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Uhrmann MF, Lorenz B, Gissel C. Cost Effectiveness of Voretigene Neparvovec for RPE65-Mediated Inherited Retinal Degeneration in Germany. Transl Vis Sci Technol 2020; 9:17. [PMID: 32879773 PMCID: PMC7442871 DOI: 10.1167/tvst.9.9.17] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 07/06/2020] [Indexed: 11/24/2022] Open
Abstract
Purpose Voretigene Neparvovec-rzyl (VN) is the first available treatment for biallelic RPE65 mutation-associated inherited retinal degeneration, which is usually associated with infancy-onset severe visual impairment and complete blindness during the third life decade. We aim to estimate the cost effectiveness of VN in Germany considering medication costs of €410,550 per eye and potential indirect cost offsets by higher labor force participation. Methods We developed an individual patient sampling model to simulate patients over their lifetime. In a Monte Carlo analysis, 1000 simulations are performed. Cycle length of the two-state Markov model is 1 year. For each cycle, visual field and best-corrected visual acuity are tracked, compared with natural progression and converted to quality of life. Direct and indirect costs are recorded and the incremental cost-utility ratio is calculated. Results In the base case scenario, VN provides 4.82 additional quality-adjusted life-years over a patient's lifetime at an incremental cost-utility ratio of €156,853 per additional quality-adjusted life-year gained. Sensitivity analyses show the robustness of the results when altering treatment effect duration, discounting of quality-adjusted life-years and costs, direct costs, and natural progression. Conclusions Under a lifetime perspective, VN proves to be cost effective for the German statutory health insurance system despite high initial treatment costs. Because VN has important implications for future gene therapies, cost-utility analyses have high economic relevance from a societal perspective. Translational Relevance Our research analyzes the value of a gene augmentation therapy in clinical care in terms of quality of life gains for patients with blindness from retinal degeneration.
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Affiliation(s)
- Matthias Fritz Uhrmann
- Department of Ophthalmology, Justus Liebig University Giessen and University Hospital of Giessen and Marburg, Campus Giessen, Germany
- Department of Health Economics, Justus Liebig University Giessen, Giessen, Germany
| | - Birgit Lorenz
- Department of Ophthalmology, Justus Liebig University Giessen and University Hospital of Giessen and Marburg, Campus Giessen, Germany
| | - Christian Gissel
- Department of Health Economics, Justus Liebig University Giessen, Giessen, Germany
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Szilberhorn L, Kaló Z, Ágh T. Cost-effectiveness of second-generation direct-acting antiviral agents in chronic HCV infection: a systematic literature review. Antivir Ther 2020; 24:247-259. [PMID: 30652971 DOI: 10.3851/imp3290] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Our objectives were to review the economic modelling methods and cost-effectiveness of second-generation direct-acting antiviral agents for the treatment of chronic HCV infection. METHODS A systematic literature search was performed in February 2017 using Scopus and OVID to review relevant publications between 2011 to present. Two independent reviewers screened potential papers. RESULTS The database search resulted in a total of 1,536 articles; after deduplication, title/abstract and full text screening, 67 studies were included for qualitative analysis. The vast majority of studies were conducted in high-income countries (n=59) and used Markov-based modelling techniques (n=60). Most of the analyses utilized long-term time horizons; 58 studies calculated lifetime costs and outcomes. The examined treatments were heterogenic among the studies; seven analyses did not directly evaluate treatments (just with screening or genotype testing). The examined treatments (n=60) were either dominant (23%), or cost-effective at base case (57%) or in given subgroups (18%). Only one (2%) study reported that the assessed treatment was not cost-effective with the given setting and price. CONCLUSIONS Despite their high initial therapeutic costs, second-generation direct-acting antiviral agents were found to be cost-effective to treat chronic HCV infection. Studies were predominantly conducted in higher income countries, although we have limited information on cost-effectiveness in low- and middle-income countries, where assessment of cost-effectiveness is even more essential due to more limited health-care resources and potentially higher public health burden due to unsafe medical interventions.
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Affiliation(s)
- László Szilberhorn
- Department of Health Policy and Health Economics, Eötvös Loránd University, Faculty of Social Sciences, Budapest, Hungary.,Syreon Research Institute, Budapest, Hungary
| | - Zoltán Kaló
- Department of Health Policy and Health Economics, Eötvös Loránd University, Faculty of Social Sciences, Budapest, Hungary.,Syreon Research Institute, Budapest, Hungary
| | - Tamás Ágh
- Syreon Research Institute, Budapest, Hungary
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Runge M, Krensel M, Westermann C, Bindl D, Nagels K, Augustin M, Nienhaus A. Cost-Effectiveness Analysis of Direct-Acting Antiviral Agents for Occupational Hepatitis C Infections in Germany. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E440. [PMID: 31936470 PMCID: PMC7013637 DOI: 10.3390/ijerph17020440] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 01/03/2020] [Accepted: 01/06/2020] [Indexed: 02/07/2023]
Abstract
Around 1% of the world's population is infected with hepatitis C. The introduction of new direct-acting antiviral agents (DAAs) in 2014 has substantially improved hepatitis C treatment outcomes. Our objective was to evaluate the long-term cost effectiveness of DAAs in health care personnel (HP) with confirmed occupational diseases in Germany. A standardised database from a German statutory accident insurance was used to analyse the cost-effectiveness ratio for the DAA regimen in comparison with interferon-based triple therapies. Taking account of the clinical progression of the disease, a Markov model was applied to perform a base case analysis for a period of 20 years. The robustness of the results was determined using a univariate deterministic sensitivity analysis. The results show that treatment with DAAs is more expensive, but also more effective than triple therapies. The model also revealed that the loss of 3.23 life years can be averted per patient over the 20 years. Compared to triple therapies, DAA treatment leads to a higher sustained virologic response (SVR). Although this results in a decrease of costs in the long term, e.g., pension payments, DAA therapy will cause greater expense in the future due to the high costs of the drugs.
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Affiliation(s)
- Melanie Runge
- Competence Centre for Epidemiology and Health Services Research for Healthcare Professionals (CVcare), University Medical Centre Hamburg-Eppendorf (UKE), 20246 Hamburg, Germany; (M.R.); (A.N.)
| | - Magdalene Krensel
- Institute for Health Services Research in Dermatology and Nursing (IVDP), University Medical Centre Hamburg-Eppendorf (UKE), 20246 Hamburg, Germany; (M.K.); (M.A.)
| | - Claudia Westermann
- Competence Centre for Epidemiology and Health Services Research for Healthcare Professionals (CVcare), University Medical Centre Hamburg-Eppendorf (UKE), 20246 Hamburg, Germany; (M.R.); (A.N.)
| | - Dominik Bindl
- Chair of Healthcare Management and Health Services Research, University of Bayreuth, 95445 Bayreuth, Germany; (D.B.); (K.N.)
| | - Klaus Nagels
- Chair of Healthcare Management and Health Services Research, University of Bayreuth, 95445 Bayreuth, Germany; (D.B.); (K.N.)
| | - Matthias Augustin
- Institute for Health Services Research in Dermatology and Nursing (IVDP), University Medical Centre Hamburg-Eppendorf (UKE), 20246 Hamburg, Germany; (M.K.); (M.A.)
| | - Albert Nienhaus
- Competence Centre for Epidemiology and Health Services Research for Healthcare Professionals (CVcare), University Medical Centre Hamburg-Eppendorf (UKE), 20246 Hamburg, Germany; (M.R.); (A.N.)
- Department of Occupational Medicine, Hazardous Substances and Public Health, Institution for Statutory Accident Insurance and Prevention in the Health and Welfare Services (BGW), 22089 Hamburg, Germany
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Mattlinger C, Thumfart JO, Heinen W, Michels H, Berres M, Vogt M, Jansky M. [Hepatitis C virus seroprevalence and dependency on country of origin of refugees in Rhineland-Palatinate, Germany in 2015]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2019; 61:1472-1480. [PMID: 30225596 DOI: 10.1007/s00103-018-2816-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND Hepatitis C, a liver disease transmitted by the hepatitis C virus (HCV), can result in liver cirrhosis and hepatocellular carcinoma (HCC). According to WHO estimates for 2015, approximately 71 million people worldwide are chronically infected with HCV, representing 1% of the world population. Worldwide migration movements lead to immigration from HCV high- to low-prevalence countries. There are, however, no published data available on HCV seroprevalence and its correlation with the country of origin in current unselected larger refugee populations (>1000 people) having entered Europe/Germany. OBJECTIVES Documentation and evaluation of hepatitis C seroprevalence and its correlation with the country of origin of refugees in Rhineland-Palatinate/Germany in 2015. METHODS As part of routine diagnostics during the initial medical examination, 12,880 refugees in Rhineland-Palatinate were screened for HCV antibodies in 2015. The data have been analyzed retrospectively and anonymously. RESULTS The collective comprising 12,880 refugees showed a HCV seroprevalence of 1.5%. This is higher than the HCV prevalence of the general German population (0.5%). In particular, a correlation between HCV seroprevalence and the country of origin could be demonstrated. CONCLUSIONS To reach the 2030 HCV-elimination target of the WHO, national and international recommendations to screen refugees/migrants from HCV high-prevalence countries for HCV should be emphasized. The chronically infected should be treated in accordance with HCV-guidelines. National, easily accessible information on HCV high-prevalence countries is required by attending physicians.
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Affiliation(s)
- Christina Mattlinger
- Zentrum für Allgemeinmedizin und Geriatrie, Abteilung Allgemeinmedizin, Universitätsmedizin Mainz, Am Pulverturm 13, 55131, Mainz, Deutschland.
| | | | - Wilma Heinen
- Gesundheitsamt der Kreisverwaltung Trier-Saarburg, Trier, Deutschland
| | - Harald Michels
- Gesundheitsamt der Kreisverwaltung Trier-Saarburg, Trier, Deutschland
| | - Manfred Berres
- RheinAhrCampus Remagen, Hochschule Koblenz, Remagen, Deutschland.,Institut für Medizinische Biometrie, Epidemiologie und Informatik, Universitätsmedizin Mainz, Mainz, Deutschland
| | - Manfred Vogt
- Abteilung Humanmedizin, Landesuntersuchungsamt Rheinland-Pfalz, Koblenz, Deutschland
| | - Michael Jansky
- Zentrum für Allgemeinmedizin und Geriatrie, Abteilung Allgemeinmedizin, Universitätsmedizin Mainz, Am Pulverturm 13, 55131, Mainz, Deutschland
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Puig-Junoy J, Pascual-Argente N, Puig-Codina L, Planellas L, Solozabal M. Cost-utility analysis of second-generation direct-acting antivirals for hepatitis C: a systematic review. Expert Rev Gastroenterol Hepatol 2018; 12:1251-1263. [PMID: 30791790 DOI: 10.1080/17474124.2018.1540929] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
High prices of second-generation direct-acting antivirals (DAAs) in the treatment of chronic hepatitis C virus (HCV) patients led to reimbursement decisions based on cost per quality-adjusted life year (QALY). Areas covered: We performed a systematic review of cost-utility analyses (CUA) comparing interventions with second-generation DAA therapies with no treatment, and with previous therapies for chronic HCV patients until July 2017. A total of 36 studies were included: 30 studies from the perspective of the healthcare payer, 3 from the societal perspective, and 3 did not report the perspective. For genotype 1, the highest number of ICER comparison corresponds to sofosbuvir (SOF) triple therapy and SOF-based combinations which reported a cost per QALY systematically ranging from negative to lower than US$100,000 when compared with no treatment or dual therapy or Simeprevir triple therapy. Expert commentary: Selected studies may be overestimating the true cost per QALY of second-generation DAAs in the treatment of HCV, mainly because of neglecting non-healthcare costs, using official list prices which are higher than actual transaction prices and not adopting the long run drug price in a dynamic approach. In addition, the impact of important price reductions of several DAAs in recent years on cost per QALY should be considered.
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Affiliation(s)
- Jaume Puig-Junoy
- a Department of Economics and Business (UPF) , Pompeu Fabra University , Barcelona , Spain.,b UPF Barcelona School of Management , Pompeu Fabra University , Barcelona , Spain.,c UPF Center for Research in Health and Economics (CRES-UPF) , Pompeu Fabra University , Barcelona , Spain
| | - Natàlia Pascual-Argente
- b UPF Barcelona School of Management , Pompeu Fabra University , Barcelona , Spain.,c UPF Center for Research in Health and Economics (CRES-UPF) , Pompeu Fabra University , Barcelona , Spain
| | - Lluc Puig-Codina
- b UPF Barcelona School of Management , Pompeu Fabra University , Barcelona , Spain
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Maunoury F, Clément A, Nwankwo C, Levy-Bachelot L, Abergel A, Di Martino V, Thervet E, Durand-Zaleski I. Cost-effectiveness analysis of elbasvir-grazoprevir regimen for treating hepatitis C virus genotype 1 infection in stage 4-5 chronic kidney disease patients in France. PLoS One 2018; 13:e0194329. [PMID: 29543897 PMCID: PMC5854359 DOI: 10.1371/journal.pone.0194329] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 02/20/2018] [Indexed: 01/20/2023] Open
Abstract
Objective To assess the cost-effectiveness of the elbasvir/grazoprevir (EBR/GZR) regimen in patients with genotype 1 chronic hepatitis C virus (HCV) infection with severe and end-stage renal disease compared to no treatment. Design This study uses a health economic model to estimate the cost-effectiveness of treating previously untreated and treatment experienced chronic hepatitis C patients who have severe and end stage renal disease with the elbasvir-grazoprevir regimen versus no treatment in the French context. The lifetime homogeneous markovian model comprises of forty combined health states including hepatitis C virus and chronic kidney disease. The model parameters were from a multicentre randomized controlled trial, ANRS CO22 HEPATHER French cohort and literature. 1000 Monte Carlo simulations of patient health states for each treatment strategy are used for probabilistic sensitivity analysis and 95% confidence intervals calculations. The results were expressed in cost per quality-adjusted life year (QALY) gained. Patients The mean age of patients in the HEPATHER French cohort was 59.6 years and 56% of them were men. 22.3% of patients had a F0 fibrosis stage (no fibrosis), 24.1% a F1 stage (portal fibrosis without septa), 7.1% a F2 stage (portal fibrosis with few septa), 21.4% a F3 stage (numerous septa without fibrosis) and 25% a F4 fibrosis stage (compensated cirrhosis). Among these HCV genotype 1 patients, 30% had severe renal impairment stage 4, 33% had a severe renal insufficiency stage 5 and 37% had terminal severe renal impairment stage 5 treated by dialysis. Intervention Fixed-dose combination of direct-acting antiviral agents elbasvir and grazoprevir compared to no-treatment. Results EBR/GZR increased the number of life years (6.3 years) compared to no treatment (5.1 years) on a lifetime horizon. The total number of QALYs was higher for the new treatment because of better utility on health conditions (6.2 versus 3.7 QALYs). The incremental cost-utility ratio (ICUR) was of €15,212 per QALY gained for the base case analysis. Conclusions This cost-utility model is an innovative approach that simultaneously looks at the disease evolution of chronic hepatitis C and chronic kidney disease. EBR/GZR without interferon and ribavirin, produced the greatest benefit in terms of life expectancy and quality-adjusted life years (QALY) in treatment-naïve or experienced patients with chronic hepatitis C genotype 1 and stage 4–5 chronic kidney disease including dialysis patients. Based on shape of the acceptability curve, EBR/GZR can be considered cost-effective at a willingness to pay of €20,000 /QALY for patients with renal insufficiency with severe and end-stage renal disease compared to no treatment.
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MESH Headings
- Amides
- Antiviral Agents/economics
- Antiviral Agents/therapeutic use
- Benzofurans/economics
- Benzofurans/therapeutic use
- Carbamates
- Cost-Benefit Analysis/methods
- Cyclopropanes
- Drug Therapy, Combination/economics
- Drug Therapy, Combination/methods
- Female
- France
- Genotype
- Hepacivirus/genetics
- Hepacivirus/isolation & purification
- Hepatitis C, Chronic/complications
- Hepatitis C, Chronic/drug therapy
- Hepatitis C, Chronic/economics
- Hepatitis C, Chronic/virology
- Humans
- Imidazoles/economics
- Imidazoles/therapeutic use
- Kidney Failure, Chronic/complications
- Kidney Failure, Chronic/economics
- Kidney Failure, Chronic/therapy
- Kidney Failure, Chronic/virology
- Liver Cirrhosis/complications
- Liver Cirrhosis/drug therapy
- Liver Cirrhosis/economics
- Liver Cirrhosis/virology
- Male
- Middle Aged
- Models, Economic
- Quality-Adjusted Life Years
- Quinoxalines/economics
- Quinoxalines/therapeutic use
- RNA, Viral/genetics
- RNA, Viral/isolation & purification
- Randomized Controlled Trials as Topic
- Renal Dialysis
- Sulfonamides
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Affiliation(s)
| | | | - Chizoba Nwankwo
- Merck & Co., Inc., Kenilworth, New Jersey, United States of America
| | | | - Armand Abergel
- Hepato-gastro enterology Service, CHU Estaing, Clermont-Ferrand, France
| | - Vincent Di Martino
- Hepatology Department, Franche-Comté University and Besançon University hospital, Besançon, France
| | - Eric Thervet
- HYPPARC Department, Nephrology Service, Paris Descartes University, Paris, France
- Georges Pompidou European Hospital (ET), Paris, France
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Abstract
The economic burden of chronic hepatitis C might exceed $10 billion annually in the United States alone. This disease has a worldwide prevalence of up to 3%, making the global burden of the disease comparably tremendous. The cost of the disease includes direct medical expenses for its hepatic and extrahepatic manifestations, and also indirect costs incurred from impaired quality of life and the loss of work productivity. Recent emergence of treatment options that are not only highly effective and safe but also costly has emphasized the need to study the disease from the economic point of view.
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Affiliation(s)
- Maria Stepanova
- Center for Outcomes Research in Liver Diseases, 2411 I Street NW, Washington, DC 20037, USA; Betty and Guy Beatty Center for Integrated Research, Inova Health System, 3300 Gallows Road, Falls Church, VA 22042, USA
| | - Zobair M Younossi
- Center for Outcomes Research in Liver Diseases, 2411 I Street NW, Washington, DC 20037, USA; Betty and Guy Beatty Center for Integrated Research, Inova Health System, 3300 Gallows Road, Falls Church, VA 22042, USA; Department of Medicine, Center for Liver Diseases, Inova Fairfax Hospital, 3300 Gallows Road, Falls Church, VA 22042, USA.
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A NEW HEALTH TECHNOLOGY ASSESSMENT SYSTEM FOR JAPAN? SIMULATING THE POTENTIAL IMPACT ON THE PRICE OF SIMEPREVIR. Int J Technol Assess Health Care 2017; 33:121-127. [DOI: 10.1017/s0266462317000174] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Objectives:Japanese authorities have announced a plan to introduce a health technology assessment (HTA) system in 2016. This study assessed the potential impact of such a policy on the price of the antivirologic drug simeprevir.Methods:Taking the antivirologic drug simeprevir as an example, we compared the current Japanese price with hypothetical prices that might result if a U.K. (cost-utility) or German (efficiency frontier) style HTA assessment was in place.Results:The simeprevir unit price under the current Japanese pricing scheme is 13,122 Japanese yen (equivalent to 109.35 U.S. dollars as of April 2015). Depending on the selection of comparators and the pricing method, and assuming that HTA will be used as a basis for price setting, the estimated prices of simeprevir vary up to four times higher than under the current Japanese pricing scheme.Conclusions:Although the analysis is based on only one drug, it cannot be taken for granted that a new HTA system would reduce public healthcare expenditure in Japan.
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Sbarigia U, Wirth D, Van Nuys K, Huber C, Brookmeyer R, Stahmeyer J, Krauth C. Economic study of the value of expanding HCV treatment capacity in Germany. BMJ Open Gastroenterol 2017; 4:e000130. [PMID: 28461903 PMCID: PMC5387957 DOI: 10.1136/bmjgast-2016-000130] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 02/07/2017] [Accepted: 02/14/2017] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Today's highly efficacious, low-toxicity interferon-free treatment regimens for chronic hepatitis C virus (HCV) can cure most patients with HCV in 12-24 weeks. The aim of this study was to understand how the introduction of shorter duration treatment regimens for HCV will impact the capacity for treatment and value to society. METHODS A Markov model of HCV transmission and progression was constructed, incorporating nationally representative data on HCV prevalence, incidence and progression; mortality, treatment costs, medical expenditures, employment probabilities and disability payments in Germany. The model was stratified by HCV genotype and exposure route (1-time healthcare exposure, injection drug use and sexual activity). Treatment scenarios were based on German treatment guidelines and projected treatment capacity. The impact of different treatment scenarios on disease transmission and prevalence, quality-adjusted life years (QALYs), treatment costs, medical expenditures, employment and disability expenditures was calculated. RESULTS Depending on their adoption profile, new treatment regimens and protocols introduced over the next several years will increase HCV treatment capacity in Germany by 8-30%, reducing disease transmission and prevalence, increasing QALYs and adding €94-310 million in discounted social value (QALYs plus medical savings net of treatment costs) over a 30-year horizon. Additional social value in the form of higher employment and lower disability would also result. CONCLUSIONS The introduction of shorter HCV treatment regimens and the resulting increased treatment capacity in Germany would result in large gains to society by reducing disease transmission and prevalence, resulting in longer, healthier, more productive lives for current and future generations.
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10
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Mühlbacher AC, Sadler A. The Probabilistic Efficiency Frontier: A Framework for Cost-Effectiveness Analysis in Germany Put into Practice for Hepatitis C Treatment Options. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2017; 20:266-272. [PMID: 28237207 DOI: 10.1016/j.jval.2016.12.015] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Revised: 12/20/2016] [Accepted: 12/20/2016] [Indexed: 05/22/2023]
Abstract
BACKGROUND The German Institute for Quality and Efficiency in Health Care (Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen) adapted the efficiency frontier (EF) approach to conform to statutory provisions on cost-effectiveness analysis of health technologies. EF serves as a framework for evaluating cost-effectiveness and indirectly for pricing and reimbursement decisions. OBJECTIVES To calculate an EF on the basis of single multidimensional benefit by taking patient preferences and uncertainty into account; to evaluate whether EF is useful to inform decision makers about cost-effectiveness of new therapies; and to find whether a treatment is efficient at given prices demonstrated through a case study on chronic hepatitis C. METHODS A single multidimensional benefit was calculated by linear additive aggregation of multiple patient-relevant end points. End points were identified and weighted by patients in a previous discrete-choice experiment (DCE). Aggregation of overall benefit was ascertained using preferences and clinical data. Monte-Carlo simulation was applied. Uncertainty was addressed by price acceptability curve (PAC) and net monetary benefit (NMB). RESULTS The case study illustrates that progress in benefit and efficiency of hepatitis C virus treatments could be depicted very well with the EF. On the basis of cost, effect, and preference data, the latest generations of interferon-free treatments are shown to yield a positive NMB and be efficient at current prices. CONCLUSIONS EF was implemented taking uncertainty into account. For the first time, a DCE was used with the EF. The study shows how DCEs in combination with EF, PAC, and NMB can contribute important information in the course of reimbursement and pricing decisions.
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Affiliation(s)
- Axel C Mühlbacher
- Gesundheitsökonomie und Medizinmanagement, Hochschule Neubrandenburg, Neubrandenburg, Germany.
| | - Andrew Sadler
- Gesundheitsökonomie und Medizinmanagement, Hochschule Neubrandenburg, Neubrandenburg, Germany
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Younossi ZM, Tanaka A, Eguchi Y, Lim YS, Yu ML, Kawada N, Dan YY, Brooks-Rooney C, Negro F, Mondelli MU. The impact of hepatitis C virus outside the liver: Evidence from Asia. Liver Int 2017; 37:159-172. [PMID: 27748564 DOI: 10.1111/liv.13272] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 09/30/2016] [Indexed: 12/11/2022]
Abstract
Between 80 and 115 million people worldwide are chronically infected with hepatitis C virus, with 60%-90% of these being undiagnosed. Untreated chronic hepatitis C (CHC) is associated with progressive liver disease, cirrhosis, hepatocellular carcinoma and liver-related mortality. A number of extrahepatic manifestations are also reported in CHC patients, further adding to the burden of the disease. CHC also impacts patients in terms of lower health-related quality of life, higher levels of fatigue and reduced productivity. Furthermore, the later stages of disease are costly for both healthcare systems and society. Pegylated-interferon (PEG-IFN)+ribavirin (RBV), for many years the mainstay of treatment, leads to sustained virological response (SVR) in 40%-70% of patients. However, a substantial number of patients are ineligible for treatment, and many patients fail to achieve SVR with this regimen. Furthermore, PEG-IFN+RBV leads to impairment of patient-reported outcomes during treatment, and most patients suffer from adverse events, associated with poor adherence, treatment discontinuation and treatment failure. The approval of second-generation direct-acting antivirals (DAAs) has revolutionized the treatment of CHC patients. All-oral, PEG-IFN and RBV-free regimens have higher efficacy rates, shorter treatment durations, fewer adverse events, higher adherence rates and improvement in PROs from as early as Week 4, compared to PEG-IFN+RBV regimens. The aim of this article is to review the evidence for HCV infection as a systemic disease, summarizing the impact of hepatitis C and its treatments on clinical, patient and economic outcomes, with a focus on data from Asia and Japan specifically.
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Affiliation(s)
- Zobair M Younossi
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, USA.,Department of Medicine, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Atsushi Tanaka
- Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Yuichiro Eguchi
- Liver Center, Saga University Hospital, Saga University, Saga, Japan
| | - Young-Suk Lim
- Department of Gastroenterology, Liver Center, Asan Medical Center, Seoul, Korea
| | - Ming-Lung Yu
- Hepatobiliary Division, Department of Internal Medicine and Hepatitis Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Norifumi Kawada
- Department of Hepatology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Yock Young Dan
- Department of Medicine, National University of Singapore, Singapore
| | | | - Francesco Negro
- Division of Gastroenterology and Hepatology and Division of Clinical Pathology, University Hospital, Geneva, Switzerland
| | - Mario U Mondelli
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
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12
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Leidner AJ, Chesson HW, Spradling PR, Holmberg SD. Assessing the Effect of Potential Reductions in Non-Hepatic Mortality on the Estimated Cost-Effectiveness of Hepatitis C Treatment in Early Stages of Liver Disease. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2017; 15:65-74. [PMID: 27480538 PMCID: PMC5802335 DOI: 10.1007/s40258-016-0261-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND Most cost-effectiveness analyses of hepatitis C (HCV) therapy focus on the benefits of reducing liver-related morbidity and mortality. OBJECTIVES Our objective was to assess how cost-effectiveness estimates of HCV therapy can vary depending on assumptions regarding the potential impact of HCV therapy on non-hepatic mortality. METHODS We adapted a state-transition model to include potential effects of HCV therapy on non-hepatic mortality. We assumed successful treatment could reduce non-hepatic mortality by as little as 0 % to as much as 100 %. Incremental cost-effectiveness ratios were computed comparing immediate treatment versus delayed treatment and comparing immediate treatment versus non-treatment. RESULTS Comparing immediate treatment versus delayed treatment, when we included a 44 % reduction in non-hepatic mortality following successful HCV treatment, the incremental cost per quality-adjusted life year (QALY) gained by HCV treatment fell by 76 % (from US$314,100 to US$76,900) for patients with no fibrosis and by 43 % (from US$62,500 to US$35,800) for patients with moderate fibrosis. Comparing immediate treatment versus non-treatment, assuming a 44 % reduction in non-hepatic mortality following successful HCV treatment, the incremental cost per QALY gained by HCV treatment fell by 64 % (from US$186,700 to US$67,300) for patients with no fibrosis and by 27 % (from US$35,000 to US$25,500) for patients with moderate fibrosis. CONCLUSION Including reductions in non-hepatic mortality from HCV treatment can have substantial effects on the estimated cost-effectiveness of treatment.
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Affiliation(s)
- Andrew J Leidner
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop G-37, Atlanta, GA, 30333, USA.
| | - Harrell W Chesson
- Division of Sexually Transmitted Disease Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Philip R Spradling
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop G-37, Atlanta, GA, 30333, USA
| | - Scott D Holmberg
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop G-37, Atlanta, GA, 30333, USA
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Younossi ZM, Blissett D, Blissett R, Henry L, Stepanova M, Younossi Y, Racila A, Hunt S, Beckerman R. The economic and clinical burden of nonalcoholic fatty liver disease in the United States and Europe. Hepatology 2016; 64:1577-1586. [PMID: 27543837 DOI: 10.1002/hep.28785] [Citation(s) in RCA: 805] [Impact Index Per Article: 100.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 08/02/2016] [Indexed: 02/06/2023]
Abstract
UNLABELLED Nonalcoholic fatty liver disease (NAFLD) is a major cause of chronic liver disease. There is uncertainty around the economic burden of NAFLD. We constructed a steady-state prevalence model to quantify this burden in the United States and Europe. Five models were constructed to estimate the burden of NAFLD in the United States and four European countries. Models were built using a series of interlinked Markov chains, each representing age increments of the NAFLD and the general populations. Incidence and remission rates were calculated by calibrating against real-world prevalence rates. The data were validated using a computerized disease model called DisMod II. NAFLD patients transitioned between nine health states (nonalcoholic fatty liver, nonalcoholic steatohepatitis [NASH], NASH-fibrosis, NASH-compensated cirrhosis, NASH-decompensated cirrhosis, hepatocellular carcinoma, liver transplantation, post-liver transplant, and death). Transition probabilities were sourced from the literature and calibrated against real-world data. Utilities were obtained from NAFLD patients using the Short Form-6D. Costs were sourced from the literature and local fee schedules. In the United States, over 64 million people are projected to have NAFLD, with annual direct medical costs of about $103 billion ($1,613 per patient). In the Europe-4 countries (Germany, France, Italy, and United Kingdom), there are ∼52 million people with NAFLD with an annual cost of about €35 billion (from €354 to €1,163 per patient). Costs are highest in patients aged 45-65. The burden is significantly higher when societal costs are included. CONCLUSION The analysis quantifies the enormity of the clinical and economic burdens of NAFLD, which will likely increase as the incidence of NAFLD continues to rise. (Hepatology 2016;64:1577-1586).
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Affiliation(s)
- Zobair M Younossi
- Center for Liver Diseases, Department of Medicine, Inova Fairfax Hospital, Falls Church, VA.
| | | | | | - Linda Henry
- Center for Outcomes Research in Liver Disease, Washington, DC
| | - Maria Stepanova
- Center for Outcomes Research in Liver Disease, Washington, DC
| | | | - Andrei Racila
- Center for Outcomes Research in Liver Disease, Washington, DC
| | - Sharon Hunt
- Betty and Guy Beatty Center for Integrated Research, Inova Health Systems, Falls Church, VA
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Cost-Effectiveness of Hepatitis C Treatment for People Who Inject Drugs and the Impact of the Type of Epidemic; Extrapolating from Amsterdam, the Netherlands. PLoS One 2016. [DOI: 10.1371/journal.pone.0163488 order by 8029-- #] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
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Cost-Effectiveness of Hepatitis C Treatment for People Who Inject Drugs and the Impact of the Type of Epidemic; Extrapolating from Amsterdam, the Netherlands. PLoS One 2016. [DOI: 10.1371/journal.pone.0163488 order by 8029-- awyx] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
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16
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Cost-Effectiveness of Hepatitis C Treatment for People Who Inject Drugs and the Impact of the Type of Epidemic; Extrapolating from Amsterdam, the Netherlands. PLoS One 2016. [DOI: 10.1371/journal.pone.0163488 and 1880=1880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
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Cost-Effectiveness of Hepatitis C Treatment for People Who Inject Drugs and the Impact of the Type of Epidemic; Extrapolating from Amsterdam, the Netherlands. PLoS One 2016. [DOI: 10.1371/journal.pone.0163488 order by 1-- -] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
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18
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Cost-Effectiveness of Hepatitis C Treatment for People Who Inject Drugs and the Impact of the Type of Epidemic; Extrapolating from Amsterdam, the Netherlands. PLoS One 2016. [DOI: 10.1371/journal.pone.0163488 order by 1-- #] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
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19
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Cost-Effectiveness of Hepatitis C Treatment for People Who Inject Drugs and the Impact of the Type of Epidemic; Extrapolating from Amsterdam, the Netherlands. PLoS One 2016. [DOI: 10.1371/journal.pone.0163488 order by 8029-- -] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
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20
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Cost-Effectiveness of Hepatitis C Treatment for People Who Inject Drugs and the Impact of the Type of Epidemic; Extrapolating from Amsterdam, the Netherlands. PLoS One 2016. [DOI: 10.1371/journal.pone.0163488 order by 1-- gadu] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
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Cost-Effectiveness of Hepatitis C Treatment for People Who Inject Drugs and the Impact of the Type of Epidemic; Extrapolating from Amsterdam, the Netherlands. PLoS One 2016; 11:e0163488. [PMID: 27711200 PMCID: PMC5053429 DOI: 10.1371/journal.pone.0163488] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 09/09/2016] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND People who inject drugs (PWID) are disproportionally affected by the hepatitis C virus (HCV) infection. The efficacy of HCV treatment has significantly improved in recent years with the introduction of direct-acting antivirals (DAAs). However, DAAs are more costly than pegylated-interferon and ribavirin (PegIFN/RBV). We aimed to assess the cost-effectiveness of four HCV treatment strategies among PWID and treatment scale-up. METHODS An individual-based model was used describing HIV and HCV transmission and disease progression among PWID. We considered two epidemiological situations. A declining epidemic, based on the situation in Amsterdam, the Netherlands, and a stable HCV epidemic, as observed in other settings. Data on HCV incidence, prevalence, treatment setting and uptake were derived from observed data among PWID in Amsterdam. We assessed the incremental cost-effectiveness ratio (ICER, costs in €/quality-adjusted life year (QALY)) of four treatment strategies: 1) PegIFN/RBV; 2) sofosbuvir/RBV for genotype 2-3 and dual DAA for genotype 1-4; 3) Dual DAA for all genotypes; 4) Dual DAA with 3x treatment uptake. RESULTS In both types of epidemic, dual DAA therapy was most cost-effective strategy. In the declining epidemic, dual DAA yielded an ICER of 344 €/QALY while in the stable epidemic dual DAA led to cost-savings. Scaling-up treatment was also highly cost-effective. Our results were robust over a range of sensitivity analyses. CONCLUSION HCV treatment with DAA-containing regimens is a highly cost-effective intervention among PWID. Based on the economic and population benefits of scaling-up treatment, stronger efforts are needed to achieve higher uptake rates among PWID.
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Younossi ZM, Park H, Dieterich D, Saab S, Ahmed A, Gordon SC. Assessment of cost of innovation versus the value of health gains associated with treatment of chronic hepatitis C in the United States: The quality-adjusted cost of care. Medicine (Baltimore) 2016; 95:e5048. [PMID: 27741116 PMCID: PMC5072943 DOI: 10.1097/md.0000000000005048] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND New direct-acting antiviral (DAA) therapy has dramatically increased cure rates for patients infected with hepatitis C virus (HCV), but has also substantially raised treatment costs. AIM The aim of this analysis was to evaluate the therapeutic benefit and net costs (i.e. efficiency frontier) and the quality-adjusted cost of care associated with the evolution of treatment regimens for patients with HCV genotype 1 in the United States. DESIGN A decision-analytic Markov model. DATA SOURCE Published literature and clinical trial data. TIME HORIZON Life Time. PERSPECTIVE Third-party payer. INTERVENTION This study compared four approved regimens in treatment-naïve genotype 1 chronic hepatitis C patients, including pegylated interferon and ribavirin (PR), first generation triple therapy (boceprevir + PR and telaprevir + PR), second generation triple therapy (sofosbuvir + PR and simeprevir + PR) and all-oral DAA regimens (ledipasvir/sofosbuvir and ombitasvir + paritaprevir/ritonavir + dasabuvir ± ribavirin). OUTCOME MEASURE Quality-adjusted cost of care (QACC). QACC was defined as the increase in treatment cost minus the increase in the patient's quality-adjusted life years (QALYs) when valued at $50,000 per QALY. RESULTS All-oral therapy improved the average sustained virologic response (SVR) rate to 96%, thereby offsetting the high drug acquisition cost of $85,714, which resulted in the highest benefit based on the efficiency frontier. Furthermore, while oral therapies increased HCV drug costs by $48,350, associated QALY gains decreased quality-adjusted cost of care by $14,120 compared to dual therapy. When the value of a QALY was varied from $100,000 to $300,000, the quality adjusted cost of care compared to dual therapy ranged from - $21,234 to - $107,861, - $89,007 to - $293,130, - $176,280 to - $500,599 for first generation triple, second generation triple, and all-oral therapies, respectively. Primary efficacy and safety measurements for drug regimens were sourced from clinical trials data rather than a real-world setting. Factors such as individual demographic characteristics, comorbidities and alcohol consumption of the individual patients treated may alter disease progression but were not captured in this analysis. CONCLUSION New DAA treatments provide short-term and long-term clinical and economic value to society. PRIMARY FUNDING SOURCE Gilead Sciences, Inc.
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Affiliation(s)
- Zobair M. Younossi
- Center For Liver Disease, Department of Medicine, Inova Fairfax Hospital
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA
- Correspondence: Zobair M. Younossi, Betty and Guy Beatty Center for Integrated Research, Claude Moore Health Education and Research Building, 3300 Gallows Road, Falls Church, VA 22042 (e-mail: )
| | | | | | - Sammy Saab
- University of California, Los Angeles, Los Angeles
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Luhnen M, Waffenschmidt S, Gerber-Grote A, Hanke G. Health Economic Evaluations of Sofosbuvir for Treatment of Chronic Hepatitis C: a Systematic Review. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2016; 14:527-543. [PMID: 27329481 DOI: 10.1007/s40258-016-0253-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND AND OBJECTIVE The approval of sofosbuvir offers new therapeutic options for patients suffering from chronic hepatitis C. In phase III trials, it has demonstrated significantly greater efficacy and safety in comparison with the old standard of care. In addition, it provides the first interferon-free regimen allowing treatment of patients without previous therapeutic options. A current debate regarding pricing and affordability can be attributed to high treatment costs. The objective of this review was to compare health economic evaluations of sofosbuvir for the treatment of chronic hepatitis C in terms of models, patient populations, interventions and results. METHODS A systematic review was conducted using the data sources Medline (1946-09/2015), Embase (1974-09/2015), the Health Technology Assessment Database (September 2015) and the UK National Health Service Economic Evaluation Database (September 2015). We included health economic evaluations that measured the cost-effectiveness of sofosbuvir-based regimens compared with regimens without sofosbuvir for the treatment of adult patients infected with chronic hepatitis C. The articles were then critically appraised regarding the effectiveness data, cost data and models utilised. RESULTS Fourteen studies were included, which analysed the cost-effectiveness of sofosbuvir in seven different countries. Differences in study characteristics were found regarding study populations, modelling and willingness-to-pay thresholds. The study results demonstrated the cost-effectiveness of the treatment combination of sofosbuvir with pegylated interferon and ribavirin in comparison with the old standard of care. Dual therapy with sofosbuvir and ribavirin was considered cost effective only in comparison with no therapy. CONCLUSION Despite high costs, the included studies indicate that sofosbuvir-based regimens are cost effective in most patients. While the results are unequivocal with regard to sofosbuvir-based triple therapy, the cost-effectiveness of sofosbuvir-based dual therapy heavily depends on country-specific willingness to pay. Although interferon-containing triple therapy has now been replaced by newly approved direct-acting antivirals in most middle- and high-income countries, the availability of these oral treatment combinations is poor in low-income countries. Therefore, the findings of our review are still of relevance.
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Affiliation(s)
- Miriam Luhnen
- Institute for Quality and Efficiency in Health Care (IQWiG), Im Mediapark 8, 50670, Cologne, Germany.
| | - Siw Waffenschmidt
- Institute for Quality and Efficiency in Health Care (IQWiG), Im Mediapark 8, 50670, Cologne, Germany
| | - Andreas Gerber-Grote
- Institute for Quality and Efficiency in Health Care (IQWiG), Im Mediapark 8, 50670, Cologne, Germany
| | - Gloria Hanke
- Institute for Quality and Efficiency in Health Care (IQWiG), Im Mediapark 8, 50670, Cologne, Germany
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Dillon JF, Lazarus JV, Razavi HA. Urgent action to fight hepatitis C in people who inject drugs in Europe. HEPATOLOGY, MEDICINE AND POLICY 2016; 1:2. [PMID: 30288305 PMCID: PMC5918492 DOI: 10.1186/s41124-016-0011-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 06/20/2016] [Indexed: 12/19/2022]
Abstract
Hepatitis C virus (HCV) infection is a leading cause of liver cirrhosis and liver cancer, is curable in most people. Injecting drug use currently accounts for 80 % of new HCV infections with a known transmission route in the European Union (EU). HCV has generally received little attention from the public or policymakers in the EU, with major gaps in national-level strategies, action plans, guidelines and the evidence base. Specifically, people who inject drugs (PWID) are often excluded from treatment owing to various patient, healthcare provider and health system factors. All policymakers responsible for health services in EU countries should ensure that prevention, treatment, care and support interventions addressing HCV in PWID are developed and implemented. According to current best practice, PWID should have access to comprehensive, evidence-based multiprofessional harm reduction (especially opioid substitution therapy and clean needles and syringes) and support/care services based in the community and modified with community involvement to accommodate this hard-to-reach population. Other recommended components of care include vaccination against hepatitis B and other infections; peer support interventions; HIV testing, prevention and treatment; drug and alcohol services; psychological care as needed; and social support services. HCV testing should be performed regularly in PWID to identify infected persons and engage them in care. HCV-infected PWID should be considered for antiviral treatment (based on an individualised assessment and delivered within multidisciplinary care/support programmes) both to cure infected individuals and prevent onward transmission. Modelling data suggest that the HCV disease burden can only be cut substantially if antiviral treatment is scaled up together with prevention programmes. Measures should be taken to reduce stigma and discrimination against PWID at the provider and institutional levels. In conclusion, strategic action at the policy level is urgently needed to increase access to HCV prevention, testing and treatment among PWID, the group at highest risk of HCV infection. Such action has the potential to substantially reduce the number of infected persons, along with the disease burden and related care costs.
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Affiliation(s)
- John F Dillon
- Division of Molecular and Clinical Medicine, School of Medicine, University of Dundee, Ninewells Hospital, Dundee, UK
| | - Jeffrey V Lazarus
- 2Centre for Health and Infectious Disease Research (CHIP) and WHO Collaborating Centre on HIV and Viral Hepatitis, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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