Gutkind Sarah, Schackman Bruce R, Morgan Jake R, Leff Jared A, Agyemang Linda, Murphy Sean M, Akiyama Matthew J, Norton Brianna L, Litwin Alain H, Linas Benjamin P
Department of Healthcare Policy & Research, Weill Cornell Medical College, New York.
Department of Medicine, Section of Infectious Diseases, Boston Medical Center, Massachusetts.
Clin Infect Dis. 2020 Mar 17;70(7):1397-1405. doi: 10.1093/cid/ciz384.
Many people who inject drugs in the United States have chronic hepatitis C virus (HCV). On-site treatment in opiate agonist treatment (OAT) programs addresses HCV treatment barriers, but few evidence-based models exist.
We evaluated the cost-effectiveness of HCV treatment models for OAT patients using data from a randomized trial conducted in Bronx, New York. We used a decision analytic model to compare self-administered individual treatment (SIT), group treatment (GT), directly observed therapy (DOT), and no intervention for a simulated cohort with the same demographic characteristics of trial participants. We projected long-term outcomes using an established model of HCV disease progression and treatment (hepatitis C cost-effectiveness model: HEP-CE). Incremental cost-effectiveness ratios (ICERs) are reported in 2016 US$/quality-adjusted life years (QALY), discounted 3% annually, from the healthcare sector and societal perspectives.
For those assigned to SIT, we projected 89% would ever achieve a sustained viral response (SVR), with 7.21 QALYs and a $245 500 lifetime cost, compared to 22% achieving SVR, with 5.49 QALYs and a $161 300 lifetime cost, with no intervention. GT was more efficient than SIT, resulting in 0.33 additional QALYs and a $14 100 lower lifetime cost per person, with an ICER of $34 300/QALY, compared to no intervention. DOT was slightly more effective and costly than GT, with an ICER > $100 000/QALY, compared to GT. In probabilistic sensitivity analyses, GT and DOT were preferred in 91% of simulations at a threshold of <$100 000/QALY; conclusions were similar from the societal perspective.
All models were associated with high rates of achieving SVR, compared to standard care. GT and DOT treatment models should be considered as cost-effective alternatives to SIT.
在美国，许多注射吸毒者患有慢性丙型肝炎病毒（HCV）。阿片类激动剂治疗（OAT）项目中的现场治疗可解决HCV治疗障碍，但基于证据的模型很少。
我们使用在纽约布朗克斯进行的一项随机试验的数据，评估了针对OAT患者的HCV治疗模型的成本效益。我们使用决策分析模型，比较自我管理的个体治疗（SIT）、团体治疗（GT）、直接观察治疗（DOT）以及对具有与试验参与者相同人口统计学特征的模拟队列不进行干预的情况。我们使用已建立的HCV疾病进展和治疗模型（丙型肝炎成本效益模型：HEP - CE）预测长期结果。从医疗保健部门和社会角度报告的增量成本效益比（ICER）以2016年美元/质量调整生命年（QALY）为单位，每年贴现3%。
对于分配到SIT的患者，我们预测89%的人将实现持续病毒学应答（SVR），获得7.21个QALY，终身成本为245,500美元；相比之下，不进行干预时，22%的人实现SVR，获得5.49个QALY，终身成本为161,300美元。GT比SIT更有效率，每人额外获得0.33个QALY，终身成本降低14,100美元，与不进行干预相比，ICER为34,300美元/QALY。DOT比GT稍有效但成本更高，与GT相比，ICER > 100,000美元/QALY。在概率敏感性分析中，在阈值 < 100,000美元/QALY时，91%的模拟中GT和DOT更受青睐；从社会角度得出的结论相似。
与标准治疗相比，所有模型实现SVR的比例都很高。GT和DOT治疗模型应被视为SIT具有成本效益的替代方案。
