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Li W, Chang TS, Chang SZ, Chen CH, Chen MY. Challenges of transferring rural adults with chronic HCV infection for further HCV RNA confirmation and free DAAs treatment: a success story of the interdisciplinary collaboration approach. BMC Infect Dis 2020; 20:737. [PMID: 33028228 PMCID: PMC7542903 DOI: 10.1186/s12879-020-05435-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Accepted: 09/20/2020] [Indexed: 01/08/2023] Open
Abstract
Background Chronic hepatitis C virus (HCV), which is a concern in many countries, is the leading cause of liver cancer around the world. Since Taiwan launched its national health insurance system in 1995, it has managed to extend health coverage to 99% of the Taiwanese population, providing free but limited antiviral treatment each year since 2017. However, many people in rural areas are unaware that they have chronic HCV; nor do they realize that new drugs with high cure rates could drastically reduce their health burden. The aim of this study is to explore the implementation facilitators of and barriers to inviting potentially infected patients in rural areas to be transferred for HCV ribonucleic acid (RNA) confirmation and new drug treatment. Methods A descriptive and prospective study design with an interdisciplinary collaboration approach was implemented. After five elements of referral were developed, telephone counseling was conducted between August 2018 and May 2019 in Yunlin, Taiwan. The elements of referral developed by the research team were: (1) forming and coordinating physicians’ schedules, (2) recruiting and training volunteers, (3) training the nursing staff, (4) raising funds or resources, and (5) connecting with village leaders. Thereafter, we collaborated with two district health centers, a private local hospital, and health clinics. Based on the medical records provided by these agencies, community adults that were HCV antibody (anti-HCV) positive were invited to join the program. Results Of the 1795 adults who were serum anti-HCV positive, 1149 (64%) accepted transfer to a qualified hospital; of these, 623 (54.2%) had an HCV infection. 552 (88.6%) of those infected started receiving direct-acting antivirals (DAAs) treatment. The top four barriers to accepting transfer were: (1) they perceived themselves to be healthy (n = 98, 32.3%); (2) mistrust of treatment/healthcare (n = 60, 20.2%); (3) limited transportation to the hospital (n = 52, 17.5%); and (4) work conflict (n = 30, 10.1%). Conclusion An interdisciplinary collaboration approach significantly contributed to the invitation of CHC patients, as well as their acceptance of HCV RNA confirmation and free DAAs treatment. Using anti-HCV data from previous medical records for case-finding and collaborating with a hospital and health clinics proved to be an efficient strategy.
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Affiliation(s)
- Wei Li
- Formosa Plastics Group Health Care, Yunlin, Taiwan
| | - Te-Sheng Chang
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Yunlin, Taiwan
| | | | - Ching-Hwa Chen
- Formosa Plastics Group, Advanced Engineer, Safety Health and Environment Center, Taipei, Taiwan
| | - Mei-Yen Chen
- Department of Nursing, Chang Gung University of Science and Technology, Chiayi, Taiwan. .,Research Fellow, Department of Cardiology, Chang Gung Memorial Hospital, No. 2, Chiapu Rd. West Sec., Putz City, Chiayi County, 613, Taiwan. .,School of Nursing, Chang Gung University, Taoyuan, Taiwan.
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2
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Younossi ZM, Stepanova M, Younossi I, Papatheodoridis G, Janssen HLA, Agarwal K, Nguyen MH, Gane E, Tsai N, Nader F. Patient-reported outcomes in patients chronic viral hepatitis without cirrhosis: The impact of hepatitis B and C viral replication. Liver Int 2019; 39:1837-1844. [PMID: 31173468 DOI: 10.1111/liv.14171] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 05/27/2019] [Accepted: 05/29/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIM Chronic infections with hepatitis B or C (HBV and HCV) are associated with adverse clinical outcomes and patient-reported outcomes (PROs). The aim is to compare PRO scores in patients with chronic HBV and HCV without advanced liver disease before and after suppression/clearance of their infection. METHODS Patients with HCV and HBV infection prior to initiation of antiviral treatment and after viral suppression/eradication completed PRO questionnaires. RESULTS We included 132 patients with HBV and 132 matched patients with HCV. Baseline PRO scores were significantly higher in patients with HBV in the domains of Physical Functioning, Role Physical, Bodily Pain, Social Functioning, and Role Emotional of SF-36, SF-6D utility, Emotional and Fatigue domains of CLDQ, Presenteeism and total Work Productivity Impairment of WPAI:SHP in comparison to patients with HCV by 5.8%-13.2% of a PRO score range (all P < 0.05). After viral suppression (HBV DNA < 20 IU/mL after 48 weeks of treatment for HBV) or eradication (SVR-12 for HCV), only Physical Functioning and Role Physical scores remained higher in HBV by 6.7%-9.9%, while other PRO scores became similar between HBV and HCV groups (P > 0.05). The most prominent improvement of PROs in HCV was noted in Vitality, Emotional, Fatigue and Worry domains. In addition, General Health, Worry and Work Productivity scores were the most improved in HBV. CONCLUSIONS Prior to treatment, PRO scores were lower in patients with HCV in comparison to HBV. After successful treatment, both groups of patients experienced improvement in some PRO domains confirming the positive impact of treatment.
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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, District of Columbia
| | - Issah Younossi
- Center for Outcomes Research in Liver Disease, Washington, District of Columbia
| | | | - Harry L A Janssen
- Toronto Centre for Liver Disease, University Health Network, Toronto, Canada
| | - Kosh Agarwal
- Institute of Liver Studies, London, United Kingdom
| | | | - Ed Gane
- Auckland Clinical Studies, Auckland, New Zealand
| | - Naoky Tsai
- Queens Medical Center, University of Hawaii, Honolulu, Hawaii
| | - Fatema Nader
- Center for Outcomes Research in Liver Disease, Washington, District of Columbia
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3
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Younossi ZM, Stepanova M, Younossi I, Racila A. Validation of Chronic Liver Disease Questionnaire for Nonalcoholic Steatohepatitis in Patients With Biopsy-Proven Nonalcoholic Steatohepatitis. Clin Gastroenterol Hepatol 2019; 17:2093-2100.e3. [PMID: 30639779 DOI: 10.1016/j.cgh.2019.01.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 12/19/2018] [Accepted: 01/04/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The chronic liver disease questionnaire for nonalcoholic steatohepatitis (CLDQ-NASH) was developed in a systematic manner for assessment of patient-reported outcomes. This instrument collects data on 36 items grouped into 6 domains: abdominal symptoms, activity/energy, emotional health, fatigue, systemic symptoms, and worry. We aimed to validate the CLDQ-NASH in a large group of patients with NASH. METHODS We collected data from patients with biopsy-proven NASH enrolled in 2 international phase 3 trials of selonsertib (NCT03053050 and NCT03053063). Our final analysis comprised 1667 patients who completed the CLDQ-NASH (age, 58 ± 9 y; 40% male; 52% with cirrhosis; and 69% with type 2 diabetes). The CLDQ-NASH was administered before treatment initiation. A standard patient-reported outcome instrument validation pipeline with internal consistency and validity assessment was applied. RESULTS The domains of CLDQ-NASH showed good to excellent internal consistency: the Cronbach's α values were 0.80 to 0.94 and item-to-own-domain correlations were greater than 0.50 for 33 of 36 items. All items correlated to the greatest extent with their own domains (discriminant validity). Known-group validity tests indicated that the instrument consistently discriminated between patients with NASH based on the presence of cirrhosis (vs bridging fibrosis; all but 1 P value < .02), obesity (all but 1 P value < .001), psychiatric comorbidities (all P values < .0001), fatigue (all P values < .001), and type 2 diabetes (all but 1 P value < .01). Of the CLDQ-NASH domains, the highest correlated domains with the Short Form-36 were as follows: physical functioning for activity (rho = 0.70), mental health for emotional (rho = 0.72), vitality for fatigue (rho = 0.75), and body pain for systemic (rho = 0.72) (all P values < .0001). In contrast, the domains of abdominal and worry, which are disease-specific, did not correlate with the domains in the Short Form-36 (all rho ≤ 0.50). CONCLUSIONS We validated the CLDQ-NASH by an analysis of data from 1667 patients with biopsy-proven NASH enrolled in phase 3 trials, observing excellent psychometric characteristics of the instrument.
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Affiliation(s)
- Zobair M Younossi
- Center For Liver Disease, 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 Diseases, Washington, District of Columbia
| | - Issah Younossi
- Center for Outcomes Research in Liver Diseases, Washington, District of Columbia
| | - Andrei Racila
- Center For Liver Disease, Department of Medicine, Inova Fairfax Hospital, Falls Church, Virginia; Center for Outcomes Research in Liver Diseases, Washington, District of Columbia
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Implementation of Value-based Medicine (VBM) to Patients With Chronic Hepatitis C (HCV) Infection. J Clin Gastroenterol 2019; 53:262-268. [PMID: 30681638 DOI: 10.1097/mcg.0000000000001174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION With the significant clinical and economic burden of chronic HCV, effective treatment must be provided efficiently and appropriately. VBM is predicated upon improving health outcomes (clinical and quality) while optimizing the cost of delivering these outcomes. This review explores the concepts of VBM and how it can be used as a strategy for HCV eradication, using the United States as a case example. Once treated with interferon-based regimens, patients with HCV experienced low cure rates, very poor health-related quality of life (HRQoL), decreased work productivity and significant costs. In this context, the old treatment of HCV produced little value to the patient and the society. However, the development of new antiviral regimens for HCV which are free of interferon, has greatly improved treatment success rates as documented with very high cure rates and by improving patient-reported outcomes (PROs), including HRQoL. However, the short-term economic investment to deliver this curative treatment to all HCV-infected patients can be sizeable. In contrast, if one takes the long-term view from the societal perspective, these new treatment regimens can lead to savings by reducing the costs of long-term complications of HCV infection. CONCLUSIONS All of the necessary tools are now available to implement strategies to eradicate HCV. The new all oral direct acting antivirals brings value to the patients and the society because it leads to improvements of clinically important outcomes. Furthermore, the costs associated with these treatment regimens can be recovered by preventing the future economic burden of HCV-complications.
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Puig-Junoy J, Pascual-Argente N, Puig-Codina L, Planellas L, Solozabal M. Cost-utility analysis of second-generation direct-acting antivirals for hepatitis C: a systematic review. Expert Rev Gastroenterol Hepatol 2018; 12:1251-1263. [PMID: 30791790 DOI: 10.1080/17474124.2018.1540929] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
High prices of second-generation direct-acting antivirals (DAAs) in the treatment of chronic hepatitis C virus (HCV) patients led to reimbursement decisions based on cost per quality-adjusted life year (QALY). Areas covered: We performed a systematic review of cost-utility analyses (CUA) comparing interventions with second-generation DAA therapies with no treatment, and with previous therapies for chronic HCV patients until July 2017. A total of 36 studies were included: 30 studies from the perspective of the healthcare payer, 3 from the societal perspective, and 3 did not report the perspective. For genotype 1, the highest number of ICER comparison corresponds to sofosbuvir (SOF) triple therapy and SOF-based combinations which reported a cost per QALY systematically ranging from negative to lower than US$100,000 when compared with no treatment or dual therapy or Simeprevir triple therapy. Expert commentary: Selected studies may be overestimating the true cost per QALY of second-generation DAAs in the treatment of HCV, mainly because of neglecting non-healthcare costs, using official list prices which are higher than actual transaction prices and not adopting the long run drug price in a dynamic approach. In addition, the impact of important price reductions of several DAAs in recent years on cost per QALY should be considered.
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Affiliation(s)
- Jaume Puig-Junoy
- a Department of Economics and Business (UPF) , Pompeu Fabra University , Barcelona , Spain.,b UPF Barcelona School of Management , Pompeu Fabra University , Barcelona , Spain.,c UPF Center for Research in Health and Economics (CRES-UPF) , Pompeu Fabra University , Barcelona , Spain
| | - Natàlia Pascual-Argente
- b UPF Barcelona School of Management , Pompeu Fabra University , Barcelona , Spain.,c UPF Center for Research in Health and Economics (CRES-UPF) , Pompeu Fabra University , Barcelona , Spain
| | - Lluc Puig-Codina
- b UPF Barcelona School of Management , Pompeu Fabra University , Barcelona , Spain
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6
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Younossi Z, Papatheodoridis G, Cacoub P, Negro F, Wedemeyer H, Henry L, Hatzakis A. The comprehensive outcomes of hepatitis C virus infection: A multi-faceted chronic disease. J Viral Hepat 2018; 25 Suppl 3:6-14. [PMID: 30398294 DOI: 10.1111/jvh.13005] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 08/16/2018] [Indexed: 02/06/2023]
Abstract
Treatment of hepatitis C virus (HCV) infection has been revolutionized with the introduction of pangenotypic, interferon- and ribavirin-free regimens associated with high cure rates and a low side effect profile. Additionally, there is evidence that HCV cure reduces HCV complications, improves patient-reported outcomes and is cost-saving in most western countries in the long term. This is a review of the comprehensive burden of HCV and the value of eliminating HCV infection. With the introduction of the interferon-free all-oral, once a day pill treatment regimen for the cure of HCV, the potential to eliminate HCV by 2030 has become a possibility for some regions of the world. Nevertheless, there are barriers to screening, linkage to care, and treatment in many countries that must be overcome in order to reach this goal. In conclusion, globally, work must continue to ensure national policies are in place to support screening, linkage to care and affordable treatment in order to eliminate HCV.
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Affiliation(s)
- Zobair Younossi
- Department of Medicine, Inova Fairfax Hospital, Falls Church, Virginia.,Beatty Center for Integrated Research, Inova Health System, Falls Church, Virginia
| | - Georgios Papatheodoridis
- Department of Gastroenterology, Medical School of National and Kapodistrian University of Athens, General Hospital of Athens Laiko, Athens, Greece
| | - Patrice Cacoub
- Department of Internal Medicine and Clinical Immunology, AP HP Hôpital La Pitié-Salpêtrière, Paris, France.,CNRS UMR 7087, INSERM UMR S-959, DHU I2B, Sorbonne Université, Paris, France
| | | | | | - Linda Henry
- Center for Outcomes Research in Liver Disease, Washington D.C
| | - Angelos Hatzakis
- Department of Hygiene, Epidemiology and Medical Statistics, Medical School of National and Kapodistrian University of Athens, Athens, Greece.,Hepatitis B and C Public Policy Association, L-2453 , Luxembourg
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7
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Younossi ZM, Tanaka A, Eguchi Y, Henry L, Beckerman R, Mizokami M. Treatment of hepatitis C virus leads to economic gains related to reduction in cases of hepatocellular carcinoma and decompensated cirrhosis in Japan. J Viral Hepat 2018; 25:945-951. [PMID: 29478258 DOI: 10.1111/jvh.12886] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Accepted: 01/17/2018] [Indexed: 12/11/2022]
Abstract
Hepatocellular carcinoma (HCC) is a serious complication of hepatitis C virus (HCV) infection. Sustained virologic response (SVR) for HCV is associated with a reduction in cirrhosis, HCC and mortality and their associated costs. Japanese HCV patients are older with higher prevalence of HCC. Here we used a decision-analytic Markov model to estimate the economic benefit of HCV cure by reducing HCC and DCC burden in Japan. A cohort of 10 000 HCV genotype 1b (GT1b) Japanese patients was modelled with a hybrid decision tree and Markov state-transition model capturing natural history of HCV over a lifetime horizon. Treatment options were approved all-oral direct-acting anti-virals (DAAs) vs no treatment. Treatment efficacy was based on clinical trials and transition rates and costs obtained from Japan-specific data. Cases of HCC, decompensated cirrhosis (DCC) and quality-adjusted life years (QALYs) were projected for patients treated with DAAs vs NT. QALYs were monetized using a willingness-to-pay threshold of ¥4-to-¥6 million. Incremental savings with treatment were calculated by adding the projected cost of complications avoided to the monetized gains in QALYs. The model showed that DAA treatment vs no treatment, reduces 2057 cases of HCC and 1478 cases of decompensated cirrhosis and saves ¥850 446.73 and ¥338 229.90 per patient (ppt). Additionally, treatment can lead to additional 2.64 QALYs gained per patient. The indirect economic gains associated with treatment-related QALY improvements were ¥10 576 000, ¥13 220 000 and ¥15 864 000 ppt (willingness-to-pay thresholds of ¥4 million, ¥5 million and ¥6 million). Total economic savings of treatment with DAAs (vs no treatment) was ¥7 526 372.63, ¥10 170 372.63 and ¥12 814 372.63, at these different willingness-to-pay thresholds. In conclusion treatment of HCV GT1b with all-oral DAAs in Japan can lead to significant direct and indirect savings related to avoidance of HCC and DCC.
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Affiliation(s)
- Z M Younossi
- Inova Health System, Betty and Guy Beatty Center for Integrated Research, Falls Church, VA, USA.,Department of Medicine, Center for Liver Diseases, Inova Fairfax Hospital, Falls Church, VA, USA
| | - A Tanaka
- Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Y Eguchi
- Liver Center, Saga University Hospital, Saga University, Saga, Japan
| | - L Henry
- Center for Outcomes Research in Liver Diseases, Washington, DC, USA
| | | | - M Mizokami
- National Center for Global Health and Medicine, Tokyo, Japan
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8
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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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Cipriano LE, Goldhaber-Fiebert JD. Population Health and Cost-Effectiveness Implications of a "Treat All" Recommendation for HCV: A Review of the Model-Based Evidence. MDM Policy Pract 2018; 3:2381468318776634. [PMID: 30288448 PMCID: PMC6157435 DOI: 10.1177/2381468318776634] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 04/20/2018] [Indexed: 12/15/2022] Open
Abstract
The World Health Organization HCV Guideline Development Group is considering a "treat all" recommendation for persons infected with hepatitis C virus (HCV). We reviewed the model-based evidence of cost-effectiveness and population health impacts comparing expanded treatment policies to more limited treatment access policies, focusing primarily on evaluations of all-oral directly acting antivirals published after 2012. Searching PubMed, we identified 2,917 unique titles. Sequentially reviewing titles and abstracts identified 226 potentially relevant articles for full-text review. Sixty-nine articles met all inclusion criteria-42 cost-effectiveness analyses and 30 models of population-health impacts, with 3 articles presenting both types of analysis. Cost-effectiveness studies for many countries concluded that expanding treatment to people with mild liver fibrosis, who inject drugs (PWID), or who are incarcerated is generally cost-effective compared to more restrictive treatment access policies at country-specific prices. For certain patient subpopulations in some countries-for example, elderly individuals without fibrosis-treatment is only cost-effective at lower prices. A frequent limitation is the omission of benefits and consequences of HCV transmission (i.e., treatment as prevention; risks of reinfection), which may underestimate or overestimate the cost-effectiveness of a "treat all" policy. Epidemiologic modeling studies project that through a combination of prevention, aggressive screening and diagnosis, and prompt treatment for all fibrosis stages, it may be possible to virtually eliminate HCV in many countries. Studies show that if resources are not available to diagnose and treat all HCV-infected individuals, treatment prioritization may be needed, with alternative prioritization strategies resulting in tradeoffs between reducing mortality or reducing incidence. Notably, because most new HCV infections are among PWID in many settings, HCV elimination requires unrestricted treatment access combined with injection transmission disruption strategies. The model-based evidence suggests that a properly constructed strategy that substantially expands HCV treatment could achieve cost-effective improvements in population health in many countries.
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Affiliation(s)
- Lauren E Cipriano
- Ivey Business School and the Department of Biostatistics and Epidemiology, Western University, London, Ontario, Canada
| | - Jeremy D Goldhaber-Fiebert
- Center for Health Policy and Center for Primary Care and Outcomes Research, Department of Medicine, Stanford University, Stanford, California
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10
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Younossi ZM. The efficacy of new antiviral regimens for hepatitis C infection: Evidence from a systematic review. Hepatology 2018; 67:1160-1162. [PMID: 29023922 DOI: 10.1002/hep.29580] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 09/12/2017] [Accepted: 10/03/2017] [Indexed: 12/12/2022]
Affiliation(s)
- Zobair M Younossi
- Center for Liver Diseases, Department of Medicine, Inova Fairfax Hospital.,Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA
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11
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Sikavi C, Chen PH, Lee AD, Saab EG, Choi G, Saab S. Hepatitis C and human immunodeficiency virus coinfection in the era of direct-acting antiviral agents: No longer a difficult-to-treat population. Hepatology 2018; 67:847-857. [PMID: 29108121 DOI: 10.1002/hep.29642] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 09/26/2017] [Accepted: 11/02/2017] [Indexed: 12/11/2022]
Abstract
UNLABELLED The treatment of chronic hepatitis C (HCV) in human immunodeficiency virus 1 (HIV)-infected individuals has been historically marked by low sustained virologic response (SVR) rates in comparison to those without HIV infection, resulting in the Food and Drug Administration labeling those coinfected as a "special population with an unmet medical need." We systematically reviewed the treatment of chronic HCV infection in those infected with HIV. We propose that with the advent of direct-acting antiviral (DAA) agents, patients coinfected with HCV and HIV have similar SVR rates as HCV-monoinfected persons and that DAAs address an unmet medical need in this population. A review was performed using Medical Subject Heading terms within the PubMed, EMBASE, and Cochrane Library databases to search for studies dated between January 2004 and July 2017. Keywords used in the study included "hepatitis C," "HIV," "coinfection," and "direct-acting antiviral." SVR rates for those with HCV and HIV coinfection treated with interferon-based therapies were substantially lower that SVR rates of HCV-monoinfected individuals. The advent of DAA agents has resulted in similar SVR rates between monoinfected and coinfected individuals, with SVR >93%. These medications have been demonstrated to have improved safety, efficacy, and tolerability in comparison to interferon-based regimens. CONCLUSION The designation of a "special population" for those with coinfection requires reconsideration; DAA therapies have resulted in similarly high rates of SVR for HCV infection in those with and without HIV infection; despite these improvements, however, clinicians must be cognizant of negative predictors of SVR and barriers to treatment that may be more common in the coinfected population. (Hepatology 2018;67:847-857).
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Affiliation(s)
- Cameron Sikavi
- Department of Medicine at Harbor, University of California at Los Angeles Medical Center, Torrance, CA
| | - Phillip H Chen
- Department of Surgery, University of California at Los Angeles, Los Angeles, CA
| | - Alex D Lee
- Department of Surgery, University of California at Los Angeles, Los Angeles, CA
| | - Elena G Saab
- Department of Surgery, University of California at Los Angeles, Los Angeles, CA
| | - Gina Choi
- Department of Surgery, University of California at Los Angeles, Los Angeles, CA.,Department of Medicine, University of California at Los Angeles, Los Angeles, CA
| | - Sammy Saab
- Department of Surgery, University of California at Los Angeles, Los Angeles, CA.,Department of Medicine, University of California at Los Angeles, Los Angeles, CA
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12
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Younossi Z, Blissett D, Blissett R, Henry L, Younossi Y, Beckerman R, Hunt S. In an era of highly effective treatment, hepatitis C screening of the United States general population should be considered. Liver Int 2018; 38:258-265. [PMID: 28719013 DOI: 10.1111/liv.13519] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 07/10/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Hepatitis C virus (HCV) treatment with all oral direct acting antiviral agents (DAA's) achieve sustained virologic response (SVR) rates of 98%. Re-assessment of general US population screening for HCV is imperative. This study compared the cost-effectiveness (CE) of three HCV screening strategies: screen all (SA), screen Birth Cohort (BCS), and screen high risks (HRS). METHODS Using a previous designed decision-analytic Markov model, estimations of the natural history of HCV and CE evaluation of the three HCV screening strategies over a lifetime horizon in the US population was undertaken. Based on age and risk status, 16 cohorts were modelled. Health states included: Fibrosis stages 0 to 4, decompensated cirrhosis, hepatocellular carcinoma, LT, post-LT, and death. The probability of liver disease progression was based on the presence or absence of virus. Treatment was with approved all-oral DAAs; 86% were assumed to be seen annually by a primary care provider; SVR rates, transition probabilities, utilities, and costs were from the literature. One-way sensitivity analyses tested the impact of key model drivers. RESULTS SA cost $272.0 billion [$135 279 per patient] and led to 12.19 QALYs per patient. BCS and HRS cost $274.5 billion ($136 568 per patient) and $284.5 billion ($141 502 per patient) with 11.65 and 11.25 QALYs per patient respectively. Compared to BCS, SA led to an additional 0.54 QALYs per patient and saved $2.59 billion; compared to HRS, SA led to 0.95 additional QALYs per patient and saved $12.5 billion. CONCLUSIONS Screening the entire US population and treating active viraemia was projected as cost-saving.
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Affiliation(s)
- Zobair Younossi
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, USA.,Department of Medicine, Center for Liver Diseases, Inova Fairfax Hospital, Falls Church, VA, USA
| | | | | | - Linda Henry
- Center for Outcomes Research in Liver Disease, Washington, DC, USA
| | - Youssef Younossi
- Center for Outcomes Research in Liver Disease, Washington, DC, USA
| | | | - Sharon Hunt
- Center for Outcomes Research in Liver Disease, Washington, DC, USA
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13
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Perazzo H, Jorge MJ, Silva JC, Avellar AM, Silva PS, Romero C, Veloso VG, Mujica-Mota R, Anderson R, Hyde C, Castro R. Micro-costing analysis of guideline-based treatment by direct-acting agents: the real-life case of hepatitis C management in Brazil. BMC Gastroenterol 2017; 17:119. [PMID: 29169329 PMCID: PMC5701370 DOI: 10.1186/s12876-017-0676-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 11/15/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Eradication of hepatitis C virus (HCV) using direct-acting agents (DAA) has been associated with a financial burden to health authorities worldwide. We aimed to evaluate the guideline-based treatment costs by DAAs from the perspective of the Brazilian Ministry of Health (BMoH). METHODS The activity based costing method was used to estimate the cost for monitoring/treatment of genotype-1 (GT1) HCV patients by the following strategies: peg-interferon (PEG-IFN)/ribavirin (RBV) for 48 weeks, PEG-IFN/RBV plus boceprevir (BOC) or telaprevir (TEL) for 48 weeks, and sofosbuvir (SOF) plus daclastavir (DCV) or simeprevir (SIM) for 12 weeks. Costs were reported in United States Dollars without (US$) and with adjustment for purchasing power parity (PPP$). Drug costs were collected at the National Database of Health Prices and an overview of the literature was performed to assess effectiveness of SOF/DCV and SOF/SIM regimens in real-world cohorts. RESULTS Treatment costs of GT1-HCV patients were PPP$ 43,176.28 (US$ 24,020.16) for PEG-IFN/RBV, PPP$ 71,196.03 (US$ 39,578.23) for PEG-IFN/RBV/BOC and PPP$ 86,250.33 (US$ 47,946.92) for PEG-IFN/RBV/TEL. Treatment by all-oral interferon-free regimens were the less expensive approach: PPP$ 19,761.72 (US$ 10,985.90) for SOF/DCV and PPP$ 21,590.91 (US$ 12,002.75) for SOF/SIM. The overview reported HCV eradication in up to 98% for SOF/DCV and 96% for SOF/SIM. CONCLUSION Strategies with all oral interferon-free might lead to lower costs for management of GT1-HCV patients compared to IFN-based regimens in Brazil. This occurred mainly because of high discounts over international DAA prices due to negotiation between BMoH and pharmaceutical industries.
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Affiliation(s)
- Hugo Perazzo
- Fundação Oswaldo Cruz, FIOCRUZ, Instituto Nacional de Infectologia Evandro Chagas, INI, Laboratório de Pesquisa Clínica em DST e AIDS, LAPCLIN-AIDS, Rio de Janeiro, Brazil.
| | - Marcelino Jose Jorge
- Fundação Oswaldo Cruz, FIOCRUZ, Instituto Nacional de Infectologia Evandro Chagas, INI, Laboratório de Pesquisa em Economia das Organizações de Saúde, LAPECOS, Rio de Janeiro, Brazil
| | - Julio Castro Silva
- Fundação Oswaldo Cruz, FIOCRUZ, Instituto Nacional de Infectologia Evandro Chagas, INI, Plataforma de Pesquisa Clínica, Rio de Janeiro, Brazil
| | - Alexandre Monken Avellar
- Fundação Oswaldo Cruz, FIOCRUZ, Instituto Nacional de Infectologia Evandro Chagas, INI, Laboratório de Pesquisa em Economia das Organizações de Saúde, LAPECOS, Rio de Janeiro, Brazil
| | - Patrícia Santos Silva
- Fundação Oswaldo Cruz, FIOCRUZ, Instituto Nacional de Infectologia Evandro Chagas, INI, Laboratório de Pesquisa em Economia das Organizações de Saúde, LAPECOS, Rio de Janeiro, Brazil
| | - Carmen Romero
- Fundação Oswaldo Cruz, FIOCRUZ, Centro de Desenvolvimento Tecnológico em Saúde, CDTS, Rio de Janeiro, Brazil
| | - Valdilea Gonçalves Veloso
- Fundação Oswaldo Cruz, FIOCRUZ, Instituto Nacional de Infectologia Evandro Chagas, INI, Laboratório de Pesquisa Clínica em DST e AIDS, LAPCLIN-AIDS, Rio de Janeiro, Brazil
| | - Ruben Mujica-Mota
- University of Exeter Medical School, UEMS, Evidence Synthesis & Modelling for Health Improvement, ESMI, Exeter, UK
| | - Rob Anderson
- University of Exeter Medical School, UEMS, Evidence Synthesis & Modelling for Health Improvement, ESMI, Exeter, UK
| | - Chris Hyde
- University of Exeter Medical School, UEMS, Evidence Synthesis & Modelling for Health Improvement, ESMI, Exeter, UK
| | - Rodolfo Castro
- Fundação Oswaldo Cruz, FIOCRUZ, Instituto Nacional de Infectologia Evandro Chagas, INI, Laboratório de Pesquisa Clínica em DST e AIDS, LAPCLIN-AIDS, Rio de Janeiro, Brazil.,Universidade Federal do Estado do Rio de Janeiro, UNIRIO, Instituto de Saúde Coletiva, ISC, Rio de Janeiro, Brazil
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Younossi ZM, Tanaka A, Eguchi Y, Lim YS, Yu ML, Kawada N, Dan YY, Brooks-Rooney C, Negro F, Mondelli MU. The impact of hepatitis C virus outside the liver: Evidence from Asia. Liver Int 2017; 37:159-172. [PMID: 27748564 DOI: 10.1111/liv.13272] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 09/30/2016] [Indexed: 12/11/2022]
Abstract
Between 80 and 115 million people worldwide are chronically infected with hepatitis C virus, with 60%-90% of these being undiagnosed. Untreated chronic hepatitis C (CHC) is associated with progressive liver disease, cirrhosis, hepatocellular carcinoma and liver-related mortality. A number of extrahepatic manifestations are also reported in CHC patients, further adding to the burden of the disease. CHC also impacts patients in terms of lower health-related quality of life, higher levels of fatigue and reduced productivity. Furthermore, the later stages of disease are costly for both healthcare systems and society. Pegylated-interferon (PEG-IFN)+ribavirin (RBV), for many years the mainstay of treatment, leads to sustained virological response (SVR) in 40%-70% of patients. However, a substantial number of patients are ineligible for treatment, and many patients fail to achieve SVR with this regimen. Furthermore, PEG-IFN+RBV leads to impairment of patient-reported outcomes during treatment, and most patients suffer from adverse events, associated with poor adherence, treatment discontinuation and treatment failure. The approval of second-generation direct-acting antivirals (DAAs) has revolutionized the treatment of CHC patients. All-oral, PEG-IFN and RBV-free regimens have higher efficacy rates, shorter treatment durations, fewer adverse events, higher adherence rates and improvement in PROs from as early as Week 4, compared to PEG-IFN+RBV regimens. The aim of this article is to review the evidence for HCV infection as a systemic disease, summarizing the impact of hepatitis C and its treatments on clinical, patient and economic outcomes, with a focus on data from Asia and Japan specifically.
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Affiliation(s)
- Zobair M Younossi
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, USA.,Department of Medicine, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Atsushi Tanaka
- Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Yuichiro Eguchi
- Liver Center, Saga University Hospital, Saga University, Saga, Japan
| | - Young-Suk Lim
- Department of Gastroenterology, Liver Center, Asan Medical Center, Seoul, Korea
| | - Ming-Lung Yu
- Hepatobiliary Division, Department of Internal Medicine and Hepatitis Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Norifumi Kawada
- Department of Hepatology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Yock Young Dan
- Department of Medicine, National University of Singapore, Singapore
| | | | - Francesco Negro
- Division of Gastroenterology and Hepatology and Division of Clinical Pathology, University Hospital, Geneva, Switzerland
| | - Mario U Mondelli
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
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15
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Younossi Z, Stepanova M, Omata M, Mizokami M, Walters M, Hunt S. Health utilities using SF-6D scores in Japanese patients with chronic hepatitis C treated with sofosbuvir-based regimens in clinical trials. Health Qual Life Outcomes 2017; 15:25. [PMID: 28143559 PMCID: PMC5282717 DOI: 10.1186/s12955-017-0598-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 01/18/2017] [Indexed: 12/15/2022] Open
Abstract
Background Health utilities are preference-based measures for health states which are typically used in economic analyses to estimate quality-adjusted life years. Our aim is to report the standard SF-6D health utility scores in Japanese patients with hepatitis C virus (HCV) during treatment with different regimens. Methods Japanese patients were enrolled in clinical trials of sofosbuvir (SOF) used in combination with or without ledipasvir (LDV) and/or ribavirin (RBV). The SF-6D health utility scores were calculated at multiple time points from the SF-36 instrument. Results Four hundred ninety-four patients with HCV (genotype 1 and 2) were enrolled: 19% with cirrhosis, 48% with a prior history of anti-HCV treatment. Of those, 153 received SOF + RBV, 170 received LDV/SOF + RBV, 171 received LDV/SOF for 12 weeks; the SVR rates were: 97, 98 and 100%, respectively. Patients treated with the three regimens had similar SF-6D scores before treatment (p = 0.87): 76.1 ± 11.5. During treatment with RBV containing regimen, patients experienced a decrement in their health utility scores to 74.3 ± 12.5 by the end of treatment (p = 0.03), while patients treated with RBV-free LDV/SOF had their SF-6D scores improved to 79.2 ± 12.8 after 12 weeks of treatment (p = 0.0004). At post-treatment week 12, in patients who achieved SVR-12, the SF-6D scores were similar between the treatment regimens (p = 0.36), and an average improvement of +1.4 points from baseline (p = 0.01) was noted. In multivariate analysis, the use of RBV was independently associated with lower utility score during treatment (beta = 4.7 ± 1.6, p < 0.0001). Conclusion Health utilities are lower in Japanese HCV patients and tend to improve after clearance of infection.
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Affiliation(s)
- Zobair Younossi
- Department of Medicine, Center for Liver Diseases, Inova Fairfax Hospital, Falls Church, VA, USA. .,Department of Medicine, Beatty Liver and Obesity Research Program, Inova Fairfax Hospital, Falls Church, VA, USA. .,Betty and Guy Beatty Center for Integrated Research, Claude Moore Health Education and Research Building, 3300 Gallows Road, Falls Church, VA, 22042, USA.
| | - Maria Stepanova
- Center for Outcomes Research in Liver Diseases, Washington, DC, USA
| | - Masao Omata
- Yamanashi Prefectural Hospital Organization, Yamanashi, Japan
| | - Masashi Mizokami
- Kohnodai Hospital, National Center for Global Health and Medicine, Chiba, Japan
| | - Mercedes Walters
- Center for Outcomes Research in Liver Diseases, Washington, DC, USA
| | - Sharon Hunt
- Center for Outcomes Research in Liver Diseases, Washington, DC, USA
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