title: Cost effectiveness of direct-acting antiviral therapy for treatment-naive patients with chronic HCV genotype 1 infection in the veterans health administration.
abstract: OBJECTIVE
  The Veterans Health Administration (VHA) is the largest single provider of care for hepatitis C virus (HCV) infection in the United States. We analyzed the cost effectiveness of treatment with the HCV protease inhibitors boceprevir and telaprevir in a defined managed care population of 102,851 patients with untreated chronic genotype 1 infection.
  
  
  METHODS
  We used a decision-analytic Markov model to examine 4 strategies: standard dual-therapy with pegylated interferon-alfa and ribavirin (PR), the combination of boceprevir and PR triple therapy, the combination of telaprevir and PR, or no antiviral treatment. A sensitivity analysis was performed. Sources of data included published rates of disease progression, the census bureau, and VHA pharmacy and hospitalization cost databases.
  
  
  RESULTS
  The estimated costs for treating each patient were $8000 for PR, $31,300 for boceprevir and PR, and $41,700 for telaprevir and PR. Assuming VHA treatment rates of 22% and optimal rates of sustained virologic response, PR, boceprevir and PR, and telaprevir and PR would reduce relative liver-related deaths by 5.2%, 10.9%, and 11.5%, respectively. Increasing treatment rates to 50% would reduce liver-related deaths by 12%, 24.7%, and 26.1%, respectively. The incremental cost-effectiveness ratios were $29,184/quality-adjusted life-years for boceprevir and PR and $44,247/quality-adjusted life-years for telaprevir and PR vs only PR. With the current 22% treatment rate, total system-wide costs to adopt boceprevir and PR or telaprevir and PR would range from $708 to $943 million.
  
  
  CONCLUSIONS
  Despite substantial up-front costs of treating HCV-infected patients in the VHA with PR, or telaprevir and PR, each regimen improves quality of life and extends life expectancy by reducing liver-related morbidity and mortality, and should be cost effective. Further efforts to expand access to direct-acting antiviral therapy are warranted.
authors.affiliation: Department of Health Sciences, College of Health and Rehabilitation Sciences, Sargent College, Boston University, Boston, Massachusetts; Department of Epidemiology, School of Public Health, Boston University, Boston, Massachusetts; VA HIV/Hepatitis Quality Enhancement Research Initiative, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts.
authors.forename: Kee
authors.initials: K
authors.lastname: Chan
authors.forename: Mai Ngan
authors.initials: MN
authors.lastname: Lai
authors.forename: Erik J
authors.initials: EJ
authors.lastname: Groessl
authors.forename: Amresh D
authors.initials: AD
authors.lastname: Hanchate
authors.forename: John B
authors.initials: JB
authors.lastname: Wong
authors.forename: Jack A
authors.initials: JA
authors.lastname: Clark
authors.forename: Steven M
authors.initials: SM
authors.lastname: Asch
authors.forename: Allen L
authors.initials: AL
authors.lastname: Gifford
authors.forename: Samuel B
authors.initials: SB
authors.lastname: Ho
mesh_terms: D000998:Antiviral Agents / Q000191:economics* / Q000627:therapeutic use*; D003362:Cost-Benefit Analysis; D004359:Drug Therapy, Combination / Q000191:economics / Q000379:methods; D005260:Female; D005838:Genotype; D016174:Hepacivirus / Q000145:classification* / Q000235:genetics* / Q000302:isolation & purification; D019698:Hepatitis C, Chronic / Q000188:drug therapy* / Q000191:economics* / Q000821:virology; D006801:Humans; D007372:Interferons / Q000191:economics / Q000627:therapeutic use; D008017:Life Expectancy; D008297:Male; D008875:Middle Aged; D009842:Oligopeptides / Q000191:economics / Q000627:therapeutic use; D011392:Proline / Q000031:analogs & derivatives / Q000191:economics / Q000627:therapeutic use; D011788:Quality of Life; D012254:Ribavirin / Q000191:economics / Q000627:therapeutic use; D016019:Survival Analysis; D016896:Treatment Outcome; D014481:United States; D014493:United States Department of Veterans Affairs; D058014:Veterans Health
chemical_list: D000998:Antiviral Agents; D009842:Oligopeptides; D012254:Ribavirin; C486464:telaprevir; C512204:N-(3-amino-1-(cyclobutylmethyl)-2,3-dioxopropyl)-3-(2-((((1,1-dimethylethyl)amino)carbonyl)amino)-3,3-dimethyl-1-oxobutyl)-6,6-dimethyl-3-azabicyclo(3.1.0)hexan-2-carboxamide; D007372:Interferons; D011392:Proline
keywords: Cirrhosis; DAA; HCC; HCV; Health Care Costs; ICER; IL; Liver Disease; PR; Prevention; QALY; SVR; VHA; Veterans Health Administration; boc; boceprevir; direct-acting antiviral; hepatitis C virus; hepatocellular carcinoma; incremental cost-effectiveness ratio; interleukin; pegylated interferon-alfa and ribavirin; quality-adjusted life-year; sustained virologic response; tel; telaprevir