Cost-effectiveness of Hepatitis C treatment by primary care providers supports by the extension for community healthcare outcomes (ECHO) model

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Purpose: The Extension for Community Healthcare Outcomes (ECHO) model has shown that hepatitis C (HCV) in under-served communities can be effectively treated by primary care providers, yielding a sustained viral response rate of 57.5% in an underserved population with complex health problems. Cost concerns however may hinder ECHO dissemination, so we examined the cost-effectiveness of ECHO for HCV.

Methods: Based on a prospective cohort study of ECHO-facilitated HCV treatment for 261 patients in 16 community sites and 5 prisons(NEJM 2011;364:2199), we updated and then used a previously published and validated cost-effectiveness model to com-pare ECHO to no antiviral therapy for each of the 261 patients. Costs included drugs, physician visits, lab tests, adverse events, HCV disease complications and multidisciplinary ECHO personnel (physician, pharmacist, psychiatrist, nurse manager, coordinator, user support analyst). We also performed an analysis of the cost of antiviral treatment if patients instead traveled to the academic center to receive care compared with ECHO personnel costs. Travel costs included mileage, patient time and for prisoners guard costs. We used quality of life adjustments to account for antiviral treatment and disease-related morbidity. Costs and effectiveness were discounted at3% yearly.

Results: ECHO access to HCV treatment increased discounted quality-adjusted life expectancy by 3.8 (SD 1.4)years overall, 3.5 (SD 1.3) years in the community and 4.2 (SD1.4) years in the prison dwellers. ECHO dominated no antiviral therapy by resulting in lower lifetime costs and higher quality-adjusted life expectancies for 62% of the 261 patients and55% of the community and 70% of the prison dwellers. Among the non-dominated patients, the incremental cost-effectiveness ratio of ECHO averaged $8300 (SD $7800) per quality-

adjusted life year (QALY) gained overall, $9400 (SD $8500) in the community and $5900 (SD $5300) in prison dwellers, well below the standard US willingness to pay threshold of $50,000per QALY gained, making ECHO “cost-effective”. When com-paring only antiviral treatment costs and travel and lost worktime costs to ECHO costs (no disease costs), the mean savings from ECHO were $1352 per person or >$350,000 for the261 patients. For 10% of patients, travel costs were lower than ECHO costs because of their geographic proximity to the academic center.

Conclusion: ECHO-facilitated HCV treatment is not only effective but also cost-effective, suggesting that ECHO provides resource efficient care access for underserved com-munities. Confirmation of these results in additional studies and in other diseases is needed and warranted.