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Merchant RC, Harrington N, Clark MA, Liu T, Morgan J, Cowan E, Solnick R, Wyler B. Testing a persuasive health communication intervention (PHCI) for emergency department patients who declined rapid HIV/HCV screening: a randomised controlled trial study protocol. BMJ Open 2024; 14:e089265. [PMID: 39134444 PMCID: PMC11331935 DOI: 10.1136/bmjopen-2024-089265] [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: 05/25/2024] [Accepted: 08/01/2024] [Indexed: 08/21/2024] Open
Abstract
INTRODUCTION Previous studies have shown that substantial percentages of emergency department (ED) patients in the USA recommended for HIV or hepatitis C (HCV) decline testing. Evidence-based and cost-effective interventions to improve HIV/HCV testing uptake are needed, particularly for people who inject drugs (PWIDs) (currently or formerly), who comprise a group at higher risk for these infections. We developed a brief persuasive health communication intervention (PHCI) designed to convince ED patients who had declined HIV/HCV testing to agree to be tested. In this investigation, we will determine if the PHCI is more efficacious in convincing ED patients to be tested for HIV/HCV when delivered by a video or in person, and whether efficacy is similar among individuals who currently, previously or never injected drugs. METHODS AND ANALYSIS We will conduct a multisite, randomised controlled trial comparing PHCIs delivered by video versus in person by a health educator to determine which delivery method convinces more ED patients who had declined HIV/HCV testing instead to be tested. We will stratify randomisation by PWID status (current, former or never/non-PWID) to permit analyses comparing the PHCI delivery method by injection-drug use history. We will also perform a cost-effectiveness analysis of the interventions compared with current practice, examining the incremental cost-effectiveness ratio between the two interventions for the ED population overall and within individual strata of PWID. As an exploratory analysis, we will assess if a PHCI video with captions confers increased or decreased acceptance of HIV/HCV testing, as compared with a PHCI video without captions. ETHICS AND DISSEMINATION The study protocol has been approved by the institutional review board of the Icahn School of Medicine. The results will be disseminated at international conferences and in peer-reviewed publications. TRIAL REGISTRATION NUMBER NCT05968573.
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Affiliation(s)
- Roland C Merchant
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Nancy Harrington
- Department of Communication, University of Kentucky, Lexington, Kentucky, USA
| | - Melissa A Clark
- Brown University School of Public Health, Providence, Rhode Island, USA
| | - Tao Liu
- Brown University School of Public Health, Providence, Rhode Island, USA
| | - Jake Morgan
- Department of Health, Law, Policy and Management, Boston University, Boston, Massachusetts, USA
| | - Ethan Cowan
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Rachel Solnick
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Benjamin Wyler
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Buti M, Vaz-Pinto I, Magno Pereira V, Casado M, Llaneras J, Barreira A, Esteves C, Guimarães M, Gorgulho A, Mourão T, Xavier E, Jasmins L, Reis AP, Faria N, Freitas B, Andrade G, Camelo-Castillo A, Rodríguez-Maresca MÁ, Carrodeguas A, Medina D, Esteban R. Emergency department contribution to HCV elimination in the Iberian Peninsula. Int J Emerg Med 2024; 17:5. [PMID: 38178000 PMCID: PMC10768527 DOI: 10.1186/s12245-023-00570-5] [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: 11/04/2022] [Accepted: 12/01/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND Undiagnosed cases of hepatitis C virus (HCV) infection result in significant morbidity and mortality, further transmission, and increased public health costs. Testing in emergency departments (EDs) is an opportunity to expand HCV screening. The goal of this project was to increase the proportion of eligible patients screened for HCV in urban areas. METHODS An opportunistic automated HCV screening program was implemented in the EDs of 4 public hospitals in Spain and Portugal at different periods between 2018 and 2023. HCV prevalence was prospectively evaluated, and single-step or reflex testing was used for confirmation in the same sample. RESULTS More than 90% of the population eligible for testing were screened in the participating centers. We found HCV antibody seroprevalence rates ranging from 0.6 to 3.9%, with between 19 and 53% of viremic individuals. CONCLUSIONS Opportunistic HCV screening in EDs is feasible, does not disrupt ED activities, is highly effective in increasing diagnosis, and contributes to WHO's HCV elimination goals.
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Affiliation(s)
- Maria Buti
- Hospital Universitari Vall d'Hebron and CIBEREHD del Instituto Carlos III, 119, 08035, Barcelona, Spain.
| | | | | | - Marta Casado
- Hospital Universitario Torrecárdenas, Almería, Spain
| | | | - Ana Barreira
- Hospital Universitari Vall d'Hebron and CIBEREHD del Instituto Carlos III, 119, 08035, Barcelona, Spain
| | | | | | | | | | | | | | | | - Nancy Faria
- Hospital Dr. Nélio Mendonça, Madeira, Portugal
| | | | | | | | | | | | | | - Rafael Esteban
- Hospital Universitari Vall d'Hebron and CIBEREHD del Instituto Carlos III, 119, 08035, Barcelona, Spain
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Lim AG, Aas CF, Çağlar ES, Vold JH, Fadnes LT, Vickerman P, Johansson KA. Cost-effectiveness of integrated treatment for hepatitis C virus (HCV) among people who inject drugs in Norway: An economic evaluation of the INTRO-HCV trial. Addiction 2023; 118:2424-2439. [PMID: 37515462 PMCID: PMC10952903 DOI: 10.1111/add.16305] [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: 11/03/2022] [Accepted: 06/26/2023] [Indexed: 07/30/2023]
Abstract
BACKGROUND AND AIMS The INTRO-HCV randomized controlled trial conducted in Norway over 2017-2019 found that integrated treatment, compared with standard-of-care hospital treatment, for hepatitis C virus (HCV) with direct-acting antivirals (DAAs) improved treatment outcomes among people who inject drugs (PWID). We evaluated cost-effectiveness of the INTRO-HCV intervention. DESIGN A Markov health state transition model of HCV disease progression and treatment with cost-effectiveness analysis from the health-provider perspective. Primary cost, utility, and health outcome data were derived from the trial. Costs and health benefits (quality-adjusted life-years, QALYs) were tracked over 50 years. Probabilistic and univariate sensitivity analyses investigated DAA price reductions and variations in HCV treatment and disease care cost assumptions, using costs from different countries (Norway, United Kingdom, United States, France, Australia). SETTING AND PARTICIPANTS PWID attending community-based drug treatment centers for people with opioid dependence in Norway. MEASUREMENTS Incremental cost-effectiveness ratio (ICER) in terms of cost per QALY gained, compared against a conventional (€70 000/QALY) willingness-to-pay threshold for Norway and lower (€20 000/QALY) threshold common among high-income countries. FINDINGS Integrated treatment resulted in an ICER of €13 300/QALY gained, with 99% and 71% probability of being cost-effective against conventional and lower willingness-to-pay thresholds, respectively. A 30% lower DAA price reduced the ICER to €6 900/QALY gained, with 91% probability of being cost-effective at the lower willingness-to-pay threshold. A 60% and 90% lower DAA price had 36% and >99% probability of being cost-saving, respectively. Sensitivity analyses suggest integrated treatment was cost-effective at the lower willingness-to-pay threshold (>60% probability) across different assumptions on HCV treatment and disease care costs with 30% DAA price reduction, and became cost-saving with 60%-90% price reductions. CONCLUSIONS Integrated hepatitis C virus treatment for people who inject drugs in community settings is likely cost-effective compared with standard-of-care referral pathways in Norway and may be cost-saving in settings with particular characteristics.
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Affiliation(s)
- Aaron Guanliang Lim
- Population Health Sciences, Bristol Medical SchoolUniversity of BristolBristolUK
| | - Christer Frode Aas
- Bergen Addiction Research, Department of Addiction MedicineHaukeland University HospitalBergenNorway
- Department of Global Public Health and Primary CareUniversity of BergenBergenNorway
- Division of PsychiatryHaukeland University HospitalBergenNorway
| | - Ege Su Çağlar
- Bergen Addiction Research, Department of Addiction MedicineHaukeland University HospitalBergenNorway
- Department of Global Public Health and Primary CareUniversity of BergenBergenNorway
| | - Jørn Henrik Vold
- Bergen Addiction Research, Department of Addiction MedicineHaukeland University HospitalBergenNorway
- Department of Global Public Health and Primary CareUniversity of BergenBergenNorway
- Division of PsychiatryHaukeland University HospitalBergenNorway
| | - Lars Thore Fadnes
- Bergen Addiction Research, Department of Addiction MedicineHaukeland University HospitalBergenNorway
- Department of Global Public Health and Primary CareUniversity of BergenBergenNorway
| | - Peter Vickerman
- Population Health Sciences, Bristol Medical SchoolUniversity of BristolBristolUK
| | - Kjell Arne Johansson
- Bergen Addiction Research, Department of Addiction MedicineHaukeland University HospitalBergenNorway
- Department of Global Public Health and Primary CareUniversity of BergenBergenNorway
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Boesecke C, Schellberg S, Schneider J, Schuettfort G, Stocker H. Prevalence, characteristics and challenges of late HIV diagnosis in Germany: an expert narrative review. Infection 2023; 51:1223-1239. [PMID: 37470977 PMCID: PMC10545628 DOI: 10.1007/s15010-023-02064-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 06/10/2023] [Indexed: 07/21/2023]
Abstract
PURPOSE We aimed to review the landscape of late HIV diagnosis in Germany and discuss persisting and emerging barriers to earlier diagnosis alongside potential solutions. METHODS We searched PubMed for studies informing the prevalence, trends, and factors associated with late HIV diagnosis in Germany. Author opinions were considered alongside relevant data. RESULTS In Germany, older individuals, heterosexuals, and migrants living with HIV are more likely to be diagnosed late. The rate of late diagnosis in men who have sex with men (MSM), however, continues to decrease. Indicator conditions less often prompt HIV testing in women and non-MSM. During the COVID-19 pandemic, the absolute number of late diagnoses fell in Germany, but the overall proportion increased, probably reflecting lower HIV testing rates. The Ukraine war and subsequent influx of Ukrainians living with HIV may have substantially increased undiagnosed HIV cases in Germany. Improved indicator testing (based on unbiased assessments of patient risk) and universal testing could help reduce late diagnoses. In patients who receive a late HIV diagnosis, rapid treatment initiation with robust ART regimens, and management and prevention of opportunistic infections, are recommended owing to severely compromised immunity and increased risks of morbidity and mortality. CONCLUSION Joint efforts are needed to ensure that UNAIDS 95-95-95 2030 goals are met in Germany. These include greater political will, increased funding of education and testing campaigns (from government institutions and the pharmaceutical industry), continued education about HIV testing by HIV experts, and broad testing support for physicians not routinely involved in HIV care.
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Affiliation(s)
| | | | - Jochen Schneider
- School of Medicine, University Hospital Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Gundolf Schuettfort
- Department of Infectious Diseases, University Hospital Frankfurt, Frankfurt, Germany
| | - Hartmut Stocker
- Department of Infectious Diseases, St. Joseph Hospital, Berlin, Germany.
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Duah E, Mathebula EM, Mashamba-Thompson T. Quality Assurance for Hepatitis C Virus Point-of-Care Diagnostics in Sub-Saharan Africa. Diagnostics (Basel) 2023; 13:684. [PMID: 36832172 PMCID: PMC9955859 DOI: 10.3390/diagnostics13040684] [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: 12/01/2022] [Revised: 02/06/2023] [Accepted: 02/10/2023] [Indexed: 02/15/2023] Open
Abstract
As part of a multinational study to evaluate the Bioline Hepatitis C virus (HCV) point-of-care (POC) testing in sub-Saharan Africa (SSA), this narrative review summarises regulatory standards and quality indicators for validating and approving HCV clinical diagnostics. In addition, this review also provides a summary of their diagnostic evaluations using the REASSURED criteria as the benchmark and its implications on the WHO HCV elimination goals 2030.
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Affiliation(s)
- Evans Duah
- Faculty of Health Science, School of Health Systems and Public Health, University of Pretoria, Pretoria 0002, South Africa
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Martyn E, Eisen S, Longley N, Harris P, Surey J, Norman J, Brown M, Sultan B, Maponga TG, Iwuji C, Flanagan S, Ghosh I, Story A, Matthews PC. The forgotten people: Hepatitis B virus (HBV) infection as a priority for the inclusion health agenda. eLife 2023; 12:e81070. [PMID: 36757862 PMCID: PMC9910830 DOI: 10.7554/elife.81070] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 01/19/2023] [Indexed: 02/10/2023] Open
Abstract
Hepatitis B virus (HBV) infection represents a significant global health threat, accounting for 300 million chronic infections and up to 1 million deaths each year. HBV disproportionately affects people who are under-served by health systems due to social exclusion, and can further amplify inequities through its impact on physical and mental health, relationship with stigma and discrimination, and economic costs. The 'inclusion health' agenda focuses on excluded and vulnerable populations, who often experience barriers to accessing healthcare, and are under-represented by research, resources, interventions, advocacy, and policy. In this article, we assimilate evidence to establish HBV on the inclusion health agenda, and consider how this view can inform provision of better approaches to diagnosis, treatment, and prevention. We suggest approaches to redress the unmet need for HBV interventions among excluded populations as an imperative to progress the global goal for the elimination of viral hepatitis as a public health threat.
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Affiliation(s)
- Emily Martyn
- The Francis Crick InstituteLondonUnited Kingdom
- London School of Hygiene & Tropical MedicineLondonUnited Kingdom
- Hospital for Tropical Diseases, Division of Infection, University College London Hospitals NHS Foundation TrustLondonUnited Kingdom
| | - Sarah Eisen
- Hospital for Tropical Diseases, Division of Infection, University College London Hospitals NHS Foundation TrustLondonUnited Kingdom
| | - Nicky Longley
- London School of Hygiene & Tropical MedicineLondonUnited Kingdom
- Hospital for Tropical Diseases, Division of Infection, University College London Hospitals NHS Foundation TrustLondonUnited Kingdom
- Department of Infectious Diseases, University College London Hospitals NHS Foundation TrustLondonUnited Kingdom
| | - Philippa Harris
- Find & Treat Service, Division of Infection, University College London Hospitals NHS Foundation TrustLondonUnited Kingdom
| | - Julian Surey
- Find & Treat Service, Division of Infection, University College London Hospitals NHS Foundation TrustLondonUnited Kingdom
- Institute of Global Health, University College LondonLondonUnited Kingdom
- Universidad Autonoma de Madrid, Ciudad Universitaria de CantoblancoMadridSpain
| | - James Norman
- Find & Treat Service, Division of Infection, University College London Hospitals NHS Foundation TrustLondonUnited Kingdom
| | - Michael Brown
- London School of Hygiene & Tropical MedicineLondonUnited Kingdom
- Department of Infectious Diseases, University College London Hospitals NHS Foundation TrustLondonUnited Kingdom
- Find & Treat Service, Division of Infection, University College London Hospitals NHS Foundation TrustLondonUnited Kingdom
| | - Binta Sultan
- Find & Treat Service, Division of Infection, University College London Hospitals NHS Foundation TrustLondonUnited Kingdom
- Mortimer Market Centre, Central and North London NHS Foundation TrustLondonUnited Kingdom
| | - Tongai G Maponga
- Stellenbosch University, Faculty of Medicine and Health SciencesTygerbergSouth Africa
| | - Collins Iwuji
- Department of Global Health, Brighton and Sussex Medical School, University of SussexBrightonUnited Kingdom
- Africa Health Research InstituteDurban, KwaZulu-NatalSouth Africa
| | - Stuart Flanagan
- Mortimer Market Centre, Central and North London NHS Foundation TrustLondonUnited Kingdom
| | - Indrajit Ghosh
- Find & Treat Service, Division of Infection, University College London Hospitals NHS Foundation TrustLondonUnited Kingdom
- Mortimer Market Centre, Central and North London NHS Foundation TrustLondonUnited Kingdom
| | - Alistair Story
- Find & Treat Service, Division of Infection, University College London Hospitals NHS Foundation TrustLondonUnited Kingdom
- Collaborative Centre for Inclusion Health, University College LondonLondonUnited Kingdom
| | - Philippa C Matthews
- The Francis Crick InstituteLondonUnited Kingdom
- Department of Infectious Diseases, University College London Hospitals NHS Foundation TrustLondonUnited Kingdom
- Mortimer Market Centre, Central and North London NHS Foundation TrustLondonUnited Kingdom
- Division of Infection and Immunity, University College LondonLondonUnited Kingdom
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Zhou J, Wang FD, Li LQ, Chen EQ. Management of in- and out-of-hospital screening for hepatitis C. Front Public Health 2023; 10:984810. [PMID: 36761331 PMCID: PMC9905736 DOI: 10.3389/fpubh.2022.984810] [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: 07/02/2022] [Accepted: 12/28/2022] [Indexed: 01/26/2023] Open
Abstract
Because of insidious progression and no significant clinical symptoms at early stage, chronic hepatitis C (CHC) is often diagnosed after the occurrence of cirrhosis and hepatocellular carcinoma. Highly effective and low drug resistance of direct-acting antiviral agents (DAAs) have enabled cure of CHC, encouraging the World Health Organization to propose a global viral hepatitis elimination program. To Date, vaccine for CHC is still under research. Therefore, reducing the source of infection is an important means of eliminating CHC other than cutting off the transmission route, which requires screening, diagnosing and treating as many patients in the population as possible. Hospital-based screening strategy have been found to be cost-effective in the management of CHC screening, as reported both nationally and internationally. Currently, China has issued In-hospital process for viral hepatitis C screening and management in China (Draft) in April, 2021, which provides a standardized implementation process and direction for in-hospital hepatitis C screening and treatment, but still requires medical institution to develop its own management process, taking into account its current situation and learning from domestic and international experience. In addition, screening for CHC outside the hospital among special populations, such as blood donors, pregnant women, homosexuals, intravenous drug users, prisoners, and residents in rural areas with scarce medical care resources, also requires attention and development of targeted and rational screening strategies. In this paper, we analyze and recommend the management of hepatitis C screening from both in-hospital and out-of-hospital perspectives, with the aim of contributing to the formulation of hepatitis C screening strategies.
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Simmons R, Plunkett J, Cieply L, Ijaz S, Desai M, Mandal S. Blood-borne virus testing in emergency departments - a systematic review of seroprevalence, feasibility, acceptability and linkage to care. HIV Med 2023; 24:6-26. [PMID: 35702813 DOI: 10.1111/hiv.13328] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 05/09/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND Blood-borne viruses (BBVs) cause significant morbidity and mortality worldwide. Emergency departments (EDs) offer a point of contact for groups at increased risk of BBVs who may be less likely to engage with primary care. We reviewed the literature to evaluate whether BBV testing in this setting might be a viable option to increase case finding and linkage to care. METHODS We searched PubMed database for English language articles published until June 2019 on BBV testing in EDs. Studies reporting seroprevalence surveys, feasibility, linkage to care, enablers and barriers to testing were included. Additional searches for grey literature were performed. RESULTS Eight-nine articles met inclusion criteria, of which 14 reported BBV seroprevalence surveys in EDs, 54 investigated feasibility and acceptability, and 36 investigated linkage to care. Most studies were HIV-focused and conducted in the USA. Seroprevalence rates were in the range 1.5-17% for HCV, 0.7-1.6% for HBV, and 0.8-13% for HIV. For studies that used an opt-in study design, testing uptake ranged from 2% to 98% and for opt-out it ranged from 16% to 91%. There was a wide range of yield: 13-100% of patients received their test result, 21-100% were linked to care, and 50-91% were retained in care. Compared with individuals diagnosed with HIV, linkage to and retention in care were lower for those diagnosed with hepatitis C. Predictors of linkage to care was associated with certain patient characteristics. CONCLUSIONS Universal opt-out BBV testing in EDs may be feasible and acceptable, but linkage to care needs to be improved by optimizing implementation. Further economic evaluations of hepatitis testing in EDs are needed.
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Affiliation(s)
- Ruth Simmons
- Blood Safety, Hepatitis, Sexually Transmitted Infections (STIs) and HIV Division, UK Health Security Agency, London, UK.,The National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Blood Borne and Sexually Transmitted Infections at University College, London, UK
| | - James Plunkett
- Blood Safety, Hepatitis, Sexually Transmitted Infections (STIs) and HIV Division, UK Health Security Agency, London, UK
| | - Lukasz Cieply
- Blood Safety, Hepatitis, Sexually Transmitted Infections (STIs) and HIV Division, UK Health Security Agency, London, UK
| | - Samreen Ijaz
- The National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Blood Borne and Sexually Transmitted Infections at University College, London, UK.,Blood Borne Virus Unit, Virus Reference Department, UK Health Security Agency, London, UK
| | - Monica Desai
- Blood Safety, Hepatitis, Sexually Transmitted Infections (STIs) and HIV Division, UK Health Security Agency, London, UK.,The National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Blood Borne and Sexually Transmitted Infections at University College, London, UK
| | - Sema Mandal
- Blood Safety, Hepatitis, Sexually Transmitted Infections (STIs) and HIV Division, UK Health Security Agency, London, UK.,The National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Blood Borne and Sexually Transmitted Infections at University College, London, UK
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Noiriel N, Williams J. Early cost-utility analysis of hepatitis C virus testing for emergency department attendees in France. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001559. [PMID: 36963042 PMCID: PMC10021824 DOI: 10.1371/journal.pgph.0001559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 01/13/2023] [Indexed: 02/25/2023]
Abstract
Testing for hepatitis C virus (HCV) is currently targeted towards those at high-risk in France. While universal screening was recently rejected, a growing body of research from other high-income countries suggests that HCV testing in emergency departments (ED) can be effective and cost-effective. In the absence of any studies on the effectiveness of HCV testing in ED attendees in France, this study aimed to perform an early economic evaluation of ED-based HCV testing. A Markov model was developed to simulate HCV testing in the ED versus no ED testing. The model captured costs from a French health service perspective, presented in 2020 euros, and outcomes, presented as quality-adjusted life years (QALYs), over a lifetime horizon. Incremental cost-effectiveness ratios (ICER) were calculated as costs per QALYs gained and compared to willingness-to-pay thresholds of €18,592 and €33,817 per QALY. Value of information analyses were also performed. ED testing for HCV was cost-effective at both thresholds when assuming ED prevalence of 1.1%, yielding an ICER of €3,800 per QALY. Testing remained cost-effective when the HCV prevalence amongst ED attendees remained higher than in the general population (0.3%). The maximum value of future research ranged from €10 to €79 million, depending on time horizons and willingness-to-pay thresholds. Our analysis suggests ED-based HCV testing may be cost-effective in France, although there is uncertainty due to the lack of empirical studies available. Further research is of high value, suggesting seroprevalence surveys and pilot studies in French ED settings are warranted.
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Affiliation(s)
- Nicolas Noiriel
- London School of Hygiene & Tropical Medicine, London, England, United Kingdom
| | - Jack Williams
- Department of Health Service Research and Policy, London School of Hygiene & Tropical Medicine, London, England, United Kingdom
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Myring G, Lim AG, Hollingworth W, McLeod H, Beer L, Vickerman P, Hickman M, Radley A, Dillon JF. Cost-effectiveness of pharmacy-led versus conventionally delivered antiviral treatment for hepatitis C in patients receiving opioid substitution therapy: An economic evaluation alongside a pragmatic cluster randomised trial. J Infect 2022; 85:676-682. [PMID: 36170895 DOI: 10.1016/j.jinf.2022.09.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 09/20/2022] [Accepted: 09/21/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Elimination targets for hepatitis C have been set across the world. In the UK almost 90% of infections are in people who inject drugs. Evidence shows community case-finding is effective at identifying and treating undiagnosed patients. The aim of this analysis was to assess, from a healthcare provider perspective, the cost-effectiveness of a new pharmacist-led test and treat pathway for hepatitis C in opioid agonist treatment (OAT) patients attending community pharmacies compared to conventional care. METHODS In a cluster randomised controlled trial, pharmacies were randomised to the pharmacist-led or conventional care pathway. Mean cost per OAT patient and per patient initiating treatment was identified for each pathway. A Markov model tracking disease progression was developed, with a 50-year time horizon and 3·5% time discount rate, to estimate the incremental cost-effectiveness ratio (ICER) per quality-adjusted life-year (QALY) gained and the probability of being cost-effective at a £30,000 per QALY willingness-to-pay threshold. Probabilistic sensitivity analysis was performed for a range of drug discounts, re-infection rates, and model assumptions. FINDINGS Mean cost per OAT patient (£3,674 vs £1,965) and per patient initiating treatment (£863 vs £404) was higher in the pharmacist-led pathway, due to higher uptake of testing and pharmacist time requirements. Over a 50-year time horizon the ICER per QALY gained was £31,612 at NHS indicative price for treatment (£38,979 for 12 weeks) and 12·1/100 person-years re-infection rate, reducing to £21,027/£10,220/-£501 per QALY gained with 30%/60%/90% drug price discounts and £25,373/£21,738/£14,912 per QALY gained at re-infection rates of 8/5/2 per 100 person-years. At 30%/60%/90% drug discount rates, the pharmacist-led pathway has an 80%/98%/100% probability of being cost-effective. INTERPRETATION The pharmacist-led pathway is effective at increasing testing and treatment uptake, with cost-effectiveness being highly dependent on drug price discounts. FUNDING Trial funding provided by the Scottish Government, Gilead Sciences, and Bristol-Myers Squibb.
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Affiliation(s)
- G Myring
- Population Health Sciences, Bristol Medical School, University of Bristol, BS8 1UD, UK; The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol BS1 2NT, UK.
| | - A G Lim
- Population Health Sciences, Bristol Medical School, University of Bristol, BS8 1UD, UK
| | - W Hollingworth
- Population Health Sciences, Bristol Medical School, University of Bristol, BS8 1UD, UK; The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol BS1 2NT, UK
| | - H McLeod
- Population Health Sciences, Bristol Medical School, University of Bristol, BS8 1UD, UK; The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol BS1 2NT, UK
| | - L Beer
- Tayside Clinical Trials Unit, Tayside Medical Science Centre, University of Dundee, Dundee DD1 9SY, UK
| | - P Vickerman
- Population Health Sciences, Bristol Medical School, University of Bristol, BS8 1UD, UK
| | - M Hickman
- Population Health Sciences, Bristol Medical School, University of Bristol, BS8 1UD, UK
| | - A Radley
- Hepatology & Gastroenterology, Clinical & Molecular Medicine, School of Medicine, University of Dundee, Dundee DD1 9SY, UK
| | - J F Dillon
- Hepatology & Gastroenterology, Clinical & Molecular Medicine, School of Medicine, University of Dundee, Dundee DD1 9SY, UK
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Williams J, Vickerman P, Smout E, Page EE, Phyu K, Aldersley M, Nebbia G, Douthwaite S, Hunter L, Ruf M, Miners A. Universal testing for hepatitis B and hepatitis C in the emergency department: a cost-effectiveness and budget impact analysis of two urban hospitals in the United Kingdom. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2022; 20:60. [PMID: 36376920 PMCID: PMC9664679 DOI: 10.1186/s12962-022-00388-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 09/24/2022] [Indexed: 11/16/2022] Open
Abstract
Background Numerous studies have shown the effectiveness of testing for hepatitis B (HBV) and hepatitis C (HCV) in emergency departments (ED), due to the elevated prevalence amongst attendees. The aim of this study was to conduct a cost-effectiveness analysis of universal opt-out HBV and HCV testing in EDs based on 2 long-term studies of the real-world effectiveness of testing in 2 large ED’s in the UK. Methods A Markov model was used to evaluate ED-based HBV and HCV testing versus no ED testing, in addition to current testing practice. The two EDs had a HBV HBsAg prevalence of 0.5–0.9% and an HCV RNA prevalence of 0.9–1.0%. The analysis was performed from a UK health service perspective, over a lifetime time horizon. Costs are reported in British pounds (GBP), and outcomes as quality adjusted life years (QALYs), with both discounted at 3.5% per year. Incremental cost-effectiveness ratios (ICER) are calculated as costs per QALY gained. A willingness-to-pay threshold of £20,000/QALY was used. The cost-effectiveness was estimated for both infections, in both ED’s. Results HBV and HCV testing were highly cost-effective in both settings, with ICERs ranging from £7,177 to £12,387 per QALY gained. In probabilistic analyses, HBV testing was 89–94% likely to be cost-effective at the threshold, while HCV testing was 94–100% likely to be cost-effective, across both settings. In deterministic sensitivity analyses, testing remained cost-effective in both locations at ≥ 0.25% HBsAg prevalence, and ≥ 0.49% HCV RNA prevalence. This is much lower than the prevalence observed in the two EDs included in this study. Conclusions HBV and HCV testing in urban EDs is highly cost-effective in the UK, and can be cost-effective at relatively low prevalence. These results should be reflected in UK and European hepatitis testing guidelines. Supplementary Information The online version contains supplementary material available at 10.1186/s12962-022-00388-7.
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Smout E, Phyu K, Hughes GJ, Parker L, Rezai R, Evans A, McLaren J, Bush S, Davey S, Aldersley MA, Ruf M, Page EE. Real-world clinical effectiveness and sustainability of universal bloodborne virus testing in an urban emergency department in the UK. Sci Rep 2022; 12:19257. [PMID: 36357472 PMCID: PMC9648896 DOI: 10.1038/s41598-022-23602-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 11/02/2022] [Indexed: 11/12/2022] Open
Abstract
Innovative testing approaches and care pathways are required to meet HIV, hepatitis B (HBV) and hepatitis C (HCV) elimination goals. Routine testing for blood-borne viruses (BBVs) within emergency departments (EDs) is suggested by the European Centre for Disease Prevention and Control but there is a paucity of supporting evidence. We evaluated the introduction of routine BBV testing in EDs at a large teaching hospital in northern England. In October 2018, we modified the electronic laboratory ordering system to reflex opt-out HIV, HBV and HCV testing for all ED attendees aged 16-65 years who had a routine blood test for urea and electrolytes (U&Es). Linkage to care (LTC) was attempted for newly diagnosed patients, those never referred and those who had previously disengaged from care. The project operated for 18 months, here we present evaluation of the initial nine months (2 October 2018-1 July 2019). We analysed testing uptake, BBV seropositivity, LTC and treatment initiation within six months post-diagnosis. Over 9 months, 17,026/28,178 (60.4%) ED attendees who had U&Es performed were tested for ≥ 1 BBV. 299 active BBV infections were identified: 70 HIV Ab/Ag-positive (0.4% seroprevalence), 73 HBsAg-positive (0.4%) and 156 HCV RNA-positive (1.0%). Only 24.3% (17/70) HIV Ab/Ag-positive individuals required LTC, compared to 94.9% (148/156) HCV RNA-positive and 53.4% (39/73) HBsAg-positive individuals. LTC was successful in 94.1% (16/17) HIV Ab/Ag-positive and 69.3% (27/39) HBsAg-positive individuals. However, at 6 months LTC was just 39.2% (58/148) for HCV RNA-positive individuals, with 64% (37/58) of these commencing treatment. Universal opt-out ED BBV testing proved feasible and effective in identifying active BBV infections, especially among marginalised populations with reduced healthcare access. Our integrated approach achieved good LTC rates although further service development is necessary, particularly for HCV RNA-positive people who inject drugs.
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Affiliation(s)
- Elizabeth Smout
- grid.515304.60000 0005 0421 4601UK Field Epidemiology Training Programme, UK Health Security Agency, Leeds, UK ,grid.515304.60000 0005 0421 4601Field Service, UK Health Security Agency, Leeds, UK
| | - Khine Phyu
- grid.418161.b0000 0001 0097 2705Leeds Teaching Hospitals Trust, Leeds General Infirmary, Great George St, Leeds, LS1 3EX UK
| | - Gareth J. Hughes
- grid.515304.60000 0005 0421 4601Field Service, UK Health Security Agency, Leeds, UK
| | - Lee Parker
- grid.418161.b0000 0001 0097 2705Leeds Teaching Hospitals Trust, Leeds General Infirmary, Great George St, Leeds, LS1 3EX UK
| | - Roozbeh Rezai
- grid.418161.b0000 0001 0097 2705Leeds Teaching Hospitals Trust, Leeds General Infirmary, Great George St, Leeds, LS1 3EX UK
| | - Amy Evans
- grid.418161.b0000 0001 0097 2705Leeds Teaching Hospitals Trust, Leeds General Infirmary, Great George St, Leeds, LS1 3EX UK
| | - Joscelyne McLaren
- grid.418161.b0000 0001 0097 2705Leeds Teaching Hospitals Trust, Leeds General Infirmary, Great George St, Leeds, LS1 3EX UK
| | - Stephen Bush
- grid.418161.b0000 0001 0097 2705Leeds Teaching Hospitals Trust, Leeds General Infirmary, Great George St, Leeds, LS1 3EX UK
| | - Sarah Davey
- grid.418161.b0000 0001 0097 2705Leeds Teaching Hospitals Trust, Leeds General Infirmary, Great George St, Leeds, LS1 3EX UK
| | - Mark A. Aldersley
- grid.418161.b0000 0001 0097 2705Leeds Teaching Hospitals Trust, Leeds General Infirmary, Great George St, Leeds, LS1 3EX UK
| | - Murad Ruf
- grid.476328.c0000 0004 0383 8490Public Health, Medical Affairs, Gilead Sciences Ltd, London, UK
| | - Emma E. Page
- grid.418161.b0000 0001 0097 2705Leeds Teaching Hospitals Trust, Leeds General Infirmary, Great George St, Leeds, LS1 3EX UK
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Finding Cases of Hepatitis C for Treatment Using Automated Screening in the Emergency Department is Effective, but What Is the Cost? Can J Gastroenterol Hepatol 2022; 2022:3449938. [PMID: 36276913 PMCID: PMC9586809 DOI: 10.1155/2022/3449938] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 08/29/2022] [Accepted: 09/19/2022] [Indexed: 11/17/2022] Open
Abstract
Case detection remains a major challenge for hepatitis C virus (HCV) elimination. We have previously published results from a pilot of an emergency department (ED) semiautomated screening program, SEARCH; Screening Emergency Admissions at Risk of Chronic HCV. Several refinements to SEARCH have been developed to streamline and reduce cost. All direct costs of HCV testing until direct-acting antiviral (DAA) therapy initiation were calculated. Cost was assessed in 2018 Australian Dollars. A cost analysis of the initial program and refinements are presented. Sensitivity analysis to understand impact of variation in staff time, laboratory test cost, changes in HCV antibody (Ab) prevalence, RNA positivity percentage, and rate of linkage to care was conducted. Impact of refinements (SEARCH (2)) to cost is presented. The total SEARCH pilot, testing 5000 patients was estimated to cost $110,549.52 (range $92,109.79-$129,581.24) comprising of $68,278.67 for HCV Ab testing, $21,568.99 for follow-up and linkage to care of positive patients and $20,701.86 to prepare HCV RNA positive patients for treatment. Internal program refinements resulted in a 25% cost reduction. Following refinements, the cost of HCV antibody screening was $8.46 per test and the total cost per positive HCV Ab, positive HCV RNA, and per treated patient were $611.77, $2,168.64, and $3,566.11, respectively. Our sensitivity analysis indicates costs per HCV case found are modest so long as HCV Ab prevalence was at least 1%. ED screening is an affordable strategy for HCV case detection and elimination.
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Yuan JM, Croxford S, Viviani L, Emanuel E, Phipps E, Desai M. Investigating the sociodemographic and behavioural factors associated with hepatitis C virus testing amongst people who inject drugs in England, Wales and Northern Ireland: A quantitative cross-sectional analysis. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2022; 109:103821. [PMID: 35994940 DOI: 10.1016/j.drugpo.2022.103821] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 08/01/2022] [Accepted: 08/05/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Hepatitis C virus (HCV) transmission in the UK is driven by injecting drug use. We explore HCV testing uptake amongst people who inject drugs (PWID) in England, Wales and Northern Ireland, and identify factors associated with i) ever having an HCV test amongst people who have ever injected drugs, and ii) recently having an HCV test (within the current or previous year) amongst people who currently inject drugs (reported injecting drugs within the last year). METHODS We analysed data from the 2019 'Unlinked Anonymous Monitoring Survey' of PWID, using logistic regression. RESULTS Of 3,127 PWID, 2,065 reported injecting drugs within the last year. Most (86.7%) PWID had a lifetime history of HCV testing. In multivariable analysis, higher odds of ever testing were associated with: female sex (aOR=1.54; 95%CI 1.11-2.14), injecting duration ≥3 years (aOR=2.94; 95%CI 2.13-4.05), ever receiving used needles/syringes (aOR=1.74; 95%CI 1.29-2.36), ever being on opioid agonist treatment (aOR=2.91; 95%CI 2.01-4.21), ever being imprisoned (aOR=1.86; 95%CI 1.40-2.48) and ever being homeless (aOR=1.54; 95%CI 1.14-2.07). Amongst PWID who had injected drugs within the last year, 49.9% had recently undertaken an HCV test. After adjustment, factors associated with higher odds of undertaking a recent HCV test included: injecting crack in the last year (aOR=1.29; 95%CI 1.03-1.61), experiencing a non-fatal overdose in the last year (aOR=1.39; 95%CI 1.05-1.85), ever being on opioid agonist treatment (aOR=1.48; 95%CI 0.97-2.25), receiving HCV information in the last year (aOR=1.99; 95%CI 1.49-2.65) and using a healthcare service in the last year (aOR=1.80; 95%CI 1.21-2.67). CONCLUSION Results suggest that PWID who have experienced homelessness and incarceration - amongst the most vulnerable and marginalised in the PWID population - are engaging with HCV testing, but overall there remain missed testing opportunities. Recent initiates to injecting have highest HCV infection risk but lower odds of testing, and peer-education may help target this group.
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Affiliation(s)
- Jin-Min Yuan
- UK Health Security Agency, 61 Colindale Avenue, London, NW9 5EQ, UK.
| | - Sara Croxford
- UK Health Security Agency, 61 Colindale Avenue, London, NW9 5EQ, UK
| | - Laura Viviani
- Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, Keppel St, London, WC1E 7HT, UK
| | - Eva Emanuel
- UK Health Security Agency, 61 Colindale Avenue, London, NW9 5EQ, UK
| | - Emily Phipps
- UK Health Security Agency, 61 Colindale Avenue, London, NW9 5EQ, UK
| | - Monica Desai
- UK Health Security Agency, 61 Colindale Avenue, London, NW9 5EQ, UK
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Xu L, Liu D. Evaluation of the effect and investment benefit of Marine ecosystem protection and restoration. Front Ecol Evol 2022. [DOI: 10.3389/fevo.2022.991198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
In order to explore the effectiveness of Marine ecosystem conservation and restoration, an evaluation method based on the effectiveness and investment benefit of Marine ecosystem conservation and restoration was proposed. This method recommends key technical problems and solutions based on the information represented by Marine ecosystem protection to explore the effectiveness of Marine ecosystem protection and restoration. The results show that the evaluation efficiency of Marine ecosystem protection and restoration and investment benefit is about 30% higher than that of traditional methods. Due to the uncertainty of Marine ecological restoration, the role of adaptive management in Marine ecological restoration has been paid more and more attention, and the systematic process of improved management adapted to new knowledge and information has been explored.
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Nebbia G, Ruf M, Hunter L, Balasegaram S, Wong T, Kulasegaram R, Surey J, Khan Z, Williams J, Karo B, Snell L, Flower B, Evans H, Douthwaite S. VirA+EmiC project: Evaluating real-world effectiveness and sustainability of integrated routine opportunistic hepatitis B and C testing in a large urban emergency department. J Viral Hepat 2022; 29:559-568. [PMID: 35357750 PMCID: PMC9322278 DOI: 10.1111/jvh.13676] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 02/14/2022] [Accepted: 03/11/2022] [Indexed: 12/26/2022]
Abstract
Innovative testing approaches and care pathways are required to meet global hepatitis B virus (HBV) and hepatitis C virus (HCV) elimination goals. Routine blood-borne virus (BBV) testing in emergency departments (EDs) in high-prevalence areas is suggested by the European Centre for Disease Prevention and Control (ECDC) but there is limited evidence for this. Universal HIV testing in our ED according to UK guidance has been operational since 2015. We conducted a real-world service evaluation of a modified electronic patient record (EPR) system to include opportunistic opt-out HBV/reflex-HCV tests for any routine blood test orders for ED attendees aged ≥16 years. Reactive laboratory results were communicated directly to specialist clinical teams. Our model for contacting patients requiring linkage to care (new diagnoses/known but disengaged) evolved from initially primarily hospital-led to collaborating with regional health and community service networks. Over 11 months, 81,088 patients attended the ED; 36,865 (45.5%) had a blood test. Overall uptake for both HBV and HCV testing was 75%. Seroprevalence was 0.9% for hepatitis B surface antigen (HBsAg) and 0.9% for HCV antigen (HCV-Ag). 79% of 140 successfully contacted HBsAg+patients required linkage to care, of which 87% engaged. 76% of 130 contactable HCV-Ag+patients required linkage, 52% engaged. Our results demonstrate effectiveness and sustainability of universal ED EPR opt-out HBV/HCV testing combined with comprehensive linkage to care pathways, allowing care provision particularly for marginalized at-risk groups with limited healthcare access. The findings support the ECDC BBV testing guidance and may inform future UK hepatitis testing guidance.
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Affiliation(s)
- Gaia Nebbia
- Department of InfectionGuy's and St Thomas' NHS Foundation TrustLondonUK
| | - Murad Ruf
- Gilead Sciences Ltd UK & IrelandMedical DepartmentLondonUK
| | - Laura Hunter
- Department of Emergency MedicineGuy's and St Thomas' NHS Foundation TrustLondonUK
| | - Sooria Balasegaram
- Field Epidemiology ServiceNational Infection ServiceUK Health Security Agency, London UKLondonUK
| | - Terry Wong
- Gastroenterology and Hepatology DepartmentGuy's and St Thomas' NHS Foundation TrustLondonUK
| | | | - Julian Surey
- Institute for Global HealthUniversity College LondonLondonUK,Universidad Autónoma de MadridMadridSpain
| | - Zana Khan
- Institute of Epidemiology and Health CareUCL and South London and Maudsley TrustLondonUK
| | - Jack Williams
- Department of Health Services Research and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
| | - Basel Karo
- International Health Protection (ZIG 1)Robert Koch Institute (RKI)BerlinGermany
| | - Luke Snell
- Department of InfectionGuy's and St Thomas' NHS Foundation TrustLondonUK
| | - Barnaby Flower
- Division of Infectious DiseasesImperial College LondonLondonUK
| | - Hannah Evans
- Field Epidemiology ServiceNational Infection ServiceUK Health Security Agency, London UKLondonUK,UK Field Epidemiology Training ProgrammeUK Health Security AgencyLondonUK
| | - Sam Douthwaite
- Department of InfectionGuy's and St Thomas' NHS Foundation TrustLondonUK
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Marcellusi A, Mennini FS, Ruf M, Galli C, Aghemo A, Brunetto MR, Babudieri S, Craxi A, Andreoni M, Kondili LA. Optimizing diagnostic algorithms to advance Hepatitis C elimination in Italy: A cost effectiveness evaluation. Liver Int 2022; 42:26-37. [PMID: 34582627 PMCID: PMC9292516 DOI: 10.1111/liv.15070] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Revised: 09/22/2021] [Accepted: 09/24/2021] [Indexed: 12/26/2022]
Abstract
OBJECTIVES Optimized diagnostic algorithms to detect active infections are crucial to achieving HCV elimination. We evaluated the cost effectiveness and sustainability of different algorithms for HCV active infection diagnosis, in a context of a high endemic country for HCV infection. METHODS A Markov disease progression model, simulating six diagnostic algorithms in the birth cohort 1969-1989 over a 10-year horizon from a healthcare perspective was used. Conventionally diagnosis of active HCV infection is through detection of antibodies (HCV-Ab) detection followed by HCV-RNA or HCV core antigen (HCV-Ag) confirmatory testing either on a second sample or by same sample reflex testing. The undiagnosed and unconfirmed rates were evaluated by assays false negative estimates and each algorithm patients' drop-off. Age, liver disease stages distribution, liver disease stage costs, treatment effectiveness and costs were used to evaluate the quality-adjusted life-years (QALYs) and the incremental cost-effectiveness ratios (ICER). RESULTS The reference option was Rapid HCV-Ab followed by second sample HCV-Ag testing which produced the lowest QALYs (866,835 QALYs). The highest gains in health (QALYs=974,458) was obtained by HCV-RNA reflex testing which produced a high cost-effective ICER (€891/QALY). Reflex testing (same sample-single visit) vs two patients' visits algorithms, yielded the highest QALYs and high cost-effective ICERs (€566 and €635/QALY for HCV-Ag and HCV-RNA, respectively), confirmed in 99.9% of the 5,000 probabilistic simulations. CONCLUSIONS Our data confirm, by a cost effectiveness point of view, the EASL and WHO clinical practice guidelines recommending HCV reflex testing as most cost effective diagnostic option vs other diagnostic pathways.
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Affiliation(s)
- Andrea Marcellusi
- Economic Evaluation and HTA (EEHTA)CEISFaculty of EconomicsUniversity of Rome “Tor Vergata”RomeItaly
- Institute of Leadership and Management in HealthKingston Business SchoolKingston UniversityLondonUK
| | - Francesco Saverio Mennini
- Economic Evaluation and HTA (EEHTA)CEISFaculty of EconomicsUniversity of Rome “Tor Vergata”RomeItaly
- Institute of Leadership and Management in HealthKingston Business SchoolKingston UniversityLondonUK
| | - Murad Ruf
- Public Health, Medical AffairsGilead ScienceLondonUK
| | - Claudio Galli
- Global Medical and Scientific AffairsCore Laboratory, AbbottRomeItaly
| | - Alessio Aghemo
- Department of Biomedical SciencesHumanitas UniversityPieve EmanueleItaly
- Division of Internal Medicine and HepatologyHumanitas Research Hospital IRCCSRozzanoItaly
| | - Maurizia R. Brunetto
- Internal MedicineDepartment of Clinical and Experimental MedicineUniversity of PisaPisaItaly
- Hepatology Unit and Laboratory of Molecular Genetics and Pathology of Hepatitis VirusesUniversity Hospital of PisaPisaItaly
| | - Sergio Babudieri
- Infectious and Tropical Disease UnitDepartment of MedicalSurgical and Experimental SciencesUniversity of SassariSassariItaly
| | - Antonio Craxi
- Gastroenterology and Hepatology UnitDepartment of Internal Medicine and Medical Specialties “PROMISE”University of PalermoPalermoItaly
| | - Massimo Andreoni
- Department of Systems MedicineUniversity of Rome “Tor Vergata”RomeItaly
- Infectious Diseases ClinicUniversity Hospital “Tor Vergata”RomeItaly
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