Quality-of-life tradeoffs for hepatitis C treatment: do patients and providers agree?

Diagnostic Overshadowing of Chronic Hepatitis C in People With Mental Health Conditions Who Inject Drugs: A Scoping Review

Diagnostic overshadowing refers to a phenomenon whereby people with mental health conditions encounter inadequate or delayed medical attention and misdiagnosis. This occurs when physical symptoms are mistakenly attributed to their mental health condition. This paper presents a scoping review focusing on direct causes and background factors of diagnostic overshadowing in the context of hepatitis C infection in people who inject drugs and have concurrent mental health conditions. Despite significant strides in hepatitis C treatment with direct-acting antiviral drugs, the complex interplay of mental health conditions and physical symptoms necessitates a nuanced approach for accurate diagnosis and effective screening. This review was conducted using Joanna Briggs Institute's methodology for scoping reviews. The databases searched included Medline, Embase, PsycInfo, Global Health, CINAHL and Scopus. This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). The search strategies identified 1995 records. Overall, 166 studies were excluded. Forty-two (42) studies met the inclusion criteria. Three (n = 3) studies represented direct causes, and 39 (n = 39) with background factors related to diagnostic overshadowing. Studies highlighted six key themes encompassing diagnostic overshadowing, with communication barriers, stigma and knowledge deficiencies being the most prominent. Recognising and addressing diagnostic overshadowing in chronic hepatitis C will lead to increased screening, diagnosis and timely administration of life-saving antiviral therapy, resulting in profound enhancements in well-being and health outcomes. Moreover, this proactive approach will play a pivotal role in advancing the global effort towards eliminating hepatitis C by 2030.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Cost-Effectiveness of One-Time Hepatitis C Screening Strategies Among Adolescents and Young Adults in Primary Care Settings

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%.

Preferences for antiviral therapy of chronic hepatitis C: a discrete choice experiment

BACKGROUND

The German Institute for Quality and Efficiency in Health Care (IQWiG) uses patient-relevant outcomes to inform decision-makers.

OBJECTIVE

IQWiG conducted a pilot study to examine whether discrete choice experiments (DCEs) can be applied in health economic evaluations in Germany to identify, weight, and prioritize multiple patient-relevant outcomes, using the example of antiviral therapy for chronic hepatitis C (HCV). A further objective was to contribute to a more structured approach towards eliciting and comparing preferences across key stakeholders.

METHODS

In autumn 2010, a DCE questionnaire was sent to patients with chronic HCV to estimate preferences across seven outcomes ("attributes"), including treatment efficacy [sustained viral response (SVR) at 6 months], adverse effects (flu-like symptoms, gastrointestinal symptoms, psychiatric symptoms, and skin symptoms/alopecia), and measures of treatment burden (duration of therapy, frequency of injections). A linear model and an effects coded full model were applied to assess the relative importance of the attributes.

RESULTS

In total N = 326 patients were included. A clear preference for SVR was shown; frequency of injections and duration of therapy shared the second rank, while psychiatric symptoms ranked third. The duration of flu-like symptoms was the least important attribute.

CONCLUSION

Our findings indicate that it is possible to perform a DCE at the national level in a health technology assessment agency. The weighting of multiple outcomes allows an indication-specific and evidence-based measure to be used in health economic evaluations. In decision-making in health care, the approach generally allows for consideration of patient-relevant trade-offs regarding the benefits and harms of medical interventions.

Cost Effectiveness and Cost Containment in the Era of Interferon-Free Therapies to Treat Hepatitis C Virus Genotype 1

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.

Listening to both sides: A qualitative comparison between patients with hepatitis C and their healthcare professionals' perceptions of the facilitators and barriers to hepatitis C treatment adherence and completion

This qualitative study compares and contrasts the perspectives of healthcare professionals who treat hepatitis C with those of patients in treatment. Comparative analysis of semi-structured interviews with 20 healthcare professionals and 20 patients undergoing treatment for hepatitis C concluded that patients and healthcare professionals disagreed on the source of communication breakdowns, but both felt that individualised clinical information improved adherence. Stigma was recognised as a barrier to treatment adherence by both patients and healthcare professionals. Limitations of the healthcare system, such as patients receiving inconsistent information and long wait times, negatively impacted both patients and providers.

Understanding Patient Preferences in Medication Nonadherence: A Review of Stated Preference Data

Nonadherence is a global problem undermining the cost-effectiveness of evidence-based medications. Aligning treatment choices with patient preferences may promote adherent behaviour: eliciting patient treatment preferences may help resolve the problem of nonadherence. As there is no reliable measure of nonadherent behaviour that can be used to derive preferences, stated-preference techniques offer a robust alternative. To understand patient preferences in medication nonadherence, we systematically appraised full-text English studies (from database inception to 24 February 2014) involving participants evaluating hypothetical scenarios to elicit preferences as an explicit means to understand medication nonadherence. Study characteristics (e.g. setting, disease, stated-preference method), attribute type and influence on choice were extracted. Seventeen full-text articles (4,456 patients) were included in the review, which reports stated-preference elicitation studies across a wide range of chronic and acute conditions. All studies were conducted in high-income settings. The influence of drug-related factors was predominant in patients' preferences for treatment. Patients preferred efficacious over safe medications except when considering the duration of therapy, but dosing and cost appeared more important when contemplating adherence. Patient characteristics, particularly medication experience, significantly influenced preferences. A disparity between stated preferences for treatment and adherence was reported. When using stated-preference techniques to understand nonadherence, this manuscript highlights that there is much room for methodological development. Studies outside of high-income settings are needed, particularly in relation to chronic diseases, for which nonadherence poses a substantial economic burden to health systems and patients. To inform the problem of sustaining adherence, prospective research is needed to understand how preferences change with time. The usefulness of stated-preference techniques to inform policy and practice requires a better understanding of how stated preferences relate to actual adherence behaviour.

Listening to both sides: A qualitative comparison between patients with hepatitis C and their healthcare professionals' perceptions of the facilitators and barriers to hepatitis C treatment adherence and completion

This qualitative study compares and contrasts the perspectives of healthcare professionals who treat hepatitis C with those of patients in treatment. Comparative analysis of semi-structured interviews with 20 healthcare professionals and 20 patients undergoing treatment for hepatitis C concluded that patients and healthcare professionals disagreed on the source of communication breakdowns, but both felt that individualised clinical information improved adherence. Stigma was recognised as a barrier to treatment adherence by both patients and healthcare professionals. Limitations of the healthcare system, such as patients receiving inconsistent information and long wait times, negatively impacted both patients and providers.

Clinical impact of treatment timing for chronic hepatitis C infection: a decision model

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.

Variations in Physician Attitudes Regarding ADHD and Their Association With Prescribing Practices

OBJECTIVE

The objective of this study was to test whether physicians' attitudes regarding the impact of ADHD on health-related quality of life (HRQL) explain differences in practices for prescribing psychostimulants in children.

METHOD

In a cross-sectional survey, U.S.-based pediatricians and psychiatrists ("physicians") used the Paper-Standard Gamble--a widely used preference-based assessment of HRQL--to rate four vignettes describing ADHD health states of varying severity. Associations between standard gamble scores and questions about prescribing practices were analyzed using ordinal logistic regression.

RESULTS

Surveys were mailed to 291 physicians; 127 (44%) returned complete forms. Lower standard gamble scores were associated with more emphasis on children's ADHD symptoms (p = .03) and less emphasis on parents' concerns about stimulant side effects (p = .03) when prescribing psychostimulants.

CONCLUSION

Differences in physician perceptions of the severity of ADHD symptoms and in their emphasis on parental concerns about side effects may help explain variations in ADHD psychostimulant prescription patterns.

The cost-effectiveness of sofosbuvir-based regimens for treatment of hepatitis C virus genotype 2 or 3 infection

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.

Cost-effectiveness of rapid hepatitis C virus (HCV) testing and simultaneous rapid HCV and HIV testing in substance abuse treatment programs

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.

The hepatitis C cascade of care: identifying priorities to improve clinical outcomes

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.

The cost-effectiveness of improved hepatitis C virus therapies in HIV/hepatitis C virus coinfected patients

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.

Patient preferences versus physicians' judgement: does it make a difference in healthcare decision making?

Clinicians and public health experts make evidence-based decisions for individual patients, patient groups and even whole populations. In addition to the principles of internal and external validity (evidence), patient preferences must also influence decision making. Great Britain, Australia and Germany are currently discussing methods and procedures for valuing patient preferences in regulatory (authorization and pricing) and in health policy decision making. However, many questions remain on how to best balance patient and public preferences with physicians' judgement in healthcare and health policy decision making. For example, how to define evaluation criteria regarding the perceived value from a patient's perspective? How do physicians' fact-based opinions also reflect patients' preferences based on personal values? Can empirically grounded theories explain differences between patients and experts-and, if so, how? This article aims to identify and compare studies that used different preference elicitation methods and to highlight differences between patient and physician preferences. Therefore, studies comparing patient preferences and physician judgements were analysed in a review. This review shows a limited amount of literature analysing and comparing patient and physician preferences for healthcare interventions and outcomes. Moreover, it shows that methodology used to compare preferences is diverse. A total of 46 studies used the following methods-discrete-choice experiments, conjoint analyses, standard gamble, time trade-offs and paired comparisons-to compare patient preferences with doctor judgements. All studies were published between 1985 and 2011. Most studies reveal a disparity between the preferences of actual patients and those of physicians. For most conditions, physicians underestimated the impact of intervention characteristics on patients' decision making. Differentiated perceptions may reflect ineffective communication between the provider and the patient. This in turn may keep physicians from fully appreciating the impact of certain medical conditions on patient preferences. Because differences exist between physicians' judgement and patient preferences, it is important to incorporate the needs and wants of the patient into treatment decisions.

Patients' willingness to accept the risks and benefits of new treatments for chronic hepatitis C virus infection

Background

Some patients with chronic hepatitis C virus (HCV) infection forego treatment due to concerns about treatment efficacy, treatment duration, and side effects.

Objective

The purpose of this study was to quantify patient preferences among possible outcomes associated with new, direct-acting antiviral agents (DAAs) for the treatment of HCV infection and determine which treatment features are most important to patients in making treatment decisions.

Methods

Adult participants with a self-reported physician diagnosis of HCV infection in five countries completed a web-enabled, choice-format conjoint analysis survey. The survey presented participants with 20 treatment-choice questions. Each treatment-choice question included a pair of hypothetical treatment profiles with varying levels of six attributes: treatment duration; chance of getting rid of the virus completely (i.e. likelihood of a sustained virologic response [SVR]); weeks on an additional, third medicine (i.e. a DAA); risk of a severe rash; risk of severe anemia; and number of times a day the third medicine is taken. Treatment-choice questions were based on a predetermined experimental design with known statistical properties. Random-parameters logit was used to estimate preference weights for all attribute levels and the mean relative importance of each attribute.

Results

284 participants completed the survey. Likelihood of an SVR was the most important outcome to participants, followed by severe anemia risk, severe rash risk, therapy type (a combination of total weeks of treatment and weeks on the third medicine), and dosing of the third medicine. Controlling for other factors, preferences were similar across all therapy types examined.

Conclusion

Patients with HCV infection indicate a willingness to accept an increased risk of side effects for sufficient improvement in the likelihood of treatment response.

Electronic Supplementary Material

Supplementary material is available for this article at 10.1007/BF03262498 and is accessible for authorized users.

Methods and issues associated with the use of quality-adjusted life-years

In this article, we will focus on how preferences and utilities are measured, including the strengths and limitations of various approaches, discuss their use in estimating quality-adjusted life-years (QALYs) and make some recommendations for further research. Preferences are either measured using direct (visual analog scale, time trade-off or standard gamble) or indirect methods. The most commonly used generic indirect measures include the Quality of Well-Being scale, EuroQol-5 Dimension, Health Utilities Index and Short Form-6 Dimension. Disease-specific preference measures are increasingly being developed and applied in studies as more sensitive measures of health status. Preference-based measures and QALY measurement need to be enhanced, and additional research is needed to improve scientific methods for estimating preferences for health assessment. Given the increased focus on comparative effectiveness research, QALYs have the potential for helping researchers, clinicians, health policy-makers and patients to understand the relative effectiveness of alternative interventions for treating medical conditions.

Patient preferences and assessment of likely adherence to hepatitis C virus treatment

To estimate patient preferences for attributes of hepatitis C virus (HCV) treatment and patients' assessment of the likely effect of treatment attributes on treatment adherence, HCV patients ≥18 years old completed an online survey that included nine 2-alternative choice questions. Each choice question was defined by the probability of sustained viral response (Efficacy), injection frequency (Frequency), duration of flu-like symptoms after every injection (Flu), injection device (Device), average number of days of work missed each week (Lost Work Days), probability of reversible hair thinning while on treatment (Alopecia) and probability of developing clinical depression while on treatment (Depression). We estimated a mean relative importance weight for each attribute. Patients also answered three rating questions to assess the extent to which treatment attributes might affect adherence. Hundred and fifty patients completed the survey. Efficacy was the most important attribute with a mean relative importance weight of 10 [95% CI: 7.9-12.1]. The remaining attributes were ranked in order of importance as follows: Depression (4.4 [95% CI: 3.6-5.1]), Flu Days(Frequency×Flu) (3.7 [95% CI: 2.2-5.3]), Lost Work Days (2.9 [95% CI: 2.3-3.5]), Alopecia (1.3 [95% CI: 0.7-1.9]) and Device (1.2 [95% CI: 0.4-2.0]). Patients with prior treatment experience were less likely to indicate that treatment attributes would affect adherence. Patients also indicated that increases in the number of flu days would increase the likelihood of nonadherence to treatment. Sustained viral response is the most important treatment attribute to patients but treatment side effects might affect treatment adherence.

Hepatitis C management: the challenge of dropout associated with male sex and injection drug use

BACKGROUND

Anecdotal reports of poor patient compliance with hepatitis C disease management exist yet little data are available on the true rates of dropout.

AIMS

To examine all referrals made to an urban tertiary care liver centre for hepatitis C virus (HCV) management, track subsequent progress and identify dropout trends.

METHODS

A cross-sectional retrospective review was conducted to examine the HCV referrals received on 2000 through 2007. The demographic, clinical and treatment data were derived from medical charts and the hospital information system.

RESULTS

A total of 588 individuals were referred for HCV disease management. The repeated referrals yielded 742 cases for analysis. Of the 742 referrals received, 141 (19%) failed to attend their initial appointment, 180 dropped out from early outpatient management, 29 failed to attend liver biopsy and 81 defected from subsequent outpatient follow-up. In total, 451 (61%) dropouts occurred. In those treated, a sustained viral response rate of 74% was observed (18/30 genotype 1; 4/5 genotype 2; 40/49 genotype 3). Statistically significant associations between history of injection drug use and dropout immediately after the referral (P<0.001), dropout from early outpatient management (P<0.001) and dropout over entire span of disease management (P<0.001) were observed. Male sex was also associated with dropout from disease management (P<0.05).

CONCLUSIONS

An exceptionally high rate of dropout exists within the HCV disease management framework, particularly in the early stages of service delivery. Dropout was associated with sex and positive history of injection drug use. The study findings have led to the development of innovative approaches helping to optimize the disease management in this population. These developments are discussed.

A multinational study of health state preference values associated with chronic myelogenous leukemia

OBJECTIVES

Chronic myelogenous leukemia (CML) is a progressive, largely fatal cancer. Emerging treatments may prolong life; however, these result in additional monetary costs. Accurate estimation of their economic impact requires reliable estimates on preferences for health states. The purpose was to estimate preference weights from the general population in four developed countries for standardized health states experienced by persons with CML.

METHODS

Time trade-off preferences with a 10-year time horizon were elicited for CML-related health states using an interviewer-administered survey from convenience samples in Canada (n=103), the United States (n=74), the UK (n=97), and Australia (n=79). Standardized descriptions of seven CML-related health states (characterizing chronic, accelerated and blast phases, each with responding and nonresponding state, and adverse events of treatment) were derived in consultation with oncologists. Generalized linear models were used to estimate whether utilities, adjusted for age and sex, differed by country.

RESULTS

The mean age of the sample (n=357) was 45 years and 46% were male. Mean unadjusted preference values of CML-related health states ranged from 0.84 for "Chronic phase responding to treatment" to 0.21 for "Blast phase, not responding to treatment." For each phase, preferences were lower for the nonresponding state. After adjustment for age and sex, considerable variability was observed in mean preference values between countries.

CONCLUSION

These data quantify the deteriorating impact of CML disease progression and the impact of nonresponse to treatment. The study results add to evidence from other disease areas that systematic differences exist in preference values between countries.

Hepatitis C treatment experiences and decision making among patients living with HIV infection

Hepatitis C infection is a major problem for approximately 250,000 HIV-infected persons in the United States. Although HIV infection is well-controlled in most of this population, they suffer liver-associated morbidity and mortality. Conversely, hepatitis C virus (HCV) treatment uptake remains quite low (15%-30%). Therefore, the purpose of this qualitative study was to explore HCV treatment experiences and decision making in adults with HIV infection. The study sample included 39 coinfected adults; 16 in the HCV-treated cohort (who were interviewed a maximum of 3 times) and 23 in the HCV-nontreatment cohort. Analysis of interviews identified 2 treatment barriers (fears and vicarious experiences) and 4 facilitating factors (experience with illness management, patient-provider relationships, gaining sober time, and facing treatment head-on). Analysis of these data also revealed a preliminary model to guide intervention development and theoretical perspectives. Ultimately, research is urgently needed to test interventions that improve HCV evaluation and treatment uptake among HIV-infected patients.

Quality of life considerations for patients with chronic hepatitis C

Chronic infection with the hepatitis C virus (HCV) has a profound effect on health-related quality of life (HRQoL) - with fatigue, depression and neurocognitive deficits among the most common complaints. Neuropsychiatric symptoms have prompted research to determine whether the HCV acts within the central nervous system. Replicating virus has been found in central nervous tissues, and changes in neurotransmitter levels in the frontal white matter of patients with chronic hepatitis C are correlated with impaired attention and concentration. Other symptoms of chronic hepatitis C that decrease HRQoL include associated sexual dysfunction and depression. Treatment of chronic HCV infection may temporarily worsen HRQoL, and common adverse effects of currently available agents include fatigue, muscle aches, depression and cognitive deficits. The relationship between sustained viral response and improvement in HRQoL is nonetheless well accepted. Although treatment-related adverse effects may dissuade people from starting therapy and reduce compliance with associated reductions in sustained viral response, for the majority of patients viral clearance produces improvements in both HRQoL and long-term prognosis. Novel agents, with improved adverse effect profiles, may afford more patients the opportunity to achieve a sustained viral response.

Treatment of hepatitis C infection for current or former substance abusers in a community setting

Substance abusers account for the largest number of hepatitis C infected cases in developed countries. We describe a care model for treating current or former substance abusers with antiviral therapy for hepatitis C virus (HCV) infection. The care model involved hepatitis nurses, a psychologist, infectious disease specialist and primary care physicians. Clients met selection criteria including regular attendance at clinic appointments and social stability. Use of alcohol and illicit substances was monitored with urine toxicology screens. The association between substance use, rates of completion of therapy and rates of response were assessed using multivariable regression analyses. A total of 109 clients (75 with genotype 1/4 and 34 with genotype 2/3) received at least one injection with pegylated interferon between November 2002 and January 2006. Treatment completion rates of 61 and 74% were achieved for genotypes 1/4 and 2/3, respectively. Treatment response rates in an intention to treat analysis were 51% for genotypes 1/4 and 68% for genotypes 2/3. A positive urine toxicology screen indicating use of illicit substances 6 months prior to initiating therapy was significantly associated with lower rates of treatment completion but not lower rates of sustained virological response. A positive urine screen indicating use of alcohol prior to therapy was significantly associated with lower rates of completion and lower rates of response. Rates of completion and response are comparable to non-substance abusing populations. Antiviral therapy for HCV infection can be successful within the context of ongoing care for substance abuse for carefully selected patients.

Patients' preferences for treatment of hepatitis C

BACKGROUND

The objective of this study was to ascertain patient preferences for treatment of hepatitis C virus (HCV).

METHODS

The authors recruited consecutive patients eligible for treatment of HCV and used adaptive conjoint analysis (ACA), a hybrid approach of conjoint analysis that uses both self-explicated ratings and pair-wise comparisons, to elicit preferences for pegylated-interferon and ribavirin. They examined the association between patient characteristics and treatment preferences using the Mann-Whitney U test and chi(2) statistic for continuous and categorical variables, respectively, and subsequently calculated adjusted odds ratios and 95% confidence intervals using logistic regression.

RESULTS

A total of 140 subjects completed the ACA task. The mean (+/-SD) age of the sample was 51+/-8 y; 85% were male, and 59% were white. When described as being associated with mild side effects, 67% (n = 94) of subjects preferred treatment for HCV. The percentage of subjects preferring therapy decreased to 51% (n = 72) when it was described as being associated with severe side effects. Preferences for treatment of HCV were stronger among subjects with a higher perceived risk of developing cirrhosis, more severe underlying liver disease, and worse HCV-related quality of life. Subjects having more severe disease placed greater weight on the importance of expected benefits and less on the risk of toxicity compared with those with mild or no fibrosis.

CONCLUSIONS

Whether to choose treatment for HCV is a difficult decision for many patients. Treatment is usually recommended for those with moderate to severe liver disease, and these results demonstrate that most patients' preferences are concordant with this practice.