Centre for Health Economics, Swansea University, Wales, UK; Health Economics & Outcomes Research Ltd., Wales, UK. firstname.lastname@example.org.
Background: Recent U.S guidelines recommend one-time birth-cohort (BC) testing for hepatitis C infection in those born from 1945 to 1965; this represents a major public health policy undertaking. The purpose of this study was to assess the role of treatment timing and prioritisation on predicted cost-effectiveness (CE). Methods: The MONARCH hepatitis C lifetime simulation model was used in conjunction with a screening and treatment decision tree to estimate the CE of BC compared to risk-based (RB) testing incorporating information on age, fibrosis stage and treatment timing. The study used a 1945-1965 BC and published disease progression, testing and treatment related parameters. Scenario analysis evaluated the impact of Hepatitis C virus (HCV) prevalence, treatment eligibility, age, fibrosis stage and timing of treatment initiation on total costs, quality adjusted life years (QALYs), HCV related complications and CE. Results: The CE of BC versus RB testing was $28,602. Assuming 91% of the population are tested, at least 278,000 people need to be treated for BC testing to remain CE. Prioritising treatment towards those with more advanced fibrosis is associated with a decrease in total cost of $7.5 billion and 59,035 fewer HCV related complications. Total QALYS and complications avoided are maximised when treatment initiation occurs as soon after screening as possible. Conclusion: This study confirms that BC screening is, on average, cost-effective. However, this remains true only when enough tested and HCV positive subjects are treated to generate sufficient cost offsets and QALY gains. Given the practical and financial challenges associated with implementing BC screening, the greatest return on investment is obtained when eligible patients are treated immediately and those with more advanced disease are prioritised.