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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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Hilmi Çekin A, Güner R, Çağkan İnkaya A, Oğuz D, Özdemir O, Fehmi Tabak Ö. Modeling the Health Economic Burden of Hepatitis C Virus Infection in Turkey: Cost-Effectiveness of Targeted Screening. THE TURKISH JOURNAL OF GASTROENTEROLOGY : THE OFFICIAL JOURNAL OF TURKISH SOCIETY OF GASTROENTEROLOGY 2023; 34:1062-1070. [PMID: 37565793 PMCID: PMC10645295 DOI: 10.5152/tjg.2023.22749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 12/29/2022] [Indexed: 08/12/2023]
Abstract
BACKGROUND/AIMS In 2016, World Health Organization introduced global goals to eliminate hepatitis C virus by 2030. The aim of this study is to analyze the epidemiologic and economic burden of hepatitis C virus in Turkey and compare current practice (regular care) with a hypothetical active screening and treatment approach (active scenario). MATERIALS AND METHODS A Markov model was used to analyze and compare regular care with a scenario developed by experts including the screening and treatment of all acute and chronic hepatitis C virus infections between 2020 and 2050. General and targeted populations were focused. The model reflected the natural history of the disease, and the inputs were based on a literature review and expert opinions. Costs were provided by previous studies and national regulations. RESULTS The active scenario resulted in higher spending for all groups compared with regular care in the first year. Cumulative costs were equalized in the 8th, 12th, 13th, and 16th year and followed by cost-savings of 49.7 million, 1.1 billion, 288.6 million, and 883.4 million Turkish liras in 20 years for prisoners, refugees, people who inject drugs (PWID), and all population, respectively. In all groups, the mortality was found to be lower with the active scenario. In total, 62.8% and 50.6% of expected deaths with regular care in 5 and 20 years, respectively, were prevented with the active scenario. CONCLUSIONS An active screening and treatment approach for hepatitis C virus infection could be cost-effective for PWID, prisoners, and refugees. Almost two-thirds of deaths in regular care could be prevented in 5 years' time with this approach.
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Affiliation(s)
- Ayhan Hilmi Çekin
- Department of Gastroenterology, Health Sciences University Antalya Training and Research Hospital, Antalya, Turkey
| | - Rahmet Güner
- Department of Infectious Diseases and Clinical Microbiology, Ministry of Health Ankara City Hospital, Ankara, Turkey
| | - Ahmet Çağkan İnkaya
- Department of Infectious Diseases and Clinical Microbiology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Dilek Oğuz
- Department of Gastroenterology, Güven Hospital, Ankara, Turkey
| | - Oktay Özdemir
- Department of Medical Education, İstanbul Health and Technology University, İstanbul, Turkey
| | - Ömer Fehmi Tabak
- Department of Infectious Diseases and Clinical Microbiology, İstanbul University Cerrahpaşa Faculty of Medicine, İstanbul, Turkey
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Shah KK, Wyld M, Hedley JA, Waller KMJ, De La Mata N, Webster AC, Morton RL. Cost-effectiveness of Kidney Transplantation From Donors at Increased Risk of Blood-borne Virus Infection Transmission. Transplantation 2023; 107:2028-2042. [PMID: 37211651 DOI: 10.1097/tp.0000000000004632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
BACKGROUND Demand for donor kidneys outstrips supply. Using kidneys from selected donors with an increased risk of blood-borne virus (BBV) transmission (hepatitis B virus and hepatitis C virus [HCV], human immunodeficiency virus) may expand the donor pool, but cost-effectiveness of this strategy is uncertain. METHODS A Markov model was developed using real-world evidence to compare healthcare costs and quality-adjusted life years (QALYs) of accepting kidneys from deceased donors with potential increased risk of BBV transmission, because of increased risk behaviors and/or history of HCV, versus declining these kidneys. Model simulations were run over a 20-y time horizon. Parameter uncertainty was assessed through deterministic and probabilistic sensitivity analyses. RESULTS Accepting kidneys from donors at increased risk of BBVs (2% from donors with increased-risk behaviors and 5% from donors with active or past HCV infection) incurred total costs of 311 303 Australian dollars with a gain of 8.53 QALYs. Foregoing kidneys from these donors incurred total costs of $330 517 and a gain of 8.44 QALYs. A cost-saving of $19 214 and additional 0.09 QALYs (~33 d in full health) per person would be generated compared with declining these donors. Increasing the availability of kidneys with increased risk by 15% led to further cost-savings of $57 425 and additional 0.23 QALY gains (~84 d in full health). Probabilistic sensitivity analysis using 10 000 iterations showed accepting kidneys from donors at increased risk led to lower costs and higher QALY gains. CONCLUSIONS Shifting clinical practice to accept increased BBV risk donors would likely produce lower costs and higher QALYs for health systems.
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Affiliation(s)
- Karan K Shah
- Health Economics and Health Technology Assessment, NHMRC Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Melanie Wyld
- Collaborative Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Centre for Transplant and Renal Research, Westmead Hospital, Sydney, NSW, Australia
| | - James A Hedley
- Collaborative Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Karen M J Waller
- Collaborative Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Nicole De La Mata
- Collaborative Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Angela C Webster
- Health Economics and Health Technology Assessment, NHMRC Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Collaborative Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Centre for Transplant and Renal Research, Westmead Hospital, Sydney, NSW, Australia
| | - Rachael L Morton
- Health Economics and Health Technology Assessment, NHMRC Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
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Ishinuki T, Ota S, Harada K, Kawamoto M, Meguro M, Kutomi G, Tatsumi H, Harada K, Miyanishi K, Kato T, Ohyanagi T, Hui TT, Mizuguchi T. Current standard values of health utility scores for evaluating cost-effectiveness in liver disease: A meta-analysis. World J Gastroenterol 2022; 28:4442-4455. [PMID: 36159009 PMCID: PMC9453766 DOI: 10.3748/wjg.v28.i31.4442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 04/26/2022] [Accepted: 07/25/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Health utility assessments have been developed for various conditions, including chronic liver disease. Health utility scores are required for socio-economic evaluations, which can aid the distribution of national budgets. However, the standard health utility assessment scores for specific health conditions are largely unknown.
AIM To summarize the health utility scores, including the EuroQOL 5-dimensions 5-levels (EQ-5D-5L), EuroQol-visual analogue scale, short from-36 (SF-36), RAND-36, and Health Utilities Index (HUI)-Mark2/Mark3 scores, for the normal population and chronic liver disease patients.
METHODS A systematic literature search of PubMed and MEDLINE, including the Cochrane Library, was performed. Meta-analysis was performed using the RevMan software. Multiple means and standard deviations were combined using the StatsToDo online web program.
RESULTS The EQ-5D-5L and SF-36 can be used for health utility evaluations during antiviral therapy for hepatitis C. HUI-Mark2/Mark3 indicated that the health utility scores of hepatitis B patients are roughly 30% better than those of hepatitis C patients.
CONCLUSION The EQ-5D-5L is the most popular questionnaire for health utility assessments. Health assessments that allow free registration would be useful for evaluating health utility in patients with liver disease.
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Affiliation(s)
- Tomohiro Ishinuki
- Department of Nursing, Surgical Sciences, Sapporo Medical University, Sapporo 0608556, Japan
| | - Shigenori Ota
- Departments of Surgery, Surgical Science and Oncology, Sapporo Medical University, Sapporo 0608543, Japan
| | - Kohei Harada
- Department of Radiology, Sapporo Medical University, Sapporo 0608543, Japan
| | - Masaki Kawamoto
- Departments of Surgery, Nemuro City Hospital, Nemuro 0870008, Japan
| | - Makoto Meguro
- Departments of Surgery, Sapporo Satozuka Hospital, Sapporo 0040811, Japan
| | - Goro Kutomi
- Departments of Surgery, Surgical Science and Oncology, Sapporo Medical University, Sapporo 0608543, Japan
| | - Hiroomi Tatsumi
- Department of Intensive Care Medicine, Sapporo Medical University, Sapporo 0608543, Japan
| | - Keisuke Harada
- Department of Emergency Medicine, Sapporo Medical University, Sapporo 0608543, Japan
| | - Koji Miyanishi
- Department of Medical Oncology, Sapporo Medical University, Sapporo 0608543, Japan
| | - Toru Kato
- Departments of Surgery, Surgical Science and Oncology, Sapporo Medical University, Sapporo 0608543, Japan
| | - Toshio Ohyanagi
- Department of Liberal Arts and Sciences, Center for Medical Education, Sapporo Medical University, Sapporo 0608556, Japan
| | - Thomas T Hui
- Departments of Surgery, Stanford University School of Medicine, Stanford, 94598, United States
| | - Toru Mizuguchi
- Department of Nursing, Surgical Sciences, Sapporo Medical University, Sapporo 0608556, Japan
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Gutkind S, Schackman BR, Morgan JR, Leff JA, Agyemang L, Murphy SM, Akiyama MJ, Norton BL, Litwin AH, Linas BP. Cost-effectiveness of Hepatitis C Virus Treatment Models for People Who Inject Drugs in Opioid Agonist Treatment Programs. Clin Infect Dis 2021; 70:1397-1405. [PMID: 31095683 DOI: 10.1093/cid/ciz384] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 05/08/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Many people who inject drugs in the United States have chronic hepatitis C virus (HCV). On-site treatment in opiate agonist treatment (OAT) programs addresses HCV treatment barriers, but few evidence-based models exist. METHODS We evaluated the cost-effectiveness of HCV treatment models for OAT patients using data from a randomized trial conducted in Bronx, New York. We used a decision analytic model to compare self-administered individual treatment (SIT), group treatment (GT), directly observed therapy (DOT), and no intervention for a simulated cohort with the same demographic characteristics of trial participants. We projected long-term outcomes using an established model of HCV disease progression and treatment (hepatitis C cost-effectiveness model: HEP-CE). Incremental cost-effectiveness ratios (ICERs) are reported in 2016 US$/quality-adjusted life years (QALY), discounted 3% annually, from the healthcare sector and societal perspectives. RESULTS For those assigned to SIT, we projected 89% would ever achieve a sustained viral response (SVR), with 7.21 QALYs and a $245 500 lifetime cost, compared to 22% achieving SVR, with 5.49 QALYs and a $161 300 lifetime cost, with no intervention. GT was more efficient than SIT, resulting in 0.33 additional QALYs and a $14 100 lower lifetime cost per person, with an ICER of $34 300/QALY, compared to no intervention. DOT was slightly more effective and costly than GT, with an ICER > $100 000/QALY, compared to GT. In probabilistic sensitivity analyses, GT and DOT were preferred in 91% of simulations at a threshold of <$100 000/QALY; conclusions were similar from the societal perspective. CONCLUSIONS All models were associated with high rates of achieving SVR, compared to standard care. GT and DOT treatment models should be considered as cost-effective alternatives to SIT.
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Affiliation(s)
- Sarah Gutkind
- Department of Healthcare Policy & Research, Weill Cornell Medical College, New York
| | - Bruce R Schackman
- Department of Healthcare Policy & Research, Weill Cornell Medical College, New York
| | - Jake R Morgan
- Department of Medicine, Section of Infectious Diseases, Boston Medical Center, Massachusetts
| | - Jared A Leff
- Department of Healthcare Policy & Research, Weill Cornell Medical College, New York
| | - Linda Agyemang
- Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York
| | - Sean M Murphy
- Department of Healthcare Policy & Research, Weill Cornell Medical College, New York
| | - Matthew J Akiyama
- Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York
| | - Brianna L Norton
- Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York
| | - Alain H Litwin
- Department of Medicine, University of South Carolina School of Medicine and Greenville Health System.,Clemson University School of Health Research, South Carolina
| | - Benjamin P Linas
- Department of Medicine, Section of Infectious Diseases, Boston Medical Center, Massachusetts.,Department of Epidemiology, Boston University School of Public Health, Massachusetts
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Hancock E, Ward Z, Ayres R, Neale J, Hussey D, Kesten JM, Hickman M, Vickerman P. Detachable low dead space syringes for the prevention of hepatitis C among people who inject drugs in Bristol, UK: an economic evaluation. Addiction 2020; 115:702-713. [PMID: 31633849 PMCID: PMC7725423 DOI: 10.1111/add.14849] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 04/30/2019] [Accepted: 09/27/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIMS Traditional detachable syringes used by people who inject drugs (PWID) retain larger volumes of blood when the plunger is depressed than syringes with fixed needles-referred to as high (HDSS) and low dead space syringes (LDSS), respectively. Evidence suggests that using HDSS may result in greater hepatitis C virus (HCV) transmission risk than LDSS. We evaluated the cost-effectiveness of an intervention to introduce detachable LDSS in a needle and syringe programme (NSP). DESIGN HCV transmission and disease progression model with cost-effectiveness analysis using a health-care perspective. Detachable LDSS are associated with increased costs (£0.008) per syringe, yearly staff training costs (£536) and an estimated decreased risk (by 47.5%) of HCV transmission compared with HDSS. The intervention was modelled for 10 years, with costs and health benefits (quality-adjusted life-years: QALYs) tracked over 50 years. SETTING Bristol, UK. PARTICIPANTS AND CASES PWID attending NSP. INTERVENTION AND COMPARATOR Gradual replacement of HDSS at NSP, with 8, 58 and 95% of HDSS being replaced by detachable LDSS in 2016, 2017 and 2018, respectively. Comparator was continuing use of HDSS. MEASUREMENTS Net monetary benefit. Benefits were measured in QALYs. FINDINGS Introducing detachable LDSS was associated with a small increase in intervention costs (£21 717) compared with not introducing detachable LDSS, but considerable savings in HCV-related treatment and care costs (£4 138 118). Overall cost savings were £4 116 401 over 50 years and QALY gains were 1000, with an estimated 30% reduction in new infections over the 10-year intervention period. In all sensitivity analyses, detachable LDSS resulted in cost savings and additional QALYs. Threshold analyses suggested that detachable LDSS would need to reduce HCV transmission risk of HDSS by 0.26% to be cost-saving and 0.04% to be cost-effective. CONCLUSIONS Replacing high dead space syringes with detachable low dead space syringes in needle and syringe programmes in the United Kingdom is likely to be a cost-saving approach for reducing hepatitis C virus transmission.
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Affiliation(s)
| | - Zoe Ward
- Population Health Sciences, University of Bristol, UK
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Fawsitt CG, Vickerman P, Cooke GS, Welton NJ. Cost-Effectiveness Analysis of Baseline Testing for Resistance-Associated Polymorphisms to Optimize Treatment Outcome in Genotype 1 Noncirrhotic Treatment-Naïve Patients With Chronic Hepatitis C Virus. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2020; 23:180-190. [PMID: 32113623 PMCID: PMC7057278 DOI: 10.1016/j.jval.2019.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 08/13/2019] [Accepted: 08/26/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES Direct-acting antivirals containing nonstructural protein 5A (NS5A) inhibitors administered over 8 to 12 weeks are effective in ∼95% of patients with hepatitis C virus. Nevertheless, patients resistant to NS5A inhibitors have lower cure rates over 8 weeks (<85%); for these patients, 12 weeks of treatment produces cure rates greater than 95%. We evaluated the lifetime cost-effectiveness of testing for NS5A resistance at baseline and optimizing treatment duration accordingly in genotype 1 noncirrhotic treatment-naïve patients from the perspective of the UK National Health Service. METHODS A decision-analytic model compared (1) standard 12-week treatment (no testing), (2) shortened 8-week treatment (no testing), and (3) baseline testing with 12-/8-week treatment for those with/without NS5A polymorphisms. Patients who failed first-line therapy were retreated for 12 weeks. Model inputs were derived from published studies. Costs, quality-adjusted life-years, and the probability of cost-effectiveness were calculated. RESULTS Baseline testing had an incremental net monetary benefit (INMB) of £11 838 versus standard 12 weeks of therapy (no testing) and low probability (31%) of being the most cost-effective, assuming £30 000 willingness to pay. Shortened 8 weeks of treatment (no testing) had an INMB of £12 294 and the highest probability (69%) of being most cost-effective. Scenario analyses showed baseline testing generally had the highest INMB and probability of being most cost-effective if first- and second-line drug prices were low (<£20k). CONCLUSIONS Optimizing treatment duration based on NS5A polymorphisms for genotype 1 noncirrhotic treatment-naive patients in the United Kingdom is not cost-effective if the drug costs are high; the strategy is generally most cost-effective when drug prices are low (<£20k).
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Affiliation(s)
- Christopher G Fawsitt
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK.
| | - Peter Vickerman
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK
| | - Graham S Cooke
- Department of Medicine, Imperial College London, London, England, UK
| | - Nicky J Welton
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK
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Cost-effectiveness of transplanting lungs and kidneys from donors with potential hepatitis C exposure or infection. Sci Rep 2020; 10:1459. [PMID: 31996734 PMCID: PMC6989464 DOI: 10.1038/s41598-020-58215-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 01/13/2020] [Indexed: 02/06/2023] Open
Abstract
Organ transplant guidelines in many settings recommend that people with potential hepatitis C virus (HCV) exposure or infection are deemed ineligible to donate. The recent availability of highly-effective treatments for HCV means that this may no longer be necessary. We used a mathematical model to estimate the expected difference in healthcare costs, difference in disability-adjusted life years (DALYs) and cost-effectiveness of removing HCV restrictions for lung and kidney donations in Australia. Our model suggests that allowing organ donations from people who inject drugs, people with a history of incarceration and people who are HCV antibody-positive could lead to an estimated 10% increase in organ supply, population-level improvements in health (reduction in DALYs), and on average save AU$2,399 (95%CI AU$1,155-3,352) and AU$2,611 (95%CI AU$1,835-3,869) per person requiring a lung and kidney transplant respectively. These findings are likely to hold for international settings, since this policy change remained cost saving with positive health gains regardless of HCV prevalence, HCV treatment cost and waiting list survival probabilities. This study suggests that guidelines on organ donation should be revisited in light of recent changes to clinical outcomes for people with HCV.
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Mar J, Ibarrondo O, Martínez-Baz I, Juanbeltz R, San Miguel R, Casado I, Arrospide A, Castilla J. Economic evaluation of a population strategy for the treatment of chronic hepatitis C with direct-acting antivirals. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2019; 110:621-628. [PMID: 30032627 DOI: 10.17235/reed.2018.5605/2018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The high initial cost of antivirals against hepatitis C prompted development of the "Strategic Plan for Tackling Chronic Hepatitis C in the Spanish National Health System". The objective of this study was the economic evaluation of the first two years of its application in Navarre, Spain. The change in the natural history of hepatitis C produced by the sustained virological response (SVR) was compared to an alternative without treatment and modeled with patient-level data. By means of a discrete events simulation model, the cost-effectiveness and the budget impact analysis of the treatment program were measured from the perspective of the Navarre Health Service. Of 656 patients treated, 98% had SVR. The average cost of the treatments was 18,743 euros per patient. The incremental cost-effectiveness ratio (ICER) with discount was 5,346 euros per quality-adjusted life years, which became more efficient as the stage of fibrosis increased until it reached levels of dominance in stage 4 fibrosis. The associated costs for chronic liver disease decreased as the benefit of the treatment was expressed. The implementation of the Strategic Plan is cost-effective, with an ICER well below the threshold, since the cost of treatment is largely compensated by savings in long-term health expenditure. The budgetary impact foresees a net saving from the third year on. The two key parameters were the decrease in the price of the treatment and the SVR in nearly 100% of the patients.
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Affiliation(s)
- Javier Mar
- Unidad Gestión Sanitaria, OSI Alto Deba, España
| | | | | | | | - Ramón San Miguel
- Departamento of Farmacia,, Complejo Hospitalario de Navarra - IdiSNA, , España
| | - Itziar Casado
- Instituto de Salud Pública de Navarra - IdiSNA, España
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Fawsitt CG, Vickerman P, Cooke G, Welton NJ. A Cost-Effectiveness Analysis of Shortened Direct-Acting Antiviral Treatment in Genotype 1 Noncirrhotic Treatment-Naive Patients With Chronic Hepatitis C Virus. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2019; 22:693-703. [PMID: 31198187 PMCID: PMC6588649 DOI: 10.1016/j.jval.2018.12.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 11/12/2018] [Accepted: 12/29/2018] [Indexed: 05/06/2023]
Abstract
BACKGROUND Direct-acting antivirals are successful in curing hepatitis C virus infection in more than 95% of patients treated for 12 weeks, but they are expensive. Shortened treatment durations, which may have lower cure rates, have been proposed to reduce costs. OBJECTIVES To evaluate the lifetime cost-effectiveness of different shortened treatment durations for genotype 1 noncirrhotic treatment-naive patients. METHODS Assuming a UK National Health Service perspective, we used a probabilistic decision tree and Markov model to compare 3 unstratified shortened treatment durations (8, 6, and 4 weeks) against a standard 12-week treatment duration. Patients failing shortened first-line treatment were re-treated with a 12-week treatment regimen. Parameter inputs were taken from published studies. RESULTS The 8-week treatment duration had an expected incremental net monetary benefit of £7737 (95% confidence interval £3242-£11 819) versus the standard 12-week treatment, per 1000 patients. The 6-week treatment had a positive incremental net monetary benefit, although some uncertainty was observed. The probability that the 8- and 6-week treatments were the most cost-effective was 56% and 25%, respectively, whereas that for the 4-week treatment was 17%. Results were generally robust to sensitivity analyses, including a threshold analysis that showed that the 8-week treatment was the most cost-effective at all drug prices lower than £40 000 per 12-week course. CONCLUSIONS Shortening treatments licensed for 12 weeks to 8 weeks is cost-effective in genotype 1 noncirrhotic treatment-naive patients. There was considerable uncertainty in the estimates for 6- and 4-week treatments, with some indication that the 6-week treatment may be cost-effective.
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Affiliation(s)
- Christopher G Fawsitt
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK.
| | - Peter Vickerman
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK
| | - Graham Cooke
- Department of Medicine, Imperial College London, London, England, UK
| | - Nicky J Welton
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK
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Shelton BA, Berdahl G, Sawinski D, Linas BP, Reese PP, Mustian MN, Reed RD, MacLennan PA, Locke JE. Optimal timing of hepatitis C treatment among HIV/HCV coinfected ESRD patients: Pre- vs posttransplant. Am J Transplant 2019; 19:1806-1819. [PMID: 30589503 PMCID: PMC6538449 DOI: 10.1111/ajt.15239] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 11/28/2018] [Accepted: 12/13/2018] [Indexed: 02/06/2023]
Abstract
Patients with end-stage renal disease (ESRD) who are coinfected with hepatitis C virus (HCV) and human immunodeficiency virus (HIV) have access to effective treatment options for HCV infection. However, they also have access to HCV-infected kidneys, which historically afford shorter times to transplantation. Given the high waitlist mortality and rapid progression of liver fibrosis among coinfected kidney-only transplant candidates, identification of the optimal treatment strategy is paramount. Two strategies, treatment pre- and posttransplant, were compared using Monte Carlo microsimulation of 1 000 000 candidates. The microsimulation was stratified by liver fibrosis stage at waitlist addition and wait-time over a lifetime time horizon. Treatment posttransplant was consistently cost-saving as compared to treatment pretransplant due to the high cost of dialysis. Among patients with low fibrosis disease (F0-F1), treatment posttransplant also yielded higher life months (LM) and quality-adjusted life months (QALM), except among F1 candidates with wait times ≥ 18 months. For candidates with advanced liver disease (F2-F4), treatment pretransplant afforded more LM and QALM unless wait time was <18 months. Moreover, treatment pretransplant was cost-effective for F2 candidates with wait times >71 months and F3 candidates with wait times >18 months. Thus, optimal timing of HCV treatment differs based on liver disease severity and wait time, favoring pretransplant treatment when cirrhosis development prior to transplant seems likely.
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Affiliation(s)
- Brittany A. Shelton
- University of Alabama at Birmingham Comprehensive Transplant Institute, Birmingham, AL, USA
| | - Gideon Berdahl
- University of Alabama at Birmingham Comprehensive Transplant Institute, Birmingham, AL, USA
| | - Deirdre Sawinski
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Peter P. Reese
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Margaux N. Mustian
- University of Alabama at Birmingham Comprehensive Transplant Institute, Birmingham, AL, USA
| | - Rhiannon D. Reed
- University of Alabama at Birmingham Comprehensive Transplant Institute, Birmingham, AL, USA
| | - Paul A. MacLennan
- University of Alabama at Birmingham Comprehensive Transplant Institute, Birmingham, AL, USA
| | - Jayme E. Locke
- University of Alabama at Birmingham Comprehensive Transplant Institute, Birmingham, AL, USA
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12
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Shelton BA, Sawinski D, Linas BP, Reese PP, Mustian M, Hungerpiller M, Reed RD, MacLennan PA, Locke JE. Population level outcomes and cost-effectiveness of hepatitis C treatment pre- vs postkidney transplantation. Am J Transplant 2018; 18:2483-2495. [PMID: 30058218 PMCID: PMC6206868 DOI: 10.1111/ajt.15040] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 07/03/2018] [Accepted: 07/23/2018] [Indexed: 01/25/2023]
Abstract
Direct-acting antivirals approved for use in patients with end-stage renal disease (ESRD) now exist. HCV-positive (HCV+) ESRD patients have the opportunity to decrease the waiting times for transplantation by accepting HCV-infected kidneys. The optimal timing for HCV treatment (pre- vs posttransplant) among kidney transplant candidates is unknown. Monte Carlo microsimulation of 100 000 candidates was used to examine the cost-effectiveness of HCV treatment pretransplant vs posttransplant by liver fibrosis stage and waiting time over a lifetime time horizon using 2 regimens approved for ESRD patients. Treatment pretransplant yielded higher quality-adjusted life years (QALYs) compared with posttransplant treatment in all subgroups except those with Meta-analysis of Histological Data in Viral Hepatitis stage F0 (pretransplant: 5.7 QALYs vs posttransplant: 5.8 QALYs). However, treatment posttransplant was cost-saving due to decreased dialysis duration with the use of HCV-infected kidneys (pretransplant: $735 700 vs posttransplant: $682 400). Using a willingness-to-pay threshold of $100 000, treatment pretransplant was not cost-effective except for those with Meta-analysis of Histological Data in Viral Hepatitis stage F3 whose fibrosis progression was halted. If HCV+ candidates had access to HCV-infected donors and were transplanted ≥9 months sooner than HCV-negative candidates, treatment pretransplant was no longer cost-effective (incremental cost-effectiveness ratio [ICER]: $107 100). In conclusion, optimal timing of treatment depends on fibrosis stage and access to HCV+ kidneys but generally favors posttransplant HCV eradication.
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Affiliation(s)
- Brittany A. Shelton
- Transplant Institute, University of Alabama at Birmingham Comprehensive, Birmingham, AL, USA
| | - Deirdre Sawinski
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Peter P. Reese
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Margaux Mustian
- Transplant Institute, University of Alabama at Birmingham Comprehensive, Birmingham, AL, USA
| | - Mitch Hungerpiller
- Transplant Institute, University of Alabama at Birmingham Comprehensive, Birmingham, AL, USA
| | - Rhiannon D. Reed
- Transplant Institute, University of Alabama at Birmingham Comprehensive, Birmingham, AL, USA
| | - Paul A. MacLennan
- Transplant Institute, University of Alabama at Birmingham Comprehensive, Birmingham, AL, USA
| | - Jayme E. Locke
- Transplant Institute, University of Alabama at Birmingham Comprehensive, Birmingham, AL, USA
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13
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Schackman BR, Gutkind S, Morgan JR, Leff JA, Behrends CN, Delucchi KL, McKnight C, Perlman DC, Masson CL, Linas BP. Cost-effectiveness of hepatitis C screening and treatment linkage intervention in US methadone maintenance treatment programs. Drug Alcohol Depend 2018; 185:411-420. [PMID: 29477574 PMCID: PMC5889754 DOI: 10.1016/j.drugalcdep.2017.11.031] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 11/06/2017] [Accepted: 11/12/2017] [Indexed: 01/26/2023]
Abstract
BACKGROUND We evaluated the cost-effectiveness of a hepatitis C (HCV) screening and active linkage to care intervention in US methadone maintenance treatment (MMT) patients using data from a randomized trial conducted in New York City and San Francisco. METHODS We used a decision analytic model to compare 1) no intervention; 2) HCV screening and education (control); and 3) HCV screening, education, and care coordination (active linkage intervention). We also explored an alternative strategy wherein HCV/HIV co-infected participants linked elsewhere. Trial data include population characteristics (67% male, mean age 48, 58% HCV infected) and linkage rates. Data from published sources include treatment efficacy and HCV re-infection risk. We projected quality-adjusted life years (QALYs) and lifetime medical costs using an established model of HCV (HEP-CE). Incremental cost-effectiveness ratios (ICERs) are in 2015 US$/QALY discounted 3% annually. RESULTS The control strategy resulted in a projected 35% linking to care within 6 months and 31% achieving sustained virologic response (SVR). The intervention resulted in 60% linking and 54% achieving SVR with an ICER of $24,600/QALY compared to no intervention from the healthcare sector perspective and was a more efficient use of resources than the control strategy. The intervention had an ICER of $76,500/QALY compared to the alternative strategy. From a societal perspective, the intervention had a net monetary benefit of $511,000-$975,600. CONCLUSIONS HCV care coordination interventions that include screening, education and active linkage to care in MMT settings are likely cost-effective at a conventional $100,000/QALY threshold for both HCV mono-infected and HIV co-infected patients.
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Affiliation(s)
- Bruce R Schackman
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY, United States.
| | - Sarah Gutkind
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY, United States
| | | | - Jared A Leff
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY, United States
| | - Czarina N Behrends
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY, United States
| | - Kevin L Delucchi
- Department of Psychiatry, UCSF School of Medicine, San Francisco, CA, United States
| | - Courtney McKnight
- Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - David C Perlman
- Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Carmen L Masson
- Department of Psychiatry, UCSF School of Medicine, San Francisco, CA, United States
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14
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Akiyama MJ, Agyemang L, Arnsten JH, Heo M, Norton BL, Schackman BR, Linas BP, Litwin AH. Rationale, design, and methodology of a trial evaluating three models of care for HCV treatment among injection drug users on opioid agonist therapy. BMC Infect Dis 2018; 18:74. [PMID: 29426304 PMCID: PMC5807730 DOI: 10.1186/s12879-018-2964-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Accepted: 01/16/2018] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND People who inject drugs (PWID) constitute 60% of the approximately 5 million people in the U.S. infected with hepatitis C virus (HCV). Treatment of PWID is complex due to addiction, mental illness, poverty, homelessness, lack of positive social support, poor adherence-related skills, low motivation and knowledge, and poor access to and trust in the health care system. New direct-acting antiviral medications are available for HCV with high cure rates and few side effects. The life expectancy and economic benefits of new HCV treatments will not be realized unless we determine optimal models of care for the majority of HCV-infected patients. The purpose of this study is to evaluate the effectiveness of directly observed therapy and group treatment compared with self-administered individual treatment in a large, urban opioid agonist therapy clinic setting in the Bronx, New York. METHODS/DESIGN In this randomized controlled trial 150 PWID with chronic HCV were recruited from opioid agonist treatment (OAT) clinics and randomized to one of three models of onsite HCV treatment in OAT: 1) modified directly observed therapy; 2) group treatment; or 3) control - self-administered individual treatment. Participants were age 18 or older, HCV genotype 1, English or Spanish speaking, treatment naïve (or treatment experienced after 12/3/14), willing to receive HCV treatment onsite, receiving methadone or buprenorphine at the medication window at least once per week, and able to provide informed consent. Outcomes of interest include adherence (as measured by self-report and electronic blister packs), HCV treatment completion, sustained virologic response, drug resistance, and cost-effectiveness. DISCUSSION This paper describes the design and rationale of a randomized controlled trial comparing three models of care for HCV therapy delivered in an opioid agonist treatment program. Our trial will be critical to rigorously identify models of care that result in high adherence and cure rates. Use of blister pack technology will help us determine the role of adherence in successful cure of HCV. Moreover, the trial methodology outlined here can serve as a template for the development of future programs and studies among HCV-infected drug users receiving opioid agonist therapy, as well as the cost-effectiveness of such programs. TRIAL REGISTRATION This trial was registered with ClinicalTrials.gov ( NCT01857245 ). Trial registration was obtained prospectively on May 20th, 2013.
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Affiliation(s)
- Matthew J. Akiyama
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY USA
| | - Linda Agyemang
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY USA
| | - Julia H. Arnsten
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY USA
| | - Moonseong Heo
- Department of Epidemiology and Population Health, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY USA
| | - Brianna L. Norton
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY USA
| | - Bruce R. Schackman
- Department of Healthcare Policy & Research, Weill Cornell Medical College, New York, NY USA
| | - Benjamin P. Linas
- Department of Epidemiology, Boston University School of Public Health, Boston, MA USA
| | - Alain H. Litwin
- Department of Medicine, University of South Carolina School of Medicine–Greenville, Greenville, South Carolina USA
- Department of Medicine, Greenville Health System, Greenville, South Carolina USA
- Department of Medicine, Clemson University School of Health Research, Clemson, South Carolina USA
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15
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Assoumou SA, Tasillo A, Leff JA, Schackman BR, Drainoni ML, Horsburgh CR, Barry MA, Regis C, Kim AY, Marshall A, Saxena S, Smith PC, Linas BP. Cost-Effectiveness of One-Time Hepatitis C Screening Strategies Among Adolescents and Young Adults in Primary Care Settings. Clin Infect Dis 2018; 66:376-384. [PMID: 29020317 PMCID: PMC5848253 DOI: 10.1093/cid/cix798] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 09/08/2017] [Indexed: 12/15/2022] Open
Abstract
Background High hepatitis C virus (HCV) rates have been reported in young people who inject drugs (PWID). We evaluated the clinical benefit and cost-effectiveness of testing among youth seen in communities with a high overall number of reported HCV cases. Methods We developed a decision analytic model to project quality-adjusted life years (QALYs), costs (2016 US$), and incremental cost-effectiveness ratios (ICERs) of 9 strategies for 1-time testing among 15- to 30-year-olds seen at urban community health centers. Strategies differed in 3 ways: targeted vs routine testing, rapid finger stick vs standard venipuncture, and ordered by physician vs by counselor/tester using standing orders. We performed deterministic and probabilistic sensitivity analyses (PSA) to evaluate uncertainty. Results Compared to targeted risk-based testing (current standard of care), routine testing increased the lifetime medical cost by $80 and discounted QALYs by 0.0013 per person. Across all strategies, rapid testing provided higher QALYs at a lower cost per QALY gained and was always preferred. Counselor-initiated routine rapid testing was associated with an ICER of $71000/QALY gained. Results were sensitive to offer and result receipt rates. Counselor-initiated routine rapid testing was cost-effective (ICER <$100000/QALY) unless the prevalence of PWID was <0.59%, HCV prevalence among PWID was <16%, reinfection rate was >26 cases per 100 person-years, or reflex confirmatory testing followed all reactive venipuncture diagnostics. In PSA, routine rapid testing was the optimal strategy in 90% of simulations. Conclusions Routine rapid HCV testing among 15- to 30-year-olds may be cost-effective when the prevalence of PWID is >0.59%.
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Affiliation(s)
- Sabrina A Assoumou
- Department of Medicine, Section of Infectious Diseases, Boston Medical Center, Massachusetts
- Department of Medicine, Section of Infectious Diseases, Boston University School of Medicine, Massachusetts
| | - Abriana Tasillo
- Department of Medicine, Section of Infectious Diseases, Boston Medical Center, Massachusetts
| | - Jared A Leff
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York
| | - Bruce R Schackman
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York
| | - Mari-Lynn Drainoni
- Department of Medicine, Section of Infectious Diseases, Boston University School of Medicine, Massachusetts
- Department of Health Law, Policy and Management, Boston University School of Public Health
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford
| | - C Robert Horsburgh
- Department of Medicine, Section of Infectious Diseases, Boston Medical Center, Massachusetts
- Department of Epidemiology, Boston University School of Public Health
| | - M Anita Barry
- Infectious Disease Bureau, Boston Public Health Commission
| | - Craig Regis
- Infectious Disease Bureau, Boston Public Health Commission
| | - Arthur Y Kim
- Division of Infectious Diseases, Massachusetts General Hospital
| | - Alison Marshall
- Boston College Connell School of Nursing
- STD/HIV Prevention Center of New England, Jamaica Plain
- South Boston Community Health Center
| | | | - Peter C Smith
- Department of Medicine, Section of Infectious Diseases, Boston Medical Center, Massachusetts
- Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Massachusetts
| | - Benjamin P Linas
- Department of Medicine, Section of Infectious Diseases, Boston Medical Center, Massachusetts
- Department of Medicine, Section of Infectious Diseases, Boston University School of Medicine, Massachusetts
- Department of Epidemiology, Boston University School of Public Health
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16
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Restelli U, Alberti A, Lazzarin A, Bonfanti M, Nappi C, Croce D. Cost-effectiveness analysis of the use of daclatasvir + sofosbuvir + ribavirin (16 weeks and 12 weeks) vs sofosbuvir + ribavirin (16 weeks and 24 weeks) for the treatment of cirrhotic patients affected with hepatitis C virus genotype 3 in Italy. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2018; 19:37-44. [PMID: 28008546 DOI: 10.1007/s10198-016-0865-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Accepted: 12/08/2016] [Indexed: 06/06/2023]
Abstract
The WHO estimates that more than 185 million people are infected with hepatitis C virus (HCV) worldwide. The aim of the study is to assess the incremental cost-effectiveness ratio (ICER) of the use of daclatasvir (DCV) + sofosbuvir (SOF) + ribavirin (RBV) for 12 and 16 weeks vs SOF + RBV for 16 and 24 weeks for the treatment of genotype 3 HCV infected cirrhotic patients from the Italian National Health Service (NHS) perspective. A published cohort-based Markov model was used to perform the analysis estimating the lifetime direct medical costs associated with the management of the pathology and the quality adjusted life years gained by patients. Deterministic and probabilistic sensitivity analyses were performed to test the robustness of the results. SOF + RBV for 16 weeks was excluded from the analysis due to the significant lower effectiveness, compared with SOF + RBV for 24 weeks (51% vs 79%). DCV + SOF + RBV would increase QALYs and costs in all the comparisons: the ICERs obtained comparing DCV + SOF + RBV for 12 and 16 weeks with SOF + RBV for 24 weeks (reference scenario) are 38,572 €/QALY and 16,436 €/QALY, respectively, both below the 40,000 €/QALY threshold identified by the Italian Health Economics Association. Sensitivity analyses confirmed the robustness of the results. The use of DCV + SOF + RBV is likely to be cost-effective compared with SOF + RBV (for 24 weeks) for the treatment of cirrhotic patients infected with genotype 3 HCV considering a threshold value of 40,000 €/QALY.
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Affiliation(s)
- Umberto Restelli
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
- Centre for Research on Health Economics, Social and Health Care Management (CREMS)-LIUC-Carlo Cattaneo Univerity, Castellanza, VA, Italy.
| | - Alfredo Alberti
- Department of Molecular Medicine, University of Padua, Padua, Italy
| | | | - Marzia Bonfanti
- Centre for Research on Health Economics, Social and Health Care Management (CREMS)-LIUC-Carlo Cattaneo Univerity, Castellanza, VA, Italy
| | - Carmela Nappi
- Health Economic and Outcome Research Bristol Myers Squibb S.r.l., Rome, Italy
| | - Davide Croce
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Centre for Research on Health Economics, Social and Health Care Management (CREMS)-LIUC-Carlo Cattaneo Univerity, Castellanza, VA, Italy
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17
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Morgan JR, Kim AY, Naggie S, Linas BP. The Effect of Shorter Treatment Regimens for Hepatitis C on Population Health and Under Fixed Budgets. Open Forum Infect Dis 2017; 5:ofx267. [PMID: 29354660 PMCID: PMC5767946 DOI: 10.1093/ofid/ofx267] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 12/06/2017] [Indexed: 12/19/2022] Open
Abstract
Background Direct acting antiviral hepatitis C virus (HCV) therapies are highly effective but costly. Wider adoption of an 8-week ledipasvir/sofosbuvir treatment regimen could result in significant savings, but may be less efficacious compared with a 12-week regimen. We evaluated outcomes under a constrained budget and cost-effectiveness of 8 vs 12 weeks of therapy in treatment-naïve, noncirrhotic, genotype 1 HCV-infected black and nonblack individuals and considered scenarios of IL28B and NS5A resistance testing to determine treatment duration in sensitivity analyses. Methods We developed a decision tree to use in conjunction with Monte Carlo simulation to investigate the cost-effectiveness of recommended treatment durations and the population health effect of these strategies given a constrained budget. Outcomes included the total number of individuals treated and attaining sustained virologic response (SVR) given a constrained budget and incremental cost-effectiveness ratios. Results We found that treating eligible (treatment-naïve, noncirrhotic, HCV-RNA <6 million copies) individuals with 8 weeks rather than 12 weeks of therapy was cost-effective and allowed for 50% more individuals to attain SVR given a constrained budget among both black and nonblack individuals, and our results suggested that NS5A resistance testing is cost-effective. Conclusions Eight-week therapy provides good value, and wider adoption of shorter treatment could allow more individuals to attain SVR on the population level given a constrained budget. This analysis provides an evidence base to justify movement of the 8-week regimen to the preferred regimen list for appropriate patients in the HCV treatment guidelines and suggests expanding that recommendation to black patients in settings where cost and relapse trade-offs are considered.
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Affiliation(s)
- Jake R Morgan
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Arthur Y Kim
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Susanna Naggie
- School of Medicine, Duke University, Durham, North Caorlina.,Duke Clinical Research Institute, Durham, North Carolina
| | - Benjamin P Linas
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center, Boston, Massachusetts.,Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts
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18
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Bennett H, Gordon J, Jones B, Ward T, Webster S, Kalsekar A, Yuan Y, Brenner M, McEwan P. Hepatitis C disease transmission and treatment uptake: impact on the cost-effectiveness of new direct-acting antiviral therapies. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2017; 18:1001-1011. [PMID: 27803989 DOI: 10.1007/s10198-016-0844-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 10/18/2016] [Indexed: 05/23/2023]
Abstract
BACKGROUND Hepatitis C virus (HCV) treatment can reduce the incidence of future infections through removing opportunities for onward transmission. This benefit is not captured in conventional cost-effectiveness evaluations of treatment and is particularly relevant in patient groups with a high risk of transmission, such as those people who inject drugs (PWID), where the treatment rates have been historically low. This study aimed to quantify how reduced HCV transmission changes the cost-effectiveness of new direct-acting antiviral (DAA) regimens as a function of treatment uptake rates. METHODS An established model of HCV disease transmission and progression was used to quantify the impact of treatment uptake (10-100%), within the PWID population, on the cost-effectiveness of a DAA regimen versus pre-DAA standard of care, conducted using daclatasvir plus sofosbuvir in the UK setting as an illustrative example. RESULTS The consequences of reduced disease transmission due to treatment were associated with additional net monetary benefit of £24,304-£90,559 per patient treated at £20,000/QALY, when 10-100% of eligible patients receive treatment with 100% efficacy. Dependent on patient genotype, the cost-effectiveness of HCV treatment using daclatasvir plus sofosbuvir improved by 36-79% versus conventional analysis, at 10-100% treatment uptake in the PWID population. CONCLUSIONS The estimated cost-effectiveness of HCV treatment was shown to improve as more patients are treated, suggesting that the value of DAA regimens to the NHS could be enhanced by improved treatment uptake rates among PWID. However, the challenge for the future will lie in achieving increased rates of treatment uptake, particularly in the PWID population.
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Affiliation(s)
- Hayley Bennett
- HEOR, Health Economics and Outcomes Research Ltd, 9 Oak Tree Court, Mulberry Drive, Cardiff Gate Business Park, Cardiff, CF23 8RS, UK.
| | - Jason Gordon
- HEOR, Health Economics and Outcomes Research Ltd, 9 Oak Tree Court, Mulberry Drive, Cardiff Gate Business Park, Cardiff, CF23 8RS, UK
- Department of Public Health, University of Adelaide, Adelaide, Australia
| | - Beverley Jones
- HEOR, Health Economics and Outcomes Research Ltd, 9 Oak Tree Court, Mulberry Drive, Cardiff Gate Business Park, Cardiff, CF23 8RS, UK
| | - Thomas Ward
- HEOR, Health Economics and Outcomes Research Ltd, 9 Oak Tree Court, Mulberry Drive, Cardiff Gate Business Park, Cardiff, CF23 8RS, UK
| | - Samantha Webster
- HEOR, Health Economics and Outcomes Research Ltd, 9 Oak Tree Court, Mulberry Drive, Cardiff Gate Business Park, Cardiff, CF23 8RS, UK
| | - Anupama Kalsekar
- World Wide Health Economics and Outcomes Research, Bristol-Myers Squibb Pharmaceuticals Ltd, Princeton, USA
| | - Yong Yuan
- World Wide Health Economics and Outcomes Research, Bristol-Myers Squibb Pharmaceuticals Ltd, Princeton, USA
| | - Michael Brenner
- UK HEOR, Bristol-Myers Squibb Pharmaceuticals Ltd, Uxbridge, UK
| | - Phil McEwan
- HEOR, Health Economics and Outcomes Research Ltd, 9 Oak Tree Court, Mulberry Drive, Cardiff Gate Business Park, Cardiff, CF23 8RS, UK
- School of Human and Health Sciences, Swansea University, Swansea, UK
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19
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COMPARISON OF METHODS FOR ESTIMATING CONTEMPORARY COSTS: AN APPLICATION TO LIVER TRANSPLANTATION IN THE UNITED KINGDOM. Int J Technol Assess Health Care 2017; 33:620-628. [PMID: 28934994 DOI: 10.1017/s026646231700071x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Our study addresses the important issue of estimating treatment costs from historical data. It is a problem frequently faced by health technology assessment analysts. We compared four approaches used to estimate current costs when good quality contemporary data are not available using liver transplantation as an example. METHODS First, the total cost estimates extracted for patients from a cohort study, conducted in the 1990s, were inflated using a published inflation multiplier. Second, resource use estimates from the cohort study were extracted for hepatitis C patients and updated using current unit costs. Third, expert elicitation was carried out to identify changes in clinical practice over time and quantify current resource use. Fourth, routine data on resource use were obtained from National Health Service Blood and Transplant (NHSBT). RESULTS The first two methods did not account for changes in clinical practice. Also the first was not specific to hepatitis patients. The use of experts confirmed significant changes in clinical practice. However, the quantification of resource use using experts is challenging as clinical specialists may not have a complete overview of clinical pathway. The NHSBT data are the most accurate reflection of transplantation and posttransplantation phase; however, data were not available for the whole pathway of care. The best estimate of total cost, combining NHSBT data and expert elicitation, is £121,211. DISCUSSION Observational data from routine care are potentially the most reliable reflection of current resource use. Efforts should be made to make such data readily available and accessible to researchers. Expert elicitation provided reasonable estimates.
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20
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Wittenborn J, Brady J, Dougherty M, Rein D. Potential epidemiologic, economic, and budgetary impacts of current rates of hepatitis C treatment in medicare and non-medicare populations. Hepatol Commun 2017; 1:99-109. [PMID: 29404448 PMCID: PMC5721427 DOI: 10.1002/hep4.1031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 02/27/2017] [Indexed: 11/12/2022] Open
Abstract
We forecast the health and budgetary impact of hepatitis C (HCV) treatment on the Medicare program based on currently observed rates of treatment among Medicare and non‐Medicare patients and identify the impact of higher rates of treatment among non‐Medicare populations. We developed a computer microsimulation model to conduct an epidemiologic forecast, a budgetary impact analysis, and a cost‐effectiveness analysis of the treatment of HCV based on three scenarios: 1) no treatment, 2) continuation of current‐treatment rates, and 3) treatment rates among non‐Medicare patients increased to match that of Medicare patients. The simulated population is based on National Health and Nutrition Examination Survey data. HCV progression rates and costs were calculated in Surveillance, Epidemiology, and End Results Program Medicare 5% claims data from the Chronic Hepatitis Cohort Study and published literature. We estimate that 13.6% of patients with HCV in the United States are enrolled in Medicare, but 75% will enter Medicare in the next 20 years. Medicare patients were over 5 times as likely to be treated in 2014‐2015 as other patients. Medicare paid over $9 billion in treatment costs in both 2015 and 2016 and will total $28.4 billion from 2017‐2026. Increasing treatment rates among non‐Medicare patients would lead to 234,000 more patients being treated, reduce HCV mortality by 19%, and decrease Medicare costs by $18.6 billion from 2017‐2026. We find that treatment remains cost‐effective under most assumptions, costing $31,718 per quality adjusted life year gained. Conclusion: Medicare treats a disproportionately large share of HCV patients. Continued low rates of treatment among non‐Medicare HCV patients will result in both reduced and deferred treatment, shifting future treatment costs to Medicare while increasing overall medical management costs, morbidity, and mortality. (Hepatology Communications 2017;1:99‐109)
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Affiliation(s)
| | | | | | - David Rein
- NORC at the University of Chicago, Chicago, IL
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21
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Ward T, Gordon J, Jones B, Bennett H, Webster S, Kalsekar A, Yuan Y, Brenner M, McEwan P. Value of Sustained Virologic Response in Patients with Hepatitis C as a Function of Time to Progression of End-Stage Liver Disease. Clin Drug Investig 2017; 37:61-70. [PMID: 27587071 DOI: 10.1007/s40261-016-0458-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Targeted intervention in patients with hepatitis C virus (HCV) closest to end-stage liver disease (ESLD) progression may offer an approach to treatment prioritisation whilst delivering benefits for patients and the healthcare system. In contrast to previous HCV economic analyses, this study aimed to estimate the health economic value of sustained virologic response (SVR) stratified by the patient's propensity to progress to ESLD. METHODS An HCV natural history model was adapted to estimate the value of avoiding ESLD complications following SVR, assessed as cost offsets and quality-adjusted life year (QALY) gains, as a function of time to ESLD at treatment initiation. These outcomes were used to estimate the financial value of achieving SVR, defined as the maximum investment that could be allocated without exceeding a willingness-to-pay threshold of £20,000/QALY. RESULTS Regardless of time to ESLD onset, achieving SVR was beneficial, resulting in cost offsets and QALY gains, due to avoidance of ESLD complications. The value of achieving SVR was greatest in patients closest to ESLD onset, resulting in increased cost offsets and QALY gains (up to £50,901 and 9.56 QALYs). In patients closest to ESLD onset, the financial value of achieving SVR was £242,051, compared with £127,116 in patients furthest from onset. CONCLUSIONS Standard cost-effectiveness evaluations may underestimate the value of treatment in HCV patients closest to ESLD development. Targeted intervention would promote efficient allocation of limited healthcare resources and reconcile concerns surrounding the affordability of new direct-acting antivirals, by minimising the number-needed-to-treat to maximise health benefit, whilst minimising healthcare expenditure.
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Affiliation(s)
- Thomas Ward
- HEOR, Health Economics and Outcomes Research Ltd, 9 Oak Tree Court, Mulberry Drive, Cardiff Gate Business Park, CF23 8RS, Cardiff, UK.
| | - Jason Gordon
- HEOR, Health Economics and Outcomes Research Ltd, 9 Oak Tree Court, Mulberry Drive, Cardiff Gate Business Park, CF23 8RS, Cardiff, UK.,Department of Public Health, University of Adelaide, Adelaide, Australia
| | - Beverley Jones
- HEOR, Health Economics and Outcomes Research Ltd, 9 Oak Tree Court, Mulberry Drive, Cardiff Gate Business Park, CF23 8RS, Cardiff, UK
| | - Hayley Bennett
- HEOR, Health Economics and Outcomes Research Ltd, 9 Oak Tree Court, Mulberry Drive, Cardiff Gate Business Park, CF23 8RS, Cardiff, UK
| | - Samantha Webster
- HEOR, Health Economics and Outcomes Research Ltd, 9 Oak Tree Court, Mulberry Drive, Cardiff Gate Business Park, CF23 8RS, Cardiff, UK
| | - Anupama Kalsekar
- World Wide Health Economics and Outcomes Research, Bristol-Myers Squibb Pharmaceuticals Ltd, Princeton, USA
| | - Yong Yuan
- World Wide Health Economics and Outcomes Research, Bristol-Myers Squibb Pharmaceuticals Ltd, Princeton, USA
| | - Michael Brenner
- UK HEOR, Bristol-Myers Squibb Pharmaceuticals Ltd, Uxbridge, UK
| | - Phil McEwan
- HEOR, Health Economics and Outcomes Research Ltd, 9 Oak Tree Court, Mulberry Drive, Cardiff Gate Business Park, CF23 8RS, Cardiff, UK.,School of Human and Health Sciences, Swansea University, Swansea, UK
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22
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Gimeno-Ballester V, Mar J, O'Leary A, Adams R, San Miguel R. Cost-effectiveness analysis of therapeutic options for chronic hepatitis C genotype 3 infected patients. Expert Rev Gastroenterol Hepatol 2017; 11:85-93. [PMID: 27500437 DOI: 10.1080/17474124.2016.1222271] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND This study provides a cost-effectiveness analysis of therapeutic strategies for chronic hepatitis C genotype 3 infected patients in Spain. METHODS A Markov model was designed to simulate the progression in a cohort of patients aged 50 years over a lifetime horizon. RESULTS Sofosbuvir (SOF) plus peginterferon and ribavirin for 12 weeks was a cost-effective option when compared to standard of care (SoC) in the treatment of both 'moderate fibrosis' and 'cirrhotic' patients. Incremental cost-effectiveness ratios were €35,276/QALY and €18,374/QALY respectively. ICERs for SOF plus daclatasvir (DCV) regimens versus SoC were over the threshold limit considered, at €56,178/QALY and €77,378/QALY for 'moderate fibrosis' and 'cirrhotic' patients respectively. CONCLUSION Addition of SOF to IFN-based regimens for genotype 3 was cost-effective for both 'moderate fibrosis' and 'cirrhotic' patients. IFN-free options including SOF and DCV association required price reductions lower than the list prices to be considered cost-effective.
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Affiliation(s)
- Vicente Gimeno-Ballester
- a Department of Pharmacy , Hospital Universitario Miguel Servet , Zaragoza , Spain.,b Faculty of Pharmacy , University of Granada , Granada , Spain
| | - Javier Mar
- c Clinical Management Service , Hospital Alto Deba , Mondragon , Spain
| | - Aisling O'Leary
- d National Centre for Pharmacoeconomics , St James Hospital , Dublin , Ireland
| | - Róisín Adams
- d National Centre for Pharmacoeconomics , St James Hospital , Dublin , Ireland
| | - Ramón San Miguel
- b Faculty of Pharmacy , University of Granada , Granada , Spain.,d National Centre for Pharmacoeconomics , St James Hospital , Dublin , Ireland.,e Department of Pharmacy , Complejo Hospitalario de Navarra , Pamplona , Spain
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23
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Linas BP, Morgan JR, Pho MT, Leff JA, Schackman BR, Horsburgh CR, Assoumou SA, Salomon JA, Weinstein MC, Freedberg KA, Kim AY. Cost Effectiveness and Cost Containment in the Era of Interferon-Free Therapies to Treat Hepatitis C Virus Genotype 1. Open Forum Infect Dis 2016; 4:ofw266. [PMID: 28480259 PMCID: PMC5414108 DOI: 10.1093/ofid/ofw266] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 12/19/2016] [Indexed: 12/14/2022] Open
Abstract
Background Interferon-free regimens to treat hepatitis C virus (HCV) genotype 1 are effective but costly. At this time, payers in the United States use strategies to control costs including (1) limiting treatment to those with advanced disease and (2) negotiating price discounts in exchange for exclusivity. Methods We used Monte Carlo simulation to investigate budgetary impact and cost effectiveness of these treatment policies and to identify strategies that balance access with cost control. Outcomes included nondiscounted 5-year payer cost per 10000 HCV-infected patients and incremental cost-effectiveness ratios. Results We found that the budgetary impact of HCV treatment is high, with 5-year undiscounted costs of $1.0 billion to 2.3 billion per 10000 HCV-infected patients depending on regimen choices. Among noncirrhotic patients, using the least costly interferon-free regimen leads to the lowest payer costs with negligible difference in clinical outcomes, even when the lower cost regimen is less convenient and/or effective. Among cirrhotic patients, more effective but costly regimens remain cost effective. Controlling costs by restricting treatment to those with fibrosis stage 2 or greater disease was cost ineffective for any patient type compared with treating all patients. Conclusions Treatment strategies using interferon-free therapies to treat all HCV-infected persons are cost effective, but short-term cost is high. Among noncirrhotic patients, using the least costly interferon-free regimen, even if it is not single tablet or once daily, is the cost-control strategy that results in best outcomes. Restricting treatment to patients with more advanced disease often results in worse outcomes than treating all patients, and it is not preferred.
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Affiliation(s)
- Benjamin P Linas
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center, Massachusetts.,Department of Epidemiology, Boston University School of Public Health, Massachusetts
| | - Jake R Morgan
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center, Massachusetts
| | - Mai T Pho
- Section of Infectious Diseases and Global Health, Department of Medicine, University of Chicago, Illinois
| | - Jared A Leff
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, New York
| | - Bruce R Schackman
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, New York
| | - C Robert Horsburgh
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center, Massachusetts.,Department of Epidemiology, Boston University School of Public Health, Massachusetts
| | - Sabrina A Assoumou
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center, Massachusetts
| | - Joshua A Salomon
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Milton C Weinstein
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Kenneth A Freedberg
- Department of Epidemiology, Boston University School of Public Health, Massachusetts.,Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston.,Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston.,Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston
| | - Arthur Y Kim
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston
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24
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Barocas JA, Linas BP. Editorial Commentary: Decision Science at Work: The Case of Hepatitis C Virus Postexposure Prophylaxis. Clin Infect Dis 2016; 64:100-101. [DOI: 10.1093/cid/ciw680] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 09/23/2016] [Indexed: 11/13/2022] Open
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25
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Johnson SJ, Parisé H, Virabhak S, Filipovic I, Samp JC, Misurski D. Economic evaluation of ombitasvir/paritaprevir/ritonavir and dasabuvir for the treatment of chronic genotype 1 hepatitis c virus infection. J Med Econ 2016; 19:983-94. [PMID: 27172133 DOI: 10.1080/13696998.2016.1189920] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To estimate clinical outcomes and cost-effectiveness of ombitasvir/paritaprevir/ritonavir and dasabuvir ± ribavirin (OMB/PTV/r + DSV ± RBV) compared with treatment regimens including pegylated interferon (PegIFN) for patients with chronic genotype 1 hepatitis C virus (HCV) infection. METHODS An Excel spreadsheet Markov model tracking progression through stages of liver disease was developed. Costs and patient utilities for liver disease stages were taken from published studies. Rates of disease progression were based on studies of untreated HCV infection and long-term follow-up of those achieving sustained virologic response (SVR) after drug treatment. Impact of OMB/PTV/r + DSV ± RBV and other drug regimens on progression was estimated through SVR rates from clinical trials. Analyses were performed for treatment-naive and treatment-experienced patients. Impact of alternative scenarios and input parameter uncertainty on the results were tested. RESULTS For genotype 1 treatment-naive HCV patients, for OMB/PTV/r + DSV ± RBV, PegIFN + ribavirin (PegIFN/RBV), sofosbuvir + PegIFN/RBV, telaprevir + PegIFN/RBV, boceprevir + PegIFN/RBV, lifetime risk of decompensated liver disease was 5.6%, 18.9%, 7.4%, 11.7%, and 14.9%; hepatocellular carcinoma was 5.4%, 9.2%, 5.7%, 7.0%, and 7.4%; and death from liver disease was 8.7%, 22.2%, 10.4%, 14.8%, and 17.6%, respectively. Estimates of the cost-effectiveness of OMB/PTV/r + DSV ± RBV for treatment-naive and treatment-experienced patients indicated that it dominated all other regimens except PegIFN/RBV. Compared with PegIFN/RBV, the incremental cost-effectiveness ratios were £13,864 and £10,258 per quality-adjusted life-year (QALY) for treatment-naive and treatment-experienced patients, respectively. The results were similar for alternative scenarios and uncertainty analyses. LIMITATIONS A mixed-treatment comparison for SVR rates for the different treatment regimens was not feasible, because many regimens did not have comparator arms; instead SVR rates were based on those from recent trials. CONCLUSIONS OMB/PTV/r + DSV ± RBV is a cost-effective oral treatment regimen for chronic genotype 1 HCV infection compared with standard treatment regimens and is estimated to reduce the lifetime risks of advanced liver disease.
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Innes H, Hutchinson SJ, Obel N, Christensen PB, Aspinall EJ, Goldberg D, Krarup H, McDonald SA, McLeod A, Weir A, Omland LH. Liver mortality attributable to chronic hepatitis C virus infection in Denmark and Scotland--using spontaneous resolvers as the benchmark comparator. Hepatology 2016; 63:1506-16. [PMID: 26773546 DOI: 10.1002/hep.28458] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Revised: 12/07/2015] [Accepted: 01/10/2016] [Indexed: 01/10/2023]
Abstract
UNLABELLED Liver mortality among individuals with chronic hepatitis C (CHC) infection is common, but the relative contribution of CHC per se versus adverse health behaviors is uncertain. We explored data on spontaneous resolvers of hepatitis C virus (HCV) as a benchmark group to uncover the independent contribution of CHC on liver mortality. Using national HCV diagnosis and mortality registers from Denmark and Scotland, we calculated the liver mortality rate (LMR) for persons diagnosed with CHC infection (LMRchronic ) and spontaneously resolved infection (LMRresolved ), according to subgroups defined by age, sex, and drug use. Through these mortality rates, we determined subgroup-specific attributable fractions (AFs), defined as (LMRchronic - LMRresolved )/LMRchronic , and then calculated the total attributable fraction (TAF) as a weighted average of these AFs. Thus, the TAF represents the overall fraction (where 0.00 = not attributable at all; and 1.00 = entirely attributable) of liver mortality attributable to CHC in the diagnosed population. Our cohort comprised 7,005 and 21,729 persons diagnosed with HCV antibodies in Denmark and Scotland, respectively. Mean follow-up duration was 6.3-6.9 years. The TAF increased stepwise with age. It was lowest for death occurring at <45 years of age (0.21 in Denmark; 0.26 in Scotland), higher for death occurring at 45-59 years (0.69 in Denmark; 0.69 in Scotland), and highest for death at 60+years (0.92 in Denmark; 0.75 in Scotland). Overall, the TAF was 0.66 (95% confidence interval [CI]: 0.55-0.78) in Denmark and 0.55 (95% CI: 0.44-0.66) in Scotland. CONCLUSIONS In Denmark and Scotland, the majority of liver death in the CHC-diagnosed population can be attributed to CHC-nevertheless, an appreciable fraction cannot, cautioning that liver mortality in this population is a compound problem that can be reduced, but not solved, through antiviral therapy alone.
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Affiliation(s)
- Hamish Innes
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK.,Health Protection Scotland, Blood borne viruses and STIs, Glasgow, UK
| | - Sharon J Hutchinson
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK.,Health Protection Scotland, Blood borne viruses and STIs, Glasgow, UK
| | - Niels Obel
- Department of Infectious Diseases, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Peer B Christensen
- Department of Infectious Diseases, Odense University Hospital, Odense, Denmark
| | - Esther J Aspinall
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK.,Health Protection Scotland, Blood borne viruses and STIs, Glasgow, UK
| | - David Goldberg
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK.,Health Protection Scotland, Blood borne viruses and STIs, Glasgow, UK
| | - Henrik Krarup
- Section of Molecular Diagnostics, Clinical Biochemistry, Aalborg University Hospital, Aalborg Hospital, Aalborg, Denmark
| | - Scott A McDonald
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK.,Health Protection Scotland, Blood borne viruses and STIs, Glasgow, UK
| | - Allan McLeod
- Health Protection Scotland, Blood borne viruses and STIs, Glasgow, UK
| | - Amanda Weir
- NHS, National Services Scotland, Edinburgh, UK
| | - Lars H Omland
- Department of Infectious Diseases, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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27
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Scott N, Iser DM, Thompson AJ, Doyle JS, Hellard ME. Cost-effectiveness of treating chronic hepatitis C virus with direct-acting antivirals in people who inject drugs in Australia. J Gastroenterol Hepatol 2016; 31:872-82. [PMID: 26514998 DOI: 10.1111/jgh.13223] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Revised: 10/19/2015] [Accepted: 10/24/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM Reducing the burden of hepatitis C virus (HCV) related liver disease will require treating people who inject drugs (PWID), the group at most risk of infection and transmission. We determine the cost-effectiveness of treating PWID with interferon-free direct-acting antiviral therapy in Australia. METHODS Using a deterministic model of HCV treatment and liver disease progression, including a fixed rate of re-infection, the expected healthcare costs and quality-adjusted life years (QALYs) of a cohort of newly HCV-infected PWID were calculated for: no treatment; treatment after initial infection ("early-treatment"); and treatment prior to developing compensated cirrhosis ("late-treatment"). Incremental cost-effectiveness ratios (ICERs) were used to compare scenarios. RESULTS Late-treatment was cost-effective compared to no treatment, with a discounted average gain of 2.98 (95%confidence interval 2.88-5.22) QALYs per person for an additional cost of $15,132 ($11,246-18,922), giving an ICER of $5078 ($2847-5295) per QALY gained. Compared to late-treatment, early-treatment gained a further discounted average of 2.27 (0.58-4.80) QALYs per person for $38,794 ($34,789-41,367), giving an ICER of $17,090 ($2847-63,282), which was cost-effective in approximately 90% of Monte-Carlo uncertainty simulations. For every 100 newly HCV-infected PWID, there were an estimated 40 (39-56) eventual liver-related deaths without treatment, compared to 7 (6-11) and 8 (7-13) with early-treatment and late-treatment available respectively. CONCLUSIONS Treating HCV-infected PWID with new therapies is cost-effective and could prevent a significant number of liver-related deaths. Although late-treatment was the most cost-effective option, the cost per QALY gained for early-treatment compared to late-treatment is likely to be below unofficial Australian willingness to pay thresholds.
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Affiliation(s)
- Nick Scott
- Centre for Population Health, Burnet Institute, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventative Medicine, Monash University, Clayton, Victoria, Australia
| | - David M Iser
- Department of Infectious Diseases, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Gastroenterology, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Alexander J Thompson
- Department of Gastroenterology, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia.,Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia
| | - Joseph S Doyle
- Centre for Population Health, Burnet Institute, Melbourne, Victoria, Australia.,Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia.,Victorian Infectious Diseases Service at the Doherty Institute, Melbourne Health, Melbourne, Victoria, Australia
| | - Margaret E Hellard
- Centre for Population Health, Burnet Institute, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventative Medicine, Monash University, Clayton, Victoria, Australia.,Department of Infectious Diseases, Alfred Hospital, Melbourne, Victoria, Australia
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28
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Crossan C, Tsochatzis EA, Longworth L, Gurusamy K, Davidson B, Rodríguez-Perálvarez M, Mantzoukis K, O'Brien J, Thalassinos E, Papastergiou V, Burroughs A. Cost-effectiveness of non-invasive methods for assessment and monitoring of liver fibrosis and cirrhosis in patients with chronic liver disease: systematic review and economic evaluation. Health Technol Assess 2015; 19:1-409, v-vi. [PMID: 25633908 DOI: 10.3310/hta19090] [Citation(s) in RCA: 109] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Liver biopsy is the reference standard for diagnosing the extent of fibrosis in chronic liver disease; however, it is invasive, with the potential for serious complications. Alternatives to biopsy include non-invasive liver tests (NILTs); however, the cost-effectiveness of these needs to be established. OBJECTIVE To assess the diagnostic accuracy and cost-effectiveness of NILTs in patients with chronic liver disease. DATA SOURCES We searched various databases from 1998 to April 2012, recent conference proceedings and reference lists. METHODS We included studies that assessed the diagnostic accuracy of NILTs using liver biopsy as the reference standard. Diagnostic studies were assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. Meta-analysis was conducted using the bivariate random-effects model with correlation between sensitivity and specificity (whenever possible). Decision models were used to evaluate the cost-effectiveness of the NILTs. Expected costs were estimated using a NHS perspective and health outcomes were measured as quality-adjusted life-years (QALYs). Markov models were developed to estimate long-term costs and QALYs following testing, and antiviral treatment where indicated, for chronic hepatitis B (HBV) and chronic hepatitis C (HCV). NILTs were compared with each other, sequential testing strategies, biopsy and strategies including no testing. For alcoholic liver disease (ALD), we assessed the cost-effectiveness of NILTs in the context of potentially increasing abstinence from alcohol. Owing to a lack of data and treatments specifically for fibrosis in patients with non-alcoholic fatty liver disease (NAFLD), the analysis was limited to an incremental cost per correct diagnosis. An analysis of NILTs to identify patients with cirrhosis for increased monitoring was also conducted. RESULTS Given a cost-effectiveness threshold of £20,000 per QALY, treating everyone with HCV without prior testing was cost-effective with an incremental cost-effectiveness ratio (ICER) of £9204. This was robust in most sensitivity analyses but sensitive to the extent of treatment benefit for patients with mild fibrosis. For HBV [hepatitis B e antigen (HBeAg)-negative)] this strategy had an ICER of £28,137, which was cost-effective only if the upper bound of the standard UK cost-effectiveness threshold range (£30,000) is acceptable. For HBeAg-positive disease, two NILTs applied sequentially (hyaluronic acid and magnetic resonance elastography) were cost-effective at a £20,000 threshold (ICER: £19,612); however, the results were highly uncertain, with several test strategies having similar expected outcomes and costs. For patients with ALD, liver biopsy was the cost-effective strategy, with an ICER of £822. LIMITATIONS A substantial number of tests had only one study from which diagnostic accuracy was derived; therefore, there is a high risk of bias. Most NILTs did not have validated cut-offs for diagnosis of specific fibrosis stages. The findings of the ALD model were dependent on assuptions about abstinence rates assumptions and the modelling approach for NAFLD was hindered by the lack of evidence on clinically effective treatments. CONCLUSIONS Treating everyone without NILTs is cost-effective for patients with HCV, but only for HBeAg-negative if the higher cost-effectiveness threshold is appropriate. For HBeAg-positive, two NILTs applied sequentially were cost-effective but highly uncertain. Further evidence for treatment effectiveness is required for ALD and NAFLD. STUDY REGISTRATION This study is registered as PROSPERO CRD42011001561. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Catriona Crossan
- Health Economics Research Group, Brunel University London, Uxbridge, UK
| | - Emmanuel A Tsochatzis
- Sheila Sherlock Liver Centre, Royal Free Hospital and UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
| | - Louise Longworth
- Health Economics Research Group, Brunel University London, Uxbridge, UK
| | | | | | - Manuel Rodríguez-Perálvarez
- Sheila Sherlock Liver Centre, Royal Free Hospital and UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
| | - Konstantinos Mantzoukis
- Sheila Sherlock Liver Centre, Royal Free Hospital and UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
| | - Julia O'Brien
- Sheila Sherlock Liver Centre, Royal Free Hospital and UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
| | - Evangelos Thalassinos
- Sheila Sherlock Liver Centre, Royal Free Hospital and UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
| | - Vassilios Papastergiou
- Sheila Sherlock Liver Centre, Royal Free Hospital and UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
| | - Andrew Burroughs
- Sheila Sherlock Liver Centre, Royal Free Hospital and UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
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Kieran JA, Norris S, O'Leary A, Walsh C, Merriman R, Houlihan D, McCormick PA, McKiernan S, Bergin C, Barry M. Hepatitis C in the era of direct-acting antivirals: real-world costs of untreated chronic hepatitis C; a cross-sectional study. BMC Infect Dis 2015; 15:471. [PMID: 26503519 PMCID: PMC4624167 DOI: 10.1186/s12879-015-1208-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Accepted: 10/12/2015] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Recent advances in Hepatitis C therapeutics offer the possibility of cure but will be expensive. The cost of treatment may be partially offset by the avoidance of advanced liver disease. We performed a micro-costing study of the ambulatory healthcare utilisation of patients with Hepatitis C supplemented with inpatient diagnosis related group costs. METHODS The staff utilisation costs associated with a Hepatitis C ambulatory visit were measured and combined with the costs of investigations to establish a mean cost per consultation. An annualised estimate of cost was produced by multiplying this by the number of consultations accessed, stratified by degree of liver impairment. Inpatient costs were established by identifying the number of inpatient episodes and multiplying by Irish diagnosis related group costs. Non-parametric bootstrapping was performed to derive mean and 95%CI values. RESULTS Two hundred and twenty-five patients were identified. The cost of an outpatient medical review was €136 (€3.60 SD). The cost of a Hepatitis C nursing review was €128 (€7.30 SD). The annual mean costs of care were as follows (95%CI): Mild €398 (€336, €482), Moderate €417(€335, €503), Compensated cirrhosis €1790 (€990, €3164), Decompensated cirrhosis €8302 (€3945, €14,637), Transplantation Year 1 €137,176 (€136,024, €138,306), Transplantation after Year 1 €5337 (€4942, €5799), Hepatocellular carcinoma €21,992 (€15,222, €29,467), Sustained virological response €44 (€16, €73). CONCLUSIONS The direct medical cost associated with Hepatitis C care in Ireland is substantial and increases exponentially with progression of liver disease. The follow-up costs of patients with a sustained virological response in this cohort were low in comparison to patients with chronic infection.
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Affiliation(s)
- Jennifer Ann Kieran
- Department of Pharmacology and Therapeutics, Trinity College Dublin, Dublin, Ireland. .,National Centre for Pharmacoeconomics, St. James Hospital, Dublin, Ireland.
| | - Suzanne Norris
- Department of Hepatology, St. James Hospital, Dublin, Ireland. .,School of Medicine, Trinity College Dublin, Dublin, Ireland.
| | - Aisling O'Leary
- National Centre for Pharmacoeconomics, St. James Hospital, Dublin, Ireland. .,School of Pharmacy, Royal College of Surgeons of Ireland, Dublin, Ireland.
| | - Cathal Walsh
- MACSI and Health Research Institute, University of Limerick, Limerick, Ireland.
| | | | - D Houlihan
- Liver Unit, St. Vincent's University Hospital, Dublin, Ireland.
| | | | - Susan McKiernan
- Department of Hepatology, St. James Hospital, Dublin, Ireland. .,School of Medicine, Trinity College Dublin, Dublin, Ireland.
| | - Colm Bergin
- Department of Genitourinary Medicine and Infectious Diseases, St. James Hospital, Dublin, Ireland. .,School of Medicine, Trinity College Dublin, Dublin, Ireland.
| | - Michael Barry
- Department of Pharmacology and Therapeutics, Trinity College Dublin, Dublin, Ireland. .,National Centre for Pharmacoeconomics, St. James Hospital, Dublin, Ireland.
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Selvapatt N, Ward T, Bailey H, Bennett H, Thorne C, See LM, Tudor-Williams G, Thursz M, McEwan P, Brown A. Is antenatal screening for hepatitis C virus cost-effective? A decade's experience at a London centre. J Hepatol 2015; 63:797-804. [PMID: 26024832 DOI: 10.1016/j.jhep.2015.05.015] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Revised: 03/20/2015] [Accepted: 05/19/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS This study aims to assess the cost-effectiveness of a routine universal antenatal hepatitis C virus (HCV) screening programme at a London centre. METHODS Ten years' retrospective antenatal screening and outcome data informed a cost-effectiveness analysis using the previously validated MONARCH model. The cost and quality of life outcomes associated with the screening and treatment of newly identified hepatitis C cases were used to generate cost-effectiveness estimates for the screening programme. RESULTS A total of 35,355 women were screened between 1st November 2003 and 1st March 2013; 136 women (0.38%) were found to be HCV antibody positive. Of 78 (0.22%) viraemic cases, 44 (0.12%) were newly diagnosed. In addition, the screening programme identified three (6.8%) vertical transmissions in children of newly diagnosed mothers. Of 16 newly diagnosed mothers biopsied, all were in the F0-F2 METAVIR disease stages, and 50% had HCV genotype 1. Postnatal treatment with pegylated interferon and ribavirin was initiated in 19 women, with 14 (74%) achieving sustained virologic response. The total cost of screening and confirmation of diagnoses was estimated to be £240,641. This translates to £5469 per newly diagnosed individual. The incremental cost-effectiveness ratio of this screening and treatment strategy was £2400 per QALY gained. Treatment with newer direct-acting antiviral regimens would have a projected cost of £9139 per QALY gained, well below the £20,000-30,000/QALY gained willingness-to-pay threshold applied by policy advisory bodies. CONCLUSIONS This study demonstrates that an antenatal screening and treatment programme is feasible and effective, at a cost considered acceptable.
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Affiliation(s)
- Nowlan Selvapatt
- Department of Hepatology, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK; Department of Hepatology, Imperial College, UK.
| | - Thomas Ward
- Health Economics and Outcomes Research Limited, Wales, UK
| | - Heather Bailey
- University College London Institute of Child Health, London, UK
| | - Hayley Bennett
- Health Economics and Outcomes Research Limited, Wales, UK
| | - Claire Thorne
- University College London Institute of Child Health, London, UK
| | - Lay-May See
- Department of Gastroenterology and Hepatology, Kingston Hospital NHS Foundation Trust, UK
| | | | - Mark Thursz
- Department of Hepatology, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK; Department of Hepatology, Imperial College, UK
| | - Phil McEwan
- Health Economics and Outcomes Research Limited, Wales, UK; Swansea Centre for Health Economics, Swansea University, Wales, UK
| | - Ashley Brown
- Department of Hepatology, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
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Gimeno-Ballester V, Mar J, San Miguel R. Cost-effectiveness analysis of simeprevir with daclatasvir for non-cirrhotic genotype-1b-naïve patients plus chronic hepatitis C. Expert Rev Pharmacoecon Outcomes Res 2015; 16:285-94. [PMID: 26327360 DOI: 10.1586/14737167.2015.1081061] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND The cost of interferon-free combination therapies remains high to provide widespread access to treatment, regardless of fibrosis stage. AIM To estimate the cost-effectiveness of simeprevir/daclatasvir (SMV/DCV) therapy in treatment-naïve chronic hepatitis C genotype-1b patients with moderate fibrosis. METHODS A Markov model was developed to simulate the natural history of chronic hepatitis C progression. The model estimated lifetime healthcare costs and quality-adjusted life-years (QALY) for a cohort of patients from the Spanish National Healthcare System perspective. The cost-effectiveness threshold considered was €40,000/QALY. The treatment strategies analyzed were SMV/DCV, peginterferon/ribavirin/telaprevir, and peginterferon/ribavirin/boceprevir. A sensitivity analysis was carried out. RESULTS The incremental cost-effectiveness ratios of the SMV/DCV strategy were €23,774/QALY and €28,524/QALY compared with that of telaprevir or boceprevir triple therapy, respectively, for genotype-1b patients with moderate fibrosis. CONCLUSIONS SMV/DCV combination compared with the standard of care previous to the arrival of second-generation direct-acting antivirals fell below generally accepted willingness-to-pay threshold. Results obtained should be supported by ongoing clinical trials.
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Affiliation(s)
- Vicente Gimeno-Ballester
- a 1 Hospital Universitario Miguel Servet-Pharmacy Department, Isabel la Católica 1-3, Zaragoza, Zaragoza 50009, Spain.,d 4 Faculty of Pharmacy, University of Granada, Granada, Spain
| | - Javier Mar
- b 2 Hospital Alto Deba-Clinical Management Service, Mondragón, Spain
| | - Ramón San Miguel
- c 3 Complejo Hospitalario de Navarra-Pharmacy Department, Pamplona, Spain.,d 4 Faculty of Pharmacy, University of Granada, Granada, Spain
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San Miguel R, Gimeno-Ballester V, Blázquez A, Mar J. Cost-effectiveness analysis of sofosbuvir-based regimens for chronic hepatitis C. Gut 2015; 64:1277-88. [PMID: 25311032 DOI: 10.1136/gutjnl-2014-307772] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Accepted: 09/18/2014] [Indexed: 12/19/2022]
Abstract
BACKGROUND A new scenario of therapy for chronic hepatitis C (CHC) is being established with the approval of sofosbuvir (SOF). OBJECTIVE To estimate the cost-effectiveness of SOF-based regimens approved in the Summary of Product Characteristics (SmPC) versus the standard of care for different genotypes and patient populations (naive or pretreated). METHODS A Markov model simulating CHC progression was used to estimate disease treatment costs and effects over patients' lifetimes, from the Spanish National Public Healthcare System perspective. Different therapeutic options were analysed for genotypes 1, 2 and 3 in naive population and for genotype 2 and 3 pretreated patients, according to data obtained from clinical trials. A one-way sensitivity analysis was performed to evaluate the uncertainty of certain parameters: treatment starting age, transition probabilities, drug costs and discount rate. A probabilistic sensitivity analysis was also carried out. RESULTS For the naive population, the option SOF+pegylated-interferon-α (pIFN)+ribavirin (RBV) for 12 weeks recorded in SmPC for genotype 1 and 3 versus pIFN+RBV for 24 weeks estimated an incremental cost-effectiveness ratio (ICER) below the €40,000/quality-adjusted life-year (QALY) benchmark. For the pretreated population, SOF triple therapy reached an ICER on the threshold limit for genotype 3. Other options included in SmPC for different genotypes exceeded the accepted efficiency limit in our setting. CONCLUSIONS The options that included SOF+RBV+pIFN in a 12-week course regimen fell below the efficiency threshold considered in our setting. IFN-free regimens administered for 24 weeks reached figures over the benchmark of €40,000/QALY.
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Affiliation(s)
- Ramón San Miguel
- Department of Pharmacy, Complejo Hospitalario de Navarra, Pamplona, Spain
| | | | - Antonio Blázquez
- Department of Medicines for Human Use, Agencia Española de Medicamentos y Productos Sanitarios, Madrid, Spain
| | - Javier Mar
- Clinical Management Service, Hospital Alto Deba, Mondragon, Spain
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Pho MT, Jensen DM, Meltzer DO, Kim AY, Linas BP. Clinical impact of treatment timing for chronic hepatitis C infection: a decision model. J Viral Hepat 2015; 22:630-8. [PMID: 26135026 PMCID: PMC4515086 DOI: 10.1111/jvh.12412] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 03/01/2015] [Indexed: 01/03/2023]
Abstract
Recent advances in the treatment of hepatitis C virus (HCV) infection have led to the availability of both highly efficacious interferon-containing and interferon-sparing regimens. However, the use of such therapies faces restrictions due to high costs. For patients who are medically eligible to receive interferon, the choice between the two will likely be impacted by preferences surrounding interferon, severity of disease, coverage policies and out-of-pocket costs. We developed a decision model to quantify the trade-offs between immediate, interferon-containing therapy and delayed, interferon-free therapy for patients with chronic, genotype 1 HCV infection. We projected the quality-adjusted life expectancy stratified by the presence or absence of cirrhosis for four strategies: (i) no treatment; (ii) immediate, one-time treatment with an interferon-containing regimen; (iii) immediate treatment as above with the opportunity for retreatment in patients who fail to achieve sustained virologic response with interferon-free therapy in 1 year; and (iv) delayed therapy with interferon-free therapy in 1 year. When compared to one-time immediate treatment with the interferon-containing regimen, delayed treatment with the interferon-free regimen in 1 year resulted in longer life expectancy, with a 0.2 quality-adjusted life year (QALY) increase in noncirrhotic patients, and a 1.1 QALY increase in patients with cirrhosis. This superiority in health benefits was lost when wait time for interferon-free therapy was greater than 3-3.2 years. In this modelling analysis, interferon-free therapy resulted in superior health benefits compared to immediate therapy with interferon until wait time exceeded 3-3.2 years. Such data can inform decision-making regarding treatment initiation for HCV as healthcare financing evolves.
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Affiliation(s)
- M T Pho
- Department of Medicine, Sections of Hospital Medicine and of Infectious Diseases and Global Health, University of ChicagoChicago, IL, USA
| | - D M Jensen
- Center for Liver Disease, Section of Gastroenterology, Hepatology and Nutrition, University of Chicago MedicineChicago, IL, USA
| | - D O Meltzer
- Section of Hospital Medicine, Department of Medicine, University of ChicagoChicago, IL, USA
| | - A Y Kim
- Department of Medicine, Massachusetts General HospitalBoston, MA, USA
| | - B P Linas
- Department of Medicine, Section of Infectious Diseases, Boston Medical CenterBoston, MA, USA
- Department of Epidemiology, Boston University School of Public HealthBoston, MA, USA
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Rein DB, Wittenborn JS, Smith BD, Liffmann DK, Ward JW. The cost-effectiveness, health benefits, and financial costs of new antiviral treatments for hepatitis C virus. Clin Infect Dis 2015; 61:157-68. [PMID: 25778747 PMCID: PMC5759765 DOI: 10.1093/cid/civ220] [Citation(s) in RCA: 119] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 01/13/2015] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND New hepatitis C virus (HCV) treatments deliver higher cure rates with fewer contraindications, increasing demand for treatment and healthcare costs. The cost-effectiveness of new treatments is unknown. METHODS We conducted a microsimulation of guideline testing followed by alternative treatment regimens for HCV among the US population aged 20 and older to estimate cases identified, treated, sustained viral response, deaths, medical costs, quality-adjusted life-years (QALYs), and the incremental cost-effectiveness ratio (ICER) of different treatment options expressed as discounted lifetime costs and benefits from the healthcare perspective. RESULTS Compared to treatment with pegylated interferon and ribavirin (PR), and a protease inhibitor for HCV genotype (G) 1 and PR alone for G2/3, treatment with PR and Sofosbuvir (PRS) for G1/4 and treatment with Sofosbuvir and ribavirin (SR) for G2/3 increased QALYs by 555 226, reduced deaths by 80 682, and increased costs by $26.2 billion at an ICER of $47 304 per QALY gained. As compared to PRS/SR, treating with an all oral regimen of Sofosbuvir and Simeprevir (SS) for G1/4 and SR for G2/3, increased QALYs by 1 110 451 and reduced deaths by an additional 164 540 at an incremental cost of $80.1 billion and an ICER of $72 169. In sensitivity analysis, where treatment with SS effectiveness was set to the list price of Viekira Pak and then Harvoni, treatment cost $24 921 and $25 405 per QALY gained as compared to PRS/SR. CONCLUSIONS New treatments are cost-effectiveness per person treated, but pent-up demand for treatment may create challenges for financing.
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Affiliation(s)
- David B. Rein
- Public Health Department, NORC at the University of Chicago, Atlanta, Georgia
| | - John S. Wittenborn
- Public Health Department, NORC at the University of Chicago, Atlanta, Georgia
| | - Bryce D. Smith
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - John W. Ward
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia
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Linas BP, Barter DM, Morgan JR, Pho MT, Leff JA, Schackman BR, Horsburgh CR, Assoumou SA, Salomon JA, Weinstein MC, Freedberg KA, Kim AY. The cost-effectiveness of sofosbuvir-based regimens for treatment of hepatitis C virus genotype 2 or 3 infection. Ann Intern Med 2015; 162:619-29. [PMID: 25820703 PMCID: PMC4420667 DOI: 10.7326/m14-1313] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Chronic infection with hepatitis C virus (HCV) genotype 2 or 3 can be treated with sofosbuvir without interferon. Because sofosbuvir is costly, its benefits should be compared with the additional resources used. OBJECTIVE To estimate the cost-effectiveness of sofosbuvir-based treatments for HCV genotype 2 or 3 infection in the United States. DESIGN Monte Carlo simulation, including deterministic and probabilistic sensitivity analyses. DATA SOURCES Randomized trials, observational cohorts, and national health care spending surveys. TARGET POPULATION 8 patient types defined by HCV genotype (2 vs. 3), treatment history (naive vs. experienced), and cirrhosis status (noncirrhotic vs. cirrhotic). TIME HORIZON Lifetime. PERSPECTIVE Payer. INTERVENTION Sofosbuvir-based therapies, pegylated interferon-ribavirin, and no therapy. OUTCOME MEASURES Discounted quality-adjusted life-years (QALYs), costs, and incremental cost-effectiveness ratios (ICERs). RESULTS OF BASE-CASE ANALYSIS The ICER of sofosbuvir-based treatment was less than $100,000 per QALY in cirrhotic patients (genotype 2 or 3 and treatment-naive or treatment-experienced) and in treatment-experienced noncirrhotic patients but was greater than $200,000 per QALY in treatment-naive noncirrhotic patients. RESULTS OF SENSITIVITY ANALYSIS The ICER of sofosbuvir-based therapy for treatment-naive noncirrhotic patients with genotype 2 or 3 infection was less than $100,000 per QALY when the cost of sofosbuvir was reduced by approximately 40% and 60%, respectively. In probabilistic sensitivity analyses, cost-effectiveness conclusions were robust to uncertainty in treatment efficacy. LIMITATION The analysis did not consider possible benefits of preventing HCV transmission. CONCLUSION Sofosbuvir provides good value for money for treatment-experienced patients with HCV genotype 2 or 3 infection and those with cirrhosis. At their current cost, sofosbuvir-based regimens for treatment-naive noncirrhotic patients exceed willingness-to-pay thresholds commonly cited in the United States. PRIMARY FUNDING SOURCE National Institute on Drug Abuse and National Institute of Allergy and Infectious Diseases.
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Estimating the clinical and economic benefit associated with incremental improvements in sustained virologic response in chronic hepatitis C. PLoS One 2015; 10:e0117334. [PMID: 25635922 PMCID: PMC4311930 DOI: 10.1371/journal.pone.0117334] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Accepted: 12/22/2014] [Indexed: 01/18/2023] Open
Abstract
Introduction Hepatitis C virus (HCV) infection is one of the principle causes of chronic liver disease. Successful treatment significantly decreases the risk of hepatic morbidity and mortality. Current standard of care achieves sustained virologic response (SVR) rates of 40–80%; however, the HCV therapy landscape is rapidly evolving. The objective of this study was to quantify the clinical and economic benefit associated with increasing levels of SVR. Methods A published Markov model (MONARCH) that simulates the natural history of hepatitis C over a lifetime horizon was used. Discounted and non-discounted life-years (LYs), quality-adjusted life-years (QALYs) and cost of complication management were estimated for various plausible SVR rates. To demonstrate the robustness of projections obtained, the model was validated to ten UK-specific HCV studies. Results QALY estimates ranged from 18.0 years for those treated successfully in fibrosis stage F0 to 7.5 years (discounted) for patients in fibrosis stage F4 who remain untreated. Predicted QALY gains per 10% improvement in SVR ranged from 0.23 (F0) to 0.64 (F4) and 0.58 (F0) to 1.35 (F4) in 40 year old patients (discounted and non-discounted results respectively). In those aged 40, projected discounted HCV-related costs are minimised with successful treatment in F0/F1 (at approximately £300), increasing to £49,300 in F4 patients who remain untreated. Validation of the model to published UK cost-effectiveness studies produce R2 goodness of fit statistics of 0.988, 0.978 and of 0.973 for total costs, QALYs and incremental cost effectiveness ratios, respectively. Conclusion Projecting the long-term clinical and economic consequences associated with chronic hepatitis C is a necessary requirement for the evaluation of new treatments. The principle analysis demonstrates the significant impact on expected costs, LYs and QALYs associated with increasing SVR. A validation analysis demonstrated the robustness of the results reported.
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Schackman BR, Leff JA, Barter DM, DiLorenzo MA, Feaster DJ, Metsch LR, Freedberg KA, Linas BP. Cost-effectiveness of rapid hepatitis C virus (HCV) testing and simultaneous rapid HCV and HIV testing in substance abuse treatment programs. Addiction 2015; 110:129-43. [PMID: 25291977 PMCID: PMC4270906 DOI: 10.1111/add.12754] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Revised: 07/11/2014] [Accepted: 09/29/2014] [Indexed: 12/13/2022]
Abstract
AIMS To evaluate the cost-effectiveness of rapid hepatitis C virus (HCV) and simultaneous HCV/HIV antibody testing in substance abuse treatment programs. DESIGN We used a decision analytic model to compare the cost-effectiveness of no HCV testing referral or offer, off-site HCV testing referral, on-site rapid HCV testing offer and on-site rapid HCV and HIV testing offer. Base case inputs included 11% undetected chronic HCV, 0.4% undetected HIV, 35% HCV co-infection among HIV-infected, 53% linked to HCV care after testing antibody-positive and 67% linked to HIV care. Disease outcomes were estimated from established computer simulation models of HCV [Hepatitis C Cost-Effectiveness (HEP-CE)] and HIV [Cost-Effectiveness of Preventing AIDS Complications (CEPAC)]. SETTING AND PARTICIPANTS Data on test acceptance and costs were from a national randomized trial of HIV testing strategies conducted at 12 substance abuse treatment programs in the United States. MEASUREMENTS Lifetime costs (2011 US$) and quality-adjusted life years (QALYs) discounted at 3% annually; incremental cost-effectiveness ratios (ICERs). FINDINGS On-site rapid HCV testing had an ICER of $18,300/QALY compared with no testing, and was more efficient than (dominated) off-site HCV testing referral. On-site rapid HCV and HIV testing had an ICER of $64,500/QALY compared with on-site rapid HCV testing alone. In one- and two-way sensitivity analyses, the ICER of on-site rapid HCV and HIV testing remained <$100,000/QALY, except when undetected HIV prevalence was <0.1% or when we assumed frequent HIV testing elsewhere. The ICER remained <$100,000/QALY in 91% of probabilistic sensitivity analyses. CONCLUSIONS On-site rapid hepatitis C virus and HIV testing in substance abuse treatment programs is cost-effective at a <$100,000/quality-adjusted life year threshold.
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Affiliation(s)
- Bruce R. Schackman
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY, USA
| | - Jared A. Leff
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY, USA
| | - Devra M. Barter
- HIV Epidemiology and Outcomes Research Unit, Section of Infectious Diseases, Department of Medicine, Boston Medical Center, Boston, MA, USA
| | - Madeline A. DiLorenzo
- Division of General Medicine, Massachusetts General Hospital, Boston, MA, USA
- The Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
| | - Daniel J. Feaster
- Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Lisa R. Metsch
- Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami, FL, USA
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Kenneth A. Freedberg
- Division of General Medicine, Massachusetts General Hospital, Boston, MA, USA
- The Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
- Department of Health Policy and Management, Harvard School of Public Health, Boston MA, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Benjamin P. Linas
- HIV Epidemiology and Outcomes Research Unit, Section of Infectious Diseases, Department of Medicine, Boston Medical Center, Boston, MA, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
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Kuwabara H, Westerhout K, Treur M, Cerri K, Mahlich J, Yatsuhashi H. Cost-effectiveness analysis of simeprevir in combination with peginterferon and ribavirin for treatment-naïve chronic hepatitis C genotype 1 patients in Japan. J Med Econ 2015; 18:502-11. [PMID: 25763827 DOI: 10.3111/13696998.2015.1029492] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
AIM Simeprevir (SMV), a protease inhibitor, recently became available for the treatment of chronic hepatitis C (HCV) genotype 1 patients in Japan. The introduction of triple therapy using SMV in combination with peginterferon and ribavirin (PR) significantly improves the cure rate. The aim was to assess the cost-effectiveness of SMV with PR (SMV/PR) compared to telaprevir with PR (TVR/PR), PR alone, or no treatment in treatment-naïve patients in Japan. METHODS A Markov model was developed to reflect the natural disease progression of HCV and to estimate the average life years and lifetime healthcare costs per patient. Sustained virologic response rates were obtained from a network meta-analysis including randomized clinical trials conducted in Japan. Patient baseline characteristics, HCV progression rates, mortality, medical resource utilization, and unit costs were obtained from Japanese sources. Outcomes were reported as incremental cost-effectiveness ratios as well as incremental cost and life years. Various sensitivity analyses were conducted to assess the uncertainty around model outcomes. RESULTS SMV/PR was estimated to be a cost-effective treatment option as more life years were gained by 0.235 and 0.873 years at a reduced cost by ¥263,037 and ¥776,900 compared to TVR/PR and PR alone, respectively. The results were robust to sensitivity analyses, in particular in the comparison of SMV/PR with PR alone. The multivariate probabilistic sensitivity analyses showed that the probability of SMV/PR being cost-effective was relatively constant at ∼87% at any willingness to pay. CONCLUSIONS SMV/PR is estimated to be the most cost-effective treatment strategy for treatment-naïve HCV genotype 1 patients in Japan.
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Innes H, Goldberg D, Dusheiko G, Hayes P, Mills PR, Dillon JF, Aspinall E, Barclay ST, Hutchinson SJ. Patient-important benefits of clearing the hepatitis C virus through treatment: a simulation model. J Hepatol 2014; 60:1118-26. [PMID: 24509410 DOI: 10.1016/j.jhep.2014.01.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Revised: 01/20/2014] [Accepted: 01/27/2014] [Indexed: 12/18/2022]
Abstract
BACKGROUND & AIMS Given an appreciable risk of adverse-effects, current therapies for chronic hepatitis C virus (HCV) infection pose a dilemma to patients. We explored, via simulation modelling, patient-important benefits of attaining a sustained viral response (SVR). METHODS We created the HCV Individualised Treatment-decision model (the HIT-model) to simulate, on a per patient basis, the lifetime course of HCV-related liver disease according to two distinct scenarios: (i) SVR attained, and (ii) SVR not attained. Then, for each model subject, the course of liver disease under these alternative scenarios was compared. The benefit of SVR was considered in terms of two patient-important outcomes: (1) the percent-probability that SVR confers additional life-years, and (2) the percent-probability that SVR confers additional healthy life-years, where "healthy" refers to years spent in compensated disease states (i.e., the avoidance of liver failure). RESULTS The benefit of SVR varied strikingly. It was lowest for patients aged 60 years with initially mild fibrosis; 1.6% (95% CI: 0.8-2.7) and 2.9% (95% CI: 1.5-4.7) probability of gaining life-years and healthy life-years, respectively. Whereas it was highest for patients with initially compensated cirrhosis aged 30 years; 57.9% (95% CI: 46.0-69.0) and 67.1% (95% CI: 54.1-78.2) probability of gaining life-years and healthy life-years, respectively. CONCLUSIONS For older patients with less advanced liver fibrosis, SVR is less likely to confer benefit when measured in terms of averting liver failure and premature death. These data have important implications. Foremost, it may inform the contemporary patient dilemma of immediate treatment with existing therapies (that have poor adverse effect profiles) vs. awaiting future regimens that promise better tolerability.
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Affiliation(s)
- Hamish Innes
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK; Health Protection Scotland, Glasgow, UK.
| | - David Goldberg
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK; Health Protection Scotland, Glasgow, UK
| | - Geoffrey Dusheiko
- UCL Institute of Liver and Digestive Disease, Royal Free Hospital, London, UK
| | | | | | | | - Esther Aspinall
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK; Health Protection Scotland, Glasgow, UK
| | | | - Sharon J Hutchinson
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK; Health Protection Scotland, Glasgow, UK
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Linas BP, Barter DM, Leff JA, Assoumou SA, Salomon JA, Weinstein MC, Kim AY, Schackman BR. The hepatitis C cascade of care: identifying priorities to improve clinical outcomes. PLoS One 2014; 9:e97317. [PMID: 24842841 PMCID: PMC4026319 DOI: 10.1371/journal.pone.0097317] [Citation(s) in RCA: 107] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Accepted: 04/17/2014] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND As highly effective hepatitis C virus (HCV) therapies emerge, data are needed to inform the development of interventions to improve HCV treatment rates. We used simulation modeling to estimate the impact of loss to follow-up on HCV treatment outcomes and to identify intervention strategies likely to provide good value for the resources invested in them. METHODS We used a Monte Carlo state-transition model to simulate a hypothetical cohort of chronically HCV-infected individuals recently screened positive for serum HCV antibody. We simulated four hypothetical intervention strategies (linkage to care; treatment initiation; integrated case management; peer navigator) to improve HCV treatment rates, varying efficacies and costs, and identified strategies that would most likely result in the best value for the resources required for implementation. MAIN MEASURES Sustained virologic responses (SVRs), life expectancy, quality-adjusted life expectancy (QALE), costs from health system and program implementation perspectives, and incremental cost-effectiveness ratios (ICERs). RESULTS We estimate that imperfect follow-up reduces the real-world effectiveness of HCV therapies by approximately 75%. In the base case, a modestly effective hypothetical peer navigator program maximized the number of SVRs and QALE, with an ICER compared to the next best intervention of $48,700/quality-adjusted life year. Hypothetical interventions that simultaneously addressed multiple points along the cascade provided better outcomes and more value for money than less costly interventions targeting single steps. The 5-year program cost of the hypothetical peer navigator intervention was $14.5 million per 10,000 newly diagnosed individuals. CONCLUSIONS We estimate that imperfect follow-up during the HCV cascade of care greatly reduces the real-world effectiveness of HCV therapy. Our mathematical model shows that modestly effective interventions to improve follow-up would likely be cost-effective. Priority should be given to developing and evaluating interventions addressing multiple points along the cascade rather than options focusing solely on single points.
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Affiliation(s)
- Benjamin P. Linas
- HIV Epidemiology and Outcomes Research Unit, Section of Infectious Diseases, Boston Medical Center, Boston, Massachusetts, United States of America
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Devra M. Barter
- HIV Epidemiology and Outcomes Research Unit, Section of Infectious Diseases, Boston Medical Center, Boston, Massachusetts, United States of America
| | - Jared A. Leff
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, New York, United States of America
| | - Sabrina A. Assoumou
- HIV Epidemiology and Outcomes Research Unit, Section of Infectious Diseases, Boston Medical Center, Boston, Massachusetts, United States of America
| | - Joshua A. Salomon
- Department of Global Health and Population, Harvard School of Public Health, Boston, Massachusetts, United States of America
| | - Milton C. Weinstein
- Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts, United States of America
| | - Arthur Y. Kim
- Massachusetts General Hospital Boston, Massachusetts, United States of America
| | - Bruce R. Schackman
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, New York, United States of America
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Statistical linkage analysis of substitutions in patient-derived sequences of genotype 1a hepatitis C virus nonstructural protein 3 exposes targets for immunogen design. J Virol 2014; 88:7628-44. [PMID: 24760894 DOI: 10.1128/jvi.03812-13] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
UNLABELLED Chronic hepatitis C virus (HCV) infection is one of the leading causes of liver failure and liver cancer, affecting around 3% of the world's population. The extreme sequence variability of the virus resulting from error-prone replication has thwarted the discovery of a universal prophylactic vaccine. It is known that vigorous and multispecific cellular immune responses, involving both helper CD4(+) and cytotoxic CD8(+) T cells, are associated with the spontaneous clearance of acute HCV infection. Escape mutations in viral epitopes can, however, abrogate protective T-cell responses, leading to viral persistence and associated pathologies. Despite the propensity of the virus to mutate, there might still exist substitutions that incur a fitness cost. In this paper, we identify groups of coevolving residues within HCV nonstructural protein 3 (NS3) by analyzing diverse sequences of this protein using ideas from random matrix theory and associated methods. Our analyses indicate that one of these groups comprises a large percentage of residues for which HCV appears to resist multiple simultaneous substitutions. Targeting multiple residues in this group through vaccine-induced immune responses should either lead to viral recognition or elicit escape substitutions that compromise viral fitness. Our predictions are supported by published clinical data, which suggested that immune genotypes associated with spontaneous clearance of HCV preferentially recognized and targeted this vulnerable group of residues. Moreover, mapping the sites of this group onto the available protein structure provided insight into its functional significance. An epitope-based immunogen is proposed as an alternative to the NS3 epitopes in the peptide-based vaccine IC41. IMPORTANCE Despite much experimental work on HCV, a thorough statistical study of the HCV sequences for the purpose of immunogen design was missing in the literature. Such a study is vital to identify epistatic couplings among residues that can provide useful insights for designing a potent vaccine. In this work, ideas from random matrix theory were applied to characterize the statistics of substitutions within the diverse publicly available sequences of the genotype 1a HCV NS3 protein, leading to a group of sites for which HCV appears to resist simultaneous substitutions possibly due to deleterious effect on viral fitness. Our analysis leads to completely novel immunogen designs for HCV. In addition, the NS3 epitopes used in the recently proposed peptide-based vaccine IC41 were analyzed in the context of our framework. Our analysis predicts that alternative NS3 epitopes may be worth exploring as they might be more efficacious.
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42
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Neoh CF, Kong DCM. The cost-effectiveness of boceprevir for hepatitis C. Expert Rev Pharmacoecon Outcomes Res 2014; 14:319-34. [DOI: 10.1586/14737167.2014.906306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Brogan AJ, Talbird SE, Thompson JR, Miller JD, Rubin J, Deniz B. Cost-effectiveness of Telaprevir combination therapy for chronic hepatitis C. PLoS One 2014; 9:e90295. [PMID: 24603445 PMCID: PMC3946047 DOI: 10.1371/journal.pone.0090295] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Accepted: 01/31/2014] [Indexed: 01/06/2023] Open
Abstract
Objective To explore the expected long-term health and economic outcomes of telaprevir (TVR) plus peginterferon alfa-2a and ribavirin (PR), a regimen that demonstrated substantially increased sustained virologic response (SVR) compared with PR alone in adults with chronic genotype 1 hepatitis C virus (HCV) and compensated liver disease in the Phase III studies ADVANCE (treatment-naïve patients) and REALIZE (relapsers, partial responders, and null responders to previous PR treatment). Study Design A decision-analytic model was developed to assess the cost-effectiveness of TVR+PR vs. PR in the United States (US). Methods Patients first moved through the 72-week decision-tree treatment phase of the model and then entered the cyclic Markov post-treatment phase. Clinical data (patient characteristics, SVR rates, and adverse event rates and durations) were obtained from ADVANCE and REALIZE. Health-state transition probabilities, drug and other costs (in 2012/2013 US dollars), and utility values were obtained from the trials, published studies, and publicly available sources. Outcomes were discounted at 3% per year. Results Regardless of treatment history, patients receiving TVR+PR were projected to experience fewer liver-disease complications, more life-years, and more quality-adjusted life-years (QALYs) than patients receiving PR. In prior relapsers, TVR+PR was dominant, with lower total medical costs and more QALYs. For the other patient subgroups, incremental costs per QALY gained were between $16,778 (treatment-naïve patients) and $34,279 (prior null responders). Extensive sensitivity analyses confirmed robust model results. Conclusions At standard willingness-to-pay thresholds, TVR+PR represents a cost-effective treatment option compared with PR alone for patients with chronic genotype 1 HCV and compensated liver disease in the US. Future analyses are needed to compare TVR+PR with all existing HCV treatment options.
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Affiliation(s)
- Anita J Brogan
- RTI Health Solutions, Research Triangle Park, North Carolina, United States of America
| | - Sandra E Talbird
- RTI Health Solutions, Research Triangle Park, North Carolina, United States of America
| | - James R Thompson
- RTI Health Solutions, Research Triangle Park, North Carolina, United States of America
| | - Jeffrey D Miller
- RTI Health Solutions, Waltham, Massachusetts, United States of America
| | - Jaime Rubin
- Vertex Pharmaceuticals Incorporated, Cambridge, Massachusetts, United States of America
| | - Baris Deniz
- Vertex Pharmaceuticals Incorporated, Cambridge, Massachusetts, United States of America
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44
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Backx M, Lewszuk A, White JR, Cole J, Sreedharan A, van Sanden S, Diels J, Lawson A, Neal KR, Wiselka MJ, Ito T, Irving WL. The cost of treatment failure: resource use and costs incurred by hepatitis C virus genotype 1-infected patients who do or do not achieve sustained virological response to therapy. J Viral Hepat 2014; 21:208-15. [PMID: 24438682 DOI: 10.1111/jvh.12132] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2013] [Accepted: 05/14/2013] [Indexed: 12/19/2022]
Abstract
Chronic hepatitis C virus (HCV) infection places a considerable economic burden on health services. Cost-effectiveness analyses of antiviral treatment for patients with chronic HCV infection are dependent on assumptions about cost reductions following sustained virological response (SVR) to therapy. This study quantified the medium-term difference in health resource usage and costs depending on treatment outcome. Retrospective chart review of patients with HCV genotype 1 infection who had received at least 2 months pegylated interferon and ribavirin therapy, with known treatment outcome was conducted. Disease status was categorized as chronic hepatitis, cirrhosis or decompensated liver disease. Health resource use was documented for each patient in each disease state. Unit costs were from the NHS 'Payment by Results' database and the British National Formulary. One hundred and ninety three patients (108 SVR, 85 non-SVR) with mean follow-up of 3.5 (SVR) and 4.9 (non-SVR) years were enrolled. No SVR patient progressed to a more severe liver disease state. Annual transition rates for non-SVR patients were 7.4% (chronic hepatitis to cirrhosis) and 4.9% (cirrhosis to decompensated liver disease). By extrapolation of modelled data over a 5-year post-treatment period, failure of patients with chronic hepatitis to achieve SVR was associated with a 13-fold increase (roughly £2300) in costs, whilst for patients who were retreated, the increase was 56-fold, equating to more than £10 000. Achievement of an SVR has significant effects on health service usage and costs. This work provides real-life data for future cost-effectiveness analyses related to the treatment for chronic HCV infection.
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Affiliation(s)
- M Backx
- NIHR Biomedical Research Unit in Gastrointestinal and Liver Diseases, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
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Javanbakht M, Mirahmadizadeh A, Mashayekhi A. The long-term effectiveness of methadone maintenance treatment in prevention of hepatitis C virus among illicit drug users: a modeling study. IRANIAN RED CRESCENT MEDICAL JOURNAL 2014; 16:e13484. [PMID: 24719731 PMCID: PMC3965864 DOI: 10.5812/ircmj.13484] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Revised: 09/06/2013] [Accepted: 10/07/2013] [Indexed: 11/25/2022]
Abstract
Background: Chronic infection with hepatitis C virus (HCV) is increasingly recognized as a major global health problem. Illicit injection drug use is an important risk factor for the rising hepatitis C virus (HCV) prevalence in IR Iran. Objectives: The objective of this study was to determine the long-term effectiveness (total quality adjusted life years (QALYs) gained) of methadone maintenance treatment (MMT program) in prevention of HCV infection among injecting drug users (IDUs). Materials and Methods: A number of Markov models were developed to model morbidity and mortality among IDUs. The input data used in modeling were collected by a self-reported method from 259 IDUs before registration and one year after MMT and also from previous studies. One way and probabilistic sensitivity analyses were done to show the effects of uncertainty in parameters on number of life years and QALYs saved. The expected consequences were estimated using a life-time time horizon for the two strategies including implementation and not implementation of the MMT program. Results: Our model estimated that total number of discounted life years lived per IDU with and without the MMT program would be 5.15 (5.05 - 5.25) and 4.63 (4.42 - 4.81), respectively. The model also estimated that total number of discounted QALYs lived per IDU with and without the MMT program would be 4.11 (3.86 - 4.41) and 2.45 (2.17 - 2.84). Simulation results indicated that all differences in life years and QALYs lived between the two strategies were statistically significant (p < 0.001). Based on our model, total discounted life years and QALYs saved in a cohort of 1000 IDUs were 1790 (1520 - 2090) and 1590 (1090- 2090), respectively. Conclusions: Considering the high prevalence of illicit injecting drug use in Iran and MMT effectiveness in prevention of HCV infection, it is necessary to develop MMT centers at regional and national levels.
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Affiliation(s)
- Mehdi Javanbakht
- Health Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Research Institute, Tehran University of Medical Sciences, Tehran, IR Iran
| | | | - Atefeh Mashayekhi
- Health Management and Economics Research Center, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, IR Iran
- Corresponding Author: Atefeh Mashayekhi, Health Management and Economics Research Center, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, IR Iran. Tel: +98-2144017935, Fax: +98-2144017935, E-mail:
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46
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The cost-effectiveness of improved hepatitis C virus therapies in HIV/hepatitis C virus coinfected patients. AIDS 2014; 28:365-76. [PMID: 24670522 DOI: 10.1097/qad.0000000000000093] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVES To evaluate the effectiveness and cost-effectiveness of strategies to treat hepatitis C virus (HCV) in HIV/HCV coinfected patients in the United States. PARTICIPANTS Simulated cohort of HIV/HCV genotype 1 coinfected, noncirrhotic, HCV treatment-naive individuals enrolled in US HIV guideline-concordant care. DESIGN/INTERVENTIONS Monte Carlo simulation comparing five strategies: no treatment; dual therapy with pegylated-interferon (PEG) and ribavirin (RBV); 'PEG/RBV trial' in which all patients initiate dual therapy and switch to triple therapy upon failure; 'IL28B triage' in which patients initiate either dual therapy or triple therapy based on their IL28B allele type; and PEG/RBV and telaprevir (TPV) triple therapy. Sensitivity analyses varied efficacies and costs and included a scenario with interferon (IFN)-free therapy. MAIN MEASURES Sustained virologic response (SVR), life expectancy, discounted quality-adjusted life expectancy (QALE), lifetime medical costs, and incremental cost-effectiveness ratios (ICERs) in $/quality-adjusted life years (QALY) gained. RESULTS 'PEG/RBV trial,' 'IL28B triage,' and 'triple therapy' each provided 72% SVR and extended QALE compared with 'dual therapy' by 1.12, 1.14, and 1.15 QALY, respectively. The ICER of 'PEG/RBV trial' compared with 'dual therapy' was $37 500/QALY. 'IL28B triage' and 'triple therapy' provided little benefit compared with 'PEG/RBV trial,' and both had ICERs exceeding $300 000/QALY. In sensitivity analyses, IFN-free treatment attaining 90% SVR had an ICER less than $100 000/QALY compared with 'PEG/RBV trial' when its cost was $109 000 or less (125% of the cost of PEG/RBV/TVR). CONCLUSION HCV protease inhibitors are most efficiently used in HIV/HCV coinfection after a trial of PEG/RBV, sparing protease inhibitors for those who attain rapid virologic response and SVR. The cost-effectiveness of IFN-free regimens for HIV/HCV coinfection will depend on the cost of these therapies.
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47
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Shepherd J, Jones J. A systematic review of the cost–effectiveness of peginterferon alfa-2b in the treatment of chronic hepatitis C. Expert Rev Pharmacoecon Outcomes Res 2014; 7:577-95. [DOI: 10.1586/14737167.7.6.577] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Cure S, Bianic F, Gavart S, Curtis S, Lee S, Dusheiko G. Cost-effectiveness of telaprevir in combination with pegylated interferon alpha and ribavirin in previously untreated chronic hepatitis C genotype 1 patients. J Med Econ 2014; 17:65-76. [PMID: 24160335 DOI: 10.3111/13696998.2013.860033] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Telaprevir (T, TVR) is a direct-acting antiviral (DAA) used for the treatment of genotype 1 chronic hepatitis C virus (HCV) infection. The sustained virological response (SVR) rates, i.e., undetectable HCV RNA levels 24 weeks after the end of treatment, is what differentiate treatments. This analysis evaluated the cost-effectiveness of TVR combined with pegylated interferon (Peg-IFN) alfa-2a plus ribavirin (RBV), with Peg-IFN and RBV (PR) alone or with boceprevir (B, BOC) plus Peg-IFN alfa-2b and RBV, in naïve patients. METHODS A Markov cohort model of chronic HCV disease progression reflected the pathway of naïve patients initiating anti-HCV therapy. SVR rates were derived from a mixed-treatment comparison including results from Phase II and III trials of TVR and BOC, and trials comparing both PR regimens. SVR has significant impact on survival, quality-of-life, and costs. Incremental cost per life year (LY) gained and quality-adjusted-life-year (QALY) gained were computed at lifetime, adopting the (National Health Service) NHS perspective. Cost and health outcomes were discounted at 3.5%. Uncertainty was assessed using deterministic and probabilistic sensitivity analyses. Sub-group analyses were also performed by interleukin (IL)-28B genotype and fibrosis stage. RESULTS Higher costs and improved outcomes were associated with T/PR relative to PR alone, resulting in an ICER of £12,733 per QALY gained. T/PR retained a significant SVR advantage over PR alone and was cost-effective regardless of IL-28B genotype and fibrosis stages. T/PR regimen 'dominated' B/PR, generating 0.2 additional QALYs and reducing lifetime cost by £2758. Sensitivity analyses consistently resulted in ICERs less than £30,000/QALY for the T/PR regimen over PR alone. LIMITATIONS No head-to-head trial provides direct evidence of better efficacy of T/PR vs B/PR. CONCLUSION The introduction of TVR-based therapy for genotype 1 HCV patients is cost-effective for naïve patients at the £30,000 willingness-to-pay threshold, regardless of IL-28B genotype or fibrosis stage.
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Cure S, Bianic F, Gavart S, Curtis S, Lee S, Dusheiko G. Cost-effectiveness of telaprevir in combination with pegylated interferon alpha and ribavirin in treatment-experienced chronic hepatitis C genotype 1 patients. J Med Econ 2014; 17:77-87. [PMID: 24032626 DOI: 10.3111/13696998.2013.844159] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Telaprevir (TVR,T) and boceprevir (BOC,B) are direct-acting antivirals (DAAs) used for the treatment of chronic genotype 1 hepatitis C virus (HCV) infection. This analysis evaluated the cost-effectiveness of TVR combined with pegylated interferon (Peg-IFN) alfa-2a plus ribavirin (RBV) compared with Peg-IFN alfa-2a and RBV (PR) alone or BOC plus Peg-IFN alfa-2b and RBV in treatment-experienced patients. METHODS A Markov cohort model of chronic genotype 1 HCV disease progression reflected the pathway of experienced patients retreated with DAA therapy. The population was stratified by previous response to treatment (i.e., previous relapsers, partial responders, and null responders). Sustained virologic response (SVR) rates were derived from a mixed-treatment comparison that included results from separate Phase III trials of TVR and BOC. Incremental cost per life year (LY) gained and quality-adjusted-life-year (QALY) gained were computed at lifetime, adopting the NHS perspective. Costs and health outcomes were discounted at 3.5%. Uncertainty was assessed using deterministic and probabilistic sensitivity analyses. Sub-group analyses were carried out by interleukin (IL)-28B genotype. RESULTS Higher costs and improved outcomes were associated with T/PR relative to PR alone for all experienced patients (ICER of £6079). T/PR was cost-effective for each sub-group population with high SVR advantage in relapsers (ICER of £2658 vs £7593 and £20,875 for partial and null responders). T/PR remained cost-effective regardless of IL-28B sub-type. Compared to B/PR, T/PR prolonged QALYs by 0.57 and reduced lifetime costs by £13,960 for relapsers. For partial responders T/PR was less costly but less efficacious than B/PR, equating to an ICER of £128,117 per QALY gained. LIMITATIONS No head-to-head trial provides direct evidence of better efficacy of T/PR vs B/PR. CONCLUSION T/PR is cost-effective compared with PR alone in experienced patients regardless of treatment history and IL-28B genotype. Compared to B/PR, T/PR is always cost-saving but only more effective in relapsers.
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50
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Mehta B, Kumar V, Chawla S, Jindal H, Bhatt B. Hepatitis C: is a vaccine the solution? Hum Vaccin Immunother 2013; 10:417-9. [PMID: 24165512 DOI: 10.4161/hv.26970] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Hepatitis C Virus (HCV) infection is a major cause of chronic hepatitis, cirrhosis, and hepatocellular carcinoma. Following acute infection, 20% of people eliminate the virus over weeks or months and are often asymptomatic. The remaining 80% of people will develop chronic disease, of which approximately 20% will eventually develop liver cirrhosis and 1-5% will develop liver cancer. About 150 million people are chronically infected with HCV, and more than 350,000 people die every year from hepatitis C related liver diseases. The economic cost of hepatitis C is significant both to the individual and to the society. In the United States the average lifetime cost of the disease was estimated at $33,407 USD with the cost of a liver transplant approximately $200,000 USD. PEG-IFN and ribavirin treatment is also expensive and, at an average cost of approximately GB £7000 in the UK for a treatment course, is unaffordable in developing countries. Hepatitis C, not only brings down the quality of the life of individuals but also affect progress of the nation by adding financial burden. If we prevent the disease from occurring or find a perfect cure of the disease, in form of a prophylactic or therapeutic vaccine, it will be a boon to not only to the individual but to the nation as a whole.
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Affiliation(s)
- Bharti Mehta
- Department of Community Medicine; PGIMS; Rohtak, India
| | - Vijay Kumar
- Department of Community Medicine; PGIMS; Rohtak, India
| | - Sumit Chawla
- Department of Community Medicine; PGIMS; Rohtak, India
| | | | - Bhumika Bhatt
- Department of Community Medicine; PGIMS; Rohtak, India
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