Candidate for the Lee B. Lusted Student Prize Competition
Purpose: Over 3 million Americans are infected with chronic hepatitis C (HCV), a serious liver disease. Current U.S. guidelines recommend no screening in the general population. There is disagreement among advisory bodies regarding screening of high-risk individuals. We assessed the cost-effectiveness of universal and risk-factor guided HCV screening for asymptomatic U.S. adults (40-60 years old) at a routine medical visit.
Methods: We developed a decision-analytic Markov model that included the natural history of chronic HCV (genotype 1, 2, or 3) and advanced liver disease. We assessed the lifetime costs (2010 USD), quality adjusted life-years (QALYs) gained, and incremental cost-effectiveness ratios (ICERs) of three screening strategies: no screening, risk-factor guided screening, and universal screening. Risk factors included combinations of history of drug use, blood transfusion prior to 1992, and sexual behaviors. Analyses of the (1999-2008) National Health and Nutrition Examination Survey data provided gender- and age-specific HCV and risk factor prevalence estimates among HCV negative and positive individuals. Those individuals identified via screening who are HCV positive and eligible for treatment receive either standard therapy (peginterferon alfa and ribavirin) in the base case or standard therapy in combination with a recently-developed protease inhibitor as a scenario analysis.
Results: For men, universal screening has an ICER of $42,900/QALY compared to no screening. In order for risk-factor guided screening to be cost-effective, ≥80% of high-risk individuals must truthfully report their status. Even if all high-risk individuals reported truthfully, universal screening is still cost-effective ($47,400/QALY). For women, universal screening has an ICER of $69,100/QALY compared to no screening. Risk-based screening has an ICER approaching $100,000/QALY even if 80% of high-risk individuals truthfully reported. Newer treatments improve incremental cost-effectiveness ratios relative to standard therapy. Screening is less cost-effective for individuals above age 50 because HCV prevalence peaks around 50 years. Low treatment acceptance, disutility of knowing one’s HCV status, and high treatment costs erode screening cost-effectiveness.
Conclusions: Universal screening is likely cost-effective for both men and women at a willingness to pay threshold of $100,000/QALY. The efficiency of risk-factor guided screening depends strongly on efficiently identifying most high-risk individuals. These findings suggest that existing U.S. HCV screening guidelines should be reconsidered.