Tan Jennifer A, Joseph Tom A, Saab Sammy
Department of Medicine, University of California at Los Angeles, Los Angeles, CA 90095, USA.
Hepatology. 2008 Nov;48(5):1387-95. doi: 10.1002/hep.22509.
The prevalence of chronic hepatitis C infection in U.S. prisons is 12% to 31%. Treatment of this substantial portion of the population has been subject to much controversy, both medically and legally. Studies have demonstrated that treatment of chronic hepatitis C with pegylated interferon (PEG IFN) and ribavirin is a cost-effective measure in the general population; however, no study has addressed whether the same is true of the prison population. The aim of this study was to determine the cost-effectiveness of hepatitis C treatment with PEG IFN and ribavirin in the U.S. prison population. Cost-effectiveness was determined via a decision analysis model employing Markov simulation. The cohort of prisoners had a distribution of genotypes and stages of fibrosis in accordance with prior studies evaluating inmate populations. The probability of transitioning from one health state to another, reinfection rates, in-prison and out-of-prison mortality rates, sustained viral response rates, costs, and quality of life weights were also obtained from the literature. Sensitivity analysis was performed. In a strategy without a pretreatment liver biopsy, treatment was cost-effective for all ages and genotypes. This model was robust to rates of disease progression, mortality rates, reinfection rates, sustained viral response rates, and costs. In a strategy employing a pretreatment liver biopsy, treatment was also cost-saving for prisoners of all ages and genotypes with portal fibrosis, bridging fibrosis, or compensated cirrhosis. Treatment was not cost-effective in patients between the ages of 40 and 49 with no fibrosis and genotype 1.
Treatment of chronic hepatitis C with PEG IFN and ribavirin in U.S. prisons results in both improved quality of life and savings in cost for almost all segments of the inmate population. If the decision to treat hepatitis C is based on pharmaco-economic measures, this significant proportion of infected individuals should not be denied access to therapy.
美国监狱中慢性丙型肝炎感染的患病率为12%至31%。对这一相当大比例人群的治疗在医学和法律上都备受争议。研究表明，聚乙二醇干扰素（PEG IFN）联合利巴韦林治疗慢性丙型肝炎在普通人群中是一种具有成本效益的措施；然而，尚无研究探讨监狱人群是否同样如此。本研究的目的是确定在美国监狱人群中使用PEG IFN和利巴韦林治疗丙型肝炎的成本效益。通过采用马尔可夫模拟的决策分析模型来确定成本效益。囚犯队列的基因型和纤维化阶段分布与先前评估囚犯群体的研究一致。从文献中还获取了从一种健康状态转变为另一种健康状态的概率、再感染率、监狱内和出狱后的死亡率、持续病毒学应答率、成本以及生活质量权重。进行了敏感性分析。在不进行治疗前肝活检的策略中，治疗对所有年龄和基因型都是具有成本效益的。该模型对疾病进展率、死亡率、再感染率、持续病毒学应答率和成本具有稳健性。在采用治疗前肝活检的策略中，对于所有年龄且患有门脉纤维化、桥接纤维化或代偿期肝硬化的基因型的囚犯，治疗也是节省成本的。对于年龄在40至49岁之间、无纤维化且为基因型1的患者，治疗不具有成本效益。
在美国监狱中使用PEG IFN和利巴韦林治疗慢性丙型肝炎可改善几乎所有囚犯群体的生活质量并节省成本。如果治疗丙型肝炎的决策基于药物经济学措施，不应拒绝这一相当大比例的感染个体接受治疗。
