Hepatitis C: Toward New Public Health Models to Improve Detection and Treatment

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Chronic hepatitis C virus (HCV) infection remains a constant public health risk, despite the recent introduction of safe and highly effective oral antiviral agents. The Centers for Disease Control and Prevention (CDC) estimates that 2.7-3.9 million people in the US are infected with chronic HCV.¹ The actual incidence of infection is likely to be significantly underestimated, as CDC records showed a total of 2,194 HCV cases reported in 2014, a year when it was probable that 30,500 cases actually occurred.¹

Major healthcare organizations have identified goals designed to significantly reduce the global burden of viral hepatitis in the coming decades, through increased HCV screening and access to care.^2,3 The target of the World Health Organization (WHO) is a 30% reduction of the incidence of HPV along with elimination of viral hepatitis as a public health threat by 2030.² In a similar vein, the US National Viral Hepatitis Action Plan set a goal of a 60% reduction in new cases by the year 2020, accompanied by a plan to increase awareness among at least two-thirds of infected individuals.³

One of the greatest obstacles to attaining these objectives in the past has been the simple math of too few physicians, particularly the specialists needed to provide optimal care for HCV. A solution to this problem, according to a study by Rattay and colleagues⁴ is to extend the knowledge of specialists to primary care physicians (PCPs) working on a local level. To this end, they investigated the potential cost effectiveness of applying the Extension for Community Healthcare Outcomes (ECHO) project model to improving diagnosis and access to treatment for people with HCV, compared to status quo treatment over the long term. Simulated models showed that by using existing resources guided by PCPs, the ECHO project would be a cost-effective manner of treating HCV on a full-scale level.

Tapping telemedicine

Utilizing a telemedicine approach in which a multidisciplinary base of specialists from major academic institutions mentored PCPs and nurse practitioners working directly with infected patients, the ECHO model (initially applied in New Mexico) allowed for community-based PCPs to provide therapeutically specialized care to a broadly underserved population. The results showed a gain of 1.41 quality-adjusted life years (QALYs) from 13.63 without ECHO to 15.04 with ECHO, which the authors attributed to higher diagnostic and treatment rates.
ECHO vastly expanded treatment access by redistributing direct treatment responsibilities to PCPS who were able to effectively treat 13 patients per year (a rate the authors noted was on the low end of the confidence scale), compared to the non-ECHO model of referral to specialists in which 2.7 patients were treated.

The benefits of the ECHO approach were more significant than just numbers of patients treated, as life expectancy for the treated HCV patients also increased. Harder to measure were the benefits of years lived without developing liver fibrosis or needing a liver transplant.

Steep downside

The main drawback to ECHO was that direct costs to payors were significantly increased by $267.4 million in the first 5 years of a patient’s treatment, for a total of $707.9 million (compared to $440.6 million without ECHO), due largely to the high prices of antiviral therapies. Additionally, the model showed that substantial increases in the numbers of patients being diagnosed and treated represented an additional $350.5 million in costs for the first year. Conversely, treatment would convert 4446 patients in the same insurance pool from active HCV status, resulting in a savings of $11 million over 5 years.

The investigators pointed out that as ECHO application has the best potential to achieve the ambitious public health goals for the large scale identification and treatment of HCV, an important component of cost management will be competitive pricing of newly emerging therapies to drive down individual costs. “Importantly, most of the financial benefits of treating HCV are not immediate, whereas most of the costs are upfront. Therefore, a long-term perspective on patient care must be adopted,” they wrote.

References:

1. Centers for Disease Control and Prevention: Viral Hepatitis. Accessed February 5, 2018.

2. World Health Organization (WHO). Global health sector strategy on viral hepatitis 2016-2021. Towards ending viral hepatitis. 2016. Accessed February 8, 2018.

3. Federal Viral Hepatitis Implementation Group, Office of HIV/AIDS and Infectious Disease Policy (OHAIDP), Department of Health and Human Services (HHS), et al. U.S. National Viral Hepatitis Action Plan (2017-2020) January 2017.

4. Rattay T, Dumont IP, Heinzow HS, Hutton DW.  Cost-effectiveness of access expansion to treatment of hepatitis C infection through primary care providers. Gastroenterol. 2017;153:1531–1543.e2.

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