The hepatitis C cascade of care: identifying priorities to improve clinical outcomes.
BACKGROUND
As highly effective hepatitis C virus (HCV) therapies emerge, data are needed to inform the development of interventions to improve HCV treatment rates. We used simulation modeling to estimate the impact of loss to follow-up on HCV treatment outcomes and to identify intervention strategies likely to provide good value for the resources invested in them.


METHODS
We used a Monte Carlo state-transition model to simulate a hypothetical cohort of chronically HCV-infected individuals recently screened positive for serum HCV antibody. We simulated four hypothetical intervention strategies (linkage to care; treatment initiation; integrated case management; peer navigator) to improve HCV treatment rates, varying efficacies and costs, and identified strategies that would most likely result in the best value for the resources required for implementation.


METHODS
Sustained virologic responses (SVRs), life expectancy, quality-adjusted life expectancy (QALE), costs from health system and program implementation perspectives, and incremental cost-effectiveness ratios (ICERs).


RESULTS
We estimate that imperfect follow-up reduces the real-world effectiveness of HCV therapies by approximately 75%. In the base case, a modestly effective hypothetical peer navigator program maximized the number of SVRs and QALE, with an ICER compared to the next best intervention of $48,700/quality-adjusted life year. Hypothetical interventions that simultaneously addressed multiple points along the cascade provided better outcomes and more value for money than less costly interventions targeting single steps. The 5-year program cost of the hypothetical peer navigator intervention was $14.5 million per 10,000 newly diagnosed individuals.


CONCLUSIONS
We estimate that imperfect follow-up during the HCV cascade of care greatly reduces the real-world effectiveness of HCV therapy. Our mathematical model shows that modestly effective interventions to improve follow-up would likely be cost-effective. Priority should be given to developing and evaluating interventions addressing multiple points along the cascade rather than options focusing solely on single points.
HIV Epidemiology and Outcomes Research Unit, Section of Infectious Diseases, Boston Medical Center, Boston, Massachusetts, United States of America; Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America.
Benjamin P
BP
Linas
HIV Epidemiology and Outcomes Research Unit, Section of Infectious Diseases, Boston Medical Center, Boston, Massachusetts, United States of America.
Devra M
DM
Barter
Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, New York, United States of America.
Jared A
JA
Leff
HIV Epidemiology and Outcomes Research Unit, Section of Infectious Diseases, Boston Medical Center, Boston, Massachusetts, United States of America.
Sabrina A
SA
Assoumou
Department of Global Health and Population, Harvard School of Public Health, Boston, Massachusetts, United States of America.
Joshua A
JA
Salomon
Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts, United States of America.
Milton C
MC
Weinstein
Massachusetts General Hospital Boston, Massachusetts, United States of America.
Arthur Y
AY
Kim
Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, New York, United States of America.
Bruce R
BR
Schackman
D000998:Antiviral Agents / Q000627:therapeutic use; D016174:Hepacivirus / Q000472:pathogenicity*; D006526:Hepatitis C / Q000097:blood / Q000188:drug therapy / Q000503:physiopathology*; D018937:Hepatitis C Antibodies / Q000097:blood; D006801:Humans; D008962:Models, Theoretical; D019057:Quality-Adjusted Life Years; D016896:Treatment Outcome
D000998:Antiviral Agents; D018937:Hepatitis C Antibodies