Hepatitis C: Let's Get 'Real'

Digestive Disease Week (DDW) 2016

William F. Balistreri, MD


June 24, 2016

In This Article

Cost and Access

Healthcare Expenditure and Trends in Healthcare Utilization

Chronic liver disease is the 12th leading cause of death in the United States.[18] Affected patients, such as those with chronic HCV infection, experience a financial burden due to their disease, including substantial healthcare expenses, negative impact on employment, and a significant impairment in quality of life.

Wadhwa and colleagues[19] evaluated the current burden of hospitalizations due to hepatitis C infection by using the National Inpatient Sample Database to find all subjects for whom hepatitis C was the discharge diagnosis from 1997 to 2012. In 1997, there were 134,161 hospitalizations due to hepatitis C, which rose to 607,056 in 2012. In addition, hospital charges for HCV-related admission increased an average of $2182 per year, while the average length of stay decreased by a small amount each year. In-hospital deaths during HCV admissions decreased an average of 4% per year. Of note, the number of admissions for HCV-related cirrhosis increased by 342%, and the number of admissions for HCV-related HCC increased by 645% during the study period.

A Detailed Cost-Mapping Study

Telaprevir regimens for chronic hepatitis C genotype 1 treatment were associated with an average cost of $189,000 per SVR. Newer DAA regimens are better tolerated and thus may not engender costs associated with side-effect management, which was often necessary with the previous regimens. This, together with their high efficacy, suggests that cost per SVR will be lower for the new regimens compared with that of prior regimens.

Nyberg and colleagues[20] used detailed cost mapping to determine the cost per SVR for patients treated with LDV/SOF ± ribavirin. All inpatient and outpatient cost codes associated with each patient undergoing HCV treatment with this regimen for 1 year were determined. Derived costs were then mapped to each unique code and all codes were linked to 1262 patients who underwent treatment during the study period. This detailed cost-mapping study included total inpatient and outpatient costs associated with all medical care given to each unique patient during treatment. Thus, it included costs over and above the expense of medications. The average cost per SVR was $75,502 for noncirrhotic patients and $100,518 for patients with cirrhosis.

Because of the better tolerability of the new agents and the high SVR, cost per SVR using LDV/SOF ± ribavirin is lower than the cost previously reported for interferon-based treatment with and without first-generation DAAs.

Access to Therapy: Real-World Experience

The improved SVR rates associated with the new DAA regimens allow highly cost-effective treatment, but the economic impact on payers has resulted in limited access to care.

Dieterich and colleagues[21] assessed patients with genotype 1 HCV who had been prescribed 8, 12, or 24 weeks of currently approved DAA regimens in a real-world setting to assess disparities in access to care. Data were obtained from providers and specialty pharmacies through Trio Health's Innervation Platform for 2878 patients in whom an all-oral treatment was intended to commence between October 2014 and June 2015. Unanticipated increases of non-start rates to double-digit levels were observed in commercial and Medicare groups. The theme of denied access to Medicaid patients was noted to have continued with newer DAA regimens. More than 33% of patients who were denied access had stage 3 or 4 fibrosis, were at risk for liver-related complications, and were described as the most urgent candidates for therapy.

Bottom Line

The new DAA regimens really work. Hopefully, in the very near future, clinicians will be able to select and administer a DAA combination that they deem to be optimal for each individual patient.

Now that we have the hepatitis C virus on the run, can a universal cure be attained? At a recent World Health Assembly, member states voted to adopt the first strategy targeted to eliminate worldwide viral hepatitis within the next 14 years. The goal of the Global Health Sector Strategy on Viral Hepatitis is to eradicate viral hepatitis by 2030, saving 7.1 million lives.[22] Targets of the strategy include raising awareness and increasing access to treatment. We have the way. Do we have the will?


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