Research Paper
A cost-effectiveness analysis of primary versus hospital-based specialist care for direct acting antiviral hepatitis C treatment

https://doi.org/10.1016/j.drugpo.2019.102633Get rights and content

Abstract

Background

Hepatitis C virus elimination may be possible by scaling up direct-acting antiviral (DAA) treatment. Due to the safety and simplicity of DAA treatment, primary care-based treatment delivery is now feasible, efficacious and may be cheaper than hospital-based specialist care. In this paper, we use Prime Study data – a randomised controlled trial comparing the uptake of DAA treatment between primary and hospital-based care settings amongst people who inject drugs (PWID) – to estimate the cost of initiating treatment for PWID diagnosed with hepatitis C in primary care compared to hospital-based care.

Methods

The total economic costs associated with delivering DAA treatment (post hepatitis C diagnosis) within the Prime study – including health provider time/training, medical tests, equipment, logistics and pharmacy costs – were collected. Appointment data were used to estimate the number/type of appointments required to initiate treatment in each case, or the stage at which loss to follow up occurred.

Results

Among the hepatitis C patients randomised to be treated within primary care, 43/57 (75%) commenced treatment at a mean cost of A$885 (95% CI: A$850–938) per patient initiating treatment. In hospital-based care, 18/53 hepatitis C patients (34%) commenced treatment at a mean cost of A$2078 (range: A$2052–2394) per patient initiating treatment – more than twice as high as primary care. The lower cost in the primary care arm was predominantly the result of increased retention in care compared to the hospital-based arm.

Conclusions

Compared to hospital-based care, providing hepatitis C services for PWID in primary care can improve treatment uptake and approximately halve the average cost of treatment initiation. To improve treatment uptake and cure, countries should consider primary care as the main model for hepatitis C treatment scale-up.

Introduction

The discovery of highly effective direct-acting antiviral (DAA) treatment for hepatitis C infection means that elimination has become a realistic public health goal (Cooke et al., 2019), and the World Health Organisation (WHO) has set elimination targets of an 80% reduction in incidence and a 65% reduction in mortality by 2030 (World Health Organization, 2016). With the cost of DAAs falling in many countries over the past few years (Belmonte, 2017; Grant, 2017; Hurley, 2018; The Hon Greg Hunt MP, 2017), the major challenge now for countries globally is to increase the number of people undergoing hepatitis C testing and ensure those who test positive receive treatment. Scaling up of testing and treatment services will incur new costs that depend on how the services are delivered; to minimise the total cost it is important that the cost per patient treated be reduced where possible. The decision to invest in hepatitis C testing and treatment scale-up should be informed by accurate and relevant estimates of the direct and auxiliary costs associated with delivering the required services.

Compared to previous interferon-based treatment regimens, DAA treatment is safe, simple to administer (tablets taken orally), of short duration (8–12 weeks), well tolerated and effective. This means that DAA treatment provision need not be limited to hospital-based specialist care; a treatment setting that many patients with hepatitis C have found difficult to access due to location, logistical complexity and stigma-related issues (McGowan & Fried, 2012). Providing DAA treatment in primary care (i.e. in general practice and drug and alcohol services) has been shown to be feasible for uncomplicated hepatitis C patients, who represent the majority of patients infected with hepatitis C (Alavi et al., 2013; Bruce et al., 2012; Jack, Willott, Manners, Varnam & Thomson, 2009; Linas et al., 2014; Wade et al., 2015). Such services can be led by general practitioners or community hepatitis nurses (CHNs), who are specifically trained to provide hepatitis C diagnosis and treatment, supported by a specialist physician (gastroenterologists, hepatologists or infectious diseases physicians). Primary care-based treatment settings are therefore likely to be more accessible to hepatitis C patients, alleviating the need to receive hospital-based care in most cases. Because of this, it is also likely that primary care-based DAA treatment can reduce the cost per patient treated by reducing the number of missed appointments, or appointments not leading to treatment commencement.

The Prime Study was the first randomised controlled trial to explore primary care based DAA provision and its effect on treatment uptake, retention in-care and cure (Wade et al., 2018a, 2018b). Conducted across Australia (Melbourne and Geelong) and New Zealand (Christchurch and Auckland), the study recruited 140 people with hepatitis C – 98% of whom had a history of injecting drug use – through primary care-based clinics, allocating them to either primary care-based treatment (intervention) or hospital-based treatment provided by a specialist (standard of care). Results from the trial indicated that patients treated through a primary care-based model were more than twice as likely to take up treatment, compared to patients treated through hospital-based care (Wade et al., 2018a 2018b). The risk of ongoing hepatitis C transmission amongst people who inject drugs (PWID) makes them a priority population for treatment and these findings are critical to inform treatment scale-up (Scott, McBryde, Thompson, Doyle & Hellard, 2017).

The costs associated with delivering specific healthcare services can be difficult to estimate for several reasons. First, service delivery incurs many different types of costs, including direct costs such as the cost of drugs, medical supplies (e.g. screening pathology tests) and other consumables, as well as program costs such as staff salaries and time spent per patient, equipment, overheads, and communication (e.g. money spent promoting the service). Second, many of the program costs can be hard to disentangle when resources are shared; for example, healthcare workers who deliver multiple services across multiple programs. Third, the variety of costs involved means that there can be substantial variation between different service delivery models. The Prime Study provides a unique opportunity to estimate the resource and cost implication of alternative models of care, including the number and types of tests typically performed, staff time costs, equipment and administration costs, and opportunity costs from missed appointments.

In this study, we assess and compare the costs of delivering DAAs to people with hepatitis C through primary care and hospital-based care, informed by pilot and costing data from the Prime Study. This is critical to inform investment cases of the realistic costs associated with delivering these services; and to ensure that the costs of DAA treatment scale-up are minimised through the use of cheaper and more effective models of care. We attempted to align our costing methods, estimates and reporting with the principles of the Reference Case for Global Health Costing (Vassall et al., 2017); a framework for improving the relevance, use and quality of costing estimates.

Section snippets

The Prime Study

The Prime Study was the main source of ‘process’ data for this analysis; the details of the trial have been published elsewhere (Wade et al., 2018a 2018b). Briefly, people with hepatitis C were recruited from primary care sites in Australia and New Zealand between November 2015 and December 2017, and consenting patients were randomized to receive DAAs at their primary care site (intervention arm) or their local hospital (standard of care arm). Primary care sites provided services frequently

Results

Data regarding appointment dates and medical tests were available from 110 eligible Prime Study patients – 57 in the primary care arm, 53 in the hospital-based arm (Fig. 2) (demographic characteristics of these patients are provided in Table 2). Out of the 57 patients in primary care, 43 (75%) commenced treatment while 14 (25%) were lost to follow up (nine of whom did not have a liver assessment). The total cost was A$38,048 (range: A$35,568–40,337), which included 57 sets of screening

Discussion

This is the first non-modelling study to estimate the costs of implementing a primary care hepatitis C treatment model compared to standard of care hospital-based models, and is therefore the first study to fully capture the true opportunity costs and inefficiencies of both treatment pathways. Primary care-based treatment models have previously been found as acceptable and effective in increasing treatment uptake (Wade et al., 2018a, 2018b) particularly amongst key treatment populations such as

Conclusions

Primary care-based hepatitis C treatment has significant cost savings compared to standard hospital-based models of care. Specifically, primary care was found to approximately halve the cost per patient initiating treatment, predominantly due to increased retention in care. Countries should consider primary care as the main model for hepatitis C treatment scale-up.

Declaration of Competing Interest

MH, JD and the Burnet Institute receive investigator-initiated research funding from Gilead Sciences, Merck, AbbVie and Bristol-Myers Squibb (BMS). AT is an advisory board member for Gilead Sciences, AbbVie, BMS, Merck and Roche Diagnostics, and a speaker for Gilead, Merck, BMS, AbbVie, Roche Diagnostics. AW has received investigator-initiated research funding from AbbVie. JD has received honoraria for advisory boards or speaking from Gilead Sciences, AbbVie and Merck. NS has received

Funding

The Prime Study is an investigator-initiated study funded by AbbVie. The investigators are responsible for the study design, data collection and analysis, interpretation of the data and preparation of manuscripts.

CRediT authorship contribution statement

Anna Y Palmer: Writing - original draft, Formal analysis, Validation. Amanda J Wade: Data curation, Investigation, Validation. Bridget Draper: Data curation, Validation. Jessica Howell: Data curation, Validation. Joseph S Doyle: Data curation, Validation. Dennis Petrie: Methodology, Validation. Alexander J Thompson: Data curation, Validation. David P Wilson: Methodology, Validation. Margaret E Hellard: Conceptualization, Validation. Nick Scott: Conceptualization, Validation, Methodology.

Acknowledgments

The authors gratefully acknowledge the support to the Burnet Institute provided by the Victorian Government Operational Infrastructure Support Program. The Prime Study is an investigator-initiated study funded by AbbVie. The investigators are responsible for the study design, data collection and analysis, interpretation of the data and preparation of manuscripts. MH is the recipient of a National Health and Medical Research Council fellowship.

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