A Modelling Analysis of Financial Incentives for Hepatitis C Testing and Treatment Uptake Delivered Through a Community-based Testing Campaign

Anna Y. Palmer; Kico Chan; Judy Gold; Chloe Layton; Imogen Elsum; Margaret Hellard; Mark Stoove; Joseph S. Doyle; Alisa Pedrana; Nick Scott

Disclosures

J Viral Hepat. 2021;28(11):1624-1634. 

In This Article

Discussion

Our study provides important estimates on the cost of finding and diagnosing people with hepatitis C infection. We found that the cost per person completing testing was A$3215, and the cost per person initiating treatment was A$1055. To maintain the same cost per person completing testing, the model found that an incentive of A$500 for RNA-positive people to return for their test results would need to deliver an 11 percentage point increase in retention in care (from 63% to 74%). To maintain the same cost per person initiating treatment, the model found that an incentive of A$200 for RNA diagnosed people initiating treatment would need to deliver a 16 percentage point increase in retention in care (from 67% to 83%). If baseline retention in care or RNA positivity was lower, incentives only needed to deliver smaller improvements to retain the same unit costs for testing completion and treatment. These findings suggest that in settings with high rates of loss to follow-up, financial incentives to improve retention in care are worth exploring.

To our knowledge, our study provides the first published estimate of the cost of finding and diagnosing people with hepatitis C infection in Australia (~A$3215 per RNA-positive person), and one of only a few studies internationally to estimate the cost of case finding since the introduction of DAA treatment.[27–30] Therefore, our study provides an important estimate for comparing the cost-effectiveness of other programs aiming to find and diagnose people with hepatitis C infection. The costs associated with finding and diagnosing people with hepatitis C infection are not regularly reported in health programs, since they are often hard to quantify where outreach and peer support are spread over multiple services. In the EC Testing Campaign, we found that the overall costs associated with finding and diagnosing people with hepatitis C were significant, accounting for 82% of total costs. This meant that the unit cost per RNA-positive person completing testing was approximately three times the cost per RNA diagnosed person initiating treatment, emphasizing the amount of effort required to find and link people with hepatitis C infection to care (particularly those who have been disengaged from care, which was the primary focus of the campaign event). Unlike other international studies conducted in the UK and Europe, which predominantly focussed on linking patients to care from drug treatment services, the EC Testing Campaign was focussed on linking individuals to care who were not regularly engaged with the health system. As such, the campaign was able to target individuals who do not regularly attend other health services (such as drug treatment centres). This may have contributed to the approximately higher costs accumulated during the campaign compared to some other international studies (€558–2670 [~AUD$884–4231] in[28] and £600–682 [~AUD$1110–1261] in[27]). However, as Australia moves towards the final stages of elimination (and the backlog of 'willing and waiting' people receive treatment[10]), finding and treating individuals who are disengaged from care will be crucial to ensure elimination are actually achieved.

Our study also estimated the cost of initiating RNA diagnosed individuals on treatment using similar methodology to previous costing studies we have conducted.[12,31] We found that the average unit cost per RNA diagnosed person initiating treatment was similar between the EC Testing Campaign (~A$1055 per person) and another primary care treatment pathway (~A$885 per person[12]), suggesting that the cost per diagnosed person initiating treatment may be reasonably consistent across primary care settings, and thus broadly more cost-effective than traditional hospital-based models of care (shown to cost A$2078 per person treated in[12]). Savings in primary-based care (compared to traditional hospital-based treatment) are predominantly due to significant decreases in loss to follow-up in the primary care setting, which in turn improve the efficiency of hepatitis C treatment programs. It is likely that the use of incentives in hepatitis C programs could further reduce loss to follow-up and thus further increase the efficiency of hepatitis C programs, particularly in settings where loss to follow-up is high.

Our modelling of monetary incentive 'thresholds' suggests that current incentive amounts used in programs (typically A$10–20) could be increased quite substantially without increasing the cost per person completing testing/initiating treatment. Further, in sensitivity analysis, we also found that the utility of incentives would be greater where current retention in care or test positivity rates are lower. This is because, as retention in care/test positivity decreases, the amount of money spent on negative tests and people who become lost to follow-up is higher. Therefore, there is a higher incentive 'threshold' we should be prepared to pay to avoid these wasted costs. As Australia moves towards elimination and hepatitis C prevalence declines, the cost of case finding is likely to increase,[32] making incentives an important strategy for reducing wasted costs associated with case finding. Further, as demonstrated in Chan et al.,[16] incentives have wide acceptability in primary health services, with incentives being a key motivating factor for client participation in hepatitis C care.

There are many precedent health programs which offer similar incentive payouts to the amounts we have modelled in this study. For example, in Australia, lower-income families who complete all three childhood immunization check points at the ages of 1, 2 and 5 years of age, are eligible for approximately A$2100 in government payments.[33] Internationally, a Cochrane review found that providing incentives improved long-term smoking cessation with monetary incentives of up to US$1185.[34] Another systematic review found that providing incentives could be effective for encouraging uptake and reducing dropouts in weight loss programs, where incentives may be up to US$799 per month.[35] While the incentives provided in these studies likely significantly increased the overall cost of the health programs, they encouraged behaviour change that had significant downstream health benefits and cost savings, such as decreased need for tertiary health treatment due to long-term health effects. Thus, even though introducing incentives of A$200 or A$500 into hepatitis C programs significantly increases the overall cost of the program (Appendix, Tables S1 & S2), the program would likely find and treat more people with hepatitis C and thus save costs over time, through reduced need to invest in future programs.

There are some limitations to our study. Firstly, given the nurses involved in the campaign had extensive experience with hepatitis C programs and pre-existing relationships with the participating clinical services, the costs associated with organizing a campaign event in another setting may be higher. For example, depending on the availability of human resources in other settings, more external project management expertise may be needed. That said, this increase in cost may be offset by applying the learnings from planning and delivering the 2019 testing campaign. Secondly, our study relied on the ability to perform reflexive hepatitis C RNA testing, which is not available in all settings in Australia. If reflexive testing is not available, this may increase the loss to follow-up rate during the testing stage of the study and therefore increase the unit cost per person completing testing. Thirdly, clinical time spent on following up attendees and initiating them on treatment was based on retrospective estimation and average reported values and could vary depending on the complexity of the person's health needs. However, given that people living with hepatitis C infection generally do not require consultation with a specialist doctor,[36] average time may be an appropriate measure. Fourthly, since the campaign was conducted as part of a larger research-orientated elimination program (EC Victoria), a proportion of costs were dedicated to evaluation-related activities. If conducted in other settings, these costs could be lessened and would reduce the overall costs of the campaign. Finally, it should be noted that providing financial incentives for testing and initiating treatment may not be appropriate in all settings. While the use of financial incentives in the EC Testing Campaign was met with positivity by staff and attendees,[16] in other settings staff expressed concerns that incentives could clash with the ethos of some health services.[20] Thus, consideration into whether incentives are acceptable and appropriate within a particular health service should occur before incorporating incentives into a hepatitis C treatment program.

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