The cost-effectiveness of birth-cohort screening for hepatitis C antibody in U.S. primary care settings

Abstract

Background: In the United States, hepatitis C virus (HCV) infection is most prevalent among adults born from 1945 through 1965, and approximately 50% to 75% of infected adults are unaware of their infection.

Objective: To estimate the cost-effectiveness of birth-cohort screening.

Design: Cost-effectiveness simulation.

Data sources: National Health and Nutrition Examination Survey, U.S. Census, Medicare reimbursement schedule, and published sources.

Target population: Adults born from 1945 through 1965 with 1 or more visits to a primary care provider annually.

Time horizon: Lifetime.

Perspective: Societal, health care.

Intervention: One-time antibody test of 1945-1965 birth cohort.

Outcome measures: Numbers of cases that were identified and treated and that achieved a sustained viral response; liver disease and death from HCV; medical and productivity costs; quality-adjusted life-years (QALYs); incremental cost-effectiveness ratio (ICER).

Results of base-case analysis: Compared with the status quo, birth-cohort screening identified 808,580 additional cases of chronic HCV infection at a screening cost of $2874 per case identified. Assuming that birth-cohort screening was followed by pegylated interferon and ribavirin (PEG-IFN+R) for treated patients, screening increased QALYs by 348,800 and costs by $5.5 billion, for an ICER of $15,700 per QALY gained. Assuming that birth-cohort screening was followed by direct-acting antiviral plus PEG-IFN+R treatment for treated patients, screening increased QALYs by 532,200 and costs by $19.0 billion, for an ICER of $35,700 per QALY saved.

Results of sensitivity analysis: The ICER of birth-cohort screening was most sensitive to sustained viral response of antiviral therapy, the cost of therapy, the discount rate, and the QALY losses assigned to disease states.

Limitation: Empirical data on screening and direct-acting antiviral treatment in real-world clinical settings are scarce.

Conclusion: Birth-cohort screening for HCV in primary care settings was cost-effective.

Primary funding source: Division of Viral Hepatitis, Centers for Disease Control and Prevention.

Figure 1. Univariate sensitivity of the incremental cost-effectiveness ratio of birth-cohort screening with standard treatment compared with risk-based screening assuming pegylated interferon with ribavirin treatment

QALY = quality-adjusted life-year; SVR = sustained viral response.

Figure 2. Cost-effectiveness acceptability curve: probability that each screening scenario is the most cost-effective by willingness to pay per incremental QALY gained

Birth cohort, standard treatment = 1-time screening of all individuals born from 1945 through 1965 with pegylated interferon with ribavirin (i.e., standard) treatment for those who enter treatment; birth cohort, direct-acting antivirals = 1-time screening of all individuals; no screening = no screening or treatment; risk-based = status quo equivalent of screening based on identified risk factors followed by pegylated interferon with ribavirin treatment for those who enter treatment. QALY = quality-adjusted life-year.