Cost-effectiveness of an outreach program for HCC screening in patients with cirrhosis: a microsimulation modeling study

Abstract

Background: Patients with cirrhosis are at high risk for hepatocellular carcinoma (HCC), but few undergo guideline-recommended semi-annual screening. Randomized clinical trials (RCTs) demonstrate that mailed outreach can increase screening versus visit-based screening. We estimated the costs and cost-effectiveness of an outreach strategy versus usual care.

Methods: We built a 10-year Markov chain Monte Carlo microsimulation model to conduct a cost-effectiveness analysis comparing a mailed outreach program versus usual care for HCC screening in a cohort of 10,000 patients with cirrhosis. Model inputs were based on literature review (2005-current), and costs were based on inflation-adjusted estimates from Surveillance, Epidemiology, and End Results (SEER)-Medicare claims data. We conducted one-way sensitivity analyses for HCC incidence, outreach costs, efficacy of the outreach strategy to increase screening, and efficacy of curative (versus palliative) HCC treatments.

Findings: Mailed outreach was estimated to cost $32.45 per patient in the first year and $21.90 per patient in subsequent years. The outreach program increased the number of HCC patients detected at an early stage by 48.4% and increased quality-adjusted life years (QALYs) by 300. Cost savings from these increases offset the costs of mailed outreach. Mailed outreach remained cost-effective across a wide range of HCC incidence rates, outreach costs, efficacy of the outreach strategy to increase screening, and the efficacy of curative HCC treatments. Annual out-of-pocket patient costs in the outreach arm were low at $13 per year.

Interpretation: Mailed outreach to encourage HCC screening in patients with cirrhosis dominates usual care and should be considered for implementation in routine practice.

Funding: National Cancer Institute and Cancer Prevention Research Institute of Texas.

Keywords: Interventions; Liver cancer; Outreach; Screening; Ultrasound.

Fig. 1

Proportions of patients with early-stage HCC in mailed outreach and usual care arms. Early-stage HCC detection over 10 years is higher in the outreach arm compared to usual care.

Fig. 2

One-way Sensitivity Analysis for Cost of Mailed Outreach. In one-way sensitivity analyses, mailed outreach remained cost-saving until outreach expenses exceeded $60 per patient per year.

Fig. 3

One-way Sensitivity Analysis for Effectiveness of Mailed Outreach. In one-way sensitivity analyses, mailed outreach was cost savings with increases in the probability of screening >5% compared to usual care.