Primary care model would treat more HCV-infected patients, increase quality-adjusted life years

Wayne Kuznar, for MDLinx | April 11, 2018

Using primary care providers to reach more patients with hepatitis C virus (HCV) infection would be a cost-effective way to greatly increase diagnoses and treatment, according to an analysis by public health researchers.

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A telehealth project would help primary care providers reach and treat more patients with hepatitis C with greater cost-effectiveness.

The method would incorporate the Project ECHO (Extension for Community Healthcare Outcomes) model, which links specialists to community practitioners through a “hub and spoke” structure. In this model, specialists at a hub, such as an academic medical center, provide teaching and mentoring via weekly video conferences to community-based practitioners. In Project ECHO, 14 hubs in the United States currently specialize in HCV care.

Although the Project ECHO model would increase upfront costs, it would also lead to a gain in quality-adjusted life years (QALYs) such that the incremental cost-effectiveness ratio would be about $10,000 per QALY compared with the current approach. This amount is well below the accepted willingness-to-pay threshold of $100,000 per QALY, reported Thilo Rattay, MPH, School of Public Health, University of Michigan, Ann Arbor, MI, and colleagues. Their findings appear in Gastroenterology.

For this study, Rattay and colleagues used a Markov model to simulate the effect of implementing Project ECHO for the diagnosis and treatment of chronic HCV infection in the general population. They estimated the cost-effectiveness of the ECHO model compared with a traditional model, in which primary care patients with HCV are referred to specialists for treatment after their HCV diagnosis.

The researchers calculated that the use of ECHO would result in a gain of 1.41 QALYs compared with status quo care (15.04 vs. 13.63 QALYs).

The difference was driven by higher rates of diagnosis and treatment, the researchers noted. With the use of ECHO, 58% of HCV-positive patients would be screened and diagnosed annually, compared with only 17.9% in the status quo.

“In our model, ECHO clinicians treated almost 13 patients with HCV in the first year of operations (or 51.7% of patients with HCV), compared with 2.7 (10.8% of patients with HCV) who are successfully referred for specialist treatment in the status quo,” wrote Rattay and coauthors. The estimate of 13 patients is conservative given actual annualized patient numbers realized by the University of Mexico Project ECHO team, they noted. Of all patients with chronic HCV, 46.55% achieved a sustained virologic response in ECHO compared with only 9.74% without ECHO.

The number of years lived without liver fibrosis also was estimated to be far superior (a gain of 12.09 years) in the ECHO model compared with status quo care.

Total lifetime health care expenditures in ECHO would be $185,983 for an average patient in the primary care patient panel, or $158 more than the $185,825 average for conventional care. Upfront treatment costs are higher in ECHO patients, but this increased cost would be partly offset by greater liver-related health care expenditures later in life among those who go untreated in the status quo model of care.

“These findings suggest that Project ECHO’s novel method of using telehealth to help primary care providers deliver specialty care adds substantial value, even if it requires an additional investment of a few hundred dollars per patient,” the authors noted.

The incremental cost-effectiveness ratio for the entire ECHO program would be $10,351 per QALY compared with the status quo.

Although payers would see an additional $339 million in HCV-related costs in years 1 through 5 of the ECHO program (mostly from increased use of direct-acting antiviral medicines), 4,446 more patients would be treated per 1 million covered lives than with the status quo, and the prevalence of HCV would decline in their insurance pool, resulting in subsequent cost savings.

“Importantly, most of the financial benefits of treating HCV are not immediate, whereas most of the costs are upfront,” the investigators wrote. “Therefore, a long-term perspective on patient care must be adopted. To that end, our findings reinforce and emphasize the need for population health models of care as well as appropriate reimbursement mechanisms to capture the full benefit of this type of ecosystem.”

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