The hepatitis C cascade of care: identifying priorities to improve clinical outcomes.
The hepatitis C cascade of care: identifying priorities to improve clinical outcomes.
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DOI：
10.1371/journal.pone.0097317
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发表时间：
2014
期刊：
影响因子：
3.7
通讯作者：
Schackman BR
中科院分区：
文献类型：
--
作者：
Linas BP;Barter DM;Leff JA;Assoumou SA;Salomon JA;Weinstein MC;Kim AY;Schackman BR
随着高效丙型肝炎病毒（HCV）疗法的出现，需要数据来指导干预措施的发展，以提高HCV治疗率。我们使用模拟模型来估计失访对HCV治疗结果的影响，并确定可能为投入的资源提供良好价值的干预策略。我们使用蒙特卡罗状态转换模型来模拟一个假设的队列的慢性HCV感染者最近筛选阳性血清HCV抗体。我们模拟了四种假设的干预策略（与护理的联系;治疗启动;综合病例管理;同伴导航），以提高HCV治疗率，不同的疗效和成本，并确定了最有可能导致实施所需资源的最佳价值的策略。持续病毒学应答（SVR）、预期寿命、质量调整预期寿命（QALE）、卫生系统和项目实施成本以及增量成本效益比（ICER）。我们估计，不完善的随访会使HCV治疗的实际有效性降低约75%。在基础案例中，一个适度有效的假设同行导航程序最大限度地提高了SVRs和QALE的数量，与下一个最佳干预措施48，700美元/质量调整生命年相比，ICER。与针对单一步骤的成本较低的干预措施相比，同时针对级联沿着多个点的假设干预措施提供了更好的结果和更高的资金价值。假设的同伴导航员干预的5年计划成本为每10，000名新诊断个体1450万美元。我们估计，不完善的后续行动期间，丙型肝炎病毒级联护理大大降低了现实世界的有效性丙型肝炎病毒治疗。我们的数学模型表明，适度有效的干预措施，以改善后续行动可能是成本效益。应优先考虑制定和评价涉及级联沿着多个点的干预措施，而不是只侧重于单个点的备选方案。
As highly effective hepatitis C virus (HCV) therapies emerge, data are needed to inform the development of interventions to improve HCV treatment rates. We used simulation modeling to estimate the impact of loss to follow-up on HCV treatment outcomes and to identify intervention strategies likely to provide good value for the resources invested in them. We used a Monte Carlo state-transition model to simulate a hypothetical cohort of chronically HCV-infected individuals recently screened positive for serum HCV antibody. We simulated four hypothetical intervention strategies (linkage to care; treatment initiation; integrated case management; peer navigator) to improve HCV treatment rates, varying efficacies and costs, and identified strategies that would most likely result in the best value for the resources required for implementation. Sustained virologic responses (SVRs), life expectancy, quality-adjusted life expectancy (QALE), costs from health system and program implementation perspectives, and incremental cost-effectiveness ratios (ICERs). We estimate that imperfect follow-up reduces the real-world effectiveness of HCV therapies by approximately 75%. In the base case, a modestly effective hypothetical peer navigator program maximized the number of SVRs and QALE, with an ICER compared to the next best intervention of $48,700/quality-adjusted life year. Hypothetical interventions that simultaneously addressed multiple points along the cascade provided better outcomes and more value for money than less costly interventions targeting single steps. The 5-year program cost of the hypothetical peer navigator intervention was $14.5 million per 10,000 newly diagnosed individuals. We estimate that imperfect follow-up during the HCV cascade of care greatly reduces the real-world effectiveness of HCV therapy. Our mathematical model shows that modestly effective interventions to improve follow-up would likely be cost-effective. Priority should be given to developing and evaluating interventions addressing multiple points along the cascade rather than options focusing solely on single points.
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