Economic evaluation of screening programs for hepatitis C virus infection: evidence from literature

Agarwood-The Fragrant Molecules of a Wounded Tree

Agarwood, popularly known as oudh or gaharu, is a fragrant resinous wood of high commercial value, traded worldwide and primarily used for its distinctive fragrance in incense, perfumes, and medicine. This fragrant wood is created when Aquilaria trees are wounded and infected by fungi, producing resin as a defense mechanism. The depletion of natural agarwood caused by overharvesting amidst increasing demand has caused this fragrant defensive resin of endangered Aquilaria to become a rare and valuable commodity. Given that instances of natural infection are quite low, artificial induction, including biological inoculation, is being conducted to induce agarwood formation. A long-term investigation could unravel insights contributing toward Aquilaria being sustainably cultivated. This review will look at the different methods of induction, including physical, chemical, and biological, and compare the production, yield, and quality of such treatments with naturally formed agarwood. Pharmaceutical properties and medicinal benefits of fragrance-associated compounds such as chromones and terpenoids are also discussed.

Using Lean-Facilitation to Improve Quality of Hepatitis C Testing in Primary Care

BACKGROUND

Lean management has been successfully employed in healthcare to improve outcomes and efficiencies. Facilitation is increasingly being used to support evidence-based practice uptake in healthcare. However, while both Lean and Facilitation are used in healthcare quality improvement, limited research has explored their integration and the sustainability of their combined effects.

OBJECTIVE

To improve hepatitis C virus (HCV) screening rates among persons born between 1945 and 1965 through the design and evaluation of a multi-modal Lean-Facilitation intervention (LFI) for Department of Veterans Affairs primary care community clinics.

DESIGN

We conducted a mixed methods quasi-experimental evaluation in eight clinics, guided by the integrated Promoting Action on Research Implementation in Health Services framework.

PARTICIPANTS

We engaged regional and local leadership (N = 9), implemented our LFI with clinicians and staff (N = 68), and conducted summative interviews with participants (N = 13).

INTERVENTION

The LFI included six implementation strategies: (1) external facilitation, (2) stakeholder engagement, (3) champion activation, (4) rapid process improvement sessions, (5) Plan-Do-Study-Act cycles, and (6) audit-feedback.

MEASURES

The primary outcome was rate of new HCV screening among previously untested patients with a primary care visit. Using interrupted time series, we analyzed intervention and time effects on HCV testing rates, and administered organizational readiness surveys, conducted summative qualitative interviews, and tracked facilitation events.

RESULTS

The LFI was associated with significant, immediate, and sustained increases in HCV testing. No change was detected at matched comparison clinics. Staff accepted the LFI and the philosophy of "bottom-up" solution development yet had mixed feedback on its appropriateness and feasibility. Enablers of implementation and early sustainment included lower satisfaction with baseline HCV testing processes and staff culture, while later sustainment was related to implementation climate support, measurement, and evaluation.

CONCLUSIONS

High-reach and relatively low effort, but persistent intervention led to significant improvement in guideline-concordant HCV testing rates which were sustained.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02936648.

Treatment patterns and medication adherence among newly diagnosed patients with migraine: a drug utilisation study

OBJECTIVES

Prophylactic drugs currently used for migraine treatment are not specific. Furthermore, few studies in existing literature describe drugs utilisation patterns and adherence to migraine prophylactic treatment. This study is aimed to describe utilisation patterns of migraine drugs, evaluate adherence to prophylactic medications and investigate drug-related costs.

DESIGN

Retrospective population-based study using an administrative health-related database.

SETTING

Primary care setting in the Campania region, Southern Italy.

PARTICIPANTS

This study was carried out between 1 January 2016 and 31 December 2018, involving 12 894 subjects with any primary or secondary hospital discharge with migraine diagnosis, or at least two medical dispensations of migraine-specific acute or prophylactic medications (triptans or pizotifen). Subjects were classified into four treatment cohorts: no treatment, acute, prophylactic and both acute and prophylactic. Subjects were followed-up for 1 year.

OUTCOME MEASURES

Utilisation patterns of migraine drugs at treatment initiation; adherence to prophylactic treatment; discontinuation, restart and switching rates; annual migraine drug costs per patient.

RESULTS

Overall, 81.1% of subjects received acute treatment as their initial migraine treatment regimen, 10.7% prophylactic treatment, 8.2% both acute and prophylactic treatment. 599 patients were treated prophylactically; of these, 26.2% adhered to their initial treatment while 73.8% reported interruptions in treatment. Among the latter, 46.4% of patients discontinued the treatment completely within 103 days (IQR 89.0), 31% restarted treatment 46 days after interruption (IQR 60.0) and 22.6% switched to another treatment within 98 days (IQR 57.5) (p<0.001). The median annual cost of drugs per patient was €103 for those treated acutely, €75 for those treated prophylactically, €163 for those treated both.

CONCLUSIONS

Migraine treatment with acute medications is still prevalent in Italy; only few patients received prophylactic treatment with poor adherence to treatment. These findings reflect an unmet need for improved prophylactic therapies in order to provide a better disease management.

Optimization of hepatitis C virus screening strategies by birth cohort in Italy

BACKGROUND AND AIMS

Cost-effective screening strategies are needed to make hepatitis C virus (HCV) elimination a reality. We determined if birth cohort screening is cost-effective in Italy.

METHODS

A model was developed to quantify screening and healthcare costs associated with HCV. The model-estimated prevalence of undiagnosed HCV was used to calculate the antibody screens needed annually, with a €25 000 cost-effectiveness threshold. Outcomes were assessed under the status quo and a scenario that met the World Health Organization's targets for elimination of HCV. The elimination scenario was assessed under five screening strategies.

RESULTS

A graduated birth cohort screening strategy (graduated screening 1: 1968-1987 birth cohorts, then expanding to 1948-1967 cohorts) was the least costly. This strategy would gain approximately 144 000 quality-adjusted life years (QALYs) by 2031 and result in an 89.3% reduction in HCV cases, compared to an 89.6%, 89.0%, 89.7% and 88.7% reduction for inversed graduated screening, 1948-77 birth cohort, 1958-77 birth cohort and universal screening, respectively. Graduated screening 1 yielded the lowest incremental cost-effectiveness ratio (ICER) of €3552 per QALY gained.

CONCLUSIONS

In Italy, a graduated screening scenario is the most cost-effective strategy. Other countries could consider a similar birth cohort approach when developing HCV screening strategies.

Is the universal population Hepatitis C virus screening a cost-effective strategy? A systematic review of the economic evidence

Background

Efficient strategies are needed in order to achieve the objective of the WHO of eradicating Hepatitis C virus (HCV). Hepatitis C infection can be eliminated by a combination of direct acting antiviral (DAA). The problem is that many individuals remain undiagnosed. The objective is to conduct a systematic review of the evidence on economic evaluations that analyze the screening of HCV followed by treatment with DAAs.

Methods

Eleven databases were performed in a 2015-2018-systematic review. Inclusion criteria were economic evaluations that included incremental cost-effectiveness ratio (ICER) in terms of cost per life year gained or quality-adjusted life year.

Results

A total of 843 references were screened. Sixteen papers/posters meet the inclusion criteria. Ten of them included a general population screening. Other populations included were baby-boomer, people who inject drugs, prisoners or immigrants. Comparator was “standard of care”, other high-risk populations or no-screening. Most of the studies are based on Markov model simulations and they mostly adopted a healthcare payer´s perspective. ICER for general population screening plus treatment versus high-risk populations or versus routinely performed screening showed to be below the accepted willingness to pay thresholds in most studies and therefore screening plus DAAs strategy is highly cost-effective.

Conclusion

This systematic review shows that screening programmes followed by DAAs treatment is cost-effective not only for high risk population but for general population too. Because today HCV can be easily cured and its long-term consequences avoided, a universal HCV screening plus DAAs therapies should be the recommended strategy to achieve the WHO objectives for HCV eradication by 2030.

Gender Differences in Medication Use: A Drug Utilization Study Based on Real World Data

A gender-specific drug utilization study was performed in the Campania region, Southern Italy. Data were based on outpatient drug prescriptions collected from administrative databases. The study population included all patients with at least one drug prescription in 2018. Prevalence was used as a measure to estimate the degree of exposure to drugs. A total of 3,899,360 patients were treated with at least one drug (54.2% females). The number of prescriptions was higher in females than males (55.6% vs. 44.4%). Females recorded higher prevalence for the majority of therapeutic groups (ATC II—anatomical therapeutic chemical), as well as for anti-inflammatory and antirheumatic products drugs (M01) (25.6% vs. 18.7%, risk ratio (RR): 0.73), beta blocking agents (C07) (14.5% vs. 11.6%, RR: 0.80), psychoanaleptics (N06) (7.1% vs. 3.7%, RR: 0.52), and antianemic preparations (B03) (2.8% vs. 6.7%, RR: 0.4). Higher prevalence was identified for males only for drugs used in diabetes (A10) (6.8% vs. 6.2%, RR: 1.1), particularly for biguanides (A10BA). Conversely, treatment duration was longer among males, explaining the higher mean cost per treated patient. This real-world study showed substantial gender differences in terms of medication use and duration of treatment and costs. These results are relevant to promoting and supporting the emerging role of precision and personalized medicine.

Drug Utilization Pattern of Antibiotics: The Role of Age, Sex and Municipalities in Determining Variation

Purpose

The purpose was to analyze drug prescription and antibiotic use by age and sex in Italy’s Campania Region, and to estimate the distribution of prescription rates in children (≤14 years old), adults (between 15 and 65 years old), and older adults (≥65 years old) at a municipality level.

Methods

This was a retrospective analysis of pharmacy records in Campania (Southern Italy), in 2016. Difference in antibiotic prescriptions in different age groups was assessed by prevalence rates. Age-adjusted prevalence rates were categorized into quintiles and mapped by the patient’s municipality of residence. Relationship between prevalence rates for the different age groups was estimated using the non-parametric Spearman rank correlation test.

Results

There were 2,738,118 were patients with at least one antibiotic prescription. Antibiotics prescription was higher in children aged <5 years and in the older adults aged >70 years. Prevalence rate distribution was different among municipalities in all age groups. A positive correlation between the rank distribution of prevalence rates at municipality level was identified for children and adults (rs=0.56; P<0.01), adults and the older adults (rs=0.79; P<0.01), and children and the older adults (rs=0.46; P<0.01). Among the studied age groups, the most prescribed antibiotic class was penicillin (except the older adults aged ≥85 years) ranging from 45% in children to 27.2% in the older adults. Fluoroquinolones were the least prescribed antibiotic class, ranging from 0.2% in children to 30.2% in the older adults.

Conclusion

A considerably high use of antibiotic drugs has been detected in Campania Region, with values exceeding the regional and national average. Prescriptions at municipal level differ from one age group to another. Antibiotic use is often unjustified, and to decrease the number of prescriptions and improve their appropriateness, several measures at territorial level are recommended.

Predictors of new oral anticoagulant drug initiation as opposed to warfarin in elderly adults: a retrospective observational study in Southern Italy

AIM

The aim of this study was to assess the predictive role of age, gender, and number and type of co-treatments for new oral anticoagulant (NOAC) vs warfarin prescription in elderly patients naïve for the aforementioned drugs.

MATERIALS AND METHODS

Data collected in the period from January 1, 2014, to December 31, 2014, in Caserta Local Health Unit administrative databases (Campania Region, Italy) were screened to identify new users of oral anticoagulants (OACs) who were 75 years or older and whose OAC prescriptions amounted to >90 days of treatment. Age, gender, and number and type of concomitant medications at the time of first OAC dispensation were retrieved. Multivariable logistic regression analysis was used to assess the role of the aforementioned predictors for NOAC initiation as opposed to warfarin.

RESULTS

Overall, 2,132 incident users of OAC were identified, of whom 967 met all inclusion criteria. In all, 490 subjects (50.7%) received an NOAC and 477 (49.3%) received warfarin. Age >75 years was positively associated with lower odds of NOAC initiation (OR: 0.969, 95% CI: 0.941-0.998, P=0.038). Similarly, multiple concomitant medication was negatively associated with NOAC initiation compared to warfarin (OR [five to nine drugs] group: 0.607, 95% CI: 0.432-0.852, P=0.004; OR [ten+ drugs] group: 0.372, 95% CI: 0.244-0.567, P<0.001). Prior exposure to platelet aggregation inhibitor drugs was associated with the initiation of NOACs (OR: 3.474, 95% CI: 2.610-4.625).

CONCLUSION

Age and multiple co-medication were negatively associated with NOAC initiation.

Adherence to chronic medication in older populations: application of a common protocol among three European cohorts

PURPOSE

The purpose of this study was to evaluate and compare medication adherence to chronic therapies in older populations across different regions in Europe.

METHODS

This explorative study applied a harmonized method of data extraction and analysis from pharmacy claims databases of three European countries to compare medication adherence at a cross-country level. Data were obtained for the period between January 1, 2010, and December 31, 2011. Patients (aged ≥65 years) who newly initiated to oral antidiabetics, antihyperlipidemics, or antiosteoporotics were identified and followed for over a 12-month period. Main outcome measures were medication adherence (medication possession ratio, [MPR]; implementation) and persistence on index treatment. All country-specific data sets were prepared by employing a common data input model. Outcome measures were calculated for each country and pooled using random effect models.

RESULTS

In total, 39,186 new users were analyzed. In pooled data from the three countries, suboptimal implementation (MPR <80%) was 52.45% (95% CI: 33.43-70.79) for antihy-perlipidemics, 61.35% (95% CI: 52.83-69.22) for antiosteoporotics, and 30.33% (95% CI: 25.53-35.60) for oral antidiabetics. Similarly, rates of non-persistence (discontinuation) were 55.63% (95% CI: 35.24-74.29) for antihyperlipidemics, 60.24% (95% CI: 45.35-73.46) for antiosteoporotics, and 46.80% (95% CI: 36.40-57.4) for oral antidiabetics.

CONCLUSION

Medication adherence was suboptimal with >50% of older people non-adherent to antihyperlipidemics and antiosteoporotics in the three European cohorts. However, the degree of variability in adherence rates among the three countries was high. A harmonized method of data extraction and analysis across health-related database in Europe is useful to compare medication-taking behavior at a cross-country level.

Missed hepatitis b/c or syphilis diagnosis among Kurdish, Russian, and Somali origin migrants in Finland: linking a population-based survey to the national infectious disease register

BACKGROUND

Migrants are considered a key population at risk for sexually transmitted and blood-borne diseases in Europe. Prevalence data to support the design of infectious diseases screening protocols are scarce. We aimed to estimate the prevalence of hepatitis B and C, human immunodefiency virus (HIV) infection and syphilis in specific migrant groups in Finland and to assess risk factors for missed diagnosis.

METHODS

A random sample of 3000 Kurdish, Russian, or Somali origin migrants in Finland was invited to a migrant population-based health interview and examination survey during 2010-2012. Participants in the health examination were offered screening for hepatitis B and C, HIV and syphilis. Notification prevalence in the National Infectious Diseases Register (NIDR) was compared between participants and non-participants to assess non-participation. Missed diagnosis was defined as test-positive case in the survey without previous notification in NIDR. Inverse probability weighting was used to correct for non-participation.

RESULTS

Altogether 1000 migrants were screened for infectious diseases. No difference in the notification prevalence among participants and non-participants was observed. Seroprevalence of hepatitis B surface antigen (HBsAg) was 2.3%, hepatitis C antibodies 1.7%, and Treponema pallidum antibodies 1.3%. No cases of HIV were identified. Of all test-positive cases, 61% (34/56) had no previous notification in NIDR. 48% of HBsAg, 62.5% of anti-HCV and 84.6% of anti-Trpa positive cases had been missed. Among the Somali population (n = 261), prevalence of missed hepatitis B diagnosis was 3.0%. Of the 324 Russian migrants, 3.0% had not been previously diagnosed with hepatitis C and 2.4% had a missed syphilis diagnosis. In multivariable regression model missed diagnosis was associated with migrant origin, living alone, poor self-perceived health, daily smoking, and previous diagnosis of another blood-borne infection.

CONCLUSIONS

More than half of chronic hepatitis and syphilis diagnoses had been missed among migrants in Finland. Undiagnosed hepatitis B among Somali migrants implies post-migration transmission that could be prevented by enhanced screening and vaccinations. Rate of missed diagnoses among Russian migrants supports implementation of targeted hepatitis and syphilis screening upon arrival and also in later health care contacts. Coverage and up-take of current screening among migrants should be evaluated.

Implementation of baby boomer hepatitis C screening and linking to care in gastroenterology practices: a multi-center pilot study

Background

Estimates suggest that only 20 % of HCV-infected patients have been identified and <10 % treated. However, baby boomers (1945-1965) are identified as having a higher prevalence of HCV which has led the Centers for Disease Control and Prevention to make screening recommendations. The aim of this study was to implement the CDC’s screening recommendations in the unique setting of gastroenterology practices in patients previously unscreened for HCV.

Methods

After obtaining patient informed consent, demographics, clinical and health-related quality of life (HRQOL) data were collected. A blood sample was screened for HCV antibody (HCV AB) using the OraQuick HCV Rapid Antibody Test. HCV AB-positive patients were tested for presence of HCV RNA and, if HCV RNA positive, patients underwent treatment discussions.

Results

We screened 2,000 individuals in 5 gastroenterology centers located close to large metropolitan areas on the East Coast (3 Northeast, 1 Mid-Atlantic and 1 Southeast). Of the screened population, 10 individuals (0.5 %) were HCV AB-positive. HCV RNA testing was performed in 90 % (9/10) of HCV AB-positive individuals. Of those, 44.4 % (4/9) were HCV RNA-positive, and all 4 (100 %) were linked to caregiver. Compared to HCV AB negative subjects, HCV AB-positive individuals tended to be black (20.0 vs. 5.2 %, p = 0.09) and reported significantly higher rates of depression: 60.0 vs. 21.5 %, p = 0.009. These individuals also reported a significantly lower HRQOL citing having more fatigue, poorer concentration, and a decreased level of energy (p < 0.05).

Discussion

Although the prevalence of HCV AB-positive was low in previously unscreened subjects screened in the gastroenterology centers, the linkage to care was very high. The sample of patients used in this study may be biased, so further studies are needed to assess the effectiveness of the CDC screening recommendations.

Conclusion

Implementation of the Baby Boomer Screening for HCV requires identifying screening environement with high prevalence of HCV+ individuals as well as an efficient process of linking them to care.