway enrichment showed that key genes of modules 1, 2, and 4 were mainly enriched in the progesterone-mediated oocyte maturation signaling pathway and oocyte meiosis signaling pathway. Conclusion The multicomponent, multitarget, and multichannel pharmacological benefits of YZHG in the therapy of inflammation-cancer transition of hepar are directly demonstrated by network pharmacology, providing a scientific basis for its mechanism.
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8
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Wong WWL, Wong J, Bremner KE, Saeed Y, Mason K, Phoon A, Feng Z, Feld JJ, Mitsakakis N, Powis J, Krahn M. Time Costs and Out-of-Pocket Costs in Patients With Chronic Hepatitis C in a Publicly Funded Health System. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022; 25:247-256. [PMID: 35094798 DOI: 10.1016/j.jval.2021.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 06/28/2021] [Accepted: 08/18/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVES Chronic hepatitis C (CHC) infection affects more than 70 million people worldwide and imposes considerable health and economic burdens on patients and society. This study estimated 2 understudied components of the economic burden, patient out-of-pocket (OOP) costs and time costs, in patients with CHC in a tertiary hospital clinic setting and a community clinic setting. METHODS This was a multicenter, cross-sectional study with hospital-based (n = 174) and community-based (n = 101) cohorts. We used a standardized instrument to collect healthcare resource use, time, and OOP costs. OOP costs included patient-borne costs for medical services, nonprescription drugs, and nonmedical expenses related to healthcare visits. Patient and caregiver time costs were estimated using an hourly wage value derived from patient-reported employment income and, where missing, derived from the Canadian census. Sensitivity analysis explored alternative methods of valuing time. Costs were reported in 2020 Canadian dollars. RESULTS The mean 3-month OOP cost was $55 (95% confidence interval [CI] $21-$89) and $299 (95% CI $170-$427) for the community and hospital cohorts, respectively. The mean 3-month patient time cost was $743 (95% CI $485-$1002) (community) and $465 (95% CI $248-$682) (hospital). The mean 3-month caregiver time cost was $31 (95% CI $0-$63) (community) and $277 (95% CI $174-$380) (hospital). Patients with decompensated cirrhosis bore the highest costs. CONCLUSIONS OOP costs and patient and caregiver time costs represent a considerable economic burden to patient with CHC, equivalent to 14% and 21% of the reported total 3-month income for the hospital-based and community-based cohorts, respectively.
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Affiliation(s)
- William W L Wong
- School of Pharmacy, University of Waterloo, Kitchener, Ontario, Canada; Toronto Health Economics and Technology Assessment Collaborative, University Health Network, Toronto, Ontario, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada.
| | - Josephine Wong
- Toronto Health Economics and Technology Assessment Collaborative, University Health Network, Toronto, Ontario, Canada
| | - Karen E Bremner
- Toronto Health Economics and Technology Assessment Collaborative, University Health Network, Toronto, Ontario, Canada
| | - Yasmin Saeed
- Toronto Health Economics and Technology Assessment Collaborative, University Health Network, Toronto, Ontario, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Kate Mason
- Toronto Community Hepatitis C Program, Toronto, Ontario, Canada
| | - Arcturus Phoon
- Toronto Health Economics and Technology Assessment Collaborative, University Health Network, Toronto, Ontario, Canada
| | - Zeny Feng
- Department of Mathematics and Statistics, University of Guelph, Guelph, Ontario, Canada
| | - Jordan J Feld
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
| | - Nicholas Mitsakakis
- Toronto Health Economics and Technology Assessment Collaborative, University Health Network, Toronto, Ontario, Canada
| | - Jeff Powis
- Michael Garron Hospital, Toronto, Ontario, Canada
| | - Murray Krahn
- Toronto Health Economics and Technology Assessment Collaborative, University Health Network, Toronto, Ontario, Canada
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Lee HW, Lee H, Kim BK, Chang Y, Jang JY, Kim DY. Cost-effectiveness of chronic hepatitis C screening and treatment. Clin Mol Hepatol 2021; 28:164-173. [PMID: 34955002 PMCID: PMC9013616 DOI: 10.3350/cmh.2021.0193] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 12/24/2021] [Indexed: 11/09/2022] Open
Abstract
Hepatitis C virus (HCV) infection is the second most common cause of chronic liver disease in South Korea, with a prevalence ranging from 0.6% to 0.8%, and HCV infection incidence increases with age. The anti-HCV antibody test, which is cheaper than the HCV RNA assay, is widely used to screen for HCV infections; however, the underdiagnosis of HCV is a major barrier to the elimination of HCV infections. Although several risk factors have been associated with HCV infections, including intravenous drug use, blood transfusions, and hemodialysis, most patients with HCV infections present with no identifiable risk factors. Universal screening for HCV in adults has been suggested to improve the detection of HCV infections. We reviewed the cost-effectiveness of HCV screening and the methodologies used to perform screening. Recent studies have suggested that universal HCV screening and treatment using direct-acting antivirals represent cost-effective approaches to the prevention and treatment of HCV infection. However, the optimal timing and frequency of HCV screening remain unclear, and further studies are necessary to determine the best approaches for the elimination of HCV infections.
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Affiliation(s)
- Hye Won Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.,Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea.,Yonsei Liver Center, Severance Hospital, Seoul, Korea
| | - Hankil Lee
- College of Pharmacy, Ajou University, Suwon, Gyeonggi-do, Korea
| | - Beom Kyung Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.,Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea.,Yonsei Liver Center, Severance Hospital, Seoul, Korea
| | - Young Chang
- Department of Internal Medicine, Digestive Disease Center, Institute for Digestive Research, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Jae Young Jang
- Department of Internal Medicine, Digestive Disease Center, Institute for Digestive Research, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Do Young Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.,Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea.,Yonsei Liver Center, Severance Hospital, Seoul, Korea
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Nersesov A, Gusmanov A, Crape B, Junusbekova G, Berkinbayev S, Jumabayeva A, Kaibullayeva J, Madenova S, Novitskaya M, Nazarova M, Gaipov A, Ashimkhanova A, Kadyrzhanuly K, Atageldiyeva K, Vento S, Issanov A. Seroprevalence and risk factors for hepatitis B and hepatitis C in three large regions of Kazakhstan. PLoS One 2021; 16:e0261155. [PMID: 34914773 PMCID: PMC8675652 DOI: 10.1371/journal.pone.0261155] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 11/25/2021] [Indexed: 12/25/2022] Open
Abstract
Background & aims Kazakhstan has implemented comprehensive programs to reduce the incidence of Hepatitis B and Hepatitis C. This study aims to assess seroprevalence and risk factors for HBsAg and anti-HCV positivity in three large regions of Kazakhstan. Methods A cross-sectional study was conducted in three regions geographically remote from each other. Participants were randomly selected using a two-stage stratified cluster sampling and were surveyed by a questionnaire based on the WHO STEP survey instrument. Blood samples were collected for HBsAg and anti-HCV testing. Results A total of 4,620 participants were enrolled. The seroprevalence was 5.5% (95%CI: 3.6%-8.4%) for HBsAg and 5.1% (95%CI: 3.5%-7.5%) for anti-HCV antibodies. Both were more prevalent in the western and northern regions than in the southern. A history of blood transfusion was significantly associated with anti-HCV presence, with odds ratios (ORs) of 2.10 (95%CI: 1.37–3.21) and was borderline associated with HBsAg 1.39 (95%CI: 0.92–2.10), respectively. Having a family member with viral hepatitis was also borderline associated (2.09 (95%CI: 0.97–4.50)) with anti-HCV positivity. Conclusions This study found a high-intermediate level of endemicity for HBsAg and a high level of endemicity for anti-HCV antibodies in three large regions of Kazakhstan. We found that history of surgery was not associated with HbsAg neither with anti-HCV seropositivity rates. Blood transfusion was associated with anti-HCV seropositivity, however, to investigate effectiveness of the introduced comprehensive preventive measures in health care settings, there is a need to conduct further epidemiological studies.
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Affiliation(s)
- Alexander Nersesov
- Asfendiyarov Kazakh National Medical University, Almaty, Kazakhstan
- Research Institute of Cardiology and Internal Diseases, Almaty, Kazakhstan
| | - Arnur Gusmanov
- Department of Medicine, Nazarbayev University School of Medicine, Nur-Sultan, Kazakhstan
| | - Byron Crape
- Department of Medicine, Nazarbayev University School of Medicine, Nur-Sultan, Kazakhstan
| | - Gulnara Junusbekova
- Research Institute of Cardiology and Internal Diseases, Almaty, Kazakhstan
- Kazakh Medical University of Continuing Education, Almaty, Kazakhstan
| | - Salim Berkinbayev
- Asfendiyarov Kazakh National Medical University, Almaty, Kazakhstan
- Research Institute of Cardiology and Internal Diseases, Almaty, Kazakhstan
| | - Almagul Jumabayeva
- Asfendiyarov Kazakh National Medical University, Almaty, Kazakhstan
- Research Institute of Cardiology and Internal Diseases, Almaty, Kazakhstan
| | - Jamilya Kaibullayeva
- Asfendiyarov Kazakh National Medical University, Almaty, Kazakhstan
- Research Institute of Cardiology and Internal Diseases, Almaty, Kazakhstan
| | - Saltanat Madenova
- Research Institute of Cardiology and Internal Diseases, Almaty, Kazakhstan
| | - Mariya Novitskaya
- Research Institute of Cardiology and Internal Diseases, Almaty, Kazakhstan
| | - Margarita Nazarova
- Research Institute of Cardiology and Internal Diseases, Almaty, Kazakhstan
| | - Abduzhappar Gaipov
- Department of Medicine, Nazarbayev University School of Medicine, Nur-Sultan, Kazakhstan
| | - Aiymkul Ashimkhanova
- Department of Medicine, Nazarbayev University School of Medicine, Nur-Sultan, Kazakhstan
| | - Kainar Kadyrzhanuly
- Department of Medicine, Nazarbayev University School of Medicine, Nur-Sultan, Kazakhstan
| | - Kuralay Atageldiyeva
- Department of Medicine, Nazarbayev University School of Medicine, Nur-Sultan, Kazakhstan
| | - Sandro Vento
- Faculty of Medicine, University of Puthisastra, Phnom Penh, Cambodia
| | - Alpamys Issanov
- Department of Medicine, Nazarbayev University School of Medicine, Nur-Sultan, Kazakhstan
- * E-mail:
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Abstract
The therapeutic targeting of the nonstructural protein 5B (NS5B) RNA-dependent RNA polymerase (RdRp) of the Hepatitis C Virus (HCV) with nucleotide analogs led to a deep understanding of this enzymes structure, function and substrate specificity. Unlike previously studied DNA polymerases including the reverse transcriptase of Human Immunodeficiency Virus, development of biochemical assays for HCV RdRp proved challenging due to low solubility of the full-length protein and inefficient acceptance of exogenous primer/templates. Despite the poor apparent specific activity, HCV RdRp was found to support rapid and processive transcription once elongation is initiated in vitro consistent with its high level of viral replication in the livers of patients. Understanding of the substrate specificity of HCV RdRp led to the discovery of the active triphosphate of sofosbuvir as a nonobligate chain-terminator of viral RNA transcripts. The ternary crystal structure of HCV RdRp, primer/template, and incoming nucleotide showed the interaction between the nucleotide analog and the 2'-hydroxyl binding pocket and how an unfit mutation of serine 282 to threonine results in resistance by interacting with the uracil base and modified 2'-position of the analog. Host polymerases mediate off-target toxicity of nucleotide analogs and the active metabolite of sofosbuvir was found to not be efficiently incorporated by host polymerases including the mitochondrial RNA polymerase (POLRMT). Knowledge from studying inhibitors of HCV RdRp serves to advance antiviral drug discovery for other emerging RNA viruses including the discovery of remdesivir as an inhibitor of severe acute respiratory syndrome coronavirus 2 (SARS-CoV2), the virus that causes COVID-19.
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Affiliation(s)
- Joy Y Feng
- Gilead Sciences, Inc., Foster City, CA, United States.
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Majethia S, Lee IH, Chastek B, Bunner S, Wolf J, Hsiao A, Mozaffari E. Economic impact of applying the AASLD-IDSA simplified treatment algorithm on the real-world management of hepatitis C. J Manag Care Spec Pharm 2021; 28:48-57. [PMID: 34677088 DOI: 10.18553/jmcp.2021.21246] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
BACKGROUND: The American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA) recommended in May 2019 that patients with hepatitis C virus (HCV) could be assessed for treatment initiation with a simplified treatment algorithm. This approach uses standard blood and fibrosis tests, rather than genotype testing, to guide the initiation of pan-genotypic direct-acting antiviral agents (DAAs) sofosbuvir/velpatasvir (SOF/VEL) or glecaprevir/pibrentasvir (GLE/PIB) treatment. OBJECTIVE: To compare health care resource utilization (HCRU) and costs for patients who initiated treatment via the simplified vs nonsimplified algorithm (genotype testing). METHODS: We identified adults with commercial and Medicare Advantage coverage who were diagnosed with HCV who initiated SOF/VEL or GLE/PIB from July 1, 2016, through August 31, 2019, in a nationally representative US administrative claims database. The index date was defined as the first pharmacy SOF/VEL or GLE/PIB fill date. Continuous enrollment 12 months before and ≥6 months after index date was required. Patients with claims for hepatitis B, HIV, decompensated liver, or prior DAAs were excluded. Patients were propensity score-matched (1:1) and grouped as "simplified" or "nonsimplified." HCV-related HCRU and costs were compared for the post-matched groups. RESULTS: 3,539 HCV patients were included, and 16.6% initiated SOF/VEL or GLE/PIB via the simplified algorithm. Pre-matched treatments were SOF/VEL (52.8%) and GLE/PIB (47.2%). More than half (55.7%) of SOF/VEL and 44.3% of GLE/PIB patients started treatment via the simplified algorithm. HCV patients initiating via the simplified algorithm were more likely to be male (65.1% vs 60.6%; P = 0.041), commercially insured (53.3% vs 46.5%; P = 0.003), and in the Midwest (25.7% vs 19.3%; P < 0.001) vs nonsimplified patients. The nonsimplified group had more liver disease (52.1% vs 46.9%; P = 0.019), metabolic disorders (45.8% vs 39.2%; P = 0.003), and dyslipidemia (39.9% vs 35.4%; P = 0.041) vs the simplified group. Of the index prescriptions, 58.9% were written by gastroenterology or infectious disease specialists, and 68.1% (simplified) vs 75.4% (nonsimplified) had a specialist visit within 90 days prior to index DAA fill (P < 0.001). Matching resulted in 584 well-matched patients in each group. At post-match baseline, the simplified treatment group had significantly lower median (interquartile range [IQR]) HCV-related medical health care costs vs the matched nonsimplified group: $373 ($201-$684) vs $727 ($456-$1,185; P < 0.001). Median noninpatient/emergency department health plan-paid costs were also significantly lower in the simplified cohort ($257 vs $504; P < 0.001). During follow-up, medical HCV-related health care costs were similar across the groups. CONCLUSIONS: This study compared economic outcomes of HCV treatment initiation via the simplified and nonsimplified algorithms. The simplified approach resulted in lower use of health care resources, greater cost savings, and greater ability of patients to access care from both specialist and nonspecialist providers. While additional studies are needed, these early findings suggest a feasible path for simplified HCV treatment in real-world managed care settings. DISCLOSURES: Funding support for this study was provided by Gilead Sciences, Inc. Majethia, Lee, Mozaffari, Wolf, and Hsiao are employees of Gilead Sciences, Inc. Bunner and Chastek are employees of Optum Life Sciences, which received funding from Gilead Sciences, Inc. to conduct this study. Bunner owns stock in UnitedHealth group, parent company of Optum. A poster based on selected data from this study was presented at the AMCP 2021 Virtual Meeting, April 12-16, 2021.
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Trends in the Economic Burden of Chronic Liver Diseases and Cirrhosis in the United States: 1996-2016. Am J Gastroenterol 2021; 116:2060-2067. [PMID: 33998785 DOI: 10.14309/ajg.0000000000001292] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 03/29/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION The management of chronic liver diseases (CLDs) and cirrhosis is associated with substantial healthcare costs. We aimed to estimate trends in national healthcare spending for patients with CLDs or cirrhosis between 1996 and 2016 in the United States. METHODS National-level healthcare expenditure data developed by the Institute for Health Metrics and Evaluations for the Disease Expenditure Project and prevalence of CLDs and cirrhosis derived from the Global Burden of Diseases Study were used to estimate temporal trends in inflation-adjusted US healthcare spending, stratified by setting of care (ambulatory, inpatient, emergency department, and nursing care). Joinpoint regression was used to evaluate temporal trends, expressed as annual percent change (APC) with 95% confidence intervals (CIs). Drivers of change in spending for ambulatory and inpatient services were also evaluated. RESULTS Total expenditures in 2016 were $32.5 billion (95% CI, $27.0-$40.4 billion). Over 65% of spending was for inpatient or emergency department care. From 1996 to 2016, there was a 4.3%/year (95% CI, 2.8%-5.8%) increase in overall healthcare spending for patients with CLDs or cirrhosis, driven by a 17.8%/year (95% CI, 14.5%-21.6%) increase in price and intensity of hospital-based services. Total healthcare spending per patient with CLDs or cirrhosis began decreasing after 2008 (APC -1.7% [95% CI, -2.1% to -1.2%]), primarily because of reductions in ambulatory care spending (APC -9.1% [95% CI, -10.7% to -7.5%] after 2011). DISCUSSION Healthcare expenditures for CLDs or cirrhosis are substantial in the United States, driven disproportionately by acute care in-hospital spending.
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Ijioma SC, Pontinha VM, Holdford DA, Carroll NV. Cost-effectiveness of syringe service programs, medications for opioid use disorder, and combination programs in hepatitis C harm reduction among opioid injection drug users: a public payer perspective using a decision tree. J Manag Care Spec Pharm 2021; 27:137-146. [PMID: 33506729 PMCID: PMC10391166 DOI: 10.18553/jmcp.2021.27.2.137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND: The hepatitis C virus (HCV) prevalence rate among injection drug users (IDUs) in North America is 55.2%, with 1.41 million individuals estimated to be HCV-antibody positive. Studies have shown the effectiveness of syringe service programs (SSPs) alone, medications for opioid use disorder (MOUD) alone, or SSP+MOUD combination in reducing HCV transmission among opioid IDUs. OBJECTIVE: To evaluate the cost-effectiveness of SSP alone, MOUD alone, and SSP + MOUD combination in preventing HCV cases among opioid IDUs in the United States. METHODS: We used a decision tree analysis model based on published literature and publicly available data. Effectiveness was presented as the number of HCV cases avoided per 100 opioid IDUs. A micro-costing approach was undertaken and included both direct medical and nonmedical costs. Cost-effectiveness was assessed from a public payer perspective over a 1-year time horizon. It was expressed as an incremental cost-effectiveness ratio (ICER) and an incremental cost savings per HCV case avoided per 100 opioid IDUs compared with cost savings with "no intervention." Costs were standardized to 2019 U.S. dollars. RESULTS: The incremental cost savings per HCV case avoided per 100 opioid IDUs compared with no intervention were as follows: SSP + MOUD combination = $347,573; SSP alone = $363,821; MOUD alone = $317,428. The ICER for the combined strategy was $4,699 compared with the ICER for the SSP group. Sensitivity analysis showed that the results of the base-case cost-effectiveness analysis were sensitive to variations in the probabilities of injection-risk behavior for the SSP and SSP + MOUD combination groups, probability of no HCV with no intervention, and costs of MOUD and HCV antiviral medications. CONCLUSIONS: The SSP + MOUD combination and SSP alone strategies dominate MOUD alone and no intervention strategies. SSP had the largest incremental cost savings per HCV case avoided per 100 opioid IDUs compared with the no intervention strategy. Public payers adopting the SSP + MOUD combination harm-reduction strategy instead of SSP alone would have to pay an additional $4,699 to avoid an additional HCV case among opioid IDUs. Although these harm-reduction programs will provide benefits in a 1-year time frame, the largest benefit may become evident in the years ahead. DISCLOSURES: This research had no external funding. The authors declare no financial interests in this article. Ijioma is a Health Economics and Outcomes Research (HEOR) postdoctoral Fellow with Virginia Commonwealth University and Indivior. Indivior is a pharmaceutical manufacturer of opioid addiction treatment drugs but was not involved in the design, analysis, or write-up of the manuscript.
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Affiliation(s)
- Stephen C Ijioma
- Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, VA
| | - Vasco M Pontinha
- Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, VA
| | - David A Holdford
- Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, VA
| | - Norman V Carroll
- Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, VA
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15
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Rajasekaran A, Franco RA, Overton ET, McGuire BM, Towns GC, Locke JE, Sawinski DL, Bell EK. Updated Pathway to Micro-elimination of Hepatitis C Virus in the Hemodialysis Population. Kidney Int Rep 2021; 6:1788-1798. [PMID: 34307975 PMCID: PMC8258460 DOI: 10.1016/j.ekir.2021.04.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 02/25/2021] [Accepted: 04/12/2021] [Indexed: 12/19/2022] Open
Abstract
Chronic hepatitis C virus (HCV) infection continues to be transmitted to hemodialysis (HD) patients within HD facilities globally. The goal of the World Health Organization to micro-eliminate HCV infection from the HD population by the year 2030 is not on target to be achieved. Obstacles to eliminate HCV in HD settings remain daunting due to a complex system created by a confluence of guidelines, legislation, regulation, and economics. HCV prevalence remains high and seroconversion continues among the HD patient population globally as a result of the HD procedure. Preventive strategies that effectively prevent HCV transmission, treatment-as-prevention, and rapid referral to treatment balanced with kidney transplant candidacy should be added to the current universal precautions approach. A safer system must be designed before HCV transmission can be halted and eliminated from the HD population.
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Affiliation(s)
- Arun Rajasekaran
- Department of Medicine, Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Ricardo A. Franco
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Edgar T. Overton
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Brendan M. McGuire
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Graham C. Towns
- Department of Medicine, Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jayme E. Locke
- Comprehensive Transplant Institute, Department of Medicine and Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Deirdre L. Sawinski
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Emmy K. Bell
- Department of Medicine, Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Thedja MD, Wibowo DP, El-Khobar KE, Ie SI, Setiawan L, Murti IS, Muljono DH. Improving Linkage to Care of Hepatitis C: Clinical Validation of GeneXpert® HCV Viral Load Point-of-Care Assay in Indonesia. Am J Trop Med Hyg 2021; 105:117-124. [PMID: 33999849 PMCID: PMC8274760 DOI: 10.4269/ajtmh.20-1588] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 03/09/2021] [Indexed: 01/07/2023] Open
Abstract
Hepatitis C virus (HCV) infection large-scale diagnosis and treatment are hampered by lack of a simple, rapid, and reliable point-of-care (POC) test, which poses a challenge for the elimination of hepatitis C as a public health problem. This study aimed to evaluate Cepheid Xpert® HCV Viral Load performance in comparison with the Roche Cobas® TaqMan® HCV Test using serum samples of HCV-infected patients in Indonesia. Viral load quantification was performed on 243 anti-HCV positive patients’ samples using both Xpert HCV VL and Roche HCV tests, followed by HCV genotyping by reverse hybridization. Strength of the relationship between the assays was measured by Pearson correlation coefficient, while level of agreement was analyzed by Deming regression and Bland–Altman plot analysis using log10-transformed viral load values. Quantifiable viral load was detected in 180/243 (74.1%), with Xpert HCV VL sensitivity of 100% (95% CI 0.98, 1.00) and specificity of 98.4% (95% CI 0.91, 0.99) based on the Roche HCV test, while HCV genotypes were determined in 172/180 (95.6%) samples. There was a good correlation between both assays (r = 0.97, P < 0.001), overall and per genotype, with good concordance by Deming regression and a mean difference of −0.25 log10 IU/mL (95% CI −0.33, −0.18) by Bland–Altman plot analysis. Xpert HCV VL test was demonstrated as a POC platform with good performance for HCV diagnosis and treatment decision that would be beneficial for decentralized services in resource-limited areas. HCV testing sites, alongside additional GeneXpert modular systems distributed toward the fight against COVID-19, could ensure some continuity, once this pandemic is controlled.
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Affiliation(s)
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- 1Eijkman Institute for Molecular Biology, Jakarta, Indonesia.,2Faculty of Medicine, Universitas Hasanuddin, Makassar, Indonesia
| | - Lyana Setiawan
- 3Virology Laboratory, Dharmais National Cancer Hospital, Jakarta, Indonesia
| | - Ignatia Sinta Murti
- 4Division of Gastroenterology, Department of Internal Medicine, Abdoel Wahab Sjahranie Regional General Hospital, Samarinda, Indonesia
| | - David Handojo Muljono
- 1Eijkman Institute for Molecular Biology, Jakarta, Indonesia.,2Faculty of Medicine, Universitas Hasanuddin, Makassar, Indonesia.,5Faculty of Medicine and Health, University of Sydney, New South Wales, Australia
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17
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Vergara M, Miquel M, Vela E, Cleries M, Pontes C, Prat A, Rué M. Use of healthcare resources and drug expenditure before and after treatment of chronic hepatitis C with direct antiviral agents. J Viral Hepat 2021; 28:728-738. [PMID: 33555102 DOI: 10.1111/jvh.13479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 01/23/2021] [Indexed: 12/09/2022]
Abstract
The aim of this study was to analyse the impact of treating chronic hepatitis C (CHC) with direct-acting agents (DAA) on the use of healthcare resources. We included all patients treated with DAA for CHC from January 2015 to December 2017 in Catalonia whose medical records from 12 months before to 24 months after treatment were available. Data were obtained from the Catalan Health Surveillance System. A total of 12,199 patients in Catalonia were treated with DAA for CHC. Of these, 11.3% had no-minimal fibrosis (F0-F1), 24.0% had moderate fibrosis (F2), 50.3% had significant fibrosis or cirrhosis (F3-F4), and 14.4% had decompensated cirrhosis. Use of healthcare resources decreased from the pre-treatment period to the post-treatment period for the following: hospital admissions due to complications of cirrhosis, from 0.19 to 0.12 per month per 100 patients (RR 0.57; 95% CI 0.47-0.68); length of hospital stay, from 12.9 to 12.2 days (RR 0.93; 95% CI 0.91-0.94); outpatient visits, from 65.0 to 49.2 (RR 0.75; 95% CI 0.74-0.75); and number of medication containers per patient per month, from 13.9 to 12.5 (RR 0.837; 95% CI 0.835-0.838). However, the number of invoices for antineoplastic treatment increased after DAA treatment, especially for patients with high morbidity or advanced fibrosis stage. In conclusion, a decrease in health resource use was seen in CHC patients treated with DAA, as measured by length of hospital stay, number of admissions due to cirrhosis complications, outpatient visits and overall drug invoicing. However, use of antineoplastic drugs increased significantly, especially in patients with cirrhosis and high morbidity.
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Affiliation(s)
- Mercedes Vergara
- Unitat d'Hepatologia, Servei d'Aparell Digestiu, Parc Taulí Sabadell Hospital Universitari, Institut d'Investigació i Innovació I3PT, Universitat Autònoma de Barcelona, Sabadell, Barcelona, Spain.,Departament de Medicina, Universitat Autònoma de Barcelona, Sabadell, Barcelona, Spain.,CIBERehd, Instituto Carlos III, Madrid, Spain
| | - Mireia Miquel
- Unitat d'Hepatologia, Servei d'Aparell Digestiu, Parc Taulí Sabadell Hospital Universitari, Institut d'Investigació i Innovació I3PT, Universitat Autònoma de Barcelona, Sabadell, Barcelona, Spain.,Departament de Medicina, Universitat Autònoma de Barcelona, Sabadell, Barcelona, Spain.,CIBERehd, Instituto Carlos III, Madrid, Spain
| | - Emili Vela
- Unitat d'informació i Coneixement, Servei Català de la Salut, Barcelona, Spain
| | - Montserrat Cleries
- Unitat d'informació i Coneixement, Servei Català de la Salut, Barcelona, Spain
| | - Caridad Pontes
- Gerència del Medicament, Àrea Assistencial, Servei Català de la Salut, Barcelona, Spain.,Departament de Farmacologia, de Terapèutica i de Toxicologia, Universitat Autònoma de Barcelona, Sabadell, Barcelona, Spain
| | - Alba Prat
- Gerència del Medicament, Àrea Assistencial, Servei Català de la Salut, Barcelona, Spain
| | - Montse Rué
- Basic Medical Sciences Department, University of Lleida, Lleida, Spain
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18
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Yuasa A, Yonemoto N, Demiya S, Foellscher C, Ikeda S. Investigation of Factors Considered by Health Technology Assessment Agencies in Eight Countries. PHARMACOECONOMICS - OPEN 2021; 5:57-69. [PMID: 33108616 PMCID: PMC7895890 DOI: 10.1007/s41669-020-00235-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 10/03/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Health technology assessment (HTA) organizations play a crucial role in optimizing healthcare resources, but the factors influencing decision making vary by country. OBJECTIVE HTAs of cancer and hepatitis C drugs were evaluated across developed countries to understand differences in decision processes and criteria. METHODS The HTA organizations evaluated are from France, Germany, Italy, Spain, the United Kingdom (UK), Australia, Canada and Japan. Economic evaluation types and 28 factors in the following categories were evaluated: clinical uncertainties/issues; disease/population/treatment consideration factors including National Institute for Health and Care Excellence's (NICE) special circumstances factors (e.g. end-of-life and innovation); and International Society for Pharmacoeconomics and Outcomes Research (ISPOR) additional value elements. Qualitative and correspondence analyses were conducted to assess the differences across organizations. RESULTS Incremental cost-effectiveness ratio (ICER) using quality-adjusted life-year (QALY) was evaluated in Canada, the UK, Australia and Japan. The highest observed clinical uncertainties were clinical benefits and comparator. For cancer drugs, correspondence analysis showed France, Australia, Canada and the UK to have common attributes observed, such as unmet needs and stakeholder persuasion. In addition, the UK reported end-of-life, issues around current treatment and innovation, whereas Germany reported manageable/insignificant adverse events more frequently. Finally, fear of contagion, equity and scientific spillover value elements were only observed in Australia. CONCLUSION Although clinical factors play a predominant role in the decision to reimburse medicine, HTA organizations consider additional aspects as well. If the methodology of HTA was clearly outlined, there would be more transparency in HTA systems leading to better understanding amongst stakeholders about decision making.
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Affiliation(s)
- Akira Yuasa
- Pfizer Japan Inc, Tokyo, Japan
- Graduate School of Medicine, International University of Health and Welfare, 1-26, Akasaka 4-chome, Minato-ku, Tokyo, 107-8402, Japan
| | | | | | | | - Shunya Ikeda
- Graduate School of Medicine, International University of Health and Welfare, 1-26, Akasaka 4-chome, Minato-ku, Tokyo, 107-8402, Japan.
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19
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Nabulsi NA, Martin MT, Sharp LK, Koren DE, Teply R, Zuckerman A, Lee TA. Predicting Treatment Failure for Initiators of Hepatitis C Virus Treatment in the era of Direct-Acting Antiviral Therapy. Front Pharmacol 2020; 11:551500. [PMID: 33364936 PMCID: PMC7751639 DOI: 10.3389/fphar.2020.551500] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 10/05/2020] [Indexed: 12/18/2022] Open
Abstract
Introduction: Hepatitis C virus (HCV), the leading cause of advanced liver disease, has enormous economic burden. Identification of patients at risk of treatment failure could lead to interventions that improve cure rates. Objectives: Our goal was to develop and evaluate a prediction model for HCV treatment failure. Methods: We analyzed HCV patients initiating direct-acting antiviral therapy at four United States institutions. Treatment failure was determined by lack of sustained virologic response (SVR) 12 weeks after treatment completion. From 20 patient-level variables collected before treatment initiation, we identified a subset associated with treatment failure in bivariate analyses. In a derivation set, separate predictive models were developed from 100 bootstrap samples using logistic regression. From the 100 models, variables were ranked by frequency of selection as predictors to create four final candidate models, using cutoffs of ≥80%, ≥50%, ≥40%, and all variables. In a validation set, predictive performance was compared across models using area under the receiver operating characteristic curve. Results: In 1,253 HCV patients, overall SVR rate was 86.1% (95% CI = 84.1%, 88.0%). The AUCs of the four final candidate models were: ≥80% = 0.576; ≥50% = 0.605; ≥40% = 0.684; all = 0.681. The best performing model (≥40%) had significantly better predictive ability than the ≥50% (p = 0.03) and ≥80% models (p = 0.02). Strongest predictors of treatment failure were older age, history of hepatocellular carcinoma, and private (vs. government) insurance. Conclusion: This study highlighted baseline factors associated with HCV treatment failure. Treatment failure prediction may facilitate development of data-driven clinical tools to identify patients who would benefit from interventions to improve SVR rates.
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Affiliation(s)
- Nadia A Nabulsi
- University of Illinois at Chicago College of Pharmacy, Chicago, IL, United States
| | - Michelle T Martin
- University of Illinois at Chicago College of Pharmacy, Chicago, IL, United States.,University of Illinois Hospital and Health Sciences System, Chicago, IL, United States
| | - Lisa K Sharp
- University of Illinois at Chicago College of Pharmacy, Chicago, IL, United States
| | - David E Koren
- Temple University Hospital, Philadelphia, PA, United States
| | - Robyn Teply
- Creighton University School of Pharmacy and Health Professions, Omaha, NE, United States
| | - Autumn Zuckerman
- Vanderbilt University Medical Center - Specialty Pharmacy Services, Nashville, TN, United States
| | - Todd A Lee
- University of Illinois at Chicago College of Pharmacy, Chicago, IL, United States
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20
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Zhao Q, Jiang S, Li M, Yao L, Ma X, Li M, Wang C, Pan Y, Zhao H, Li B. Incidence trend and age-period-cohort analysis of reported hepatitis C among residents aged 30 to 79 in northeastern China, 2008 to 2017. Medicine (Baltimore) 2020; 99:e22005. [PMID: 32899048 PMCID: PMC7478665 DOI: 10.1097/md.0000000000022005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The purpose of this study was to acquire the epidemic trend of age-standardized reported incidence and to analyze the age effect, period effect, and cohort effect on the reported incidence of hepatitis C in Jilin Province, China.We collected the annual reported incidence data of hepatitis C by gender (2008-2017). Annual percentage change and annual average percentage change were calculated by joinpoint Poisson regression analysis. The age effect, period effect, and cohort effect on the incidence of hepatitis C were estimated by an age-period-cohort model, and the relative risk was determined.Joinpoint regression analysis showed that the age-standardized reported incidence of hepatitis C indicated a declining trend integrally. Among people aged 30 to 44 (youth), the incidence trend declined the fastest, while trends declined the slowest among women and the overall population aged over 66 (elderly people) and men aged 45 to 65 (middle-aged group). The results of the age-period-cohort model showed that the reported incidence increased first and then decreased with age. Throughout the period, the risk of hepatitis C also increased first and then decreased. Compared with the median birth cohort of the same age group, the birth cohort of the patients with the highest incidence of hepatitis C was in the 1930s, followed by the 1940s and 1950s. The birth cohort of the patients with the lowest incidence was in the 1980s, followed by the 1970s and 1960s.Although the overall reported incidence trend of hepatitis C is declining and the risk of the young birth cohort is low, many factors affecting infection and testing with hepatitis C still exist in China. We should focus on high-risk population management and formulate corresponding public health strategies to accelerate the implementation of the global health strategy to eliminate hepatitis C published by the World Health Organization.
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Affiliation(s)
- Qinglong Zhao
- Jilin Provincial Center for Disease Control and Prevention
| | - Shan Jiang
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University
| | - Meina Li
- The First Hospital of Jilin University, Changchun, Jilin, China
| | - Laishun Yao
- Jilin Provincial Center for Disease Control and Prevention
| | - Xiaoyu Ma
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University
| | - Meng Li
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University
| | - Changcong Wang
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University
| | - Yingan Pan
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University
| | - Hantong Zhao
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University
| | - Bo Li
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University
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Machado SM, Vigani AG, Leite AG, Diaz ACM, Ferreira PRA, Carnaúba-Júnior D, Tenore SB, Brandão-Mello CE, Gonzalez MP, Siroma F, Prado KD, Nunes DV, Lisboa-Neto G, Pinho JRR, Malta FM, Azevedo RS, Witkin SS, Mendes-Correa MC. Effectiveness of direct-acting antivirals for hepatitis C virus infection in hepatitis C/HIV coinfected individuals: A multicenter study. Medicine (Baltimore) 2020; 99:e21270. [PMID: 32791706 PMCID: PMC7387014 DOI: 10.1097/md.0000000000021270] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
In a hepatitis C virus (HCV)/HIV-positive Brazilian cohort, evaluate the safety and efficacy of HCV DAAs, the frequency of resistance substitutions in the HCV NS5A and NS5B genes and identify predictors of treatment failure.Retrospective multicenter study of HCV/HIV patients treated with sofosbuvir (SOF)-based regimens at 10 reference centers in Brazil.Clinical and virological data were collected. Genetic diversity in the NS5A and NS5B genes was assessed by direct nucleotide sequencing. The primary outcome was sustained virological response (SVR) 12 weeks after DAA completion.Of 643 HCV/HIV patients analyzed, 74.7% were male, median CD4+ T cell count was 617 cells/mm, 90% had an undetectable HIV viral load. HCV genotype 1 was detected in 80.2%, and 60% were taking at least 1 medication other than antiretroviral drugs during their DAA therapy. Cirrhosis was present in 42%. An SOF/daclatasvir (DCV) regimen was used in most patients (98%). The frequency of NS5A polymorphisms associated with clinically relevant resistance to DCV was 2%; no relevant NS5B variants were identified. The SVR12 rate was 92.8% in an intention to treat (ITT) analysis and 96% in a modified ITT (m-ITT) analysis. AE occurred in 1.6% of patients. By multivariate analysis, therapeutic failure was associated, in the m-ITT analysis, with concomitant use of anticonvulsant drugs (P = .001), age (P = .04), and female gender (P = .04).SOF/DCV regimens were associated with a high SVR rate in an HCV/HIV population. The use of concurrent anticonvulsant drugs and DAAs decreases the chances of achieving an SVR.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | - João Renato R. Pinho
- University of São Paulo School of Medicine, São Paulo
- LIM 07, Institute of Tropical Medicine, São Paulo
| | | | | | - Steven S. Witkin
- Department of Obstetrics and Gynecology, Weill Cornell Medicine, New York, NY
- LIM 52, Institute of Tropical Medicine, São Paulo
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Schwambach KH, Farias MR, Neto GB, Blatt CR. Cost and Effectiveness of the Treatment of Chronic Hepatitis C in Brazil: Real-World Data. Value Health Reg Issues 2020; 23:49-54. [PMID: 32702649 DOI: 10.1016/j.vhri.2020.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 03/09/2020] [Accepted: 05/11/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To introduce and discuss the cost and effectiveness of using sofosbuvir, daclatasvir, and simeprevir antivirals, in combination or not with peginterferon alfa and ribavirin, for the treatment of hepatitis C, as based on real-world data. METHODS We analyzed the treatment and outcomes of 253 patients from a retrospective cohort held in a specialized assistance service in the municipality of Porto Alegre, Brazil. Regarding costs, we considered only the direct costs of the antiviral medications per unit (pills), according to the financial receipts of the public procurements. We calculated the total cost of treatment per individual and the cost per cure expressed in sustained virologic response (SVR). RESULTS Most patients (66.8%) were carriers of the genotype 1 of hepatitis, and 92.9% reached the SVR. The average cost of the treatment for genotype-1 patients was $5,862.31 USD per patient and $6,310.34 for the cure; for genotype-3 patients, on the other hand, the cost was $5,144.27 per patient and $5,974.76 for the cure. The drugs purchasing cost was around 40% less than was estimated for the process of incorporating them into the public health system. CONCLUSION The results indicated that good rates of effectiveness were achieved with different combinations of the medicines. The costs of the medicines were still deemed too high for the Brazilian reality, however. Therefore the results contribute to support the formulation and review of public policies based on strong evidence and on real-world data for the treatment of hepatitis C.
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Affiliation(s)
- Karin Hepp Schwambach
- Graduate Program in Medicine Hepatology, Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil.
| | - Mareni Rocha Farias
- Graduate Program of Pharmacy, Federal University of Santa Catarina, Florianópolis, Brazil
| | | | - Carine Raquel Blatt
- Graduate Program in Medicine Hepatology, Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil
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23
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Falade-Nwulia O, Ward KM, McCormick S, Mehta SH, Pitts SR, Katz S, Chander G, Thomas DL, Sulkowski M, Latkin CA. Network-based recruitment of people who inject drugs for hepatitis C testing and linkage to care. J Viral Hepat 2020; 27:663-670. [PMID: 32045086 PMCID: PMC7299737 DOI: 10.1111/jvh.13274] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 01/15/2020] [Accepted: 01/22/2020] [Indexed: 12/13/2022]
Abstract
Although oral direct-acting agent (DAA) therapies have the potential to reduce the burden of hepatitis C virus (HCV) infection, treatment uptake remains low, particularly among people who inject drugs (PWID). This study examined the feasibility of an innovative peer-based recruitment strategy to engage PWID in HCV testing and treatment. We interviewed an initial set of HCV antibody-positive PWID as 'primary indexes' to gather demographic, drug use, health information and drug network characteristics. Primary indexes were then briefly educated on HCV and its treatment and encouraged to recruit their injection drug 'network members' for HCV testing and linkage to care. Eligible network members were enrolled as 'secondary indexes' and completed the same index study procedures. In sum, 17 of 36 primary indexes initiated the recruitment of 64 network members who were HCV antibody positive and eligible to become indexes. In multivariable analysis, successful recruitment of at least one network member was positively associated with prior HCV treatment (OR 2.80; CI [1.01, 7.72]), daily or more injection drug use (OR 2.38; CI [1.04, 5.47]), and a higher number of injection drug network members (OR 1.20; CI [1.01, 1.42]). Among the 69 participants with chronic HCV not previously linked to HCV care at enrolment, 91% (n = 63) completed a linkage to HCV care appointment, 45% (n = 31) scheduled an appointment with an HCV provider, and 20% (n = 14) initiated HCV therapy. These findings suggest a potential benefit for peer-driven, network-based interventions focused on HCV treatment-experienced PWID as a mechanism to increase HCV linkage to care.
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Affiliation(s)
| | | | - Sean McCormick
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Shruti H. Mehta
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Stephanie Katz
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - David L. Thomas
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mark Sulkowski
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Carl A. Latkin
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
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24
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Jung J, Feldman R, Kalidindi Y, Riley T. Association of Direct-Acting Antiviral Therapy for Hepatitis C With After-Treatment Costs Among Medicare Beneficiaries. JAMA Netw Open 2020; 3:e208081. [PMID: 32602909 PMCID: PMC7327546 DOI: 10.1001/jamanetworkopen.2020.8081] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022] Open
Abstract
IMPORTANCE Direct-acting antiviral (DAA) therapy for hepatitis C is highly effective but expensive. Evidence is scarce on whether DAA therapy reduces downstream medical costs. OBJECTIVE To examine the association of DAA therapy with posttreatment medical costs among Medicare beneficiaries. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study obtained data from various Medicare claims files for 2013 to 2017. The study population comprised patients with a hepatitis C diagnosis in 2014 who were enrolled in fee-for-service Medicare and Part D. Multivariate regression models were used to compare changes in medical costs over a 30-month posttreatment follow-up period between patients who used DAA therapy (treatment group) and a propensity score-matched cohort of patients who did not use DAA (control group). The model was estimated separately for patients with and those without cirrhosis. Data were analyzed between September 1, 2019, and March 31, 2020. EXPOSURES Completion of DAA therapy. MAIN OUTCOMES AND MEASURES Two outcomes were established: hepatitis C or liver disease-related costs and total medical costs. Costs were measured by Medicare-allowed payments, which included Medicare reimbursements, patient responsibilities, and third-party payments. RESULTS A propensity score-matched cohort of 15 198 patients (9038 men [59.5%]; mean [SD] age, 60.2 [10.8] years) was analyzed. During the first 6 months after DAA therapy, hepatitis C or liver disease-related costs decreased by $2498 (95% CI, -$3356 to -$1640) in patients with cirrhosis and by $486 (95% CI, -$603 to -$369) in patients without cirrhosis compared with control or untreated patients. Cumulative reductions in hepatitis C or liver disease-related costs during 30 months after DAA treatment were $15 808 (95% CI, -$22 530 to -$9085) in patients with cirrhosis and $5372 (95% CI, -$6384 to -$4360) in patients without cirrhosis. Among those who used DAA therapy compared with control patients, total medical costs decreased by $2905 (95% CI, -$4832 to -$979) in patients with cirrhosis and by $1287 (95% CI, -$2393 to -$283) in patients without cirrhosis during the first 6 months after DAA therapy. No statistically significant association was found between DAA therapy and total medical cost reductions after 12 months of follow-up. Cumulative reductions in total costs during 30 months after DAA therapy were $7074 (95% CI, -$18 448 to $4298) in patients with cirrhosis and $7497 (95% CI, -$14 287 to -$709) in patients without cirrhosis. CONCLUSIONS AND RELEVANCE This study reported that DAA therapy appeared to be associated with a decrease in hepatitis C or liver disease-related costs for 30 months after treatment and with reduction in total medical costs for only 12 months after treatment in patients with or without cirrhosis. Longer-term follow-up studies with diverse outcomes are necessary to assess the value of DAA therapy.
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Affiliation(s)
- Jeah Jung
- Department of Health Policy and Administration, The Pennsylvania State University College of Health and Human Development, University Park
| | - Roger Feldman
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis
| | - Yamini Kalidindi
- Department of Health Policy and Administration, The Pennsylvania State University College of Health and Human Development, University Park
| | - Thomas Riley
- Department of Medicine, The Pennsylvania State University College of Medicine, Hershey
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25
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Schreiner AD, Bian J, Zhang J, Haulsee ZM, Marsden J, Durkalski-Mauldin V, Mauldin PD, Moran WP, Rockey DC. The Association of Abnormal Liver Tests with Hepatitis C Testing in Primary Care. Am J Med 2020; 133:214-221.e1. [PMID: 31369723 PMCID: PMC6980508 DOI: 10.1016/j.amjmed.2019.07.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 06/27/2019] [Accepted: 07/01/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND As hepatitis C virus birth cohort (1945-1965) screening in primary care improves, testing patterns in response to persistently abnormal liver tests are less well known. METHODS This retrospective cohort study of a patient-centered medical home between 2007 and 2016 evaluates the association of abnormal liver chemistries and other clinical and demographic factors with hepatitis C antibody (HCV Ab) testing in patients with persistently abnormal liver tests. Patients with at least 2 consecutive abnormal liver tests were categorized by the clinical pattern of liver chemistry abnormality, including cholestatic, hepatocellular, and mixed patterns. The primary outcomes were: 1) completed HCV Ab tests; and 2) positive HCV Ab results for those patients tested. RESULTS Of 4512 patients with consecutive abnormal liver tests, only 730 (16%) underwent HCV Ab testing within 1 year of the second abnormality; 81/730 (11%) had HCV Ab detected. A logistic regression model revealed that mixed (odds ratio [OR] 2.20; 95% confidence interval [CI], 1.72-2.82) and hepatocellular (OR 1.43; 95% CI, 1.15-1.79) patterns of liver test abnormality, female sex, and alcohol and tobacco abuse were associated with higher odds of HCV Ab testing. Hepatocellular (OR 7.51; 95% CI, 2.18-25.94) and mixed patterns (OR 5.88; 95% CI, 1.64-21.15) of liver test abnormalities, male sex, Medicaid enrollment, and drug and tobacco abuse had higher odds of positive HCV Ab results. CONCLUSIONS There is opportunity to improve hepatitis C diagnostic testing in patients with consecutively elevated liver tests, and hepatocellular and mixed patterns of abnormality should prompt primary care providers to action.
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Affiliation(s)
- Andrew D Schreiner
- Department of Medicine, Medical University of South Carolina, Charleston, SC.
| | - John Bian
- Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Jingwen Zhang
- Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Z Merle Haulsee
- Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Justin Marsden
- Department of Medicine, Medical University of South Carolina, Charleston, SC
| | | | - Patrick D Mauldin
- Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - William P Moran
- Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Don C Rockey
- Department of Medicine, Medical University of South Carolina, Charleston, SC
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26
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Beheshti D. Adverse health effects of abuse-deterrent opioids: Evidence from the reformulation of OxyContin. HEALTH ECONOMICS 2019; 28:1449-1461. [PMID: 31715653 DOI: 10.1002/hec.3944] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 06/22/2019] [Accepted: 07/28/2019] [Indexed: 05/26/2023]
Abstract
The United States is currently in the midst of the worst drug epidemic in its history, with nearly 64,000 overdose deaths in 2016. In response, pharmaceutical companies have begun introducing abuse-deterrent painkillers, pills with properties that make the drug more difficult to misuse. The first such painkiller, a reformulated version of OxyContin, was released in 2010. Previous research has found no net effect on opioid mortality, with users substituting from OxyContin toward heroin. This paper explores health effects of the reformulation beyond mortality. In particular, I show that heroin is substantially more likely to be injected than OxyContin, increasing exposure to blood-borne diseases. Exploiting variation across states in OxyContin misuse prior to the reformulation, I find relative increases in the spread of hepatitis B and C in states most likely to be affected by the reformulation. In aggregate, the estimates suggest that absent the reformulation, we would have observed approximately 76% fewer cases of hepatitis C and 53% fewer cases of hepatitis B from 2011 to 2015. I find some suggestive evidence that the reformulation also lead to increases in HIV and hepatitis A, although these findings are less robust. These findings have important implications for future policies addressing the opioid crisis.
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Affiliation(s)
- David Beheshti
- Department of Economics, University of Texas at Austin, Austin, Texas
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27
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Yang Y, Wu FP, Wang WJ, Shi JJ, Li YP, Zhang X, Dang SS. Real life efficacy and safety of direct-acting antiviral therapy for treatment of patients infected with hepatitis C virus genotypes 1, 2 and 3 in northwest China. World J Gastroenterol 2019; 25:6551-6560. [PMID: 31802834 PMCID: PMC6886016 DOI: 10.3748/wjg.v25.i44.6551] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 11/08/2019] [Accepted: 11/13/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Regimens involving direct-acting antiviral agents (DAAs) are recommended for the treatment of infection with hepatitis C virus (HCV) genotypes 1, 2 and 3. But real-world data is still not enough, especially in Asia.
AIM To investigate the efficacy and safety of DAA-based regimens in a real-life setting in China.
METHODS This study included 366 patients infected with HCV genotypes 1, 2 and 3, with or without cirrhosis, who were observed between May 2015 and December 2018. They were treated with ledipasvir and sofosbuvir (SOF) (genotype 1) with or without ribavirin (RBV), SOF and RBV (genotype 2), or SOF and daclatasvir (genotype 3), with or without RBV, for 12 or more wk. The participants’ sustained virological responses (SVR) at post-treatment week 12 (SVR12) was the primary endpoint. The occurrence of adverse events and drug-drug interactions were recorded.
RESULTS In the 366 patients, genotype 1 (59.0%) was the most common genotype, followed by genotypes 2 (34.4%) and 3 (6.6%). Liver cirrhosis was diagnosed in 154 (42.1%) patients. Fifty (13.7%) patients were treatment-experienced. Intention-to-treat analysis revealed that SVR12 was 86.3% (316/366). For modified intention-to-treat analysis, SVR12 was achieved in 96.6% of overall patients (316/327), 96.3% in patients with genotype 1, 97.5% in those with genotype 2, and 95.0% in those with genotype 3. Most of the treatment failures were due to lack of follow-up (3 cases had non-responses, 1 had virological breakthrough, 11 relapsed and 36 did not participate in the follow-up). There was no significant difference in SVR between different genotypes and liver statuses (P < 0.05). Patients with lower alanine aminotransferase levels at baseline who achieved an end of treatment response were more likely to achieve SVR12 (P < 0.05). High SVR was observed regardless of age, gender, liver status, alpha-fetoprotein, HCV RNA levels or history of antiviral therapy (P > 0.05 for all). The cumulative hepatocellular carcinoma occurrence and recurrence rate after using the DAAs was 0.9%. Most of the adverse events were mild. We found two cases of special adverse events. One case involved facial and bilateral lower extremity edema, and the other case showed an interesting change in lipid levels while on medication. No severe adverse events were noted.
CONCLUSION The DAA-based regimens tested in this study have excellent effectiveness and safety in all patients infected with HCV genotypes 1, 2 and 3, including those with cirrhosis.
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Affiliation(s)
- Ying Yang
- Department of Infectious Diseases, the Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710004, Shaanxi Province, China
| | - Feng-Ping Wu
- Department of Infectious Diseases, the Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710004, Shaanxi Province, China
| | - Wen-Jun Wang
- Department of Infectious Diseases, the Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710004, Shaanxi Province, China
| | - Juan-Juan Shi
- Department of Infectious Diseases, the Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710004, Shaanxi Province, China
| | - Ya-Ping Li
- Department of Infectious Diseases, the Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710004, Shaanxi Province, China
| | - Xin Zhang
- Department of Infectious Diseases, the Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710004, Shaanxi Province, China
| | - Shuang-Suo Dang
- Department of Infectious Diseases, the Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710004, Shaanxi Province, China
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28
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Younossi ZM, Stepanova M, Asselah T, Foster G, Patel K, Bräu N, Swain M, Tran T, Esteban R, Colombo M, Pianko S, Henry L, Bourliere M. Hepatitis C in Patients With Minimal or No Hepatic Fibrosis: The Impact of Treatment and Sustained Virologic Response on Patient-Reported Outcomes. Clin Infect Dis 2019; 66:1742-1750. [PMID: 29272349 DOI: 10.1093/cid/cix1106] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 12/16/2017] [Indexed: 12/14/2022] Open
Abstract
Background While the necessity of treatment of hepatitis C virus (HCV)-infected patients with advanced liver disease is widely accepted, the benefit of treating patients without significant liver disease is less well established. Our aim was to assess the effect of treating HCV in patients with no or minimal fibrosis (Metavir stage F0-F1) on patient-reported outcomes (PROs). Methods HCV-infected patients with F0-F1 from 16 clinical trials were included. PROs were collected before, during, and after treatment. Results A total of 1548 HCV-infected patients with F0-F1 were included (mean age 46 years, 43% male, 81% treatment-naive). Patients were treated with interferon (IFN) + sofosbuvir (SOF) + ribavirin (RBV) (n = 91) or SOF + RBV with or without ledipasvir (n = 479) or IFN- and RBV-free regimens with SOF + ledipasvir or SOF + velpatasvir or SOF + velpatasvir + voxilaprevir (n = 978). By the end of treatment, patients receiving IFN-containing regimens experienced significant decreases in most PRO domains (-4.5 to -28.7 on a 0-100 scale), while subjects treated with IFN-free RBV-containing regimens had a modest impairment (-2.3 to -8.9) (P ≤ .01). In contrast, treatment with regimens without IFN and RBV led to PRO improvements (+1.2 to +10.9). Regardless of the regimen, sustained virologic responses (SVRs) at 12 and 24 weeks were universally associated with PRO improvements (+2.1 to +14.7, P < .0001. Conclusions HCV-infected subjects with no or minimal fibrosis treated with IFN- and RBV-free regimens experienced on-treatment and post-SVR PRO improvements.
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Affiliation(s)
- Zobair M Younossi
- Center for Liver Diseases, Department of Medicine, Inova Fairfax Hospital, Falls Church, Virginia.,Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, Virginia
| | - Maria Stepanova
- Center for Outcomes Research in Liver Disease, Washington, D.C
| | - Tarik Asselah
- Centre de Recherche sur l'Inflammation, Institut national de la santé et de la recherche médicale, Unité mixte de recherche, Université Paris Diderot, Department of Hepatology, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy, France
| | | | - Keyur Patel
- Toronto Center for Liver Disease, University of Toronto, Ontario, Canada
| | - Norbert Bräu
- James J. Peters Veterans Affairs Medical Center, New York, New York
| | - Mark Swain
- Calgary Liver Unit, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Tram Tran
- Liver Transplantation, Cedars-Sinai Medical Center, Los Angeles, California
| | - Rafael Esteban
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebron and Universitat Autònoma de Barcelona, Spain
| | - Massimo Colombo
- Humanitas Clinical and Research Center, Humanitas Research Hospital, Rozzano, Italy
| | - Stephen Pianko
- Department of Gastroenterology, Monash Health, Melbourne, Victoria, Australia
| | - Linda Henry
- Center for Outcomes Research in Liver Disease, Washington, D.C
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Health-related Quality of Life in Nonalcoholic Fatty Liver Disease Associates With Hepatic Inflammation. Clin Gastroenterol Hepatol 2019; 17:2085-2092.e1. [PMID: 30580090 DOI: 10.1016/j.cgh.2018.12.016] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 11/17/2018] [Accepted: 12/14/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Chronic liver disease has negative effects on health-related quality of life (HRQL). We analyzed data from the European non-alcoholic fatty liver disease (NAFLD) registry to assess the effects of NAFLD on HRQL. METHODS We collected data from 304 patients (mean age, 52.3 ± 12.9 years) with histologically defined NAFLD enrolled prospectively into the European NAFLD Registry in Germany, the United Kingdom, and Spain. The chronic liver disease questionnaire (CLDQ) was completed within 6 months of liver biopsy collection. RESULTS The mean CLDQ overall score was 5.0 ± 1.2, with the lowest score in the category fatigue (4.3 ± 1.6) and the highest scores for activity (5.4 ± 1.4). Women had significantly lower CLDQ scores than men (4.6 ± 1.3 vs 5.3 ± 1.1; P < .001). We found negative correlations between CLDQ scores and presence of obesity (P < .001), type 2 diabetes (P < .001), and dyslipidaemia (P < .01). There was a negative correlation between level of aspartate aminotransferase, but not alanine aminotransferase, and HRQL. Higher histological score of steatosis (1 vs 3) resulted in lower mean CLDQ score (5.3 ± 1.1 vs 4.5 ± 1.4; P < .01); higher level of lobular inflammation (0 vs 3) also resulted in lower mean CLDQ score (5.3 ± 1.2 vs 3.9 ± 1.8; P <. 001). In contrast, advanced fibrosis (F3-4) compared to early or intermediate fibrosis (F0-2) had no significant effect on mean CLDQ score (4.9 ± 1.2 vs 5.1 ± 1.3; P = .072). In multivariate analysis, patients sex, age, presence of type 2 diabetes, and inflammation were independently associated with low HRQL. CONCLUSION In an analysis of data from the European NAFLD registry, we observed a substantial burden of symptoms in patients. In addition to age, sex, and the presence of diabetes, detection of lobular inflammation in biopsies correlated with lower HRQL.
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30
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Skill NJ, Butler J, O’Brien DC, Kays JK, Kubal CA, Liangpunsakul S, Ninad N, Maluccio MA. Financial Burden of Liver Transplant vs Resection for Hepatocellular Carcinoma. Transplant Proc 2019; 51:1907-1912. [DOI: 10.1016/j.transproceed.2019.04.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 04/22/2019] [Indexed: 02/07/2023]
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31
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Vij N. Delaware and Hepatitis C:: Is it time for universal screening? Dela J Public Health 2019; 5:46-47. [PMID: 34467028 PMCID: PMC8396748 DOI: 10.32481/djph.2019.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
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32
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Comparison of prevention, screening and treatment of hepatitis C in Iran, Egypt and Georgia. J Virus Erad 2019. [DOI: 10.1016/s2055-6640(20)30053-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Younossi ZM, Henry L, P Ong J, Tanaka A, Eguchi Y, Mizokami M, Lim YS, Dan YY, Yu ML, Stepanova M. Systematic review with meta-analysis: extrahepatic manifestations in chronic hepatitis C virus-infected patients in East Asia. Aliment Pharmacol Ther 2019; 49:644-653. [PMID: 30761562 DOI: 10.1111/apt.15131] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 08/21/2018] [Accepted: 12/16/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Although the prevalence of extrahepatic manifestations of chronic hepatitis C virus (HCV) infection has been reported from Western countries, their prevalence in East Asian countries is not well known. AIM To perform a systematic review to quantify the prevalence of selected extrahepatic manifestations of HCV among patients from East Asia. METHODS Medline, CINAHL, EMBASE, Cochrane and country-specific databases were reviewed according to standard guidelines for meta-analyses. Only articles with patients from East Asian countries were included. RESULTS After review, 34 articles were selected (Japan = 9; China = 5, Korea = 3, Taiwan = 16, multiple countries = 1) with 646 228 subjects, 66 436 with HCV. Mean age for HCV-infected patients was 56 years (range 41-72 years), 50% were male (range 26%-73%). The pooled prevalence of type 2 diabetes in East Asian HCV patients was 19.0% (95% confidence interval 15.6%-22.9%) (n = 19 studies) with an increased risk when compared to non-HCV: odds ratio (OR) 1.58 (1.28-1.94). The prevalence of chronic kidney disease in HCV was 9.2% (5.0%-16.2%) (n = 7 studies), also with a significantly increased risk: OR=1.98 (1.41-2.77). Pooled prevalence of cardiovascular disease in HCV was 8.6% (3.5%-19.9%) (n = 6 studies), also with an increased risk: OR = 1.55 (1.21-1.98). The prevalence of lichen planus in HCV was 8.9% (3.6%-20.6%) (n = 6 studies) while the prevalence of rheumatoid arthritis was 4.5% (0.6%-25.7%) (n = 4 studies). CONCLUSIONS These data show increased risk of developing extrahepatic manifestations in East Asian patients with HCV. Both hepatic and extrahepatic manifestations of the infection should be used to accurately determine the total burden of the disease in the region.
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Byenfeldt M, Elvin A, Fransson P. Influence of Probe Pressure on Ultrasound-Based Shear Wave Elastography of the Liver Using Comb-Push 2-D Technology. ULTRASOUND IN MEDICINE & BIOLOGY 2019; 45:411-428. [PMID: 30401508 DOI: 10.1016/j.ultrasmedbio.2018.09.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 09/25/2018] [Accepted: 09/26/2018] [Indexed: 06/08/2023]
Abstract
It has been postulated that in the liver, applying increased probe pressure during ultrasound-based shear wave elastography (SWE) might lead to a false increase in the SWE result. We aimed to determine the influence of increased intercostal probe pressure when performing SWE of the liver. We also investigated the number of measurements required to achieve technically successful and reliable SWE examinations. This prospective, clinical study included 112 patients and 2240 SWE measurements of the liver. We applied probe pressure intercostally, to reduce the skin-to-liver capsule distance (SCD), which could stabilize the SWE signal and thus increase the number of technically successful measurements. We performed 10 measurements with maximum probe pressure and 10 with normal pressure in each patient. Thus, two analysis groups were compared for differences. Compared with normal pressure, maximum probe pressure significantly reduced the SCD (p < 0.001) and significantly increased the number of technically successful measurements from 981 to 1098, respectively (p < 0.001). The SWE results with normal and maximum probe pressure were 5.96 kPa (interquartile range: 2.41) and 5.45 kPa (interquartile range: 1.96), respectively (p < 0.001). In obese patients, a large SCD poses a diagnostic challenge for ultrasound SWE. We found that maximum intercostal probe pressure could reduce the SCD and increase the number of technically successful measurements, without falsely increasing the SWE result. Only three measurements were required to achieve technically successful and reliable SWE examinations.
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Affiliation(s)
| | - Anders Elvin
- Department of Molecular Medicine and Surgery, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - Per Fransson
- Department of Nursing, Umeå University, Umeå, Sweden
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Behzadifar M, Gorji HA, Rezapour A, Behzadifar M, Bragazzi NL. The role of insurance providers in supporting treatment and management of hepatitis C patients. BMC Health Serv Res 2019; 19:25. [PMID: 30630488 PMCID: PMC6329117 DOI: 10.1186/s12913-019-3869-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 01/04/2019] [Indexed: 01/18/2023] Open
Abstract
Today, one of the most important global public health challenges is represented by hepatitis C virus (HCV), which imposes relevant costs. Globally speaking, the median cost of HCV-related complications ranges from $280 for an uncomplicated hepatitis to $139,070 for a liver transplantation. There are effective therapies for HCV patients worldwide, which has increased the hope of improving the process of managing and curing these patients. The adherence of patients to the pharmacological treatment and the use of effective drugs in the management of HCV disease are of crucial importance for health policy- and decision-makers. Studies show that, globally, insurance coverage for patients with HCV is not adequate in that still many patients are not covered by insurance programs. This issue as well as the economic conditions of countries are very serious challenges for ensuring an effective treatment. The most important and greatest help currently available to ensure HCV treatment is to implement plans to reduce costs and support patients. Some studies have shown that the expansion of coverage by private payers seems able to generate positive spillover benefits to public insures. Insurers, in addition to maintaining and increasing their own interests, are trying to increase their social status as a sponsor of patients. In conclusion, HCV disease requires serious policies and affordable insurance coverage.
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Affiliation(s)
- Masoud Behzadifar
- Department of Health Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Hasan Abolghasem Gorji
- Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran.
| | - Aziz Rezapour
- Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Meysam Behzadifar
- Social Determinants of Health Research Center, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Nicola Luigi Bragazzi
- School of Public Health, Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
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Quinn K, Fong C, Guarino H, Mateu-Gelabert P. Development, validation, and potential applications of the hepatitis C virus injection-risk knowledge scale (HCV-IRKS) among young opioid users in New York City. Drug Alcohol Depend 2019; 194:453-459. [PMID: 30503906 PMCID: PMC6312493 DOI: 10.1016/j.drugalcdep.2018.11.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 11/20/2018] [Accepted: 11/23/2018] [Indexed: 01/18/2023]
Abstract
BACKGROUND Hepatitis C virus (HCV) incidence has increased dramatically in the United States in recent years and is associated with the opioid epidemic due to high HCV transmission risk among people who inject drugs (PWID). HCV transmission knowledge is difficult to ascertain given the lack of psychometrically-tested measures. We developed and validated an HCV injection-risk knowledge scale. METHODS Analyses used data from 539 New York City opioid users ages 18-29 recruited via respondent-driven sampling in 2014-16. Blood samples yielded HCV antibody status. Principal components analysis (PCA) of nine knowledge items answered true, false, or don't know identified useful scale items. We evaluated internal consistency with the Cronbach's alpha coefficient and assessed construct validity by comparing knowledge levels with those from a previously validated general HCV knowledge scale and by comparing key sub-group knowledge levels. RESULTS PCA identified one component with five items that explained 45% of the total variance and had high internal consistency (alpha=0.91). All items referred to transmission through drug-injection equipment and practices: sharing cookers, cottons, diluting water, water containers, and cleaning syringes with water. The mean percent correct was 75%, and as expected, was moderately correlated with general HCV knowledge (Spearman's rho=0.55). As hypothesized, knowledge levels were highest for those previously tested for HCV, those with HCV antibody-positive status, PWID, and those who had received harm reduction information in various settings. CONCLUSIONS The 5-item, validated HCV Injection-Risk Knowledge Scale (HCV-IRKS) may provide educators, care providers, and researchers with critical information for reducing HCV among PWID.
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Affiliation(s)
- Kelly Quinn
- National Development and Research Institutes, Inc., 71 West 23rd St., 4th Floor, New York, NY, 10010, USA; Behavioral Science Training Program in Drug Abuse Research, NYU Rory Myers College of Nursing, 433 First Ave., New York, NY, 10010, USA; Department of Population Health, NYU Langone Health, 227 E 30th St., New York, NY, 10016, USA.
| | - Chunki Fong
- National Development and Research Institutes, Inc., 71 West 23rd St., 4th Floor, New York, NY, 10010, USA.
| | - Honoria Guarino
- National Development and Research Institutes, Inc., 71 West 23rd St., 4th Floor, New York, NY, 10010, USA.
| | - Pedro Mateu-Gelabert
- National Development and Research Institutes, Inc., 71 West 23rd St., 4th Floor, New York, NY, 10010, USA.
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Buti M, Domínguez-Hernández R, Casado MÁ, Sabater E, Esteban R. Healthcare value of implementing hepatitis C screening in the adult general population in Spain. PLoS One 2018; 13:e0208036. [PMID: 30485377 PMCID: PMC6261617 DOI: 10.1371/journal.pone.0208036] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 11/09/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Elimination of hepatitis C virus (HCV) infection requires high diagnostic rates and universal access to treatment. Around 40% of infected individuals are unaware of their infection, which indicates that effective screening strategies are needed. We analyzed the efficiency (incremental cost-utility ratio, ICUR) of 3 HCV screening strategies: a) general population of adults, b) high-risk groups, and c) population with the highest anti-HCV prevalence plus high-risk groups. METHODS An analytical decision model, projecting progression of the disease over a lifetime, was used to establish the candidate population for HCV screening. HCV data were obtained from the literature: anti-HCV prevalence (0.56%-1.54%), viremic patients (31.5%), and percentage of undiagnosed persons among those with viremia (35%). It was assumed that most patients would be treated and have HCV therapy response (98% SVR); transition probabilities, utilities, and disease management annual costs were obtained from the literature. Efficiency over the life of patients under the National Health System perspective was measured as quality-adjusted life years (QALY) and total cost (screening, diagnosis, pharmacological and disease management). A discount rate of 3% was applied to costs and outcomes. RESULTS Screening of the adult population would identify a larger number of additional chronic hepatitis C cases (N = 52,694) than screening the highest anti-HCV prevalence population plus high-risk groups (N = 42,027) or screening high-risk groups (N = 26,128). ICUR for the general population vs. high-risk groups was €8914/QALY gained per patient (€18,157 incremental cost and 2.037 QALY). ICUR for the general population vs. population with highest anti-HCV prevalence plus high-risk groups was €7,448/QALY gained per patient (€7,733 incremental cost and 1.038 QALY). These ICUR values are below the accepted efficiency threshold (€22,000-€30,000). CONCLUSION HCV screening and treatment of the general adult population is cost-effective compared to screening of high-risk groups or the population with the highest anti-HCV prevalence plus high-risk groups.
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Affiliation(s)
- María Buti
- Hospital General Universitario Vall d'Hebron, CIBERehd, Barcelona, Spain
| | | | | | | | - Rafael Esteban
- Hospital General Universitario Vall d'Hebron, CIBERehd, Barcelona, Spain
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Negro F. Expanded benefits of curing the extrahepatic manifestations of HCV infection. Gut 2018; 67:1917-1919. [PMID: 29871969 DOI: 10.1136/gutjnl-2018-316578] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 03/15/2018] [Accepted: 05/11/2018] [Indexed: 12/29/2022]
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Davis SM, Davidov D, Kristjansson AL, Zullig K, Baus A, Fisher M. Qualitative case study of needle exchange programs in the Central Appalachian region of the United States. PLoS One 2018; 13:e0205466. [PMID: 30312333 PMCID: PMC6185728 DOI: 10.1371/journal.pone.0205466] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 09/25/2018] [Indexed: 02/04/2023] Open
Abstract
Background The Central Appalachian region of the United States is in the midst of a hepatitis C virus epidemic driven by injection of opioids, particularly heroin, with contaminated syringes. In response to this epidemic, several needle exchange programs (NEP) have opened to provide clean needles and other supplies and services to people who inject drugs (PWID). However, no studies have investigated the barriers and facilitators to implementing, operating, and expanding NEPs in less populous areas of the United States. Methods This qualitative case study consisted of interviews with program directors, police chiefs, law enforcement members, and PWID affiliated with two NEPs in the rural state of West Virginia. Interview transcripts were coded inductively and analyzed using qualitative data analysis software. Final common themes related to barriers and facilitators of past program openings, current program operations, and future program plans, were derived through a consensus of two data coders. Results Both NEPs struggled to find existing model programs, but benefited from broad community support that facilitated implementation. The largest operational barrier was the legal conundrum created by paraphernalia laws that criminalize syringe possession. However, both PWID and law enforcement appreciated the comprehensive services provided by these programs. Program location and transportation difficulties were additional noted barriers. Future program operations are threatened by funding shortages and bans, but necessitated by unexpected program demand. Conclusion Despite broad community support, program operations are threatened by growing participant volumes, funding shortages, and the federal government’s prohibition on the use of funds to purchase needles. Paraphernalia laws create a legal conundrum in the form of criminal sanctions for the possession of needles, which may inadvertently promote needle sharing and disease transmission. Future studies should examine additional barriers to using clean needles provided by rural NEPs that may blunt the effectiveness of NEPs in preventing disease transmission.
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Affiliation(s)
- Stephen M. Davis
- Department of Health Policy, Management, and Leadership, West Virginia University, Morgantown, United States of America
- Department of Emergency Medicine, West Virginia University, Morgantown, United States of America
- * E-mail:
| | - Danielle Davidov
- Department of Emergency Medicine, West Virginia University, Morgantown, United States of America
- Department of Social and Behavioral Sciences, West Virginia University, Morgantown, United States of America
| | - Alfgeir L. Kristjansson
- Department of Social and Behavioral Sciences, West Virginia University, Morgantown, United States of America
| | - Keith Zullig
- Department of Social and Behavioral Sciences, West Virginia University, Morgantown, United States of America
| | - Adam Baus
- Department of Social and Behavioral Sciences, West Virginia University, Morgantown, United States of America
| | - Melanie Fisher
- Department of Medicine, Section of Infectious Diseases, West Virginia University, Morgantown, United States of America
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Cacoub P, Bourliere M, Asselah T, De Ledinghen V, Mathurin P, Hézode C, Henry L, Stepanova M, Younossi ZM. French Patients with Hepatitis C Treated with Direct-Acting Antiviral Combinations: The Effect on Patient-Reported Outcomes. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2018; 21:1218-1225. [PMID: 30314623 DOI: 10.1016/j.jval.2018.01.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 01/03/2018] [Accepted: 01/14/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND In addition to high efficacy, new anti-hepatitis C virus (HCV) regimens improve patient-reported outcomes (PROs), which must be considered by policymakers in different countries when deciding upon treatment coverage. OBJECTIVE To assess PROs of French patients with HCV treated with different antiviral regimens. METHODS French patients with HCV from 11 clinical trials were included. PROs were measured before, during, and after treatment (Short Form-36 version 2, Functional Assessment of Chronic Illness Therapy-Fatigue, Chronic Liver Disease Questionnaire-HCV, and Work Productivity and Activity Index: Specific Health Problem). RESULTS A total of 931 subjects (age 54 ± 10 years, 60.3% males, 55% employed, 33.5% cirrhotic, 50% treatment-naive, and 45.6% genotype 1) were treated with a combination of interferon, ribavirin, and sofosbuvir (IFN + RBV + SOF) (N = 11; excluded from comparisons), SOF/RBV ± ledipasvir (LDV) (N = 202), IFN/RBV-free (LDV/SOF, SOF/velpatasvir, or SOF/velpatasvir/voxilaprevir) (N = 594), or placebo (N = 124). The sustained virologic response 12 (SVR-12) rates were 87.1% for IFN-free RBV-containing regimens, 97.6% for IFN/RBV-free regimens, and 0% for placebo. Baseline PRO scores were not different across the treatment groups (all P > 0.10). At the end of treatment, patients treated with IFN-free SOF/RBV ± LDV experienced moderate declines in their PRO scores (up to -7.9% of a PRO range size; P < 0.05), and placebo-treated group did not have significant changes in their PROs (P > 0.05). In contrast, the IFN/RBV-free group experienced significant on-treatment improvement in most PROs (up to +7.9%; P < 0.05). Despite those on-treatment differences, most PROs improved with SVR-12 and SVR-24 regardless of the regimen. In comparison with matched controls from the United States treated with the same regimens, French subjects had lower baseline PROs but similar or greater post-SVR PRO improvements. CONCLUSIONS The use of IFN- and RBV-free regimens leads to significant PRO improvement during treatment and after SVR in French patients with HCV.
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Affiliation(s)
- Patrice Cacoub
- Sorbonne Universités, UPMC Univ Paris 06, UMR 7211, and Inflammation-Immunopathology Biotherapy Department, Paris, France
| | | | | | - Victor De Ledinghen
- Department of Internal Medicine and Clinical Immunology, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | | | | | - Linda Henry
- Center for Outcomes Research in Liver Diseases, Washington, DC, USA
| | - Maria Stepanova
- Center for Outcomes Research in Liver Diseases, Washington, DC, USA
| | - Zobair M Younossi
- Department of Medicine, Center for Liver Diseases, Inova Fairfax Hospital, Falls Church, VA, USA; Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, USA.
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Shiryaev VA, Radchenko EV, Palyulin VA, Zefirov NS, Bormotov NI, Serova OA, Shishkina LN, Baimuratov MR, Bormasheva KM, Gruzd YA, Ivleva EA, Leonova MV, Lukashenko AV, Osipov DV, Osyanin VA, Reznikov AN, Shadrikova VA, Sibiryakova AE, Tkachenko IM, Klimochkin YN. Molecular design, synthesis and biological evaluation of cage compound-based inhibitors of hepatitis C virus p7 ion channels. Eur J Med Chem 2018; 158:214-235. [PMID: 30218908 DOI: 10.1016/j.ejmech.2018.08.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 06/04/2018] [Accepted: 08/03/2018] [Indexed: 12/14/2022]
Abstract
The hepatitis C caused by the hepatitis C virus (HCV) is an acute and/or chronic liver disease ranging in severity from a mild brief ailment to a serious lifelong illness that affects up to 3% of the world population and imposes significant and increasing social, economic, and humanistic burden. Over the past decade, its treatment was revolutionized by the development and introduction into clinical practice of the direct acting antiviral (DAA) agents targeting the non-structural viral proteins NS3/4A, NS5A, and NS5B. However, the current treatment options still have important limitations, thus, the development of new classes of DAAs acting on different viral targets and having better pharmacological profile is highly desirable. The hepatitis C virus p7 viroporin is a relatively small hydrophobic oligomeric viral ion channel that plays a critical role during virus assembly and maturation, making it an attractive and validated target for the development of the cage compound-based inhibitors. Using the homology modeling, molecular dynamics, and molecular docking techniques, we have built a representative set of models of the hepatitis C virus p7 ion channels (Gt1a, Gt1b, Gt1b_L20F, Gt2a, and Gt2b), analyzed the inhibitor binding sites, and identified a number of potential broad-spectrum inhibitor structures targeting them. For one promising compound, the binding to these targets was additionally confirmed and the binding modes and probable mechanisms of action were clarified by the molecular dynamics simulations. A number of compounds were synthesized, and the tests of their antiviral activity (using the BVDV model) and cytotoxicity demonstrate their potential therapeutic usefulness and encourage further more detailed studies. The proposed approach is also suitable for the design of broad-spectrum ligands interacting with other multiple labile targets including various viroporins.
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Affiliation(s)
- Vadim A Shiryaev
- Department of Organic Chemistry, Samara State Technical University, Molodogvardeyskaya 244, Samara, 443100, Russia.
| | - Eugene V Radchenko
- Department of Chemistry, Lomonosov Moscow State University, Leninskie Gory 1/3, Moscow, 119991, Russia
| | - Vladimir A Palyulin
- Department of Chemistry, Lomonosov Moscow State University, Leninskie Gory 1/3, Moscow, 119991, Russia
| | - Nikolay S Zefirov
- Department of Chemistry, Lomonosov Moscow State University, Leninskie Gory 1/3, Moscow, 119991, Russia
| | - Nikolay I Bormotov
- State Research Center of Virology and Biotechnology 'Vector', Koltsovo, Novosibirsk Region, 630559, Russia
| | - Olga A Serova
- State Research Center of Virology and Biotechnology 'Vector', Koltsovo, Novosibirsk Region, 630559, Russia
| | - Larisa N Shishkina
- State Research Center of Virology and Biotechnology 'Vector', Koltsovo, Novosibirsk Region, 630559, Russia
| | - Marat R Baimuratov
- Department of Organic Chemistry, Samara State Technical University, Molodogvardeyskaya 244, Samara, 443100, Russia
| | - Kseniya M Bormasheva
- Department of Organic Chemistry, Samara State Technical University, Molodogvardeyskaya 244, Samara, 443100, Russia
| | - Yulia A Gruzd
- Department of Organic Chemistry, Samara State Technical University, Molodogvardeyskaya 244, Samara, 443100, Russia
| | - Elena A Ivleva
- Department of Organic Chemistry, Samara State Technical University, Molodogvardeyskaya 244, Samara, 443100, Russia
| | - Marina V Leonova
- Department of Organic Chemistry, Samara State Technical University, Molodogvardeyskaya 244, Samara, 443100, Russia
| | - Anton V Lukashenko
- Department of Organic Chemistry, Samara State Technical University, Molodogvardeyskaya 244, Samara, 443100, Russia
| | - Dmitry V Osipov
- Department of Organic Chemistry, Samara State Technical University, Molodogvardeyskaya 244, Samara, 443100, Russia
| | - Vitaliy A Osyanin
- Department of Organic Chemistry, Samara State Technical University, Molodogvardeyskaya 244, Samara, 443100, Russia
| | - Alexander N Reznikov
- Department of Organic Chemistry, Samara State Technical University, Molodogvardeyskaya 244, Samara, 443100, Russia
| | - Vera A Shadrikova
- Department of Organic Chemistry, Samara State Technical University, Molodogvardeyskaya 244, Samara, 443100, Russia
| | - Anastasia E Sibiryakova
- Department of Organic Chemistry, Samara State Technical University, Molodogvardeyskaya 244, Samara, 443100, Russia
| | - Ilya M Tkachenko
- Department of Organic Chemistry, Samara State Technical University, Molodogvardeyskaya 244, Samara, 443100, Russia
| | - Yuri N Klimochkin
- Department of Organic Chemistry, Samara State Technical University, Molodogvardeyskaya 244, Samara, 443100, Russia
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Wurcel AG, Burke DJ, Wang JJ, Engle B, Noonan K, Knox TA, Kim AY, Linas BP. The Burden of Untreated HCV Infection in Hospitalized Inmates: a Hospital Utilization and Cost Analysis. J Urban Health 2018; 95:467-473. [PMID: 30027427 PMCID: PMC6095754 DOI: 10.1007/s11524-018-0277-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Hepatitis C virus (HCV) is highly prevalent in incarcerated populations. The high cost of HCV therapy places a major burden on correctional system healthcare budgets, but the burden of untreated HCV is not known. We investigated the economic impact of HCV through comparison of length of stay (LOS), frequency of 30-day readmission, and costs of hospitalizations in inmates with and without HCV using a 2004-2014 administrative claims database. Inmates with HCV had longer LOS, higher frequency of 30-day readmission, and increased cost of hospitalizations. Costs were higher in inmates with HCV even without advanced liver disease and in inmates with HIV/HCV compared to HCV alone. We conclude that although HCV treatment may not avert all of the observed increases in hospitalization, modest reductions in hospital utilization with HCV cure could help offset treatment costs. Policy discussions on HCV treatment in corrections should be informed by the costs of untreated HCV infection.
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Affiliation(s)
- Alysse G Wurcel
- Division of Geographic Medicine and Infectious Diseases, Department of Medicine, Tufts Medical Center, Boston, USA. .,Department of Public Health and Community Medicine, Tufts University School of Medicine, 136 Harrison Ave, M and V 2nd Floor, Room 234, Boston, MA, 02111, USA.
| | - Deirdre J Burke
- Division of Geographic Medicine and Infectious Diseases, Department of Medicine, Tufts Medical Center, Boston, USA
| | - Jianing J Wang
- Boston Medical Center, Boston University Schools of Medicine and Public Health, Boston, MA, USA
| | - Brian Engle
- Department of Public Health and Community Medicine, Tufts University School of Medicine, 136 Harrison Ave, M and V 2nd Floor, Room 234, Boston, MA, 02111, USA
| | | | - Tamsin A Knox
- Department of Public Health and Community Medicine, Tufts University School of Medicine, 136 Harrison Ave, M and V 2nd Floor, Room 234, Boston, MA, 02111, USA
| | - Arthur Y Kim
- Division of Infectious Diseases, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Benjamin P Linas
- Boston Medical Center, Boston University Schools of Medicine and Public Health, Boston, MA, USA
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Behzadifar M, Gorji HA, Rezapour A, Bragazzi NL, Alavian SM. The role of the Primary Healthcare Network in Iran in hepatitis C virus elimination by 2030. J Virus Erad 2018. [DOI: 10.1016/s2055-6640(20)30265-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Younossi ZM, Stepanova M, Henry L, Han KH, Ahn SH, Lim YS, Chuang WL, Kao JH, Kinh N, Lai CL, Yuen MF, Chan HLY, Lai W. The effect of interferon-free regimens on health-related quality of life in East Asian patients with chronic hepatitis C. Liver Int 2018; 38:1179-1187. [PMID: 29197140 DOI: 10.1111/liv.13650] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 11/26/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Interferon (IFN)-based regimens cause significant impairment of health-related quality of life (HRQL). Hepatitis C virus (HCV) cure with IFN-free regimens improves HRQL. The effect of these regimens on HRQL in East Asian HCV patients is unclear due to lack of published evidence. AIM To assess HRQL in East Asian HCV patients treated with an IFN-free regimen with sofosbuvir+ribavirin. METHODS Patients completed Short Form-36 (SF-36) before, during and after treatment. RESULTS 686 subjects were included (China: 56.7%; S. Korea: 18.8%; Taiwan: 12.7%; genotype 2: 40.8%; genotype 1: 29.6%; genotype 3: 18.4%; genotype 6: 11.2%; cirrhosis: 13.4%; treatment-naïve: 66.5%). Patients received either pegylated-IFN, sofosbuvir, and ribavirin (IFN+SOF+RBV) for 12 weeks (n = 155, genotypes 1 and 6) or SOF+RBV for 12-24 weeks (n = 531, all genotypes). The SVR-12 rates were 95.5% and 96.0%; respectively (P = .76). Baseline HRQL scores were similar between treatment groups (all P > .05). By the end of treatment, the IFN-treated group experienced significant declines in most HRQL scores (on average, by up to -13.3 points on a 0-100 scale from the baseline level, P < .02) while subjects on SOF/RBV had milder impairments (up to -5.4 points). Achieving SVR-12 was associated with HRQL improvement regardless of regimen (up to +2.9 points, P < .05). The use of IFN-free treatment was a consistent independent predictor of higher HRQL scores during treatment (β: +2.1 to +10.7 points, P < .02). CONCLUSIONS East Asian HCV patients treated with an IFN-free regimen had better on-treatment HRQL scores. These data should inform policymakers about the comprehensive benefits of IFN-free regimens in East Asian patients with HCV.
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Affiliation(s)
- Zobair M Younossi
- Department of Medicine, Center for Liver Diseases, Inova Fairfax Hospital, Falls Church, VA, USA.,Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, USA
| | - Maria Stepanova
- Center for Outcomes Research in Liver Disease, Washington, DC, USA
| | - Linda Henry
- Center for Outcomes Research in Liver Disease, Washington, DC, USA
| | - Kwang-Hyub Han
- Yonsei University College of Medicine, Seoul, South Korea
| | - Sang Hoon Ahn
- Yonsei University College of Medicine, Seoul, South Korea
| | - Young-Suk Lim
- Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Wan-Long Chuang
- Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jia-Horng Kao
- National Taiwan University College of Medicine and Hospital, Taipei, Taiwan
| | - Nguyen Kinh
- National Hospital of Tropical Diseases, Hanoi, Vietnam
| | | | | | - Henry Lik-Yuen Chan
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China
| | - Wei Lai
- Peking University People's Hospital, Beijing, China
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A survey of medication preparation and administration practices among members of the Canadian Anesthesiologists’ Society. Can J Anaesth 2018; 65:1100-1109. [DOI: 10.1007/s12630-018-1164-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 04/04/2018] [Accepted: 04/11/2018] [Indexed: 10/14/2022] Open
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Saab S, Le L, Saggi S, Sundaram V, Tong MJ. Toward the elimination of hepatitis C in the United States. Hepatology 2018; 67:2449-2459. [PMID: 29181853 DOI: 10.1002/hep.29685] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 11/13/2017] [Accepted: 11/20/2017] [Indexed: 12/12/2022]
Abstract
The emergence of effective direct-acting antiviral (DAA) agents has reignited discussion over the potential for hepatitis C elimination in the United States. Eliminating hepatitis C will require a critical examination of technical feasibility, economic considerations, and social/political attention. Tremendous advancement has been made with the availability of sensitive diagnostic tests and highly effective DAAs capable of achieving sustained viral response (SVR) in more than 95% of patients. Eliminating hepatitis C also requires escalating existing surveillance networks to monitor for new epidemics. All preventive interventions such as clean syringe and needle exchange programs, safe injection sites, opioid substitution therapies, and mental health services need to be expanded. Although costs of DAAs have raised budget concerns for hepatitis C elimination, studies have shown that eliminating hepatitis C will produce a savings of up to 6.5 billion USD annually along with other intangible benefits such as increased work productivity and quality of life. Economic models and meta-analyses strongly suggest universal hepatitis C screening for all adults rather than just for birth cohort and high-risk populations. Social and political factors are at least as important as technical feasibility and economic considerations. Due to lack of promotion and public awareness, HCV elimination efforts continue to receive inadequate funding. Social stigma continues to impede meaningful policy changes. Eliminating hepatitis C is an attainable public health goal that will require intense collaboration and sustained public support. (Hepatology 2018;67:2449-2459).
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Affiliation(s)
- Sammy Saab
- Department of Surgery, University of California Los Angeles, Los Angeles, CA
| | - Long Le
- Department of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Satvir Saggi
- Olive View Medical Center, University of California Los Angeles, Los Angeles, CA
| | - Vinay Sundaram
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
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47
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Younossi ZM. Editorial: direct-acting antivirals significantly improve quality of life in patients with hepatitis C virus infection-Author's reply. Aliment Pharmacol Ther 2018; 47:537-538. [PMID: 29341278 DOI: 10.1111/apt.14481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Affiliation(s)
- Z M Younossi
- Betty and Guy Beatty Center for Integrated Research, Claude Moore Health Education and Research Building, Falls Church, VA, USA
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