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Health Services Research & Development

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2012 HSR&D/QUERI National Conference Abstract

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2012 National Meeting

3151 — Potential Cost Effectiveness of New Direct-Acting Antiviral (DAA) Therapy for Untreated Chronic Hepatitis C Genotype 1 Infection in the VA System

Chan K, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, and Boston University; Lai MN, and Groessl EJ, VA San Diego Healthcare System and University of California, San Diego; Hanchate A, VA Boston Healthcare System and Boston University; Wong JB, Tufts University, Boston, MA; Clark J, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, and Boston University; Asch SM, VA Palo Alto Healthcare System and Stanford University; Gifford AL, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, and Boston University; Ho SB, VA San Diego Healthcare System and University of California, San Diego;

Objectives:
The newly approved direct acting antivirals (DAAs), Boceprevir (BOC) and Telaprevir (TEL) have significantly improved SVR rates for HCV Genotype 1 (GT1) patients. The objective was to project potential costs and benefits of DAAs on GT1 patients in the Veterans Health Administration (VHA).

Methods:
A decision-analytic Markov model was developed to simulate the lifetime progression of HCV disease and to estimate the costs and clinical impacts of DAA in the current cohort of 103,331 GT1 treatment-naïve patients. Federal pricing for drug costs and published antiviral efficacy data were used, corrected for baseline fibrosis, demographics and co-morbidities of VHA patients. Treatment costs included drugs, inpatient/outpatient visits, and laboratory tests. Four treatment strategies were studied: (1) no treatment, (2) dual therapy pegylated interferon alfa and ribavirin (PR), (3) BOC+PR triple therapy, and (4) TEL+PR triple therapy.

Results:
Taking into account published virologic response rates relative to control, response guided therapy, and stopping rules, the average treatment weeks included 1) PR for 38 weeks, 2) BOC for 30 wks with PR for 35 wks, or 3) TEL for 12 wks with PR for 27 wks. Estimated current treatment costs for PR, BOC+PR, and TEL+PR are $8000, $ 31,300 and $ 41,700 per average patient, respectively. Assuming continuation of the current treatment rate of 21%, the total system-wide costs to adopt BOC+PR or TEL+PR would be $679 million and $905 million, respectively. Assuming a 21% treatment rate, the relative reduction in liver-related death from no treatment is 5%, 8.7%, and 8.4% for PR, Boc+PR, and Tel+PR, respectively. If 50% of patients are treated, the relative reduction in liver-related death from no treatment is 11.9%, 20.5%, and 20.3% for PR, BOC+PR, and TEL+PR, respectively. Preliminary incremental cost effectiveness ratios for treatment BOC+PR, and TEL+PR vs. PR alone are $21,393 per QALY and $41,982 per QALY, respectively.

Implications:
Our model indicates potential high upfront investments with BOC+PR, and TEL+PR, with acceptable incremental cost effectiveness compared with standard PR or no treatment. Despite greater efficacy, the overall impact of DAA on liver related death may be limited due to low antiviral treatment rates.

Impacts:
These data illustrate the implications of increasing antiviral treatment rates and optimizing adherence in the VHA system. This model will allow continued estimations of costs and benefits in the VHA with rapidly evolving new therapies with greater tolerance and efficacy.


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