Use of Healthcare Resources and Drug Expenditure Before and After Treatment of Chronic Hepatitis C With Direct Antiviral Agents

Mercedes Vergara; Mireia Miquel; Emili Vela; Montserrat Cleries; Caridad Pontes; Alba Prat; Montse Rué


J Viral Hepat. 2021;28(5):728-738. 

In This Article


Study Population

A total of 13,329 patients were treated with DAA, but 1,130 were excluded according to the criteria as shown in the flow chart (Figure 1). A total of 12,199 patients with CHC treated with DAA between 1 January 2015 and 31 December 2017 met the inclusion criteria (2,486 in 2015, 5,641 in 2016 and, 4,072 in 2017, respectively); 7,158 (58.7%) were men. The mean age was 57.7 (±12.4) years, and 2,228 (18.3%) patients had HIV co-infection. The most frequent fibrosis stage was cirrhosis, in 3,672 (30.1%) patients. The most frequent comorbidities were diabetes mellitus (2,193 (18%) patients) and depression (3,128 (25.6%) patients). Almost half of the patients were defined as moderate risk on the AGM stratum (Table 1).

Figure 1.

Flow chart of included and excluded patients

Use of Healthcare Resources and Drug Expenditure Pre- and Post-DAA Treatment

Use of healthcare resources was lower in the post-treatment period than the pre-treatment period, with a decrease in hospital admissions due to cirrhosis complications from 0.19 to 0.12 per 100 patients per month (RR 0.57; 95% CI 0.47–0.68), a decrease in length of hospital stay from 12.9 to 12.2 days per 100 patients per month (RR 0.93; 95% CI 0.91–0.94) and a decrease in outpatient visits (specialists) from 65.0 to 49.2 (RR 0.75; 95% CI 0.74–0.75). In contrast, the rate of primary care consultation increased slightly after DAA treatment from 90.5 to 91.5 (RR 1.03; 95% CI 1.02–1.04) (Figure 2). No significant differences were observed in the number of emergency department visits or hospital admissions. The number of medication containers received per patient per month decreased from 13.9 to 12.5 (RR 0.84; 95% CI 0.84–0.84) (Figure 3), and the use of antineoplastic drugs increased, as shown in Figure 4.

Figure 2.

Relative variation of healthcare resource use in the 12 months before and 24 months after treatment with DAA

Figure 3.

Relative use of different drugs in the 12 months before and 24 months after treatment with DAA

Figure 4.

Variation in the monthly rate of antineoplastic drugs dispensed before and after DAA treatment

Analysis According to Fibrosis Stage. The distribution of patients according to fibrosis stage was as follows: 15.5% had stage 0 or 1, 22.6% had stage 2, 18.2% had stage 3, 27.7 had compensated cirrhosis, and 16% had decompensated cirrhosis.

Patients with decompensated cirrhosis before antiviral treatment had the biggest decrease in healthcare resource use, not only in number of hospital admissions, from 7.0 to 5.3, but also in the relative risk of hospital admission due to complications of cirrhosis, from 1.3 to 0.6, outpatient visits, from 94.3 to 74.2, and emergency department and primary care visits (Table 2). However, use of medications only decreased for certain types: enzyme use decreased from 0.24 to 0.06 containers per month, antihaemorrhagics from 6.5 to 2.5 and anti-inflammatories and antirheumatics—which are contraindicated in this type of patient due to renal complications—from 5.2 to 4.4.

For patients in all the other categories, the only reductions were outpatient visits and number of drug invoices. As fibrosis stage increased, the number of invoices per month for antineoplastic drugs pre- and post-treatment increased from 1.89 to 2.23 in stage 1 fibrosis, 0.89 to 9.19 in patients with compensated cirrhosis and from 1.2 to 4.9 in decompensated cirrhosis (Table 3).

Analysis According to Risk Group. Based on comorbidities, 17.2% of patients were considered high-risk. In this patient group, healthcare resource use was equal or decreased post-treatment. The most pronounced decrease was in hospitalization secondary to complications of cirrhosis, from 0.76 to 0.45 patients per month, and in outpatient visits, from 99.38 to 85.41 (Table S1). Similar changes occurred in patients with moderate risk. In patients with basal or low risk, the only healthcare resources with decreased use were outpatient visits and number of invoices (Figure 5).

Figure 5.

Variation in healthcare resource use in high-risk patients before and after DAA treatment

All groups had fewer invoices post-DAA treatment, except for antineoplastic drugs which increased in all patient groups (Table S2).

In general, there was a tendency to increased resource use post-DAA treatment in lower-risk groups and decreased resource use as the comorbidity burden increased.

Analysis According to HIV Co-infection. Patients with HIV co-infection (2,228 (18.3%)) showed similar results to those of the entire cohort (Table S3), except for an increase in the number of primary care visits, with a relative risk of 1.12 (95% CI 1.11–1.14). Invoicing of all medication groups increased, especially antineoplastic drugs, with a relative risk of 8.625 (95% CI 7.146–10.409) (Table S4).