Early hepatitis C treatment may not be cost-saving in France - but early diagnosis will save money

Treating hepatitis C earlier than recommended by current French and European treatment guidelines, before the development of severe liver fibrosis, may not result in substantial cost savings even if the price of direct-acting antivirals falls, according to findings from a mathematical model presented at the 48^th International Liver Congress (EASL 2013) in Amsterdam last month.

But the study also showed that early diagnosis of hepatitis C and initiation of treatment before the development of serious liver damage – prior to reaching F3 fibrosis or cirrhosis – has the potential to save large sums of money and to make it affordable to treat a much larger number of people.

Some have argued that it would be possible to save money in the long term by increasing rates of hepatitis C diagnosis to identify people before they develop serious liver disease. Furthermore, by expanding treatment to all people diagnosed with hepatitis C, it might be possible to save money in the long term by reducing the costs of hospital care for people with severe liver disease.

Little research has been carried out to evaluate whether treating people with hepatitis C early in the disease course, before they develop severe liver disease, would save money in the long term.

Using data from the French health system, Michaël Schwarzinger presented the results of a modelling study which looked at the costs of treating hepatitis C infection at each stage of fibrosis. The model took into account the levels of health service utilisation associated with each stage of the disease.

These costs were offset against the costs of hepatitis C treatment using pegylated interferon, ribavirin and either telaprevir or boceprevir, to determine whether different thresholds for starting treatment might raise or lower costs for the French health system.

The investigators used two data sources to calculate the costs attributable to chronic HCV mono-infection.

First, they estimated the annual hospitalisation costs attributable to HCV for 49,391 people identified in the French national hospital database according to the stage of liver disease, from mild fibrosis through to liver transplant. These costs were tracked from January 2008 until the person’s death, or until December 2010 if they survived.

Second, the investigators calculated the annual treatment administration costs according to liver disease stage for 128 mono-infected people receiving outpatient care from January 2009 until either a diagnosis of cirrhosis or until April 2012.

They then estimated the immediate costs at 2010 values associated with treating 55-year-old patients with genotype 1 HCV infection, 60% male with genotype-1 infection. People received treatment with triple therapy based on one of the currently licensed protease inhibitors (telaprevir or boceprevir). The investigators also estimated the lifetime savings that would be achieved if this treatment were successful.

The costs of providing outpatient care were modest, reaching a high of €228 per year for individuals with compensated cirrhosis.

Hospitalisation involved considerably more expense, increasing from approximately €280 per year for people with mild fibrosis, to €11,000 a year for a patient with decompensated but stable cirrhosis, to over €90,000 for a patient dying in the first year after liver transplant.

The lifetime costs of care were associated with the severity of liver disease at diagnosis. French HCV treatment guidelines recommend that someone should initiate therapy if they have progressed to fibrosis stage F2 or above. The model assumed that treatment began either at the time that person reached the F2 stage or immediately if the person had already reached or gone beyond this stage.

The model analysed the lifetime cost of diagnosing people prior to reaching the stage of F2 fibrosis, including the cost of treating at the F2 stage. This calculation was carried out in order to determine whether attempts to improve rates of early diagnosis of hepatitis C through more comprehensive screening would result in cost savings.

The lifetime treatment costs for a patient with mild fibrosis (F1) were €32,167. Lifetime costs increased to almost €36,690 for a patient aged 56 with moderate fibrosis (F2) and to over €73,000 for an individual with cirrhosis.

The analysis showed that the lifetime cost of care and treatment was somewhat lower if hepatitis C was diagnosed at the F0 stage of fibrosis when compared to F1 stage fibrosis (a difference of €4694). The lifetime cost saving was greater if hepatitis C was diagnosed at the F1 stage when compared to the F2 stage (a saving of €7523).  Much greater savings were possible if people were diagnosed prior to reaching the F3 or F4 stages (severe fibrosis or cirhhosis).

Reductions in drug costs had a very modest impact on the lifetime cost of treatment when considering the cost savings achieved by treating at fibrosis stages F1 or F2.

The investigators concluded that the lifetime cost of treatment at current prices was higher if treatment was initiated during fibrosis stages F0 and F1 than if treatment was delayed to the F2 stage. Diagnosis of hepatitis C at the F1 stage prior to the development of severe fibrosis, on the other hand, would be cost-saving. If 10,000 people with hepatitis C were diagnosed in the F1 stage rather than the F3 stage, the lifetime saving would amount to €180 million – enough to meet the lifetime treatment costs of an extra 5595 people diagnosed at the F1 stage.