Received 8 March 2016
Revised 29 June 2016
Accepted 18 August 2016
Published 6 September 2016
Abstract
Objectives With the developments of near-cures for hepatitis C virus (HCV), who to screen has become a high-priority policy issue in many western countries. Cost-effectiveness of screening programmes should be one consideration when developing policy. The objective of this work is to synthesise the cost-effectiveness of HCV screening programmes.
Setting A systematic review was completed. 5 databases were searched until May 2016 (NHSEED, MEDLINE, the HTA Health Technology Assessment Database, EMBASE, EconLit).
Participants Any study reporting an economic evaluation (any type) of screening compared with opportunistic or no screening for HCV was included. Exclusion criteria were: (1) abstracts or commentaries, (2) economic evaluations of other interventions for HCV, including blood donors screening, diagnosis tests for HCV, screening for concurrent disease or medications for treatment.
Primary and secondary outcome measures Data extraction included type of model, target population, perspective, comparators, time horizon, discount rate, clinical inputs, cost inputs and outcome. Quality was evaluated using the Consolidated Health Economic Evaluation Reporting Standards checklist. Data are summarised using narrative synthesis by population.
Results 2305 abstracts were identified with 52 undergoing full-text review. 30 papers met inclusion criteria addressing 7 populations: drug users (n=6), high risk (n=5), pregnant (n=4), prison (n=3), birth cohort (n=8), general population (n=5) and other (n=6). The majority (77%) of the studies were high quality. Drug users, birth cohort and high-risk populations were associated with cost-effectiveness ratios of under £30 000 per quality-adjusted-life-year (QALY). The remaining populations were associated with cost-effectiveness ratios that exceeded £30 000 per QALY.
Conclusions Economic evidence for screening populations is robust. If a cost per QALY of £30 000 is considered reasonable value for money, then screening birth cohorts, drug users and high-risk populations are policy options that should be considered.
Objectives With the developments of near-cures for hepatitis C virus (HCV), who to screen has become a high-priority policy issue in many western countries. Cost-effectiveness of screening programmes should be one consideration when developing policy. The objective of this work is to synthesise the cost-effectiveness of HCV screening programmes.
Setting A systematic review was completed. 5 databases were searched until May 2016 (NHSEED, MEDLINE, the HTA Health Technology Assessment Database, EMBASE, EconLit).
Participants Any study reporting an economic evaluation (any type) of screening compared with opportunistic or no screening for HCV was included. Exclusion criteria were: (1) abstracts or commentaries, (2) economic evaluations of other interventions for HCV, including blood donors screening, diagnosis tests for HCV, screening for concurrent disease or medications for treatment.
Primary and secondary outcome measures Data extraction included type of model, target population, perspective, comparators, time horizon, discount rate, clinical inputs, cost inputs and outcome. Quality was evaluated using the Consolidated Health Economic Evaluation Reporting Standards checklist. Data are summarised using narrative synthesis by population.
Results 2305 abstracts were identified with 52 undergoing full-text review. 30 papers met inclusion criteria addressing 7 populations: drug users (n=6), high risk (n=5), pregnant (n=4), prison (n=3), birth cohort (n=8), general population (n=5) and other (n=6). The majority (77%) of the studies were high quality. Drug users, birth cohort and high-risk populations were associated with cost-effectiveness ratios of under £30 000 per quality-adjusted-life-year (QALY). The remaining populations were associated with cost-effectiveness ratios that exceeded £30 000 per QALY.
Conclusions Economic evidence for screening populations is robust. If a cost per QALY of £30 000 is considered reasonable value for money, then screening birth cohorts, drug users and high-risk populations are policy options that should be considered.
Discussion Only
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The studies performed regarding screening for HCV are generally of good quality and a robust body of evidence has developed. Generally, screening drug users, birth cohorts, high-risk populations and the general population appear to be good value for money if a cost per QALY of £30 000 is used as the threshold for reasonable value. The current evidence suggests screening programmes may not be good value for money in high-risk groups and pregnant women, although the evidence is heterogeneous focusing on a variety of populations and economic outcomes. Surprisingly, screening programmes for prisoners appears not to be good value for money. A variety of other screening programmes have been assessed in the literature targeting genito-urinary clinics, individuals who had minor or major surgery, patients presenting to the emergency room, recently deployed military, those with the history of gastroscopy and visitors to public STD clinics. None of these programmes appear to be good value for money.
Recently, a study evaluating economic evaluations of hepatitis B and HCV evaluating screening and testing strategies was performed.41 The focus of our study was to assess the cost-effectiveness of only screening programmes. Further, our study was able to attain the most recent studies and also divided the studies based on population studied; this allows stakeholders to better evaluate the applicable studies based on population. Each of these populations is a unique group that have different challenges for screening programmes. Therefore, through summarising the studies by screened population, we are able to gain a better summary of the cost-effectiveness of these screening programmes and the variation seen within each group.
Several variables affected the findings of the reported economic evaluations, in particular, the prevalence of asymptomatic HCV, the acceptability of screening and the acceptability of treatment. Of these, prevalence has the largest impact on the outcomes of the economic evaluations. In general, one would expect the cost-effectiveness of screening to be inversely correlated to prevalence; the higher the prevalence in the targeted group, the lower the cost per QALY as more cases would be identified per person screened. Our synthesis supports this finding with data that demonstrates screening populations with higher prevalence of HCV (ie, drug users) generally resulting in better value for money.
However, there is little information about how prevalence, the acceptability of screening and the acceptability of treatment may drive the required implementation plans.
The expected budget impact remains unknown and would be substantially impacted by the proposed implementation plan. A thorough budget impact analysis, particularly for the large birth cohort and general population screening programmes where the overall cost may be large, must be completed.
Limitations
While this systematic review includes robust studies with good quality, several limitations should be considered. The systematic review is limited by the available data in the literature. The results may not be generalisable to all jurisdictions; for example, only one cost-utility analysis has been conducted in Canada and this study only evaluated a birth cohort. Cost analyses differed by time periods that would not have accounted for all currently available drugs such as simeprevir and sofosibvir. Further, none of the studies addressed the implementation of a screening programme and the costs associated with it, which is paramount in choosing the appropriate screening programme.
Conclusion
Screening birth cohorts, drug users and high-risk populations would be good value for money, and should be evaluated as a possibility for implementation. Further evaluations need to be performed regarding the best methods for implementation, with subsequent budget impact analysis.
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