Published: November 04, 2011
Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco and
Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner
SAN FRANCISCO -- Birth-cohort screening for hepatitis C virus (HCV) infection proved highly cost-effective, even when adjusted for universal treatment with direct-acting antiviral therapy, according to a study reported here.
Universal HCV testing in people born from 1945 to 1965 would detect 800,000 new cases of HCV infection and prevent 82,000 deaths at a cost of $15,700 per quality-adjusted life year (QALY) gained.
Assuming treatment with pegylated interferon and ribavirin would prevent an estimated 121,000 deaths at a cost of $35,700 per QALY, still well within the generally accepted range for cost effectiveness.
The findings were reported simultaneously here at the American Association for the Study of Liver Diseases meeting and online in Annals of Internal Medicine.
"Without new case identification strategies, the adverse consequences of chronic HCV infection are forecasted to result in an increasing public health burden over the next two decades," David P. Rein, PhD, of the National Opinion Research Center at the University of Chicago, and co-authors wrote in conclusion.
"Birth-cohort screening appears to be a reasonable strategy to identify asymptomatic cases of HCV," they added.
More than four million Americans have antibodies to HCV, which leads to chronic infection in about 75% of cases. HCV infection occurs most often in adults born between 1945 and 1965, most of whom acquire infection 20 to 40 years before diagnosis, the authors wrote in their introduction.
Estimates of HCV-related mortality ranged between 7,000 and 13,000 deaths in 2005. Without changes in the current approach to case identification, the number of HCV deaths will increase to 35,000 a year by 2030, the authors continued.
Clinical trials of pegylated interferon and ribavirin have demonstrated efficacy in 46% of patients infected with HCV genotype 1 (which accounts for 70% of infected white patients and 90% of African Americans in the U.S.) and 81% of patients infected with genotype 2 or 3.
The CDC recommends antibody testing for individuals with a history of behaviors, exposures, or health indicators associated with HCV infection (such as intravenous drug use and hemodialysis). Even so, as many as 50% of HCV-infected individuals may be unaware of their status, the authors wrote.
Expanding screening recommendations to the birth cohort covering 1945 to 1965 offers one potential means to increase detection and treatment of HCV infection. Such a strategy would increase healthcare costs, but whether the additional cost would offset potential benefits of expanded screening is unclear.
To address the issue, Rein and colleagues performed an analysis based on data derived from the National Health and Nutrition Examination Survey, census data, Medicare reimbursement information, and published sources.
The analytic model included the estimated cost of HCV testing in the 67 million Americans born from 1945 through 1965 who had at least one visit to a primary care provider in 2006. The authors also calculated the lifetime cost of treating the estimated 2.4 million patients with HCV-positive test results, illness-related lost productivity, increased loss of QALYs, and other relevant factors.
As compared with the current approach to identification of HCV infection, birth-cohort screening would identify 808,580 additional cases of HCV infection at a cost of $2,874 per case. Treatment of the additional cases would result in an additional 348,800 QALYs gained at a total cost of $5.5 billion, resulting in incremental cost-effectiveness ratio (ICER) of $15,700 per QALY.
Expanding the definition of treatment to consist of a direct-acting antiviral, pegylated interferon, and ribavirin results in an additional 532,200 QALYs gained at a cost of $19 billion and an ICER of $35,700 per QALY saved.
Sensitivity analysis yielded a stable ICER that was most sensitive to discounting and QALY losses assigned to disease states, the authors wrote.
Acknowledging limitations of their analysis, Rein and colleagues cited a scarcity of empirical data on screening and treatment with a direct-acting antiviral in real-world clinical settings. Nonetheless, they concluded, "birth-cohort screening for HCV in primary-care settings was highly cost-effective."
The study was supported by the CDC.
The authors had no relevant disclosures.
Primary source: Annals of Internal Medicine
Source reference:
Rein DB, et al "The cost-effectiveness of birth cohort hepatitis C antibody screening in U.S. primary care settings" Ann Intern Med 2011; 155(9): epub.
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