title: Cost-effectiveness of new antiviral regimens for treatment-naïve U.S. veterans with hepatitis C.
abstract: Recently approved, interferon-free medication regimens for treating hepatitis C are highly effective, but extremely costly. We aimed to identify cost-effective strategies for managing treatment-naïve U.S. veterans with new hepatitis C medication regimens. We developed a Markov model with 1-year cycle length for a cohort of 60-year-old veterans with untreated genotype 1 hepatitis C seeking treatment in a typical year. We compared using sofosbuvir/ledipasvir or ombitasvir/ritonavir/paritaprevir/dasabuvir to treat: (1) any patient seeking treatment; (2) only patients with advanced fibrosis or cirrhosis; or (3) patients with advanced disease first and healthier patients 1 year later. The previous standard of care, sofosbuvir/simeprevir or sofosbuvir/pegylated interferon/ribavirin, was included for comparison. Patients could develop progressive fibrosis, cirrhosis, or hepatocellular carcinoma, undergo transplantation, or die. Complications were less likely after sustained virological response. We calculated the incremental cost per quality-adjusted life year (QALY) and varied model inputs in one-way and probabilistic sensitivity analyses. We used the Veterans Health Administration perspective with a lifetime time horizon and 3% annual discounting. Treating any patient with ombitasvir-based therapy was the preferred strategy ($35,560; 14.0 QALYs). All other strategies were dominated (greater costs/QALY gained than more effective strategies). Varying treatment efficacy, price, and/or duration changed the preferred strategy. In probabilistic sensitivity analysis, treating any patient with ombitasvir-based therapy was cost-effective in 70% of iterations at a $50,000/QALY threshold and 65% of iterations at a $100,000/QALY threshold.
  
  
  CONCLUSIONS
  Managing any treatment-naïve genotype 1 hepatitis C patient with ombitasvir-based therapy is the most economically efficient strategy, although price and efficacy can impact cost-effectiveness. It is economically unfavorable to restrict treatment to patients with advanced disease or use a staged treatment strategy. (Hepatology 2016;63:428-436).
authors.affiliation: Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.|VA Center for Health Equity Research & Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.|Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA.
authors.forename: Alexis P
authors.initials: AP
authors.lastname: Chidi
authors.affiliation: Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.|VA Center for Health Equity Research & Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.
authors.forename: Shari
authors.initials: S
authors.lastname: Rogal
authors.affiliation: Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.|Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA.
authors.forename: Cindy L
authors.initials: CL
authors.lastname: Bryce
authors.affiliation: Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.|VA Center for Health Equity Research & Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Fine
authors.affiliation: Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.|VA Center for Health Equity Research & Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.|VA Center for Medication Safety, Department of Veterans Affairs, Hines, IL.
authors.forename: Chester B
authors.initials: CB
authors.lastname: Good
authors.affiliation: Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.|VA Center for Health Equity Research & Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.
authors.forename: Larissa
authors.initials: L
authors.lastname: Myaskovsky
authors.affiliation: Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, PA.
authors.forename: Vinod K
authors.initials: VK
authors.lastname: Rustgi
authors.affiliation: Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA.
authors.forename: Allan
authors.initials: A
authors.lastname: Tsung
authors.affiliation: Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.|VA Center for Health Equity Research & Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.
authors.forename: Kenneth J
authors.initials: KJ
authors.lastname: Smith
mesh_terms: D000368:Aged; D000998:Antiviral Agents / Q000191:economics* / Q000627:therapeutic use*; D001562:Benzimidazoles / Q000627:therapeutic use; D003362:Cost-Benefit Analysis; D004338:Drug Combinations; D005449:Fluorenes / Q000627:therapeutic use; D019698:Hepatitis C, Chronic / Q000188:drug therapy*; D006801:Humans; D008875:Middle Aged; D019057:Quality-Adjusted Life Years; D000069474:Sofosbuvir / Q000627:therapeutic use; D014481:United States; D058014:Veterans Health / Q000191:economics*
chemical_list: D000998:Antiviral Agents; D001562:Benzimidazoles; D004338:Drug Combinations; D005449:Fluorenes; C586541:ledipasvir; D000069474:Sofosbuvir