- Category: HCV Testing & Diagnosis
- Published on Tuesday, 22 November 2011 00:00
- Written by Liz Highleyman
Screening all people in the U.S. in the 46 to 66 year age group for hepatitis C virus (HCV) infection would identify more than 800,000 additional cases, and offering testing plus treatment if needed would be cost-effective, according to an analysis presented at the American Association for the Study of Liver Diseases Liver Meeting (AASLD 2011) this month in San Francisco.
Over years or decades, chronic hepatitis C can lead to advanced liver disease including cirrhosis and liver cancer. Many people do not experience symptoms until they develop serious liver damage, and experts estimate that one-half to three-quarters of people living with HCV do not know they are infected. HCV screening is currently not considered part of routine care for people without traditional risk factors such injection drug use.
David Rein and colleagues compared the costs associated with current HCV antibody testing practices versus birth cohort screening, or 1-time testing of all primary care patients born between 1945 and 1965 -- the "Baby Boomer" generation. Studies have shown that this cohort has the highest HCV prevalence of any age group.
The researchers developed a mathematical model (Monte Carlo simulation) of hepatitis C disease progression, HCV screening, and hepatitis C treatment, programming it with patient characteristics representative of U.S. residents who had at least 1 primary care visit during 2006.
Rein's team estimated HCV prevalence using National Health and Nutrition Examination Survey (NHANES) data from 2004-2006. They estimated that currently 18.5% of primary care patients have already been screened for HCV, based on published data; for birth cohort screening, they increased this rate to 91%.
They assumed that all insured patients who tested HCV antibody positive would be referred for clinical evaluation, but that a large proportion would decline treatment or have contraindications. They further assumed that people who start antiviral therapy would incur costs and achieve sustained virological response (SVR) rates similar to those observed in community settings.
Only the minority of people with chronic hepatitis C who experience liver disease progression require treatment; liver biopsy and various non-invasive methods are used to determine the extent of liver damage, but the rate of progression is difficult to predict.
- Full implementation of birth cohort screening would require testing 46 million people in the 46-66 age group.
- Universal testing of people in this birth cohort would detect approximately 808,500 additional cases of hepatitis C, at a cost of $2874 per case.
- Birth cohort HCV screening plus treatment with pegylated interferon/ribavirin if needed, compared with current risk-based screening, would cost $81 per person and $15,700 per quality-adjusted life-year gained.
- If treatment also included the HCV protease inhibitors boceprevir (Victrelis) or telaprevir (Incivek), it would cost $284 per person and $35,700 per quality-adjusted life-year.
Birth cohort screening and treatment with pegylated interferon/ribavirin, compared with current risk-based screening would:
- Prevent 138,441 cases of liver cirrhosis;
- Prevent 32,157 cases of hepatocellular carcinoma;
- Prevent 82,360 deaths;
- Gain 348,806 total quality-adjusted life-years;
- Increase medical costs by a total of $5.4 billion.
Birth cohorts screening and treatment with HCV protease inhibitors plus pegylated interferon/ribavirin would:
- Prevent 203,238 cases of liver cirrhosis;
- Prevent 47,189 cases of hepatocellular carcinoma;
- Prevent 120,879 deaths;
- Gain 532,241 total quality-adjusted life-years;
- Increase medical costs by a total of $19.0 billion.
Based on these findings, the researchers concluded, "Birth cohort screening is likely to be considered cost-effective by policy-makers."
However, they continued, "Implementing and financing costs of treatment is a larger challenge," with full implementation likely costing between $5.5 and $19.0 billion.
As a basis of comparison, they noted that the cost of birth cohort HCV screening and treatment with pegylated interferon/ribavirin would be equivalent to the cost of colon cancer or high blood pressure screening, and less than that of cervical cancer, breast cancer, or cholesterol screening.
"Future improvements in SVR may improve the cost-effectiveness of such screening if the costs required to achieve more favorable SVR rates can be contained," they added.
Investigator affiliations: National Opinion Research Center, University of Chicago, Chicago, IL; Division of Viral Hepatitis, CDC, Atlanta, GA; Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC; Center for Health Research/Southeast, Kaiser Permanente Georgia, Atlanta, GA.
DB Rein, BD Smith, JS Wittenborn, et al. The Cost-Effectiveness of Birth Cohort Hepatitis C Antibody Screening in U.S. Primary Care Settings. 62nd Annual Meeting of the American Association for the Study of Liver Diseases (AASLD 2011). San Francisco, November 4-8. 2011. Abstract 479.