Joint Utility Estimators in Substance Use Disorders

The use of health utility in cost-utility analysis: A systematic review in substance use disorders

BACKGROUND AND AIM

We aim to identify within-trial and modelled Cost-Utility Analysis (CUA) in substance use disorders (SUD) and review the applicability assessment associated with health utility used in modelled CUA.

STUDY DESIGN AND METHODS

We searched Medline, Embase, EconLit and the Pharmaceutical Benefits Advisory Committee (PBAC) databases. A global systematic literature search was undertaken to determine the CUA of SUD interventions. Key characteristics of the studies and use of health utility were described. The applicability assessment associated with health utility used in modelled CUA was reviewed using The Health Utility Application Tool (HAT).

RESULTS

The final review retrieved 49 CUA (14 within-trial and 35 modelled CUA). Three major health utility measurements were used - standard gamble, EQ-5D-5L and SF-6D. EQ-5D-5L was mainly used in within-trial CUA, whereas standard gamble, EQ-5D-5L and SF-6D were equally cited in modelled CUA and within-trial CUA. Twenty-nine articles using modelled CUA citing health utilities from published literature were assessed. Only half and one-third of CUA studies described the type of quality-of-life measure and value sets used in health utility studies, respectively. Only two-thirds showed the authors addressed questions about the similarities in clinical conditions, and health state description between health utility studies and economic evaluation studies.

CONCLUSION

Justifications for chosen health utilities in modelled CUA studies were mostly absent in SUD. We suggested health economists use the HAT to make judgements when assessing health utility from published estimates. The use of this tool will increase the reliability of economic evaluation carried out to assist government and policymakers in making informed decisions around health topics.

An economic evaluation of community pharmacy-dispensed naloxone in Canada

Aims

To determine the cost-effectiveness of pharmacy-based intranasal (IN) and intramuscular (IM) naloxone distribution in Canada.

Methods

We developed a state-transition model for pharmacy-based naloxone distribution, every 3 years, to illicit, prescription, opioid-agonist therapy and nonopioid use populations compared to no naloxone distribution. We used a monthly cycle length, lifetime horizon and a Canadian provincial Ministry of Health perspective. Transition probabilities, cost and utility data were retrieved from the literature. Costs (2020) and quality-adjusted life years (QALY) were discounted 1.5% annually. Microsimulation, 1-way and probabilistic sensitivity analyses were conducted.

Results

Distribution of naloxone to all Canadians compared to no distribution prevented 151 additional overdose deaths per 10,000 persons, with an incremental cost-effectiveness ratio (ICER) of $50,984 per QALY for IM naloxone and an ICER of $126,060 per QALY for IN naloxone. Distribution of any naloxone to only illicit opioid users was the most cost-effective. One-way sensitivity analysis showed that survival rates for illicit opioid users were most influenced by the availability of either emergency medical services or naloxone.

Conclusion

Distribution of IM and IN naloxone to all Canadians every 3 years is likely cost-effective at a willingness-to-pay threshold of $140,000 Canadian dollars/QALY (~3 × gross domestic product from the World Health Organization). Distribution to people who use illicit opioids was most cost-effective and prevented the most deaths. This is important, as more overdose deaths could be prevented through nationwide public funding of IN naloxone kits through pharmacies, since individuals report a preference for IN naloxone and these formulations are easier to use, save lives and are cost-effective. Can Pharm J (Ott) 2024;157:xx-xx.

Estimating Joint Health State Utility Algorithms Under Partial Information

OBJECTIVES

We explored the performance of existing joint health state utility estimators when data are not available on utilities that isolate single-condition health states excluding any co-occurring condition.

METHODS

Using data from the National Epidemiologic Survey on Alcohol and Related Conditions-III, we defined 2 information sets: (1) a full-information set that includes the narrowly defined health state utilities used in most studies that test the performance of joint health state utility estimators, and (2) a limited information set that includes only the more broadly defined health state utilities more commonly available to researchers. We used an example of alcohol use disorder co-occurring with cirrhosis of the liver, depressive disorder, or nicotine use disorder to illustrate our analysis.

RESULTS

We found that the performance of joint health state utility estimators is appreciably different under limited information than under full information. Full-information estimators typically overestimate the joint state utility, whereas limited-information estimators underestimate the joint state utility, except for the minimum estimator, which is overestimated in all cases.

CONCLUSIONS

Researchers using joint health state utility estimators should understand the information set available to them and use methodological guidance appropriate for that information set. We recommend the minimum estimator under limited information based on its ease of use, consistency (and therefore a predictable direction of bias), and lower root mean squared error.

Modeling the impact of COVID-19 pandemic-driven increases in alcohol consumption on health outcomes and hospitalization costs in the United States

BACKGROUND AND AIMS

Alcohol consumption increased in the early phases of the COVID-19 pandemic in the United States. Alcohol use disorder (AUD) and risky drinking are linked to harmful health effects. This paper aimed to project future health and cost impacts of shifts in alcohol consumption during the COVID-19 pandemic.

DESIGN

An individual-level simulation model of the long-term drinking patterns for people with life-time AUD was used to simulate 10 000 individuals and project model outcomes to the estimated 25.9 million current drinkers with life-time AUD in the United States. The model considered three scenarios: (1) no change (counterfactual for comparison); (2) increased drinking levels persist for 1 year ('increase-1') and (3) increased drinking levels persist for 5 years ('increase-5').

SETTING

United States.

PARTICIPANTS

Current drinkers with life-time AUD.

MEASUREMENTS

Life expectancy [life-years (LYs)], quality-adjusted life-years (QALYs), alcohol-related hospitalizations and associated hospitalization costs and alcohol-related deaths, during a 5-year period.

FINDINGS

Short-term increases in alcohol consumption (increase-1 scenario) resulted in a loss of 79 000 [95% uncertainty interval (UI]) 26 000-201 000] LYs, a loss of 332 000 (104 000-604 000) QALYs and 295 000 (82 000-501 000) more alcohol-related hospitalizations, costing an additional $5.4 billion ($1.5-9.3 billion) over 5 years. Hospitalizations for cirrhosis of the liver accounted for approximately $3.0 billion ($0.9-4.8 billion) in hospitalization costs, more than half the increase across all alcohol-related conditions. Health and cost impacts were more pronounced for older age groups (51+), women and non-Hispanic black individuals. Increasing the duration of pandemic-driven increases in alcohol consumption in the increase-5 scenario resulted in larger impacts.

CONCLUSIONS

Simulations show that if the increase in alcohol consumption observed in the United States in the first year of the pandemic continues, alcohol-related mortality, morbidity and associated costs will increase substantially over the next 5 years.

A National Catalog of Mapped Short-Form Six-Dimension Utility Scores for Chronic Conditions in the United States From 2010 to 2015

OBJECTIVES

This study examined health preference utility weights and utility decrements associated with different types of chronic conditions in the United States.

METHODS

We used the 2010-2015 Medical Expenditure Panel Survey data for persons aged ≥ 18 years with 12-Item Short-Form Survey Physical and Mental Component Summary scores. 12-Item Short-Form Survey scores were converted to Short-Form Six-Dimension (SF-6D) preference scores to measure utilities of different chronic diseases. We used the Clinical Classification Code to identify 30 chronic diseases from 12 categories, such as cardiovascular diseases, cerebrovascular diseases, hypertension, hyperlipidemia, obesity, cancers, musculoskeletal diseases, endocrine or metabolic diseases, oral diseases, respiratory diseases, and mental disorders. A generalized linear model was used to quantify the utility decrements for 30 chronic diseases, controlling for demographic characteristics.

RESULTS

We identified 132 737 adults (mean age 47.2 years, 52.2% female, 80% white); 73% had at least one identified chronic disease, and the mean SF-6D was 0.786. Among 30 chronic diseases, the unadjusted mean SF-6D scores of patients with cognitive disorder (0.607) were the lowest, followed by congestive heart failure (0.629), rheumatoid arthritis (0.654), and lung cancer (0.662). After controlling for demographic variables (ie, age, sex) and comorbidities, cognitive disorders (-0.116), mood disorders (-0.099), rheumatoid arthritis (-0.090), liver cancer (-0.078), and stroke (-0.063) showed the highest decrements in the SF-6D scores (P < .05).

CONCLUSIONS

This study provides a nationally representative catalog of utility weights for major chronic diseases in the US general population. The utility decrements will enable researchers to calculate the health utilities of patients with multiple comorbid diseases.

Cost-effectiveness of mass screening for Hepatitis C virus among all inmates in an Irish prison

BACKGROUND

In Irish prisons, there is a high proportion of people who inject drugs (PWID; 26%) and a high prevalence of HCV (16%), making prison a high priority setting for HCV testing and treatment. We evaluate the cost-effectiveness of a mass HCV screening intervention in Mountjoy Prison, Dublin, compared to the standard-of-care of intermittent screening on committal.

METHODS

Primary cost data was collected from the intervention using an overall provider perspective. Standard-of-care (SOC) costs were estimated through interview. All costs were inflated to 2020 Euros. An HCV transmission and disease progression model among incarcerated and community PWID and ex-injectors was calibrated to the Dublin HCV epidemic, allowing inclusion of population-level health benefits. The model used intervention data, suggesting 419 individuals were screened, 50 HCV infections diagnosed and 32 individuals initiated treatment, to project the resulting costs and health benefits (quality adjusted life years or QALYs) over 50 years with 5% discounting. The incremental cost effectiveness ratio (ICER), cost per QALY gained, was estimated for the screening intervention compared to the standard-of-care. Probabilistic sensitivity analyses (PSA) determined the probability that the intervention was cost-effective compared to a willingness-to-pay threshold of €30,000/QALY as used in Ireland. The ICER for 1- or 3-yearly mass screening in all Dublin prisons was also calculated.

RESULTS

The total direct costs of the intervention (not including treatment drug costs) was €82,392, with most costs being due to staff (43%) and overhead or management costs (38%). Despite having little epidemiological impact due to the small numbers treated, over 50 years the incremental cost of the intervention was €36,592 and 3.8 QALYs were gained, giving a mean ICER of €9,552/QALY. The majority (84%) of PSA runs were below the willingness-to-pay threshold. Yearly mass screening had an ICER of €2,729/QALY compared to SOC and gave a higher net monetary benefit (€7,393,382) than screening every 3 years (€6,252,816).

CONCLUSION

Prison mass screening could be a cost-effective initiative for increasing testing and treatment of HCV in Ireland.

SF-6D utility scores for alcohol use disorder status and alcohol consumption risk levels in the US population

AIMS

To estimate US population health utilities for subgroups defined by alcohol use disorder (AUD) status and consumption level.

DESIGN

Cross-sectional survey.

SETTING

Community settings in the United States (i.e. excluding institutional settings).

PARTICIPANTS

A total of 36,042 adults (age 18+) in non-institutional settings in the United States.

MEASUREMENTS

We used 12-item Short Form Survey (SF-12) data from the National Epidemiologic Survey on Alcohol and Related Conditions-III to calculate mean Short Form-6 dimension (SF-6D) utility scores across World Health Organization alcohol consumption risk levels-very high risk, high risk, medium risk, low risk and an additional abstinent level-for three groups: (1) the general population (n = 36,042), (2) individuals with life-time AUD (n = 9925) and (3) individuals with current AUD (n = 5083), and assessed minimally important differences (MIDs) between consumption levels. Each group is a subset of the previous group.

FINDINGS

The general population's mean SF-6D utility was higher than that of individuals with life-time or current AUD across all consumption risk levels (0.79 versus 0.76 for both AUD groups). For all groups, SF-6D utilities increased as consumption risk level decreased to non-abstinent levels, and reducing consumption from very high risk to any lower level was associated with a statistically significant and meaningful improvement in utility. For individuals with life-time or current AUD, becoming abstinent from high-, medium- and low-risk levels was associated with significantly and meaningfully worse utilities.

CONCLUSIONS

Higher alcohol consumption risk levels appear to be associated with lower health index scores for the general population and individuals with a history of alcohol use disorder, meaning that higher alcohol consumption is associated with worse health-related quality of life.

Health-related quality of life of alcohol use disorder with co-occurring conditions in the US population

BACKGROUND

Alcohol use disorder (AUD) commonly co-occurs with other health conditions or other substance use, complicating our understanding of the health-related quality of life (HRQoL) of AUD. We described the HRQoL of alcohol use disorder in the presence of co-occurring conditions and identified the contribution of each.

METHODS

Secondary analysis of National Epidemiologic Survey on Alcohol and Related Conditions III data, consisting of 36,309 non-institutionalized US adults; descriptive and regression analysis. HRQoL measured via the SF-6D; AUD via the Alcohol Use Disorder and Associated Disabilities Interview Schedule (AUDADIS-5); physical, mental health, and substance use disorders/conditions as reported or assessed via AUDADIS-5.

RESULTS

AUD was independently associated with lower HRQoL for individuals experiencing co-occurring conditions. Compared to no AUD, past year AUD reduced SF-6D score by 0.0304 (SE = 0.0027) and prior-to-past-year AUD reduced SF-6D by 0.0163 (SE = 0.0023). AUD's co-occurring conditions were independently associated with lower HRQoL, beyond the reduction from AUD: any co-occurring physical health condition was associated with a 0.062 point reduction in SF-6D score (SE = 0.0023), any mental health condition with a 0.084 point reduction (SE = 0.0025), and any substance use disorder with a 0.038 point reduction (SE = 0.0023).

CONCLUSIONS

AUD's association with diminished HRQoL may be explained in large part by the presence of co-occurring conditions among individuals reporting AUD, as these co-occurring conditions are associated with substantial decrements in HRQoL-often eclipsing the magnitude of the decrements associated with AUD alone. Alcohol use interventions endeavoring to improve HRQoL should consider the entirety of an individual to design patient-centered care.

Cost-effectiveness of Hepatitis C Virus Treatment Models for People Who Inject Drugs in Opioid Agonist Treatment Programs

BACKGROUND

Many people who inject drugs in the United States have chronic hepatitis C virus (HCV). On-site treatment in opiate agonist treatment (OAT) programs addresses HCV treatment barriers, but few evidence-based models exist.

METHODS

We evaluated the cost-effectiveness of HCV treatment models for OAT patients using data from a randomized trial conducted in Bronx, New York. We used a decision analytic model to compare self-administered individual treatment (SIT), group treatment (GT), directly observed therapy (DOT), and no intervention for a simulated cohort with the same demographic characteristics of trial participants. We projected long-term outcomes using an established model of HCV disease progression and treatment (hepatitis C cost-effectiveness model: HEP-CE). Incremental cost-effectiveness ratios (ICERs) are reported in 2016 US$/quality-adjusted life years (QALY), discounted 3% annually, from the healthcare sector and societal perspectives.

RESULTS

For those assigned to SIT, we projected 89% would ever achieve a sustained viral response (SVR), with 7.21 QALYs and a $245 500 lifetime cost, compared to 22% achieving SVR, with 5.49 QALYs and a $161 300 lifetime cost, with no intervention. GT was more efficient than SIT, resulting in 0.33 additional QALYs and a $14 100 lower lifetime cost per person, with an ICER of $34 300/QALY, compared to no intervention. DOT was slightly more effective and costly than GT, with an ICER > $100 000/QALY, compared to GT. In probabilistic sensitivity analyses, GT and DOT were preferred in 91% of simulations at a threshold of <$100 000/QALY; conclusions were similar from the societal perspective.

CONCLUSIONS

All models were associated with high rates of achieving SVR, compared to standard care. GT and DOT treatment models should be considered as cost-effective alternatives to SIT.

An Economic Evaluation of the Cost-Effectiveness of Opt-Out Hepatitis B and Hepatitis C Testing in an Emergency Department Setting in the United Kingdom

OBJECTIVES

The prevalence of hepatitis is high in emergency department (ED) attendees in the United Kingdom, with a prevalence of up to 2% for hepatitis B (HBV) HBsAg, and 2.9% for hepatitis C (HCV) RNA. The aim of this paper is to perform an economic evaluation of opt-out ED-based HCV and HBV testing.

METHODS

A Markov model was developed to analyze the cost-effectiveness of opt-out HCV and HBV testing in EDs in the UK. The model used data from UK studies of ED testing to parameterize the HCV and HBV prevalence (1.4% HCV RNA, 0.84% HBsAg), test costs, and intervention effects (contact rates and linkage to care). For HCV, we used an antibody test cost of £3.64 and RNA test cost of £68.38, and assumed direct-acting antiviral treatment costs of £10 000. For HBV, we used a combined HBsAg and confirmatory test cost of £5.79. We also modeled the minimum prevalence of HCV (RNA-positive) and HBV (HBsAg) required to make ED testing cost-effective at a £20 000 willingness to pay per quality-adjusted life-year threshold.

RESULTS

In the base case, ED testing was highly cost-effective, with HCV and HBV testing costing £8019 and £9858 per quality-adjusted life-year gained, respectively. HCV and HBV ED testing remained cost-effective at 0.25% HCV RNA or HBsAg prevalence or higher.

CONCLUSIONS

Emergency department testing for HCV and HBV is highly likely to be cost-effective in many areas across the UK depending on their prevalence. Ongoing studies will help evaluate ED testing across different regions to inform testing guidelines.

How to identify and treat data inconsistencies when eliciting health-state utility values for patient-centered decision making

BACKGROUND

Health utilities express the perceptions patients have on the impact potential adverse events of medical treatments may have on their quality of life. Being able to accurately assess health utilities is crucial when deciding what is the best treatment when multiple and diverse treatment options exist, or when performing a cost / utility analysis. Due to the emotional and other complexities that may exist when such data are elicited, the values of the health utilities may be inaccurate and cause inconsistencies. Existing literature indicates that such inconsistencies may be very frequent. However, no method has been developed for dealing with such inconsistencies in an effective manner.

METHODS

Given a set of health utilities, this paper first explores ways for determining if there are any inconsistencies in their values. It also proposes a number of quadratic optimization approaches to best estimate the actual (and hence unknown) values when a set of initial health utility values are provided by the patient and certain inconsistencies have been detected. This is achieved by readjusting the initial values in a way that is minimal and also satisfies certain consistency requirements.

RESULTS

The proposed methods are applied on an illustrative example related to localized prostate cancer. Data from some published studies were used to illustrate how a set of initial values can be analyzed. This analysis aims at readjusting them in a minimal manner that would also satisfy some key numerical constraints pertinent to health utility values.

CONCLUSIONS

The numerical results and the computational complexities of the proposed models indicate that the proposed approaches are practical as they involve quadratic optimization modeling. These approaches are novel as the problem of addressing numerical inconsistencies in the elicitation process of health utilities has not been addressed adequately. The approaches are also critical in shared decision making and also when performing cost / utility analyses because health utilities play a central role in determining the quality-adjusted life years when making decisions in these healthcare domains.

Cost-Effectiveness of Intranasal Naloxone Distribution to High-Risk Prescription Opioid Users

OBJECTIVES

To determine the cost-effectiveness of pharmacy-based intranasal naloxone distribution to high-risk prescription opioid (RxO) users.

METHODS

We developed a Markov model with an attached tree for pharmacy-based naloxone distribution to high-risk RxO users using 2 approaches: one-time and biannual follow-up distribution. The Markov structure had 6 health states: high-risk RxO use, low-risk RxO use, no RxO use, illicit opioid use, no illicit opioid use, and death. The tree modeled the probability of an overdose happening, the overdose being witnessed, naloxone being available, and the overdose resulting in death. High-risk RxO users were defined as individuals with prescription opioid doses greater than or equal to 90 morphine milligram equivalents (MME) per day. We used a monthly cycle length, lifetime horizon, and US healthcare perspective. Costs (2018) and quality-adjusted life-years (QALYs) were discounted 3% annually. Microsimulation was performed with 100 000 individual trials. Deterministic and probabilistic sensitivity analyses were conducted.

RESULTS

One-time distribution of naloxone prevented 14 additional overdose deaths per 100 000 persons, with an incremental cost-effectiveness ratio (ICER) of $56 699 per QALY. Biannual follow-up distribution led to 107 additional lives being saved with an ICER of $84 799 per QALY compared with one-time distribution. Probabilistic sensitivity analyses showed that a biannual follow-up approach would be cost-effective 50% of the time at a willingness-to-pay (WTP) threshold of $100 000 per QALY. Naloxone effectiveness and proportion of overdoses witnessed were the 2 most influential parameters for biannual distribution.

CONCLUSION

Both one-time and biannual follow-up naloxone distribution in community pharmacies would modestly reduce opioid overdose deaths and be cost-effective at a WTP of $100 000 per QALY.

Cost-effectiveness of scaling-up HCV prevention and treatment in the United States for people who inject drugs

AIMS

To examine the cost-effectiveness of hepatitis C virus (HCV) treatment of people who inject drugs (PWID), combined with medication-assisted treatment (MAT) and syringe-service programs (SSP), to tackle the increasing HCV epidemic in the United States.

DESIGN

HCV transmission and disease progression models with cost-effectiveness analysis using a health-care perspective.

SETTING

Rural Perry County, KY (PC) and urban San Francisco, CA (SF), USA. Compared with PC, SF has a greater proportion of PWID with access to MAT or SSP. HCV treatment of PWID is negligible in both settings.

PARTICIPANTS

PWID data were collected between 1998 and 2015 from Social Networks Among Appalachian People, U Find Out, Urban Health Study and National HIV Behavioral Surveillance System studies.

INTERVENTIONS AND COMPARATOR

Three intervention scenarios modeled: baseline-existing SSP and MAT coverage with HCV screening and treatment with direct-acting antiviral for ex-injectors only as per standard of care; intervention 1-scale-up of SSP and MAT without changes to treatment; and intervention 2-scale-up as intervention 1 combined with HCV screening and treatment for current PWID.

MEASUREMENTS

Incremental cost-effectiveness ratios (ICERs) and uncertainty using cost-effectiveness acceptability curves. Benefits were measured in quality-adjusted life-years (QALYs).

FINDINGS

For both settings, intervention 2 is preferred to intervention 1 and the appropriate comparator for intervention 2 is the baseline scenario. Relative to baseline, for PC intervention 2 averts 1852 more HCV infections, increases QALYS by 3095, costs $21.6 million more and has an ICER of $6975/QALY. For SF, intervention 2 averts 36 473 more HCV infections, increases QALYs by 7893, costs $872 million more and has an ICER of $11 044/QALY. The cost-effectiveness of intervention 2 was robust to several sensitivity analysis.

CONCLUSIONS

Hepatitis C screening and treatment for people who inject drugs, combined with medication-assisted treatment and syringe-service programs, is a cost-effective strategy for reducing hepatitis C burden in the United States.

Cost-effectiveness of integrating buprenorphine-naloxone treatment for opioid use disorder into clinical care for persons with HIV/hepatitis C co-infection who inject opioids

BACKGROUND

Untreated opioid use disorder (OUD) affects the care of HIV/HCV co-infected people who inject opioids. Despite active injection opioid use, there is evidence of increasing engagement in HIV care and adherence to HIV medications among HIV/HCV co-infected persons. However, less than one-half of this population is offered HCV treatment onsite. Treatment for OUD is also rare and largely occurs offsite. Integrating buprenorphine-naloxone (BUP-NX) into onsite care for HIV/HCV co-infected persons may improve outcomes, but the clinical impact and costs are unknown. We evaluated the clinical impact, costs, and cost-effectiveness of integrating (BUP-NX) into onsite HIV/HCV treatment compared with the status quo of offsite referral for medications for OUD.

METHODS

We used a Monte Carlo microsimulation of HCV to compare two strategies for people who inject opioids: 1) standard HIV care with onsite HCV treatment and referral to offsite OUD care (status quo) and 2) standard HIV care with onsite HCV and BUP-NX treatment (integrated care). Both strategies assume that all individuals are already in HIV care. Data from national databases, clinical trials, and cohorts informed model inputs. Outcomes included mortality, HCV reinfection, quality-adjusted life years (QALYs), costs (2017 US dollars), and incremental cost-effectiveness ratios.

RESULTS

Integrated care reduced HCV reinfections by 7%, cases of cirrhosis by 1%, and liver-related deaths by 3%. Compared to the status quo, this strategy also resulted in an estimated 11/1,000 fewer non-liver attributable deaths at one year and 28/1,000 fewer of these deaths at five years, at a cost-effectiveness ratio of $57,100/QALY. Integrated care remained cost-effective in sensitivity analyses that varied the proportion of the population actively injecting opioids, availability of BUP-NX, and quality of life weights.

CONCLUSIONS

Integrating BUP-NX for OUD into treatment for HIV/HCV co-infected adults who inject opioids increases life expectancy and is cost-effective at a $100,000/QALY threshold.

Cost-effectiveness of hepatitis C screening and treatment linkage intervention in US methadone maintenance treatment programs

BACKGROUND

We evaluated the cost-effectiveness of a hepatitis C (HCV) screening and active linkage to care intervention in US methadone maintenance treatment (MMT) patients using data from a randomized trial conducted in New York City and San Francisco.

METHODS

We used a decision analytic model to compare 1) no intervention; 2) HCV screening and education (control); and 3) HCV screening, education, and care coordination (active linkage intervention). We also explored an alternative strategy wherein HCV/HIV co-infected participants linked elsewhere. Trial data include population characteristics (67% male, mean age 48, 58% HCV infected) and linkage rates. Data from published sources include treatment efficacy and HCV re-infection risk. We projected quality-adjusted life years (QALYs) and lifetime medical costs using an established model of HCV (HEP-CE). Incremental cost-effectiveness ratios (ICERs) are in 2015 US$/QALY discounted 3% annually.

RESULTS

The control strategy resulted in a projected 35% linking to care within 6 months and 31% achieving sustained virologic response (SVR). The intervention resulted in 60% linking and 54% achieving SVR with an ICER of $24,600/QALY compared to no intervention from the healthcare sector perspective and was a more efficient use of resources than the control strategy. The intervention had an ICER of $76,500/QALY compared to the alternative strategy. From a societal perspective, the intervention had a net monetary benefit of $511,000-$975,600.

CONCLUSIONS

HCV care coordination interventions that include screening, education and active linkage to care in MMT settings are likely cost-effective at a conventional $100,000/QALY threshold for both HCV mono-infected and HIV co-infected patients.