Candidate for the Lee B. Lusted Student Prize Competition
Purpose: Chronic hepatitis C (HCV) is a serious liver disease affecting over 3 million Americans. New, more effective treatments have recently been developed, though they are likely more expensive than current therapies. Their development calls for cost-effectiveness assessment, especially in relationship to existing guidelines that discourage general population screening for chronic HCV. We assessed the cost-effectiveness of new HCV treatments and their impact on 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 (genotypes 1, 2, or 3) and advanced liver disease as well as combinations of HCV screening and treatment options. We assessed the lifetime costs (2010 USD), quality-adjusted life-years (QALYs) gained, and incremental cost-effectiveness ratios (ICERs) of strategies that included: no screening, risk-factor guided screening, and universal screening, followed by either standard treatment (peginterferon alfa and ribavirin) or standard therapy in combination with a recently-developed protease inhibitor for patients with genotype 1 virus (Telaprevir, Vertex Pharmaceuticals).
Results: In men, universal screening followed by treatment of genotype 1 chronic HCV positive individuals with new combination therapy had an ICER of less than $50,000/QALY when the cost of the new protease inhibitor was less than $40,600 for a course of therapy. In women, universal screening followed by new treatment had an ICER of less than $50,000/QALY when the cost of the new protease inhibitor was less than $21,600 for a course of therapy. Strategies with risk-factor guided screening with either treatment option were generally dominated. Increasing treatment acceptance rates over historical levels further improves the cost effectiveness of screening for hepatitis C followed by the new combination therapy. For example, in men, if treatment initiation rates are double historical levels, universal screening followed by combination therapy has an ICER of less than $50,000/QALY for prices of the new protease inhibitor up to $43,200 for a course of therapy.
Conclusions: Newer combination therapy for genotype 1 individuals identified via universal screening is likely cost-effective assuming moderate improvements in efficacy over standard therapy, even assuming fairly substantial increases in total drug costs. Findings from this study suggest new therapies may justify a policy shift toward higher rate of screening and treatment of HCV infections in the U.S.
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