A Microsimulation Study of the Cost-Effectiveness of Hepatitis C Virus Screening Frequencies in Hemodialysis Centers

Abstract

Background: National guidelines recommend twice-yearly hepatitis C virus (HCV) screening for patients receiving in-center hemodialysis. However, studies examining the cost-effectiveness of HCV screening methods or frequencies are lacking.

Methods: We populated an HCV screening, treatment, and disease microsimulation model with a cohort representative of the US in-center hemodialysis population. Clinical outcomes, costs, and cost-effectiveness of the Kidney Disease Improving Global Outcomes (KDIGO) 2018 guidelines-endorsed HCV screening frequency (every 6 months) were compared with less frequent periodic screening (yearly, every 2 years), screening only at hemodialysis initiation, and no screening. We estimated expected quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICERs) between each screening strategy and the next less expensive alternative strategy, from a health care sector perspective, in 2019 US dollars. For each strategy, we modeled an HCV outbreak occurring in 1% of centers. In sensitivity analyses, we varied mortality, linkage to HCV cure, screening method (ribonucleic acid versus antibody testing), test sensitivity, HCV infection rates, and outbreak frequencies.

Results: Screening only at hemodialysis initiation yielded HCV cure rates of 79%, with an ICER of $82,739 per QALY saved compared with no testing. Compared with screening at hemodialysis entry only, screening every 2 years increased cure rates to 88% and decreased liver-related deaths by 52%, with an ICER of $140,193. Screening every 6 months had an ICER of $934,757; in sensitivity analyses using a willingness-to-pay threshold of $150,000 per QALY gained, screening every 6 months was never cost-effective.

Conclusions: The KDIGO-recommended HCV screening interval (every 6 months) does not seem to be a cost-effective use of health care resources, suggesting that re-evaluation of less-frequent screening strategies should be considered.

Graphical abstract

Figure 1

ICERs for different screening intervals on the basis of percent of centers with an outbreak starting in year 2. Bars depict ICERs (in 2019 US dollars per QALY) for each screening strategy (screen at hemodialysis center entry only, every 2 years, yearly, or every 6 months) compared with next least expensive, nondominated strategy (initial reference: no screening). Each strategy uses base case parameters, varying prevalence of a simulated outbreak from 1% of centers (per literature estimate) up to an outbreak occurring in 50% of centers. In each case, a single outbreak occurs starting in year 2 of the simulation and lasts 19–60 months on the basis of screening frequency (see Supplemental Table 2). If a strategy is dominated, it does not appear on the graph. Dashed black line denotes $150,000 willingness-to-pay threshold.

Figure 2

Cost-effectiveness acceptability curve comparing guideline-recommended screening interval (every 6 months) with other frequencies. Graph represents results of the probabilistic sensitivity analyses, comparing the no HCV screening strategy and the guideline-recommended every 6-month screening with the other three strategies combined (one time, every 2 years, and yearly screening). The x-axis depicts different willingness-to-pay thresholds in US$, with dotted lines indicating $50,000, $100,000, and $150,000, respectively. The y-axis is the probability that a given strategy (or any of a combination of strategies) will be the “winner” at the corresponding willingness-to-pay threshold: the strategy that yields the highest number of QALYs for a cost under the willingness-to-pay threshold. The probability was determined by doing 1000 runs, each with a different set of parameters drawn from the probability distributions noted in Supplemental Table 4 and then calculating the strategy with the highest net monetary benefit (QALYs gained × willingness-to-pay threshold − incremental costs comparing each strategy with the next least expensive, nondominated strategy) at each willingness-to-pay threshold.