1
|
Cost-utility Analysis of Second-generation Direct-acting Antivirals for Hepatitis C. HEPATITIS MONTHLY 2021. [DOI: 10.5812/hepatmon118646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
Background: Hepatitis C virus (HCV) can lead to increased mortality, disability, and liver transplantation if left untreated, and it is associated with a possible increase in disease burden in the future, all of which would surely have a significant impact on the health system. New antiviral regimens are effective in the treatment of the disease yet expensive. Objectives: The purpose of the present study was to assess the cost-effectiveness of three medication regimens, namely, ledipasvir/sofosbuvir (LDV/SOF), velpatasvir/sofosbuvir, and daclatasvir/sofosbuvir (DCV/SOF) for HCV patients with genotype 1 in Iran. Methods: A Markov model with a lifetime horizon was developed to predict the costs and outcomes of the three mentioned medication therapy strategies. The final outcome of the study was quality-adjusted life-years (QALYs), which was obtained using the previously published studies. The study was conducted from the perspective of the Health Ministry; therefore, only direct medical costs were estimated. The results were provided as the incremental cost-effectiveness ratio (ICER) per QALY. Ultimately, the one-way and probabilistic sensitivity analyses were used to measure the strength of study results. Results: The results showed that the QALYs for LDV/SOF, DCV/SOF, and VEL/SOF were 13.25, 13.94, and 14.61, and the costs were 4,807, 7,716, and 4,546$, respectively. The VEL/SOF regimen had lower costs and higher effectiveness than the LDV/SOF and DCV/SOF regimens, making it a dominant strategy. The tornado diagram results showed that the study results had the highest sensitivity to chronic hepatitis C (CHC) and compensated cirrhosis (CC) state costs. Moreover, the scatter plots showed that the VEL/SOF was the dominant therapeutic strategy in 73% of the simulations compared to LDV/SOF and 66% of the simulations compared to DCV/SOF; moreover, it was in the acceptable region in 92% of the simulations and below the threshold. Therefore, it was considered the most cost-effective strategy. Moreover, the results showed that DCV/SOF was in the acceptable region below the threshold in 69% of the simulations compared to LDV/SOF. Therefore, the DCV/SOF regimen was more cost-effective than LDV/SOF. Conclusions: According to the present study results, it is suggested that the VEL/SOF regimen be used as the first line of therapy in patients with HCV genotype 1. Moreover, DCV/SOF can be the second-line medication regimen.
Collapse
|
2
|
Yahya G, Hashem Mohamed N, Pijuan J, Seleem NM, Mosbah R, Hess S, Abdelmoaty AA, Almeer R, Abdel‐Daim MM, Shulaywih Alshaman H, Juraiby I, Metwally K, Storchova Z. Profiling the physiological pitfalls of anti-hepatitis C direct-acting agents in budding yeast. Microb Biotechnol 2021; 14:2199-2213. [PMID: 34378349 PMCID: PMC8449668 DOI: 10.1111/1751-7915.13904] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 07/16/2021] [Accepted: 07/17/2021] [Indexed: 02/05/2023] Open
Abstract
Sofosbuvir and Daclatasvir are among the direct-acting antiviral (DAA) medications prescribed for the treatment of chronic hepatitis C (CHC) virus infection as combination therapy with other antiviral medications. DAA-based therapy achieves high cure rates, reaching up to 97% depending on the genotype of the causative hepatitis C virus (HCV). While DAAs have been approved as an efficient and well-tolerated therapy for CHC, emerging concerns about adverse cardiac side effects, higher risk of recurrence and occurrence of hepatocellular carcinoma (HCC) and doubts of genotoxicity have been reported. In our study, we investigated in detail physiological off-targets of DAAs and dissected the effects of these drugs on cellular organelles using budding yeast, a unicellular eukaryotic organism. DAAs were found to disturb the architecture of the endoplasmic reticulum (ER) and the mitochondria, while showing no apparent genotoxicity or DNA damaging effect. Our study provides evidence that DAAs are not associated with genotoxicity and highlights the necessity for adjunctive antioxidant therapy to mitigate the adverse effects of DAAs on ER and mitochondria.
Collapse
Affiliation(s)
- Galal Yahya
- Department of Microbiology and ImmunologyFaculty of PharmacyZagazig UniversityAl Sharqia44519Egypt
- Department of Molecular GeneticsFaculty of BiologyTechnical University of KaiserslauternPaul‐Ehrlich Str. 24Kaiserslautern67663Germany
| | | | - Jordi Pijuan
- Laboratory of Neurogenetics and Molecular Medicine ‐ IPERInstitut de Recerca Sant Joan de DéuBarcelona08950Spain
| | - Noura M. Seleem
- Department of Microbiology and ImmunologyFaculty of PharmacyZagazig UniversityAl Sharqia44519Egypt
| | - Rasha Mosbah
- Infection Control UnitHospitals of Zagazig UniversityAl SharqiaEgypt
| | - Steffen Hess
- Department of Cell BiologyFaculty of BiologyTechnical University of KaiserslauternKaiserslauternGermany
| | - Ahmed A. Abdelmoaty
- Department of Tropical MedicineFaculty of MedicineZagazig UniversityZagazig44519Egypt
| | - Rafa Almeer
- Department of ZoologyCollege of ScienceKing Saud UniversityP.O. Box 2455Riyadh11451Saudi Arabia
| | - Mohamed M. Abdel‐Daim
- Department of ZoologyCollege of ScienceKing Saud UniversityP.O. Box 2455Riyadh11451Saudi Arabia
- Pharmacology DepartmentCollege of Veterinary MedicineSuez Canal UniversityIsmailiaEgypt
| | | | - Ibrahim Juraiby
- General Directorate of Health AffairsMinistry of HealthJazan82723Saudi Arabia
| | - Kamel Metwally
- Department of Pharmaceutical ChemistryFaculty of PharmacyTabuk UniversityTabuk47713Saudi Arabia
- Department of Medicinal ChemistryFaculty of PharmacyZagazig UniversityZagazig44519Egypt
| | - Zuzana Storchova
- Department of Molecular GeneticsFaculty of BiologyTechnical University of KaiserslauternPaul‐Ehrlich Str. 24Kaiserslautern67663Germany
| |
Collapse
|
3
|
Wei X, Zhao J, Yang L. Cost-effectiveness of new antiviral treatments for non-genotype 1 hepatitis C virus infection in China: a societal perspective. BMJ Glob Health 2021; 5:bmjgh-2020-003194. [PMID: 33246983 PMCID: PMC7703443 DOI: 10.1136/bmjgh-2020-003194] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 10/29/2020] [Accepted: 11/04/2020] [Indexed: 12/14/2022] Open
Abstract
Objective This study aimed to estimate the cost-effectiveness of direct-acting antivirals (DAAs) among patients with non-genotype 1 for the eradication of hepatitis C virus (HCV) infection in China. Methods A decision-analytic Markov model was developed to estimate the lifetime costs, quality-adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICERs) for DAAs and pegylated interferon plus ribavirin (PEG-RBV) from a societal perspective. The model inputs were derived from the literature, a patient survey, HCV expert opinions and a specialised drug price database available in China. Sensitivity analysis was conducted to evaluate the model robustness and calculate reasonable prices of DAAs. Results For patients infected with HCV genotype 2, the pan-genotypic regimen sofosbuvir/velpatasvir (SOF/VEL) was the most cost-effective strategy compared with PEG-RBV, with an ICER of US$5653/QALY. For genotype 3, the combination of sofosbuvir plus daclatasvir (SOF-DCV) was the most cost-effective approach, with an ICER of US$3314/QALY. All DAA regimens for genotype 6 were cost-saving, and sofosbuvir plus ribavirin (SOF-RBV) was the optimal regimen. One-way sensitivity analysis demonstrated that the ICERs were most sensitive to the utility values, discount rate and drug costs. Probabilistic sensitivity analysis indicated that using a threshold equal to one time the gross domestic product (GDP) per capita in China (US$9769/QALY, 2018), the probability of SOF/VEL, SOF-DCV and SOF-RBV being cost-effective was 58%, 83% and 71% for genotype 2, 3 and 6, respectively. Threshold analysis showed that the price of DAAs should be reduced by some degree to achieve better affordability. Conclusions DAAs were cost-effective compared with traditional treatments. A reasonable reduction in the price of DAAs will increase drug affordability and is of great significance as a global strategy to eradicate viral hepatitis.
Collapse
Affiliation(s)
- Xia Wei
- Department of Health policy and management, School of Public Health, Peking University, Beijing, China
| | - Jingyu Zhao
- Department of Health policy and management, School of Public Health, Peking University, Beijing, China
| | - Li Yang
- Department of Health policy and management, School of Public Health, Peking University, Beijing, China
| |
Collapse
|
4
|
Szilberhorn L, Kaló Z, Ágh T. Cost-effectiveness of second-generation direct-acting antiviral agents in chronic HCV infection: a systematic literature review. Antivir Ther 2020; 24:247-259. [PMID: 30652971 DOI: 10.3851/imp3290] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Our objectives were to review the economic modelling methods and cost-effectiveness of second-generation direct-acting antiviral agents for the treatment of chronic HCV infection. METHODS A systematic literature search was performed in February 2017 using Scopus and OVID to review relevant publications between 2011 to present. Two independent reviewers screened potential papers. RESULTS The database search resulted in a total of 1,536 articles; after deduplication, title/abstract and full text screening, 67 studies were included for qualitative analysis. The vast majority of studies were conducted in high-income countries (n=59) and used Markov-based modelling techniques (n=60). Most of the analyses utilized long-term time horizons; 58 studies calculated lifetime costs and outcomes. The examined treatments were heterogenic among the studies; seven analyses did not directly evaluate treatments (just with screening or genotype testing). The examined treatments (n=60) were either dominant (23%), or cost-effective at base case (57%) or in given subgroups (18%). Only one (2%) study reported that the assessed treatment was not cost-effective with the given setting and price. CONCLUSIONS Despite their high initial therapeutic costs, second-generation direct-acting antiviral agents were found to be cost-effective to treat chronic HCV infection. Studies were predominantly conducted in higher income countries, although we have limited information on cost-effectiveness in low- and middle-income countries, where assessment of cost-effectiveness is even more essential due to more limited health-care resources and potentially higher public health burden due to unsafe medical interventions.
Collapse
Affiliation(s)
- László Szilberhorn
- Department of Health Policy and Health Economics, Eötvös Loránd University, Faculty of Social Sciences, Budapest, Hungary.,Syreon Research Institute, Budapest, Hungary
| | - Zoltán Kaló
- Department of Health Policy and Health Economics, Eötvös Loránd University, Faculty of Social Sciences, Budapest, Hungary.,Syreon Research Institute, Budapest, Hungary
| | - Tamás Ágh
- Syreon Research Institute, Budapest, Hungary
| |
Collapse
|
5
|
Ibrahim Mohammed Ebid AH, Ashraf Ahmed O, Hassan Agwa S, Mohamed Abdel-Motaleb S, Mohamed Elsawy A, Hagag RS. Safety, efficacy and cost of two direct-acting antiviral regimens: A comparative study in chronic hepatitis C Egyptian patients. J Clin Pharm Ther 2019; 45:539-546. [PMID: 31889322 DOI: 10.1111/jcpt.13104] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 11/26/2019] [Accepted: 11/29/2019] [Indexed: 12/16/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Direct-acting antivirals (DAAs) have become the most widely used treatment of chronic hepatitis C infection. Comparative studies on DAAs regimens approved by the Egyptian Ministry of Health for easy-to-treat genotype 4 (G4) Egyptian patients are still deficient. In this prospective study, we compared the efficacy and cost of two DAA regimens that are used in the treatment of Egyptian chronic hepatitis C virus (HCV) G4. The cost-saving regimen is determined. METHODS Eligible patients were randomized into 2 groups. Group 1 (Gp 1) received sofosbuvir plus daclatasvir, and group 2 (Gp 2) received ombitasvir, paritaprevir and ritonavir plus ribavirin (RBV) for 12 weeks. Data were collected and evaluated at baseline and at weeks 4, 8 and 12. Sustained virologic response 12 weeks after the end of treatment (SVR12 ) was evaluated. Cost-minimization analysis (CMA) was performed. RESULTS AND DISCUSSION Eligibility was achieved in 107 patients, Gp1 included 57 patients, and Gp 2 included 50 patients. Two patients dropped out from Gp 2 due to non-compliance. All patients in the two groups showed negative HCV blood levels at the end of treatment. At the 24th week, 3 relapsers (5.2%) were detected in Gp1 and 2 relapsers (4.1%) were detected in Gp 2. SVR12 was 54/57 (94.7%) and 46/48 (95.8%) for Gp 1 and Gp 2, respectively. After the 12th week of treatment, a significant decrease in aspartate aminotransferase (AST), alanine aminotransferase (ALT) and haemoglobin levels were observed in both groups. Albumin levels declined in Gp 2 only. CMA showed higher cost in Gp 2 than Gp 1, although similar efficacy and safety. WHAT IS NEW AND CONCLUSION The two DAA regimens showed high SVR12 and safety in Egyptian HCV G4 patients. Sofosbuvir plus daclatasvir is the cost-saving regimen.
Collapse
Affiliation(s)
| | - Osama Ashraf Ahmed
- Department of Internal Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Sara Hassan Agwa
- Department of Clinical & Chemical Pathology at MASRI, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | | | - Amira Mohamed Elsawy
- Department of Pharmacy Practice, Faculty of Pharmacy, Helwan University, Cairo, Egypt
| | - Radwa Samir Hagag
- Department of Pharmacy Practice, Faculty of Pharmacy, Egyptian Russian University, Badr City, Egypt
| |
Collapse
|
6
|
High sustained virologic response rates of sofosbuvir-based regimens in Chinese patients with HCV genotype 3a infection in a real-world setting. Virol J 2019; 16:74. [PMID: 31159813 PMCID: PMC6547524 DOI: 10.1186/s12985-019-1184-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 05/24/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Patients with hepatitis C virus (HCV) genotype 3 infection remain a difficult-to-cure population. This study evaluated the efficacy and safety of sofosbuvir-based regimen in genotype 3 patients in a real-world setting. METHODS HCV genotype 3a-infected adults with compensated liver disease were treated with sofosbuvir (SOF)/velpatasvir (VEL) or SOF/daclatasvir (DCV) with or without ribavirin (RBV) for 12 or 24 weeks, respectively. Efficacy was measured by sustained virologic response at post-treatment week 12 (SVR12). Adverse events were evaluated throughout the treatment and follow-up course. RESULTS A total of 41 genotype 3a-infected patients were included. Of them, 10 patients (24%) had cirrhosis, 3 (7%) had renal impairment, and 2 (5%) failed previous treatment. Nine patients (22%) were treated with SOF/VEL and 32 (78%) with SOF/DCV with or without RBV. SVR 12 was achieved in 100% (9/9) of patients treated with SOF/VEL for 12 weeks and in 97% (31/32) of those treated with SOF/DCV for 12 or 24 weeks. RBV addition and extension of treatment duration did not improve the SVR of SOF/DCV (RR: 1.04; P = 0.99 and RR: 1.09; P = 0.375, respectively). Ten patients with cirrhosis, 1 on hemodialysis and 2 with treatment-experience achieved SVR12. One treatment-naïve non-cirrhotic patient on hemodialysis treated with SOF/DCV for 24 weeks relapsed at week 8 post-treatment. No serious adverse events and relevant laboratory abnormalities were observed. CONCLUSION SOF/VEL and SOF/DCV are highly efficacious and well tolerated in genotype 3a-infected patients with or without cirrhosis. RBV coadministration and extension of SOF/DCV treatment appear to add no improvement for efficacy.
Collapse
|
7
|
Wong Y, Cheen MHH, Hsiang JC, Kumar R, Tan J, Teo EK, Thurairajah PH. Economic evaluation of direct-acting antivirals for the treatment of genotype 3 hepatitis C infection in Singapore. JGH Open 2019; 3:210-216. [PMID: 31276038 PMCID: PMC6586564 DOI: 10.1002/jgh3.12139] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 12/04/2018] [Accepted: 12/10/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIM The prohibitively high cost of direct-acting antivirals (DAA) for hepatitis C virus (HCV) infection remains a barrier to treatment access in Singapore. We aimed to evaluate whether DAA as first-line therapy would be cost-effective for genotype 3 (GT3) HCV patients compared with pegylated interferon and ribavirin (PR). METHODS A decision tree analysis was used to compare the costs and outcomes of DAA and PR as first-line therapy. Treatment effectiveness, defined as sustained virological response, was assessed using a retrospective cohort of treated GT3 HCV patients. Direct medical costs were estimated from the payer's perspective using billing information. We obtained health utilities from published literature. We performed extensive one-way sensitivity analyses and probabilistic sensitivity analyses to account for uncertainties regarding the model parameters. RESULTS In base case analysis, first-line therapy with DAA and PR yielded quality-adjusted life years (QALYs) of 0.69 and 0.62 at a cost of USD 54 634 and USD 23 857, respectively. The resultant incremental cost-effectiveness ratio (ICER) (USD 449 232/QALY) exceeded the willingness-to-pay threshold (USD 53 302/QALY). The ICER was robust for uncertainties regarding the model parameters. The cost of DAA is the key factor influencing the cost-effectiveness of HCV treatment. At current price, DAA as first-line therapy is not cost-effective compared with PR, with or without consideration of retreatment. Threshold analysis suggested that DAA can be cost-effective if it costs less than USD 17 002 for a 12-week treatment course. CONCLUSION At current price, DAA as first-line therapy is not cost-effective compared with PR in GT3 HCV patients in Singapore.
Collapse
Affiliation(s)
- Yu‐Jun Wong
- Department of Gastroenterology and HepatologyChangi General HospitalSingapore
| | - McVin HH Cheen
- Department of PharmacySingapore General HospitalSingapore
| | - John C Hsiang
- Department of Gastroenterology and HepatologyChangi General HospitalSingapore
| | - Rahul Kumar
- Department of Gastroenterology and HepatologyChangi General HospitalSingapore
| | - Jessica Tan
- Department of Gastroenterology and HepatologyChangi General HospitalSingapore
| | - Eng K Teo
- Department of Gastroenterology and HepatologyChangi General HospitalSingapore
| | - Prem H Thurairajah
- Department of Gastroenterology and HepatologyChangi General HospitalSingapore
| |
Collapse
|
8
|
Chung W, Kim KA, Jang ES, Ki M, Choi HY, Jeong SH. Cost-effectiveness of sofosbuvir plus ribavirin therapy for hepatitis C virus genotype 2 infection in South Korea. J Gastroenterol Hepatol 2019; 34:776-783. [PMID: 30462841 DOI: 10.1111/jgh.14554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 11/12/2018] [Accepted: 11/14/2018] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM For genotype 2 chronic hepatitis C (CHC), the efficacy and safety of sofosbuvir plus ribavirin therapy (SOF + RBV) was better than pegylated interferon plus ribavirin therapy (PR) at a greater drug cost. This study investigated the cost-effectiveness of SOF + RBV compared with PR for treatment-naïve genotype 2 CHC in South Korea. METHODS Using a decision analytic Markov model, a cost-effectiveness analysis comparing SOF + RBV with PR or no treatment for treatment-naïve genotype 2 CHC was performed with probabilistic and deterministic sensitivity analyses from the payer's perspective in 2017. Three cohorts of patients aged 40-49, 50-59, and 60-69 years were simulated to progress through the fibrosis stages F0-F4 to end-stage liver disease, hepatocellular carcinoma, or death. Published and calculated data on the clinical efficacy of the regimen, health-related quality of life, costs, and transition probabilities were used. RESULTS While the incremental cost-effectiveness ratio for PR was dominant over no treatment, the incremental cost-effectiveness ratios for SOF + RBV were $20 058 for the patients in their 40s, $19 662 for those in their 50s, and $22 278 for those in their 60s compared with PR. Probabilistic sensitivity analysis indicated an 89.0% probability for the SOF + RBV to be cost-effective at a willingness to pay of $29 754.4 (per-capita gross domestic product in 2017) for the patients in their 40s and 94.1% and 89.1% for the patients in their 50s and 60s, respectively. CONCLUSIONS The SOF + RBV is a cost-effective option for genotype 2 treatment-naïve CHC patients, especially for the patients with liver cirrhosis in Korea.
Collapse
Affiliation(s)
- Wankyo Chung
- Department of Public Health Science and Institute of Health and Environment, Graduate School of Public Health, Seoul National University, Seoul, Korea
| | - Kyung-Ah Kim
- Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Gyeonggi, Korea
| | - Eun Sun Jang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi, Korea
| | - Moran Ki
- Department of Cancer Control and Population Health, Graduate School of Cancer Science and Policy, National Cancer Center, Goyang, Gyeonggi, Korea
| | - Hwa Young Choi
- Department of Cancer Control and Population Health, Graduate School of Cancer Science and Policy, National Cancer Center, Goyang, Gyeonggi, Korea
| | - Sook-Hyang Jeong
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi, Korea
| |
Collapse
|
9
|
Puig-Junoy J, Pascual-Argente N, Puig-Codina L, Planellas L, Solozabal M. Cost-utility analysis of second-generation direct-acting antivirals for hepatitis C: a systematic review. Expert Rev Gastroenterol Hepatol 2018; 12:1251-1263. [PMID: 30791790 DOI: 10.1080/17474124.2018.1540929] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
High prices of second-generation direct-acting antivirals (DAAs) in the treatment of chronic hepatitis C virus (HCV) patients led to reimbursement decisions based on cost per quality-adjusted life year (QALY). Areas covered: We performed a systematic review of cost-utility analyses (CUA) comparing interventions with second-generation DAA therapies with no treatment, and with previous therapies for chronic HCV patients until July 2017. A total of 36 studies were included: 30 studies from the perspective of the healthcare payer, 3 from the societal perspective, and 3 did not report the perspective. For genotype 1, the highest number of ICER comparison corresponds to sofosbuvir (SOF) triple therapy and SOF-based combinations which reported a cost per QALY systematically ranging from negative to lower than US$100,000 when compared with no treatment or dual therapy or Simeprevir triple therapy. Expert commentary: Selected studies may be overestimating the true cost per QALY of second-generation DAAs in the treatment of HCV, mainly because of neglecting non-healthcare costs, using official list prices which are higher than actual transaction prices and not adopting the long run drug price in a dynamic approach. In addition, the impact of important price reductions of several DAAs in recent years on cost per QALY should be considered.
Collapse
Affiliation(s)
- Jaume Puig-Junoy
- a Department of Economics and Business (UPF) , Pompeu Fabra University , Barcelona , Spain.,b UPF Barcelona School of Management , Pompeu Fabra University , Barcelona , Spain.,c UPF Center for Research in Health and Economics (CRES-UPF) , Pompeu Fabra University , Barcelona , Spain
| | - Natàlia Pascual-Argente
- b UPF Barcelona School of Management , Pompeu Fabra University , Barcelona , Spain.,c UPF Center for Research in Health and Economics (CRES-UPF) , Pompeu Fabra University , Barcelona , Spain
| | - Lluc Puig-Codina
- b UPF Barcelona School of Management , Pompeu Fabra University , Barcelona , Spain
| | | | | |
Collapse
|
10
|
Cipriano LE, Goldhaber-Fiebert JD. Population Health and Cost-Effectiveness Implications of a "Treat All" Recommendation for HCV: A Review of the Model-Based Evidence. MDM Policy Pract 2018; 3:2381468318776634. [PMID: 30288448 PMCID: PMC6157435 DOI: 10.1177/2381468318776634] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 04/20/2018] [Indexed: 12/15/2022] Open
Abstract
The World Health Organization HCV Guideline Development Group is considering a "treat all" recommendation for persons infected with hepatitis C virus (HCV). We reviewed the model-based evidence of cost-effectiveness and population health impacts comparing expanded treatment policies to more limited treatment access policies, focusing primarily on evaluations of all-oral directly acting antivirals published after 2012. Searching PubMed, we identified 2,917 unique titles. Sequentially reviewing titles and abstracts identified 226 potentially relevant articles for full-text review. Sixty-nine articles met all inclusion criteria-42 cost-effectiveness analyses and 30 models of population-health impacts, with 3 articles presenting both types of analysis. Cost-effectiveness studies for many countries concluded that expanding treatment to people with mild liver fibrosis, who inject drugs (PWID), or who are incarcerated is generally cost-effective compared to more restrictive treatment access policies at country-specific prices. For certain patient subpopulations in some countries-for example, elderly individuals without fibrosis-treatment is only cost-effective at lower prices. A frequent limitation is the omission of benefits and consequences of HCV transmission (i.e., treatment as prevention; risks of reinfection), which may underestimate or overestimate the cost-effectiveness of a "treat all" policy. Epidemiologic modeling studies project that through a combination of prevention, aggressive screening and diagnosis, and prompt treatment for all fibrosis stages, it may be possible to virtually eliminate HCV in many countries. Studies show that if resources are not available to diagnose and treat all HCV-infected individuals, treatment prioritization may be needed, with alternative prioritization strategies resulting in tradeoffs between reducing mortality or reducing incidence. Notably, because most new HCV infections are among PWID in many settings, HCV elimination requires unrestricted treatment access combined with injection transmission disruption strategies. The model-based evidence suggests that a properly constructed strategy that substantially expands HCV treatment could achieve cost-effective improvements in population health in many countries.
Collapse
Affiliation(s)
- Lauren E Cipriano
- Ivey Business School and the Department of Biostatistics and Epidemiology, Western University, London, Ontario, Canada
| | - Jeremy D Goldhaber-Fiebert
- Center for Health Policy and Center for Primary Care and Outcomes Research, Department of Medicine, Stanford University, Stanford, California
| |
Collapse
|
11
|
El Kassas M, Elbaz T, Elsharkawy A, Omar H, Esmat G. HCV in Egypt, prevention, treatment and key barriers to elimination. Expert Rev Anti Infect Ther 2018; 16:345-350. [PMID: 29506418 DOI: 10.1080/14787210.2018.1448709] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Currently, direct-acting antivirals (DAAs) are considered the ideal choice for the treatment of chronic HCV patients due to their proven efficacy (SVR> 90%), and minimal adverse effects. Egypt launched a large treatment program aimed at providing treatment coverage for Egyptian HCV- infected patients. Areas covered: This review covers the treatment and prevention efforts made by the Egyptian National Committee for the Control of Viral Hepatitis (NCCVH) with the available model of care for HCV patients in Egypt, in addition to the barriers that prevent elimination of HCV from Egypt. Expert commentary: Egypt could provide a model for establishing the largest HCV management system aimed at eliminating HCV from the country with the highest worldwide prevalence. Despite the huge efforts and achieved results in combating the HCV epidemic in Egypt, certain improvements are needed in order to attain HCV elimination, such as the development of an enhanced screening program working in parallel to the present treatment options.
Collapse
Affiliation(s)
- Mohamed El Kassas
- a Endemic Medicine Department, Faculty of Medicine , Helwan University , Cairo , Egypt
| | - Tamer Elbaz
- b Endemic Hepatogastroenterology, Faculty of Medicine , Cairo University , Cairo , Egypt
| | - Aisha Elsharkawy
- b Endemic Hepatogastroenterology, Faculty of Medicine , Cairo University , Cairo , Egypt
| | - Heba Omar
- b Endemic Hepatogastroenterology, Faculty of Medicine , Cairo University , Cairo , Egypt
| | - Gamal Esmat
- b Endemic Hepatogastroenterology, Faculty of Medicine , Cairo University , Cairo , Egypt
| |
Collapse
|
12
|
Omar H, El Akel W, Elbaz T, El Kassas M, Elsaeed K, El Shazly H, Said M, Yousif M, Gomaa AA, Nasr A, AbdAllah M, Korany M, Ismail SA, Shaker MK, Doss W, Esmat G, Waked I, El Shazly Y. Generic daclatasvir plus sofosbuvir, with or without ribavirin, in treatment of chronic hepatitis C: real-world results from 18 378 patients in Egypt. Aliment Pharmacol Ther 2018; 47:421-431. [PMID: 29193226 DOI: 10.1111/apt.14428] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 08/22/2017] [Accepted: 10/30/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Treatment of chronic hepatitis C using combination of sofosbuvir (SOF) and daclatasvir (DCV) was used in several clinical trials and multicentre studies, which were somewhat limited to genotypes 1-3. The national program in Egypt is using SOF-DCV combination for large scale treatment. AIM To assess the efficacy and safety of combined SOF-DCV in treating patients with HCV-G4 in a real-world setting. METHODS Data and outcome of chronic HCV patients who were treated for 12 weeks with generic medications: DCV 60 mg plus SOF 400 mg ± ribavirin (RBV) within the national hepatitis C treatment program in Egypt are presented. Treatment-naïve patients without cirrhosis were treated without RBV, and those who had cirrhosis or were treatment-experienced (interferon experienced or SOF experienced) received RBV. Efficacy and safety were assessed, and baseline factors associated with sustained virological response at post-treatment week 12 (SVR12) were explored. RESULTS During the first 2 months of the programme, 18 378 patients with HCV-G4 started treatment with SOF-DCV with or without RBV. Overall, 95.1% achieved SVR12 (95.4% among patients treated without RBV and 94.7% for patients treated with RBV, P = .32). Treatment was prematurely discontinued in only 1.5% of patients. The most common events leading to discontinuation were patient withdrawal (n = 76) and pregnancy (n = 5). Five deaths occurred within this group. CONCLUSIONS Real-world experience of generic SOF-DCV in patients with chronic HCV-G4 proved to be safe and associated with a high SVR12 rate, in patients with different stages of fibrosis.
Collapse
Affiliation(s)
- H Omar
- Faculty of Medicine, Cairo University, Cairo, Egypt
| | - W El Akel
- Faculty of Medicine, Cairo University, Cairo, Egypt
| | - T Elbaz
- Faculty of Medicine, Cairo University, Cairo, Egypt
| | - M El Kassas
- Faculty of Medicine, Helwan University, Cairo, Egypt
| | - K Elsaeed
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - H El Shazly
- National Liver Institute, Menoufiya University, Shebeen EL Kom, Egypt
| | - M Said
- Faculty of Medicine, Cairo University, Cairo, Egypt
| | - M Yousif
- Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - A A Gomaa
- Faculty of Medicine, Fayoum University, Fayoum, Egypt
| | - A Nasr
- Faculty of Medicine, Assiut University, Assiut, Egypt
| | | | - M Korany
- National Committee for Control of Viral Hepatitis, Cairo, Egypt
| | - S A Ismail
- National Hepatology and Tropical Medicine Research Institute, Cairo, Egypt
| | - M K Shaker
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - W Doss
- Faculty of Medicine, Cairo University, Cairo, Egypt
| | - G Esmat
- Faculty of Medicine, Cairo University, Cairo, Egypt
| | - I Waked
- National Liver Institute, Menoufiya University, Shebeen EL Kom, Egypt
| | - Y El Shazly
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| |
Collapse
|
13
|
He T, Lopez-Olivo MA, Hur C, Chhatwal J. Systematic review: cost-effectiveness of direct-acting antivirals for treatment of hepatitis C genotypes 2-6. Aliment Pharmacol Ther 2017; 46:711-721. [PMID: 28836278 DOI: 10.1111/apt.14271] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 05/25/2017] [Accepted: 07/27/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND The availability of direct-acting antivirals (DAAs) has dramatically changed the landscape of hepatitis C virus (HCV) therapy; however, the cost and budget requirements for DAA treatment have been widely debated. AIMS To systematically review published studies evaluating the cost-effectiveness of DAAs for HCV genotype 2-6 infections, and synthesise and re-evaluate results with updated drug prices. METHODS We conducted a systematic search of various electronic databases, including Medline, EMBASE, Cochrane library and EconLit for cost-effectiveness studies published from 2011 to 2016. Studies evaluating DAAs for genotypes 2-6 were included. Reported costs, quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICERs) were abstracted. We re-estimated ICERs by varying the price of DAAs from $20 000 to $100 000, and estimated the threshold price at which DAA regimens would be deemed cost-effective (ICER≤$100 000/QALY). RESULTS A total of 92 ICERs for 7 different DAA regimens from 10 published articles were included. Among the abstracted 92 ICERs, 20 were for genotype 2, 40 for genotype 3, 30 for genotype 4, 2 for genotype 5 and none for genotype 6; therefore, only genotypes 2-5 were analysed. At the discounted price of $40 000, 87.0% analyses found DAA regiments to be cost-effective, and 7.6% found to be cost-saving. The median threshold price below which DAAs would be deemed cost-effective was between $144 400 and $225 000, and cost-saving between $17 300 and $25 400. CONCLUSIONS HCV treatment with DAAs is highly cost-effective in patients with HCV genotypes 2-5 at a $100 000/QALY threshold. Timely HCV treatment would be an optimal strategy from both a public health and economic perspective.
Collapse
Affiliation(s)
- T He
- Department of Internal Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - M A Lopez-Olivo
- Department of General Internal Medicine, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - C Hur
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Liver Center and Gastrointestinal Division, Massachusetts General Hospital, Boston, MA, USA
| | - J Chhatwal
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Liver Center and Gastrointestinal Division, Massachusetts General Hospital, Boston, MA, USA
| |
Collapse
|
14
|
Mattingly TJ, Slejko JF, Mullins CD. Hepatitis C Treatment Regimens Are Cost-Effective: But Compared With What? Ann Pharmacother 2017; 51:961-969. [PMID: 28715911 DOI: 10.1177/1060028017722007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Numerous economic models have been published evaluating treatment of chronic hepatitis C virus (HCV) infection, but none provide a comprehensive comparison among new antiviral agents. OBJECTIVE Evaluate the cost-effectiveness of all recommended therapies for treatment of genotypes 1 and 4 chronic HCV. METHODS Using data from clinical trials, observational analyses, and drug pricing databases, Markov decision models were developed for HCV genotypes 1 and 4 to compare all recommended drugs from the perspective of the third-party payer over a 5-, 10-, and 50-year time horizon. A probabilistic sensitivity analysis (PSA) was conducted by assigning distributions for clinical cure, age entering the model, costs for each health state, and quality-adjusted life years (QALYs) for each health state in a Monte Carlo simulation of 10 000 repetitions of the model. RESULTS In the lifetime model for genotype 1, effects ranged from 18.08 to 18.40 QALYs and total costs ranged from $88 107 to $184 636. The lifetime model of genotype 4 treatments had a range of effects from 18.23 to 18.43 QALYs and total costs ranging from $87 063 to $127 637. Grazoprevir/elbasvir was the optimal strategy followed by velpatasvir/sofosbuvir as the second-best strategy in most simulations for both genotypes 1 and 4, with drug costs and efficacy of grazoprevir/elbasvir as the primary model drivers. CONCLUSIONS Grazoprevir/elbasvir was cost-effective compared with all strategies for genotypes 1 and 4. Effects for all strategies were similar with cost of drug in the initial year driving the results.
Collapse
Affiliation(s)
| | - Julia F Slejko
- 1 University of Maryland School of Pharmacy, Baltimore, MD, USA
| | | |
Collapse
|
15
|
Saint-Laurent Thibault C, Moorjaney D, Ganz ML, Sill B, Hede S, Yuan Y, Gorsh B. Cost-effectiveness of combination daclatasvir-sofosbuvir for treatment of genotype 3 chronic hepatitis C infection in the United States. J Med Econ 2017; 20:692-702. [PMID: 28294645 DOI: 10.1080/13696998.2017.1307204] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND A phase III trial evaluated the efficacy and safety of Daklinza (daclatasvir or DCV) in combination with sofosbuvir (SOF) for treatment of genotype (GT) 3 hepatitis C virus (HCV) patients. AIM This study evaluated the cost-effectiveness of DCV + SOF vs SOF in combination with ribavirin (RBV) over a 20-year time horizon from the perspective of a United States (US) payer. METHODS A published Markov model was adapted to reflect US demographic characteristics, treatment patterns, costs of drug acquisition, monitoring, disease and adverse event management, and mortality risks. Clinical inputs came from the ALLY-3 and VALENCE trials. The primary outcome was the incremental cost-utility ratio. Life-years, incidence of complications, number of patients achieving sustained virological response (SVR), and the total cost per SVR were secondary outcomes. Costs (2014 USD) and quality-adjusted life years (QALYs) were discounted at 3% per year. Deterministic, probabilistic, and scenario sensitivity analyses were conducted. RESULTS DCV + SOF was associated with lower costs and better effectiveness than SOF + RBV in the base case and in almost all scenarios (i.e. treatment-experienced, non-cirrhotic, time horizons of 5, 10, and 80 years). DCV + SOF was less costly, but also slightly less effective than SOF + RBV in the cirrhotic and treatment-naïve population scenarios. Results were sensitive to variations in the probability of achieving SVR for both treatment arms. DCV + SOF costs less than $50,000 per QALY gained in 79% of all probabilistic iterations compared with SOF + RBV. CONCLUSION DCV + SOF is a dominant option compared with SOF + RBV in the US for the overall GT 3 HCV patient population.
Collapse
Affiliation(s)
| | | | | | - Bruce Sill
- d Bristol-Myers Squibb , Hartford , CT , USA
| | | | - Yong Yuan
- e Bristol-Myers Squibb , Plainsboro , NJ , USA
| | - Boris Gorsh
- f GlaxoSmithKline , Upper Providence , PA , USA
| |
Collapse
|
16
|
Abstract
The hepatitis C virus (HCV) NS5A replication complex inhibitor daclatasvir (Daklinza(®)) is indicated for use in combination with sofosbuvir, with or without ribavirin, in a pangenotypic all-oral regimen. In patients with chronic HCV genotype 1 or 3 infection without cirrhosis, a 12-week regimen of daclatasvir plus sofosbuvir achieved high sustained virological response rates 12 weeks' post-treatment (SVR12), regardless of prior treatment experience, according to the results of the AI444040 and ALLY-3 trials. In the ALLY-3+ trial, high SVR12 rates were achieved with a 12- or 16-week regimen of daclatasvir plus sofosbuvir and ribavirin in patients with chronic HCV genotype 3 infection and advanced fibrosis or compensated cirrhosis. A daclatasvir plus sofosbuvir-based regimen demonstrated efficacy in patients with chronic HCV genotype 1, 3 or 4 infection and advanced cirrhosis or post-transplant recurrence in the ALLY-1 trial, and in patients co-infected with HCV genotype 1, 3 or 4 and HIV-1 in the ALLY-2 trial. Results of clinical trials were supported by real-world data from early-access programmes that included high numbers of patients who would have been excluded from phase 3 trials because of advanced disease and/or concomitant medical conditions. Daclatasvir plus sofosbuvir with or without ribavirin was generally well tolerated. In conclusion, an all-oral regimen comprising daclatasvir plus sofosbuvir with or without ribavirin is an important option for use in treatment-naive or treatment-experienced patients with chronic HCV genotype 1, 3 or 4 infection, including in patients with advanced liver disease, post-transplant recurrence and HIV-1 co-infection.
Collapse
|
17
|
Leidner AJ, Chesson HW, Spradling PR, Holmberg SD. Assessing the Effect of Potential Reductions in Non-Hepatic Mortality on the Estimated Cost-Effectiveness of Hepatitis C Treatment in Early Stages of Liver Disease. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2017; 15:65-74. [PMID: 27480538 PMCID: PMC5802335 DOI: 10.1007/s40258-016-0261-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND Most cost-effectiveness analyses of hepatitis C (HCV) therapy focus on the benefits of reducing liver-related morbidity and mortality. OBJECTIVES Our objective was to assess how cost-effectiveness estimates of HCV therapy can vary depending on assumptions regarding the potential impact of HCV therapy on non-hepatic mortality. METHODS We adapted a state-transition model to include potential effects of HCV therapy on non-hepatic mortality. We assumed successful treatment could reduce non-hepatic mortality by as little as 0 % to as much as 100 %. Incremental cost-effectiveness ratios were computed comparing immediate treatment versus delayed treatment and comparing immediate treatment versus non-treatment. RESULTS Comparing immediate treatment versus delayed treatment, when we included a 44 % reduction in non-hepatic mortality following successful HCV treatment, the incremental cost per quality-adjusted life year (QALY) gained by HCV treatment fell by 76 % (from US$314,100 to US$76,900) for patients with no fibrosis and by 43 % (from US$62,500 to US$35,800) for patients with moderate fibrosis. Comparing immediate treatment versus non-treatment, assuming a 44 % reduction in non-hepatic mortality following successful HCV treatment, the incremental cost per QALY gained by HCV treatment fell by 64 % (from US$186,700 to US$67,300) for patients with no fibrosis and by 27 % (from US$35,000 to US$25,500) for patients with moderate fibrosis. CONCLUSION Including reductions in non-hepatic mortality from HCV treatment can have substantial effects on the estimated cost-effectiveness of treatment.
Collapse
Affiliation(s)
- Andrew J Leidner
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop G-37, Atlanta, GA, 30333, USA.
| | - Harrell W Chesson
- Division of Sexually Transmitted Disease Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Philip R Spradling
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop G-37, Atlanta, GA, 30333, USA
| | - Scott D Holmberg
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop G-37, Atlanta, GA, 30333, USA
| |
Collapse
|
18
|
Wong WWL, Lee KM, Singh S, Wells G, Feld JJ, Krahn M. Drug therapies for chronic hepatitis C infection: a cost-effectiveness analysis. CMAJ Open 2017; 5:E97-E108. [PMID: 28401125 PMCID: PMC5378540 DOI: 10.9778/cmajo.20160161] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Before 2011, pegylated interferon plus ribavirin was the standard therapy for chronic hepatitis C. Interferon-free direct-acting antiviral agents were then approved. Although these treatments appear to be more effective, they are substantially more expensive. In anticipation of the need for information regarding the comparative cost-effectiveness of new regimens in a recent therapeutic review, we conducted the analysis to inform listing decision in Canada. METHODS A state-transition model was developed in the form of a cost-utility analysis. Regimens included in the analysis were comprehensive. The cohort under consideration had a mean age of 50 years. The cohort was defined by treatment status and cirrhosis status. Inputs for the model were derived from published sources and validated by clinical experts. RESULTS For each genotype 1 population, at least 1 of the interferon-free agents appeared to be economically attractive compared with pegylated interferon-ribavirin, at a willingness-to-pay of $50 000 per quality-adjusted life-year. The drug that was the most cost-effective varied by population. For genotype 2-4 population, the direct-acting antiviral therapies appeared not to be economically attractive compared with pegylated interferon-ribavirin for the treatment-naive; however, there were direct-acting antiviral therapies that appeared to be attractive when compared with no treatment for the treatment-experienced. INTERPRETATION Public health policy should be informed by consideration of health benefit, social and ethical values, feasibility and cost-effectiveness. Our analysis assists the development of reimbursements and policies for interferon-free direct-acting antiviral agent regimens for chronic hepatitis C infection by informing the last criterion. Considering the rapid development of treatments for chronic hepatitis C, further update and expanded reviews will be necessary.
Collapse
Affiliation(s)
- William W L Wong
- School of Pharmacy (Wong), University of Waterloo, Kitchener, Ont.; Toronto Health Economics and Technology Assessment Collaborative (THETA) (Wong, Krahn), Faculty of Pharmacy, University of Toronto, Toronto, Ont.; Canadian Agency for Drugs and Technologies in Health (CADTH) (Lee, Singh), Ottawa, Ont.; School of Epidemiology, Public Health and Preventative Medicine (Lee), University of Ottawa, Ottawa, Ont.; Cardiovascular Research Methods Centre (Wells), University of Ottawa Heart Institute, Ottawa, Ont.; Toronto Centre for Liver Disease (Feld), University Health Network, University of Toronto, Toronto, Ont
| | - Karen M Lee
- School of Pharmacy (Wong), University of Waterloo, Kitchener, Ont.; Toronto Health Economics and Technology Assessment Collaborative (THETA) (Wong, Krahn), Faculty of Pharmacy, University of Toronto, Toronto, Ont.; Canadian Agency for Drugs and Technologies in Health (CADTH) (Lee, Singh), Ottawa, Ont.; School of Epidemiology, Public Health and Preventative Medicine (Lee), University of Ottawa, Ottawa, Ont.; Cardiovascular Research Methods Centre (Wells), University of Ottawa Heart Institute, Ottawa, Ont.; Toronto Centre for Liver Disease (Feld), University Health Network, University of Toronto, Toronto, Ont
| | - Sumeet Singh
- School of Pharmacy (Wong), University of Waterloo, Kitchener, Ont.; Toronto Health Economics and Technology Assessment Collaborative (THETA) (Wong, Krahn), Faculty of Pharmacy, University of Toronto, Toronto, Ont.; Canadian Agency for Drugs and Technologies in Health (CADTH) (Lee, Singh), Ottawa, Ont.; School of Epidemiology, Public Health and Preventative Medicine (Lee), University of Ottawa, Ottawa, Ont.; Cardiovascular Research Methods Centre (Wells), University of Ottawa Heart Institute, Ottawa, Ont.; Toronto Centre for Liver Disease (Feld), University Health Network, University of Toronto, Toronto, Ont
| | - George Wells
- School of Pharmacy (Wong), University of Waterloo, Kitchener, Ont.; Toronto Health Economics and Technology Assessment Collaborative (THETA) (Wong, Krahn), Faculty of Pharmacy, University of Toronto, Toronto, Ont.; Canadian Agency for Drugs and Technologies in Health (CADTH) (Lee, Singh), Ottawa, Ont.; School of Epidemiology, Public Health and Preventative Medicine (Lee), University of Ottawa, Ottawa, Ont.; Cardiovascular Research Methods Centre (Wells), University of Ottawa Heart Institute, Ottawa, Ont.; Toronto Centre for Liver Disease (Feld), University Health Network, University of Toronto, Toronto, Ont
| | - Jordan J Feld
- School of Pharmacy (Wong), University of Waterloo, Kitchener, Ont.; Toronto Health Economics and Technology Assessment Collaborative (THETA) (Wong, Krahn), Faculty of Pharmacy, University of Toronto, Toronto, Ont.; Canadian Agency for Drugs and Technologies in Health (CADTH) (Lee, Singh), Ottawa, Ont.; School of Epidemiology, Public Health and Preventative Medicine (Lee), University of Ottawa, Ottawa, Ont.; Cardiovascular Research Methods Centre (Wells), University of Ottawa Heart Institute, Ottawa, Ont.; Toronto Centre for Liver Disease (Feld), University Health Network, University of Toronto, Toronto, Ont
| | - Murray Krahn
- School of Pharmacy (Wong), University of Waterloo, Kitchener, Ont.; Toronto Health Economics and Technology Assessment Collaborative (THETA) (Wong, Krahn), Faculty of Pharmacy, University of Toronto, Toronto, Ont.; Canadian Agency for Drugs and Technologies in Health (CADTH) (Lee, Singh), Ottawa, Ont.; School of Epidemiology, Public Health and Preventative Medicine (Lee), University of Ottawa, Ottawa, Ont.; Cardiovascular Research Methods Centre (Wells), University of Ottawa Heart Institute, Ottawa, Ont.; Toronto Centre for Liver Disease (Feld), University Health Network, University of Toronto, Toronto, Ont
| |
Collapse
|