Primary Care Option for Hepatitis C Treatment Cost-Effective

Medscape Medical News > Conference News

Miriam E. Tucker

November 14, 2013

WASHINGTON, DC — The Extension for Community Healthcare Outcomes (ECHO) program, which trains primary care physicians to treat patients infected with hepatitis C in underserved communities, is cost-effective, a new analysis shows.

"ECHO provides resource-efficient access to care for underserved communities," John Wong, MD, from Tufts University in Boston, told Medscape Medical News.

He presented the findings here at The Liver Meeting 2013.

The ECHO program, developed at the University of New Mexico Health Sciences Center, uses teleconferencing to help primary care physicians and specialists at the university comanage patients with chronic hepatitis C infection in 16 underserved rural areas and 5 correctional facilities.

Initial efficacy findings for 407 patients showed that the rates of sustained viral response at ECHO sites were nearly identical to those at university clinics (58.2% vs 57.5%) (N Engl J Med.2011;364:2199-2207).

“The cost is $3000; that's nothing, and the cure rate is as good as at a university.”

Dr. Wong and his team compared the cost of pegylated interferon plus ribavirin with no treatment for each of 261 patients at the 21 ECHO sites. Mean patient age was 42 years, 73% were male, and 95% were white. A quarter had cirrhosis, 30% had moderate hepatitis, and 56% had genotype 1 hepatitis C.

Factored into the model were costs for office visits, lab tests, antiviral drugs, adverse effects, psychiatry, travel, productivity, and corrections personnel.

Compared with no treatment, the researchers projected that ECHO management would reduce the lifetime incidence of cirrhosis by 63%, decompensated cirrhosis by 46%, hepatocellular carcinoma by 45%, and liver death by 46%.

With ECHO, projected life expectancy would increase by 4.4 years, producing a cost saving of $12,200 without discounting for future disease costs. With discounting, ECHO had a cost of $9,000.

Compared with no antiviral therapy, the program saves money in 35% of patients overall, in 30% of patients in the community setting, and in 43% of patients in correctional facilities. Another 23% benefited with ECHO management, but some at higher costs. In 42% of patients, the treatment didn't work.

The incremental cost-effectiveness ratio — the rate of additional cost to additional benefit — was $3700 for the entire study population, $5800 for the community, and $1400 for the corrections facilities.

The incremental cost-effectiveness ratio reflects what the intervention costs to increase life expectancy by 1 year of perfect health (cost-quality-adjusted life-year gained). The World Health Organization considers an intervention to be very cost-effective if that ratio is less than the per capita gross domestic product of a country, and to be cost-effective if it is less than 3 times the per capita GDP, Dr. Wong explained.

"The mean per capita GDP in the United States is $50,000, so this is 10-fold lower, and therefore very cost-effective," he said.

Dr. Wong reported that ECHO now includes triple therapy and that he expects the much-anticipated polymerase inhibitor sofosbuvir and the protease inhibitor simeprevir to be added once they are approved by the US Food and Drug Administration. He said he anticipates that ECHO will be cost-effective as long as triple therapy remains effective.

Both session comoderators told Medscape Medical News that they are impressed with the findings.

"I think it shows that increasing access isn't costly, it's cost effective. The cost is $3000; that's nothing, and the cure rate is as good as at a university," said comoderator Sammy Saab, MD, from the David Geffen School of Medicine at UCLA.

"If the new hepatitis C drugs have a better safety profile, a lot of the treatment can be undertaken by primary care providers, which would be a huge boon for people," added comoderator Kiran Bambha, MD, from the University of Colorado Medical Center in Denver.

Dr. Wong and Dr. Bambha have disclosed no relevant financial relationships. Dr. Saab is a consultant to Bristol-Myers Squibb.

The Liver Meeting 2013: American Association for the Study of Liver Diseases (AASLD). Abstract 245. Presented November 5, 2013.

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ECHO model cost-effective for HCV

11/06/13

By: ALICIA AULT, Family Practice News Digital Network

Alicia Ault/IMNG Medical Media
Dr. John B. Wong

WASHINGTON – Using the ECHO model of primary care to treat hepatitis C is cost saving in 35% of patients and very cost effective overall, according to a retrospective analysis presented by Dr. John B. Wong, at the annual meeting of the American Association for the Study of Liver Diseases.

Project ECHO (Extension for Community Healthcare Outcomes) was begun at the University of New Mexico, Albuquerque, and has been adopted by the Veterans Affairs department, among other organizations, as a means of extending primary care to those who might not otherwise have access.

This is not about the antiviral treatment, it’s about the engagement of primary care physicians, to train them, educate them, and help them take care of patients with hepatitis C," said Dr. Wong, chief of the division of clinical decision making at Tufts Medical Center, Boston. "It’s about increasing access," he added.

Dr. Wong presented the results of a cost-effectiveness analysis he and his Tufts colleagues conducted on a study of ECHO’s effectiveness in treating HCV, published in the New England Journal of Medicine in 2011 (N. Engl. J. Med. 2011;364:2199-207).

That prospective cohort study evaluated ECHO in the HCV treatment of 261 patients at 16 community sites and 5 prisons.

Dr. Wong and his colleagues updated the data, using information from the United Network for Organ Sharing; the Surveillance, Epidemiology and End Results Program; and life tables from the Centers for Disease Control and Prevention. They also used the previously established and validated Markov cohort simulation model to compare ECHO to no antiviral therapy for each of the 261 patients.

Costs taken into account included expenses for drugs, physician visits, lab tests, adverse events, HCV disease complications, and multidisciplinary ECHO personnel (physician, pharmacist, psychiatrist, nurse manager, coordinator, and user support analyst).

Dr. Wong said that the researchers also performed an analysis of the cost of antiviral treatment if patients traveled to the academic center to receive care instead of having ECHO come to them. Travel costs included mileage, patient time, and guard costs for prisoners. The investigators used quality-of-life adjustments to account for antiviral treatment and disease-related morbidity, and discounted costs and effectiveness at 3% a year.

They calculated that ECHO led to a 63% reduction in lifetime cirrhosis when compared with no antiviral therapy. Hepatocellular carcinoma declined by 45% and liver death by 46%. There was a 4.4-year gain in life expectancy overall, and a 5.5-year gain in quality-adjusted life expectancy.

For 42% of the 261 patients, the incremental effectiveness did not outweigh the cost – and the opportunity cost – of taking an antiviral, said Dr. Wong. In another 23% of patients, the antiviral therapy extended life, but in the end, when the costs of the disease and the antivirals were added in, there was an extra cost associated with the therapy.

But in 35% of the patients, there was an extension of life – as much as 8 additional years – and a reduction in cost of treatment, as much as $40,000.

he incremental cost-effectiveness ratio – a formula calculated by dividing the additional cost by the additional benefit – for ECHO is $3,700, Dr. Wong said. The World Health Organization considers anything less than the per capita gross domestic product of a country to be "very cost effective," and anything less than three times that per capita number to be "cost effective," he said. He noted that the mean GDP in the United States is $50,000, putting the ECHO intervention well within the WHO’s range for very cost effective.

The gains were even greater for patients living in correctional institutions, with an incremental cost-effectiveness ratio of $1,400.

The study is limited by the fact that it is a computer simulation, and some travel data were missing, said Dr. Wong.

Additional trials are needed to confirm the results, he said.

The University of New Mexico recently started an institute to spread the ECHO model.

Dr. Wong reported no conflicts of interest.

aault@frontlinemedcom.com
On Twitter @aliciaault

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