Miriam E. Tucker

November 14, 2013

WASHINGTON, DC — The Extension for Community Healthcare Outcomes (ECHO) program, which trains primary care physicians to treat patients infected with hepatitis C in underserved communities, is cost-effective, a new analysis shows.

"ECHO provides resource-efficient access to care for underserved communities," John Wong, MD, from Tufts University in Boston, told Medscape Medical News.

He presented the findings here at The Liver Meeting 2013.

The ECHO program, developed at the University of New Mexico Health Sciences Center, uses teleconferencing to help primary care physicians and specialists at the university comanage patients with chronic hepatitis C infection in 16 underserved rural areas and 5 correctional facilities.

Initial efficacy findings for 407 patients showed that the rates of sustained viral response at ECHO sites were nearly identical to those at university clinics (58.2% vs 57.5%) (N Engl J Med. 2011;364:2199-2207).

The cost is $3000; that's nothing, and the cure rate is as good as at a university.

Dr. Wong and his team compared the cost of pegylated interferon plus ribavirin with no treatment for each of 261 patients at the 21 ECHO sites. Mean patient age was 42 years, 73% were male, and 95% were white. A quarter had cirrhosis, 30% had moderate hepatitis, and 56% had genotype 1 hepatitis C.

Factored into the model were costs for office visits, lab tests, antiviral drugs, adverse effects, psychiatry, travel, productivity, and corrections personnel.

Compared with no treatment, the researchers projected that ECHO management would reduce the lifetime incidence of cirrhosis by 63%, decompensated cirrhosis by 46%, hepatocellular carcinoma by 45%, and liver death by 46%.

With ECHO, projected life expectancy would increase by 4.4 years, producing a cost saving of $12,200 without discounting for future disease costs. With discounting, ECHO had a cost of $9,000.

Compared with no antiviral therapy, the program saves money in 35% of patients overall, in 30% of patients in the community setting, and in 43% of patients in correctional facilities. Another 23% benefited with ECHO management, but some at higher costs. In 42% of patients, the treatment didn't work.

The incremental cost-effectiveness ratio — the rate of additional cost to additional benefit — was $3700 for the entire study population, $5800 for the community, and $1400 for the corrections facilities.

The incremental cost-effectiveness ratio reflects what the intervention costs to increase life expectancy by 1 year of perfect health (cost-quality-adjusted life-year gained). The World Health Organization considers an intervention to be very cost-effective if that ratio is less than the per capita gross domestic product of a country, and to be cost-effective if it is less than 3 times the per capita GDP, Dr. Wong explained.

"The mean per capita GDP in the United States is $50,000, so this is 10-fold lower, and therefore very cost-effective," he said.

Dr. Wong reported that ECHO now includes triple therapy and that he expects the much-anticipated polymerase inhibitor sofosbuvir and the protease inhibitor simeprevir to be added once they are approved by the US Food and Drug Administration. He said he anticipates that ECHO will be cost-effective as long as triple therapy remains effective.

Both session comoderators told Medscape Medical News that they are impressed with the findings.

"I think it shows that increasing access isn't costly, it's cost effective. The cost is $3000; that's nothing, and the cure rate is as good as at a university," said comoderator Sammy Saab, MD, from the David Geffen School of Medicine at UCLA.

"If the new hepatitis C drugs have a better safety profile, a lot of the treatment can be undertaken by primary care providers, which would be a huge boon for people," added comoderator Kiran Bambha, MD, from the University of Colorado Medical Center in Denver.

Dr. Wong and Dr. Bambha have disclosed no relevant financial relationships. Dr. Saab is a consultant to Bristol-Myers Squibb.

The Liver Meeting 2013: American Association for the Study of Liver Diseases (AASLD). Abstract 245. Presented November 5, 2013.


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