Cost effectiveness of hepatitis C treatments: Need for a comprehensive evaluation

Dear Editor,

The article by Tsai, et al. provides a real‐world cost‐effectiveness framework for pegylated interferon (PEG‐IFN) plus ribavirin (RBV) combination therapy using a retrospective national health data [1]. What makes this article interesting is that while in the United States and Europe there is an increased uptake of the new directly acting antiviral agents (DAA) in the treatment of hepatitis C (HCV); in Taiwan, the older treatments are still being evaluated for their cost effectiveness profile.

The reason for the shift to DAA is due to the modest sustained virologic response (SVR) rates of PEG‐IFN plus RBV treatment ranging from 68 to 75% for treatment‐naïve patients and 23–88% for treatment‐experienced patients [2]. The authors themselves cite an SVR rate of 70–75% and 85–90% for HCV Genotype 1/4 and HCV‐2/3, respectively, in Taiwan [1]. What is missing from the real world analysis is the quantification of side‐effects associated with IFN plus RBV and also the poor adherence to these medications [3]. Studies have demonstrated that poor adherence and lack of persistence to these older hepatitis C treatments result in poor SVR rates, which in turn increases health care costs due to high morbidity and disease‐related mortality [[4], [5]]. This necessitates cost‐effectiveness analysis of DAA treatment regimen which have demonstrated excellent efficacy rates compared to the standard of care and this assists in making decisions based on incremental cost ratios and if need be, the affordability of these new agents.

Also, there are some minor concerns relating to costs, and how they were valued in the study. It was not clear if the costs were inflated to present year costs, as the study took data from multiple years. More importantly, the costs in this study were identified as only direct medical costs. This study also mentions that this standard of care regimen might have significant adverse events, early discontinuation, and dose reduction, which leads to a low community effectiveness of 13% [1]. Analyses such these need to account for costs of treating side effects and complications of the therapy. This consideration should be taken into effect due to the high probability of patients experiencing adverse events or complications. By accounting the treatment‐related costs of these events and complications in the cost effectiveness analysis including the impact of adherence, the cost effectiveness ratios for PEG‐IFN plus RBV might be higher than what is being presented in the study. It is extremely critical that all factors are presented to concerned stakeholders including uncertainty analysis or scenario analysis so as to make an informed health care decision.

Acknowledgement

The authors thank Dr. Khalid M. Kamal, Associate Professor, Division of Pharmaceutical, Administrative and Social Sciences, Duquesne University School of Pharmacy for his assistance in conceptualizing and editing the letter.