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Cost-effectiveness of hepatitis C treatment
for patients in early stages of liver disease
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"Earlier initiation of treatment was more cost-effective under scenarios of higher disease progression rates, when quality of life assumptions favored treatment, when treatments were more effective, and when lower treatment costs were assumed.....We modeled treatment as a generic regimen of highly effective antivirals with a base case cost of $100,000 per patient.......Strategies for HCV testing and linkage to care have been found to be cost effective in reducing HCV morbidity and mortality"
Hepatology
March 16 2015
This article has been accepted for publication and undergone full peer review but has not been
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Andrew J. Leidnera Harrell W. Chessonb Fujie Xua John W. Warda Philip R. Spradlinga Scott D. Holmberga
Affiliation:
a. Division of Viral Hepatitis
Centers for Disease Control and Prevention
b. Division of Sexually Transmitted Disease Prevention
Centers for Disease Control and Prevention
Abstract
New treatments for hepatitis C virus (HCV) may be highly effective but are associated with substantial costs that may compel clinicians and patients to consider delaying treatment. This study investigated the cost-effectiveness of these treatments with a focus on patients in early stages of liver disease. We developed a state-transition (or Markov) model to calculate costs incurred and quality-adjusted life-years (QALYs) gained following HCV treatment and we computed incremental cost-effectiveness ratios (cost per QALY gained, in US$2012) for treatment at different stages of liver disease versus delaying treatment until the subsequent liver disease stage. Our analysis did not include the potential treatment benefits associated with reduced non liver-related mortality or preventing HCV transmission. All parameter values, particularly treatment cost, were varied in sensitivity analyses. The base case scenario represented a 55-year-old patient with genotype 1 HCV infection with a treatment cost of $100,000 and treatment effectiveness of 90%. In this scenario, a 55-year-old patient with moderate liver fibrosis (Metavir stage F2), the cost-effectiveness of immediately initiating treatment at F2 (vs. delaying treatment until F3) was $37,300/QALY. For patients immediately treated at F0 (vs. delaying treatment until F1), the threshold of treatment costs that yielded $50,000/QALY and $100,000/QALY cost-effectiveness ratios were $22,200 and $42,400, respectively.
Conclusion: Immediate treatment of HCV-infected patients with moderate and advanced fibrosis appears to be cost-effective. Immediate treatment of patients with minimal or no fibrosis can be cost-effective as well, particularly when lower treatment costs are assumed.
We modeled treatment as a generic regimen of highly effective antivirals with a base case cost of $100,000 per patient.
Discussion
This analysis investigates a common clinical situation, in which the clinician and patient must choose between starting treatment of HCV infection immediately or delaying treatment until later. In the base case scenarios-a 55 year-old patient, treatment cost of $100,000, and treatment effectiveness of 90%,-immediate (vs. delayed) treatment of a patient with fibrosis level of F0, F1, and F2 was associated with cost-effectiveness ratios, respectively, of $242,900, $174,100, and $37,300 per QALY gained. Earlier initiation of treatment was more cost-effective under scenarios of higher disease progression rates, when quality of life assumptions favored treatment, when treatments were more effective, and when lower treatment costs were assumed. We also found that for patients diagnosed and treated at F0, the treatment cost thresholds that yielded $50,000/QALY and $100,000/QALY cost-effectiveness ratios were $22,200 and $42,400, respectively.
Although we know of no other study to assess the cost-effectiveness of HCV treatment considering the stage-specific treatment decision for all the early stages of liver disease, at least two recent cost-effectiveness studies have also investigated the issue of timing of HCV treatment. Younossi et al. 35 found that treating all patients with an all-oral treatment regimen yielded an ICER of $15,700 when compared to treating only patients with F2-F4 fibrosis with an all-oral regimen. Their base case assumptions were more favorable towards a "treat all" strategy than those used in this study.
Strategies for HCV testing and linkage to care have been found to be cost effective in reducing HCV morbidity and mortality.39-42 New therapeutic agents can increase the health benefits associated with these strategies. However, payers and other stakeholders are concerned about their cost and are therefore evaluating these expenditures against the health benefits achieved with these agents. The potential expenditures for HCV screening and treatment strategies are not trivial, given that the US has approximately 3 million43 HCV-infected persons. Results from our model indicate that HCV therapy appears to be cost-effective for HCV-infected persons with evidence of moderate liver disease.
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