Keywords
Expenditure - hepatitis C - incidence - infection - treatment
Introduction
Hepatitis C infection is a known underlying factor contributing to hepatocellular
carcinogenesis. The use of direct-acting antiviral (DAA) medication is a form of clinical
management for controlling hepatitis C virus (HCV) infection and reducing the hepatocellular
carcinoma incidence.[1] This medication is introduced to several endemic areas with a hope that it can help
better control and eradicate diseases.[2] Roche et al. concluded that it is essential to study the effectiveness of DAA medication for
the conclusion of the advantage.[3]
In Thailand, HCV infection is also very common. The use of DAA medication is the new
public health strategy to counteract HCV infection and its complications.[4]
[5]
[6] Poovorawan et al. proposed a dramatical decrease of HCV infection and its complications including
hepatocellular carcinoma within a 20-year period of implementation of DAA medication.[5] The huge concern is on the treatment expenditures. Several alternative options are
proposed and it is required to assess the effect of each alternative option. Here,
the authors assess and estimate the required treatment expenditures for HCV infection
and advantages in the reduction of hepatocellular carcinoma incidence based on an
analysis of possible options in an endemic area.
Materials and Methods
The main aim of this study is to estimate the required treatment expenditures for
HCV infection and advantages in the reduction of hepatocellular carcinoma incidence
based on an analysis of possible options in an endemic area, Thailand. The basic data
on expenditure required for DAA medication in the setting are referred to a previous
nationwide study.[4] The estimation of required expenditures is done according to the path probability
of each possible option to expand the coverage of DAAs as follows: (a) coverage for
all cases, (b) expanded selective coverage for cases with fibrosis in the range of
F2–F4 which is the present strategy in the study setting, (c) doubling the number
of DAA treatments plus coverage for all cases, and (d) doubling the number of DAA
treatments plus selective coverage expanded selective coverage for cases with fibrosis
in the range of F2–F4. The advantage in each alternative option is also estimated
and is defined as the expected reduction rate of HCV-related hepatocellular carcinoma
incidence with reference to the previous reports by Wasitthankasem et al.[4] for general local population and Duberg et al.[5] for increasing the effectiveness of doubling DAA medication. Cost–utility analysis
is further performed comparing each alternative option.
Results
According to this study, the expected required expenditure and advantage in each alternative
option for DAA medication is shown in [Table 1]. According to the results obtained from the cost–utility analysis [Table 2], the best alternative option recommended is the DAA medication coverage for all
cases.
Table 1
The expected required expenditure and advantage in each alternative option for direct-acting
antiviral medications
|
Alternative optiona
|
Expected expenditure (million USD)
|
Coverage (%)b
|
Expected advantage (%)c
|
|
aThe studied alternative options include 1. Coverage for all cases, 2. Expanded selective
coverage for cases with fibrosis in the range of F2-F4, 3. Doubling the number of
DAA treatments plus coverage for all cases, and 4. Doubling the number of DAA treatments
plus selective coverage expanded selective coverage for cases with fibrosis in the
range of F2-F4, bCoverage is hereby referred to the percentage of the patients with hepatitis C that
will be covered by each alternative option and referred to the previous report by
Poovorawan et al.,[5]
cExpanded coverage is defined as the expected reduction rate of hepatitis C-related
hepatocellular carcinoma incidence referred to the previous reports by Wasitthankasem
et al.[4] and Duberg et al.[6] DAAs – Direct-acting antivirals
|
|
1
|
1494
|
100
|
82.5
|
|
2
|
1240
|
83
|
37.7
|
|
3
|
2988
|
100
|
100
|
|
4
|
2480
|
83
|
64.1
|
Table 2
Cost-utility analysis for each alternative option for direct-acting antiviral medications
|
Alternative optiona
|
Cost (USD)b
|
Expected advantage (%)c
|
Cost utility (USD)d
|
|
aThe studied alternative options include 1. Coverage for all cases, 2 Expanded selective
coverage for cases with fibrosis in the range of F2-F4, 3. Doubling the number of
DAA treatments plus coverage for all cases, and 4. Doubling the number of DAA treatments
plus selective coverage expanded selective coverage for cases with fibrosis in the
range of F2-F4, bCost is defined as expected expenditure as shown in [Table 1], cUtility is defined as expected advantage as shown in [Table 1], dCost utility is calculated by cost divided by utility. DAAs – Direct-acting antivirals
|
|
1
|
1494
|
82.5
|
1810.91
|
|
2
|
1240
|
37.7
|
3289.1
|
|
3
|
2988
|
100
|
2988
|
|
4
|
2480
|
64.1
|
3868.96
|
Discussion
The use of DAA medication is the hope for successful management of HCV infection and
HCV-related disease including hepatocellular carcinoma. The eradication of the disease
is usually mentioned. Nevertheless, the huge obstacle for achieving the target is
the expenditure for medication. In Thailand, HCV infection is not uncommon and is
an important contributing cause of hepatocellular carcinoma. The introduction of DAA
medication becomes the new public health strategy in the control of HCV infection
and hepatocellular carcinoma in Thailand.[4] Due to the high expenditure, the proposal for reducing the cost of DAAs is raised
and expected to be the way to reach the success in HCV elimination.[4]
Based on the present study, it can be confirmed that there is a possibility that HCV
eradication and control of HCV-related hepatocellular carcinoma are possible in Thailand.
The use of coverage for all cases plus doubling DAA medication is the alternative
option that can help achieve that target. Nevertheless, the expenditure is still the
huge consideration. Chhatwal et al. noted that there was a requirement for analysis of the real situation in the developing
countries in endemic areas, which could reflect the real advantage of implementation
of DAA medication.[7] According to the present cost–utility analysis, the presently used strategies, expanded
selective coverage for cases with fibrosis in the range of F2–F4, is not the most
appropriate alternative. The best alternative option that is hereby recommended is
DAA medication coverage for all cases.
Conclusion
In this work, a medical economic analysis was done to find the most appropriate option
for HCV treatment with aim at reduction of hepatocellular carcinoma. According to
the present medical economics analysis, the DAA medication coverage for all cases
is the most preferable option.
