David B. Rein, PhD; Bryce D. Smith, PhD; John S. Wittenborn, BS; Sarah B. Lesesne, BS; Laura D. Wagner, MPH; Douglas W. Roblin, PhD; Nita Patel, DrPH; John W. Ward, MD; Cindy M. Weinbaum, MD, MPH
Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention, NORC at the University of Chicago, or any other of the authors' affiliations.
Acknowledgment: The authors thank Yngve Falck-Ytter, Katherine Krauskopf, Omar Massoud, and Andrew Talal for their help with data inputs to guide the DAA analysis; our 2 peer reviewers for their input, which made this a stronger manuscript; and Susan Murchie for her editorial assistance.
Grant Support: By the Centers for Disease Control and Prevention Division of Viral Hepatitis through contract 200-2003-02489-0007.
Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M11-1516.
Reproducible Research Statement:Study protocol: Not available. Statistical code: SAS code used to generate results from simulated data available from Dr. Rein (e-mail, firstname.lastname@example.org). Data set: Simulated data available from Dr. Rein (e-mail, email@example.com).
Requests for Single Reprints: David B. Rein, PhD, NORC at the University of Chicago, 3520 Piedmont Road NE, Atlanta, GA 30305; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Rein: NORC at the University of Chicago, 3520 Piedmont Road NE, Atlanta, GA 30305.
Drs. Smith, Patel, Ward, and Weinbaum: Division of Viral Hepatitis, Centers for Disease Control and Prevention, MS G37, 1600 Clifton Road, Atlanta, GA 30333.
Mr. Wittenborn and Ms. Wagner: RTI International, 2951 Flowers Road, Suite 119, Atlanta, GA 30341.
Ms. Lesesne: Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 263 Rosenau Hall, CB #7400, Chapel Hill, NC 27599.
Dr. Roblin: The Center for Health Research/Southeast, Kaiser Permanente Georgia, 3495 Piedmont Road NE, Building 9, Atlanta, GA 30305.
Author Contributions: Conception and design: D.B. Rein, B.D. Smith, J.S. Wittenborn, J.W. Ward, C.M. Weinbaum.
Analysis and interpretation of the data: D.B. Rein, B.D. Smith, J.S. Wittenborn, S.B. Lesesne, L.D. Wagner.
Drafting of the article: D.B. Rein.
Critical revision of the article for important intellectual content: D.B. Rein, B.D. Smith, J.S. Wittenborn, L.D. Wagner, D.W. Roblin, N. Patel, J.W. Ward.
Final approval of the article: D.B. Rein, B.D. Smith, J.S. Wittenborn, D.W. Roblin, J.W. Ward, C.M. Weinbaum.
Statistical expertise: D.B. Rein, J.S. Wittenborn, L.D. Wagner, N. Patel.
Obtaining of funding: D.B. Rein, J.W. Ward, C.M. Weinbaum.
Administrative, technical, or logistic support: J.S. Wittenborn, L.D. Wagner, D.W. Roblin.
Collection and assembly of data: D.B. Rein, J.S. Wittenborn, S.B. Lesesne, D.W. Roblin.
Rein DB, Smith BD, Wittenborn JS, Lesesne SB, Wagner LD, Roblin DW, et al. The Cost-Effectiveness of Birth-Cohort Screening for Hepatitis C Antibody in U.S. Primary Care Settings. Ann Intern Med. 2012;156:263-270. doi: 10.7326/0003-4819-156-4-201202210-00378
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Published: Ann Intern Med. 2012;156(4):263-270.
In the United States, hepatitis C virus (HCV) infection is most prevalent among adults born from 1945 through 1965, and approximately 50% to 75% of infected adults are unaware of their infection.
To estimate the cost-effectiveness of birth-cohort screening.
National Health and Nutrition Examination Survey, U.S. Census, Medicare reimbursement schedule, and published sources.
Adults born from 1945 through 1965 with 1 or more visits to a primary care provider annually.
Societal, health care.
One-time antibody test of 1945–1965 birth cohort.
Numbers of cases that were identified and treated and that achieved a sustained viral response; liver disease and death from HCV; medical and productivity costs; quality-adjusted life-years (QALYs); incremental cost-effectiveness ratio (ICER).
Compared with the status quo, birth-cohort screening identified 808 580 additional cases of chronic HCV infection at a screening cost of $2874 per case identified. Assuming that birth-cohort screening was followed by pegylated interferon and ribavirin (PEG-IFN+R) for treated patients, screening increased QALYs by 348 800 and costs by $5.5 billion, for an ICER of $15 700 per QALY gained. Assuming that birth-cohort screening was followed by direct-acting antiviral plus PEG-IFN+R treatment for treated patients, screening increased QALYs by 532 200 and costs by $19.0 billion, for an ICER of $35 700 per QALY saved.
The ICER of birth-cohort screening was most sensitive to sustained viral response of antiviral therapy, the cost of therapy, the discount rate, and the QALY losses assigned to disease states.
Empirical data on screening and direct-acting antiviral treatment in real-world clinical settings are scarce.
Birth-cohort screening for HCV in primary care settings was cost-effective.
Division of Viral Hepatitis, Centers for Disease Control and Prevention.
Most people in the United States infected with hepatitis C virus (HCV) were born from 1945 through 1965 and are undiagnosed. Because complications of hepatitis C increase with time, its burden is now rapidly increasing.
In simulated models, an approach of 1-time screening for hepatitis C in this birth cohort followed by treatment was cost-effective.
Data on the real-world effectiveness of newer drugs for hepatitis C are extremely limited.
A change from solely risk-based screening for hepatitis C to 1-time screening of all persons born from 1945 through 1965 should be considered.
Univariate sensitivity of the incremental cost-effectiveness ratio of birth-cohort screening with standard treatment compared with risk-based screening assuming pegylated interferon with ribavirin treatment.
QALY = quality-adjusted life-year; SVR = sustained viral response.
Cost-effectiveness acceptability curve: probability that each screening scenario is the most cost-effective by willingness to pay per incremental QALY gained.
Birth cohort, standard treatment = 1-time screening of all individuals born from 1945 through 1965 with pegylated interferon with ribavirin (i.e., standard) treatment for those who enter treatment; birth cohort, direct-acting antivirals = 1-time screening of all individuals; no screening = no screening or treatment; risk-based = status quo equivalent of screening based on identified risk factors followed by pegylated interferon with ribavirin treatment for those who enter treatment. QALY = quality-adjusted life-year.
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