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 48th 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
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.
- compensated cirrhosis
The earlier stage of
cirrhosis, during which the liver is damaged but still able to perform most of
its functions. See also ‘cirrhosis’ and ‘decompensated cirrhosis’.
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
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
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.