Cost-effectiveness and Budgetary Impact of Hepatitis C Virus Testing, Treatment, and Linkage to Care in US Prisons

BACKGROUND

Hepatitis C virus (HCV) testing and treatment uptake in prisons remains low. We aimed to estimate clinical outcomes, cost-effectiveness (CE), and budgetary impact (BI) of HCV testing and treatment in United States (US) prisons or linkage to care at release.

METHODS

We used individual-based simulation modeling with healthcare and Department of Corrections (DOC) perspectives for CE and BI analyses, respectively. We simulated a US prison cohort at entry using published data and Washington State DOC individual-level data. We considered permutations of testing (risk factor based, routine at entry or at release, no testing), treatment (if liver fibrosis stage ≥F3, for all HCV infected or no treatment), and linkage to care (at release or no linkage). Outcomes included quality-adjusted life-years (QALY); cases identified, treated, and cured; cirrhosis cases avoided; incremental cost-effectiveness ratios; DOC costs (2016 US dollars); and BI (healthcare cost/prison entrant) to generalize to other states.

RESULTS

Compared to "no testing, no treatment, and no linkage to care," the "test all, treat all, and linkage to care at release" model increased the lifetime sustained virologic response by 23%, reduced cirrhosis cases by 54% at a DOC annual additional cost of $1440 per prison entrant, and would be cost-effective. At current drug prices, targeted testing and liver fibrosis-based treatment provided worse outcomes at higher cost or worse outcomes at higher cost per QALY gained. In sensitivity analysis, fibrosis-based treatment restrictions were cost-effective at previous higher drug costs.

CONCLUSIONS

Although costly, widespread testing and treatment in prisons is considered to be of good value at current drug prices.

Index of host habitat preference explored by movement-based simulations and trap captures

Animal species likely have different strengths of host habitat preference (HHP) that might be characterized by a standardized index ranging from 0 (no preference) to 1 (maximum preference). We hypothesized that in some species, HHP may result from individuals dispersing out of the host habitat having a probability of turning back at the boundary, or after entering host habitat by reducing speed or increasing size of turning angles. Computer simulations of individuals moving between various sized patches of host and nonhost habitat were conducted based on these three behaviours hypothesized to affect HHP. In the rebounding model, simulations resulted in equilibria of animal numbers inside and outside of host habitat that depend on sizes of these areas, initial number and the rebounding probability. Curvilinear regression of simulation results suggested an equation that predicted numbers in the host habitat and was solved for rebounding probability. A modified equation that sampled population densities (e.g., insect pheromone trap catches) inside and outside host habitat areas gave the rebounding probability, an index of HHP, without requiring the sizes of the areas. Simulations with traps and moving animals verified that the modified equation could predict the index correctly. The modified equation also estimates an index of HHP from sampled densities due to speed reductions and a combination of this and rebounding. Changes in angular turning size upon entering host habitat, however, did not affect habitat preference. Using pheromone trap captures, we found that the lesser date moth Batrachedra amydraula has a HHP for date Phoenix dactylifera plantations of 0.96. Host habitat preference indexes also were calculated from sampled insect densities reported in the literature. The new index of HHP is useful to characterize habitat patches of many organisms and aid understanding of animal spatial distributions and speciation processes. In addition, the index can be applied in studies of invasive species, trap crops of pest insects and conservation management.

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%.

Modelling lifelong effects of different prophylactic treatment strategies for severe haemophilia A

BACKGROUND

Lifelong prophylactic replacement therapy with clotting factor concentrates is recommended for severe haemophilia. The prophylactic dose determines both clinical outcome and treatment cost. In the absence of clinical studies, computer simulation was used to explore lifelong effects and clotting factor consumption for various prophylactic dose levels, and optimize strategies for switching between prophylactic and on-demand treatment.

DESIGN AND METHODS

Individual patients' lifetime joint bleeds, radiological arthropathy (Pettersson score, 0-78) and consumption were simulated for each treatment strategy. Treatment effectiveness (expressed as % of patients maintaining a lifetime Pettersson score ≤14) and clotting factor consumption were modelled for lifelong prophylaxis at dose levels 1000-4500 IU kg(-1) year(-1) , for on-demand treatment and for switching strategies. Treatment efficiency (consumption per unit of effectiveness) was used to compare strategies.

RESULTS

Compared to lifelong on-demand treatment, lifelong prophylaxis at 1000 IU kg(-1) year(-1) increased effectiveness from 21 to 36%, at an additional consumption of 0.9 × 10(6) IU kg(-1) . For lifelong prophylaxis, each additional 1000 IU kg(-1) year(-1) resulted in a proportional increase in consumption by ±5 × 10(6) IU kg(-1) but a less than proportional reduction in arthropathy by ±50%; consequently, increasing consumption progressively diminished treatment efficiency. Switching strategies slightly reduce effectiveness and consumption. Optimum switching criteria were similar across prophylactic dose levels.

CONCLUSION

According to the simulation model, low-dose prophylaxis (1000 IU kg(-1) year(-1) ) improved outcome at a limited increase in consumption compared to on-demand treatment. Increasing prophylactic dose further improved health outcomes, but at decreasing efficiency. Optimal prophylactic dose should therefore be selected balancing acceptable health impact and available budget.

Multiphysics Modeling of Microwave Heating of a Frozen Heterogeneous Meal Rotating on a Turntable

A 3-dimensional (3-D) multiphysics model was developed to understand the microwave heating process of a real heterogeneous food, multilayered frozen lasagna. Near-perfect 3-D geometries of food package and microwave oven were used. A multiphase porous media model combining the electromagnetic heat source with heat and mass transfer, and incorporating phase change of melting and evaporation was included in finite element model. Discrete rotation of food on the turntable was incorporated. The model simulated for 6 min of microwave cooking of a 450 g frozen lasagna kept at the center of the rotating turntable in a 1200 W domestic oven. Temperature-dependent dielectric and thermal properties of lasagna ingredients were measured and provided as inputs to the model. Simulated temperature profiles were compared with experimental temperature profiles obtained using a thermal imaging camera and fiber-optic sensors. The total moisture loss in lasagna was predicted and compared with the experimental moisture loss during cooking. The simulated spatial temperature patterns predicted at the top layer was in good agreement with the corresponding patterns observed in thermal images. Predicted point temperature profiles at 6 different locations within the meal were compared with experimental temperature profiles and root mean square error (RMSE) values ranged from 6.6 to 20.0 °C. The predicted total moisture loss matched well with an RMSE value of 0.54 g. Different layers of food components showed considerably different heating performance. Food product developers can use this model for designing food products by understanding the effect of thickness and order of each layer, and material properties of each layer, and packaging shape on cooking performance.