Elsevier

Journal of Hepatology

Volume 39, Issue 5, November 2003, Pages 814-825
Journal of Hepatology

Screening for hepatitis C in genito-urinary medicine clinics: a cost utility analysis

https://doi.org/10.1016/S0168-8278(03)00392-1Get rights and content

Abstract

Background/Aims: To estimate the cost utility (cost per QALY) of screening for hepatitis C (HCV) infection in people attending genito-urinary medicine clinics in England.

Methods: An epidemiological model of screening and diagnosis was combined with a Markov chain model of treatment with combination therapy to estimate cost utility. Parameters for the model were informed by literature review, expert opinion and a survey of current screening practice.

Results: The base case estimate was about £85,000 per QALY. Selective screening is more cost effective. If screening is restricted to only 20% or 10% of attenders, cost utility is estimated as £39,647 and £34,288 per QALY. If screening is restricted only to those with a history of injecting drug use, cost utility would be £27,138 per QALY. Estimates are particularly sensitive to acceptance rates for screening and treatment.

Conclusions: Universal screening for HCV in GUM clinics is unlikely to be cost effective. There is limited evidence to support screening of people other than those with a history of injecting drug use and even this policy should be considered with some care and in the context of further research.

Introduction

Hepatitis C virus (HCV) is an important public health problem, affecting up to 1% of the general population in the UK and approaching 90% in some studies of injecting drug users. Chronicity of infection occurs in up to 85% of those infected, and the sequelae of chronic infection contribute significantly to the global burden of disease.

Screening for HCV in GUM clinics is not specifically supported by national policy or professional consensus, but is widespread in the UK. As part of a wider assessment of screening for HCV [1], we carried out a survey of screening in GUM clinics in England, which showed that 78% of GUM clinics report screening for HCV. The majority of clinics reported selective screening, with sexual behaviours and injecting drug use being the main criteria employed. In order to investigate the value for money of screening, we carried out a modelling study of the cost utility of screening in GUM clinics. We investigated the value of (a) considering all attenders at GUM clinics at high risk of HCV carriage (universal screening); (b) restricting screening to a specified group, current or former injecting drug users; or (c) screening in a larger minority of attenders, allowing flexibility of defining the ‘at risk’ population in this setting.

Section snippets

Methods

We developed a screening programme model in Microsoft Excel, integrating an epidemiological model of screening and diagnosis with a Markov model of combination therapy. The treatment element of the model was published in 2001 [2]. The model takes the perspective of the NHS and calculates cost-utility (£/QALY) of screening versus not screening in a single round of screening of a hypothetical cohort, i.e. a prevalent round of screening. The following issues are not addressed by the model:

Results

We found no more recent information on the effectiveness of combination therapy than was included in the review by Shepherd et al. Sustained virological response rates were therefore assumed to be 33% following 24 weeks of treatment and 41% following 48 weeks of treatment with combination therapy.

In the base case we used an estimate for the prevalence of HCV in GUM clinic attenders of 1.5% based on the largest study (n=7986) carried out in the UK. We estimated the number of GUM attenders from

Discussion

This study has improved on previous evaluations of screening for hepatitis C [11], [12], [13], [14], [15], [16]. Most of these were set outside the UK and did not evaluate entire screening programmes, i.e. including diagnosis and treatment.

The present study has some methodological limitations. The model does not stratify for age at identification and if the real population being screened is skewed towards those younger than the average of 32 assumed in the model then the cost utility of

Acknowledgements

Shepherd and colleagues for allowing us to incorporate their model of combination therapy into the screening model.

References (50)

  • K. Stein et al.

    Screening for hepatitis C among injecting drug users and in genitourinary medicine (GUM) clinics

    Health Technol Assess

    (2002)
  • J. Shepherd et al.

    Combination therapy (interferon alpha and ribavirin) in the treatment of chronic hepatitis C: a rapid and systematic review

    Health Technol Assess

    (2000)
  • M. Serfaty et al.

    Risk factors and medical follow up of drug users tested for hepatitis C- can the risk of transmission be reduced?

    Drug Alcohol Rev

    (1997)
  • The Governments Actuary's Department. Interim Life Tables: Expectation of Life, Great Britian-based on data for the...
  • J.G. McHutchinson et al.

    Interferon alfa-2b alone or in combination with ribavirin as initial treatment for chronic hepatitis C

    N Engl J Med

    (1998)
  • L.L. Kjaergard et al.

    Interferon alfa with or without ribavirin for chronic hepatitis C: systematic review of randomised trials

    Br Med J

    (2001)
  • A.M. Johnson et al.

    Sexual attitudes and lifestyles

    (1994)
  • D. Goldberg et al.

    virus among genitourinary clinic attenders in Scotland: unlinked anonymous testing

    Int J STD AIDS

    (2001)
  • R.S. Tedder et al.

    virus: evidence for sexual transmission

    Br Med J

    (1991)
  • M. Ishizuka

    Economic evaluation of health care program for hepatitis C virus antibody screening

    Nippon Koshu Eisei Zasshi

    (1999)
  • J.C. Desenclos et al.

    Faut-il depister l'hepatite C? Analyse des strategies de depistage oriente de l'infection par le virus de l'hepatite C. [Should hepatitis C be screened? Analysis of oriented screening strategies for hepatitis C virus infection]

    Gastroenterol Clin Biol

    (1997)
  • M. Rotily et al.

    Faut-il depister l'hepatite C? Analyse socio-economique de differentes strategies de depistage de l'hepatite chronique C dans la population francaise. [Should hepatitis C be screened? Socioeconomic analysis of different screening strategies for chronic hepatitis C in French population]

    Gastroenterol Clin Biol

    (1997)
  • P. Leal et al.

    What is the cost utility of screening for hepatitis C virus (HCV) in intravenous drug users?

    J Med Screen

    (1999)
  • D.H. Osmond et al.

    Risk Factors for hepatitis C virus seropositivity in heterosexual couples

    J Am Med Assoc

    (1993)
  • K.R. Neal et al.

    Risk factors for hepatitis C virus infection. A case-control study of blood donors in the Trent Region (UK)

    Epidemiol Infect

    (1994)

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