Cost-Effectiveness Analysis of Risk-Factor Guided and Birth-Cohort Screening for Chronic Hepatitis C Infection in the United States

Background No consensus exists on screening to detect the estimated 2 million Americans unaware of their chronic hepatitis C infections. Advisory groups differ, recommending birth-cohort screening for baby boomers, screening only high-risk individuals, or no screening. We assessed one-time risk assessment and screening to identify previously undiagnosed 40–74 year-olds given newly available hepatitis C treatments. Methods and Findings A Markov model evaluated alternative risk-factor guided and birth-cohort screening and treatment strategies. Risk factors included drug use history, blood transfusion before 1992, and multiple sexual partners. Analyses of the National Health and Nutrition Examination Survey provided sex-, race-, age-, and risk-factor-specific hepatitis C prevalence and mortality rates. Nine strategies combined screening (no screening, risk-factor guided screening, or birth-cohort screening) and treatment (standard therapy–peginterferon alfa and ribavirin, Interleukin-28B-guided (IL28B) triple-therapy–standard therapy plus a protease inhibitor, or universal triple therapy). Response-guided treatment depended on HCV genotype. Outcomes include discounted lifetime costs (2010 dollars) and quality adjusted life-years (QALYs). Compared to no screening, risk-factor guided and birth-cohort screening for 50 year-olds gained 0.7 to 3.5 quality adjusted life-days and cost $168 to $568 per person. Birth-cohort screening provided more benefit per dollar than risk-factor guided screening and cost $65,749 per QALY if followed by universal triple therapy compared to screening followed by IL28B-guided triple therapy. If only 10% of screen-detected, eligible patients initiate treatment at each opportunity, birth-cohort screening with universal triple therapy costs $241,100 per QALY. Assuming treatment with triple therapy, screening all individuals aged 40–64 years costs less than $100,000 per QALY. Conclusions The cost-effectiveness of one-time birth-cohort hepatitis C screening for 40–64 year olds is comparable to other screening programs, provided that the healthcare system has sufficient capacity to deliver prompt treatment and appropriate follow-on care to many newly screen-detected individuals.

[1]  G. Dore,et al.  Trends in mortality after diagnosis of hepatitis B or C infection: 1992-2006. , 2011, Journal of hepatology.

[2]  M. Weinstein,et al.  Cost-effectiveness of treatment for chronic hepatitis C infection in an evolving patient population. , 2003, JAMA.

[3]  D. Mitra,et al.  Treatment patterns and adherence among patients with chronic hepatitis C virus in a US managed care population. , 2010, Value in health : the journal of the International Society for Pharmacoeconomics and Outcomes Research.

[4]  P. Belperio,et al.  A sustained virologic response reduces risk of all-cause mortality in patients with hepatitis C. , 2011, Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association.

[5]  G. Naglie,et al.  Health-State Utilities and Quality of Life in Hepatitis C Patients , 2003, American Journal of Gastroenterology.

[6]  Inda,et al.  The prevalence of hepatitis C virus infection in the United States, 1988 through 1994. , 1999, The New England journal of medicine.

[7]  Milton C Weinstein,et al.  Empirically calibrated model of hepatitis C virus infection in the United States. , 2002, American journal of epidemiology.

[8]  J B Wong,et al.  Estimates of the Cost-Effectiveness of a Single Course of Interferon-2b in Patients with Histologically Mild Chronic Hepatitis C , 1997, Annals of Internal Medicine.

[9]  Patrick W. Sullivan,et al.  Preference-Based EQ-5D Index Scores for Chronic Conditions in the United States , 2006, Medical decision making : an international journal of the Society for Medical Decision Making.

[10]  D. Jolley,et al.  The impact of diagnosis of hepatitis C virus on quality of life , 1999, Hepatology.

[11]  K. Conboy,et al.  Screening for hepatitis C virus in a health maintenance organization. , 2000, Archives of internal medicine.

[12]  D. Holtzman,et al.  Hepatitis C virus testing of persons born during 1945-1965: recommendations from the Centers for Disease Control and Prevention. , 2012, Annals of internal medicine.

[13]  M. Ghany,et al.  Diagnosis, management, and treatment of hepatitis C: An update , 2009, Hepatology.

[14]  M. Manns,et al.  Boceprevir for untreated chronic HCV genotype 1 infection. , 2011, The New England journal of medicine.

[15]  髙折 晃史,et al.  19th Conference on Retroviruses and Opportunistic Infections , 2012 .

[16]  Jennifer A. Roberts,et al.  Cost effectiveness of interferon α or peginterferon α with ribavirin for histologically mild chronic hepatitis C , 2005, Gut.

[17]  M. Alter,et al.  Incidence and transmission patterns of acute hepatitis C in the United States, 1982-2006. , 2011, Archives of internal medicine.

[18]  G. Dusheiko,et al.  P70 Telaprevir in combination with peginterferon and ribavirin in genotype 1 HCV Treatment-Naïve patients: final results of phase 3 ADVANCE Study , 2011, Gut.

[19]  Geoffrey Dusheiko,et al.  Telaprevir for previously untreated chronic hepatitis C virus infection. , 2011, The New England journal of medicine.

[20]  Michael J. O'Grady,et al.  Economic model of a birth cohort screening program for hepatitis C virus , 2012, Hepatology.

[21]  E. Monnet,et al.  Long‐term outcome of chronic hepatitis C in a population‐based cohort and impact of antiviral therapy: a propensity‐adjusted analysis , 2011, Journal of viral hepatitis.

[22]  J. Janisse,et al.  Demographics of a large cohort of urban chronic hepatitis C patients , 2008, Hepatology international.

[23]  M. Manns,et al.  Early virologic response to treatment with peginterferon alfa‐2b plus ribavirin in patients with chronic hepatitis C , 2003, Hepatology.

[24]  F. Carrat,et al.  Cost Effectiveness of Fibrosis Assessment Prior to Treatment for Chronic Hepatitis C Patients , 2011, PloS one.

[25]  R. Monina Klevens,et al.  The Increasing Burden of Mortality From Viral Hepatitis in the United States Between 1999 and 2007 , 2012, Annals of Internal Medicine.

[26]  M. Brandeau,et al.  Cost-Effectiveness of Screening and Vaccinating Asian and Pacific Islander Adults for Hepatitis B , 2007, Annals of Internal Medicine.

[27]  R. Goetzel,et al.  Cost Burden of Illness for Hepatitis C Patients with Employer-Sponsored Health Insurance , 2002 .

[28]  E L Murphy,et al.  Prevalence of hepatitis C virus infection in the United States. , 1999, The New England journal of medicine.

[29]  G. Dore,et al.  Estimation of stage‐specific fibrosis progression rates in chronic hepatitis C virus infection: A meta‐analysis and meta‐regression , 2008, Hepatology.

[30]  M. Gold.  Cost-effectiveness in health and medicine , 2016 .

[31]  D. Battistutta,et al.  Predictive markers for hepatitis C antibody ELISA specificity in Australian blood donors , 1992, Transfusion medicine.

[32]  D. Owens,et al.  New Protease Inhibitors for the Treatment of Chronic Hepatitis C , 2012, Annals of Internal Medicine.

[33]  B. Branson,et al.  Comparing the Costs of HIV Screening Strategies and Technologies in Health-Care Settings , 2008, Public health reports.

[34]  J. Martin,et al.  National Vital Statistics Reports , 2002 .

[35]  J. Pawlotsky.  Diagnostic tests for hepatitis C. , 1999, Journal of hepatology.

[36]  J. Tsevat,et al.  Health values of patients with chronic hepatitis C infection. , 2004, Archives of internal medicine.

[37]  M. Alter,et al.  The Prevalence of Hepatitis C Virus Infection in the United States, 1999 through 2002 , 2006, Annals of Internal Medicine.

[38]  Z. Younossi,et al.  Cost effectiveness of screening for hepatitis C virus in asymptomatic, average-risk adults. , 2001, The American journal of medicine.

[39]  Ellen Meara,et al.  Trends in medical spending by age, 1963-2000. , 2004, Health affairs.

[40]  William M. Lee,et al.  Interleukin-28B polymorphism improves viral kinetics and is the strongest pretreatment predictor of sustained virologic response in genotype 1 hepatitis C virus. , 2010, Gastroenterology.

[41]  S. El-Kamary,et al.  All-cause, liver-related, and non-liver-related mortality among HCV-infected individuals in the general US population. , 2011, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[42]  William M. Lee,et al.  Peginterferon alfa-2b or alfa-2a with ribavirin for treatment of hepatitis C infection. , 2009, The New England journal of medicine.

[43]  G. Fattovich,et al.  A survey of adverse events in 11,241 patients with chronic viral hepatitis treated with alfa interferon. , 1996, Journal of hepatology.

[44]  D. Russell,et al.  Quality-of-Life Weights for the US Population: Self-Reported Health Status and Priority Health Conditions, by Demographic Characteristics , 2007, Medical care.

[45]  M. Golden,et al.  Cost-effectiveness and population outcomes of general population screening for hepatitis C. , 2012, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[46]  Thomas Fleming,et al.  Red book : pharmacy's fundamental reference , 2004 .

[47]  R. Chou,et al.  Screening for Hepatitis C Virus Infection: A Review of the Evidence for the U.S. Preventive Services Task Force , 2004, Annals of Internal Medicine.

[48]  J. Ward,et al.  The Cost-Effectiveness of Birth-Cohort Screening for Hepatitis C Antibody in U.S. Primary Care Settings , 2012, Annals of Internal Medicine.

[49]  P. Bedossa,et al.  Appropriateness of liver biopsy. , 2000, Canadian journal of gastroenterology = Journal canadien de gastroenterologie.

[50]  Sprint Investigators,et al.  Boceprevir for Untreated Chronic HCV Genotype 1 Infection , 2011 .

[51]  James Waterman Glover.  United States Life Tables , 2013 .

[52]  J. Emparanza,et al.  [The prevalence of hepatitis C virus infection]. , 1998, Gastroenterologia y hepatologia.

[53]  E. Armstrong,et al.  Burden of illness of hepatitis C from a managed care organization perspective , 2004, Current medical research and opinion.

[54]  N. Theise,et al.  Treatment rates in patients with chronic hepatitis C after liver biopsy , 2006, Journal of viral hepatitis.

[55]  K. Promrat,et al.  Outcome of Screening for Hepatitis C Virus Infection Based on Risk Factors , 2008, The American Journal of Gastroenterology.