By Michael Smith, North American Correspondent, MedPage Today
Published: March 16, 2012
Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco.
Broader screening for hepatitis C would be cost-effective but would not by itself markedly reduce morbidity and mortality from the virus, researchers reported.
A detailed mathematical model of the U.S. hepatitis C epidemic showed that testing most adults once would be more cost-effective than the current practice of only testing people with risk factors such as injection drug use, according to Phillip Coffin, MD, and colleagues at the University of Washington in Seattle.
In a scenario with optimal referral, treatment, and cure rates, they reported, screening 60% of the general population averted an additional 7.1% of liver-related deaths, compared with risk-factor screening, they wrote online in Clinical Infectious Diseases.
But screening is only the first step, the researchers argued -- it would have to be followed by measures to ensure patients obtained treatment.
The study is the second in recent weeks to suggest that broader screening for the virus would be a cost-effective approach.
In February 2011, researchers led by David Rein, PhD, of the social science research organization NORC at the University of Chicago in Atlanta, reported that testing all adults born from 1945 to 1965 would be more cost-effective than the current risk-factor approach.
Coffin and colleagues said the conclusions of the two studies are "similar," despite differences in methods. Their own analysis of treating just the 1945-to-1965 birth cohort also showed cost-effectiveness, they reported.
The epidemic of hepatitis C transmission peaked decades ago, but about four million people in the U.S. are currently infected with the virus and up to 75% of those don't know they have the disease, the researchers noted.
Current incidence is low but chronic infection now results in more deaths annually than HIV. In the absence of treatment, Coffin and colleagues noted, chronic infection is predicted to lead to almost 300,000 deaths from 2020 to 2029.
"The stealth epidemic of hepatitis C has finally matured, leaving a narrow window of opportunity to find those with advancing disease, connect them with care, and prevent the tragic and costly consequences of liver cancer and end-stage liver disease," Coffin said in a statement.
To see how best to find those with disease, he and colleagues used statistical modeling techniques, comparing the current risk-factor screening with broader approaches.
They reported that one-time screening of adults ages 20 through 69 would have an incremental cost per quality-adjusted life year gained (ICER) of $7,900.
The cost-effectiveness ratio for screening by birth year was actually better -- with an ICER of $4,200, compared with risk-factor screening -- if parameters such as cost, clinician uptake, and median age of diagnoses were the same.
But the impact of screening alone on liver-related deaths was not great -- about a 1% reduction for every 15% of the population screened, Coffin and colleagues reported.
Those figures could be improved, they found, with better linkage to care and treatment outcomes.
"We need a large-scale, coordinated effort to identify people with this infection and make sure they get the care they need," Coffin said.
Indeed, better screening strategies will only be of use "if efforts are implemented to increase acceptability of screening by patients and clinicians and (to) improve linkage to care," argued Sylvie Deuffic-Burban, PhD, of Université Lille Nord de France in Lille, France, and Yazdan Yazdanpanah, MD, PhD, of Hôpital Bichat Claude Bernard in Paris.
In an accompanying editorial commentary, they note that one-time screening might be preferred, because it could be done at the same time as universal HIV testing, which is now recommended both in the U.S. and France.
But they cautioned that another aspect of the analysis remains to be done -- which approach would have the least impact on overall health budgets?
"Such an analysis, which may favor one-time screening of high-risk birth cohorts because it targets a smaller number of patients, will provide additional information for decision-making in a context in which financial resources are scarce," they wrote.
The research had support from the National Institute of Allergy and Infectious Diseases and the National Center for Research Resources.
Coffin did not report any relevant conflicts.
Editorialist Deuffic-Burban reported financial links with Roche, Janssen Pharmaceuticals, Schering-Plough, Merck, and GlaxoSmithKline. Co-author Yazdanpanah reported financial links with Abbott, Bristol-Myers Squibb, Gilead, Merck, Roche, Tibotec, and ViiV Healthcare.
Primary source: Clinical Infectious Diseases
Source reference:
Coffin PO, et al "Cost-effectiveness and population outcomes of general population screening for hepatitis C" Clin Inf Dis 2012; DOI: 10.1093/cid/cis011.
Additional source: Clinical Infectious Diseases
Source reference:
Deuffic-Burban S, Yazdanpanah Y "It is time to change the paradigm for hepatitis C virus testing" Clin Inf Dis 2012; DOI: 10.1093/cid/cis047.
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