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The Costs of Hepatitis C by Liver Disease Stage: Estimates from the Veterans Health Administration

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Abstract

Background

The release of highly effective but costly medications for the treatment of hepatitis C virus combined with a doubling in the incidence of hepatitis C virus have posed substantial financial challenges for many healthcare systems. We provide estimates of the cost of treating patients with hepatitis C virus that can inform the triage of pharmaceutical care in systems with limited healthcare resources.

Methods

We conducted an observational study using a national US cohort of 206,090 veterans with laboratory-identified hepatitis C virus followed from Fiscal Year 2010 to 2014. We estimated the cost of: non-advanced Fibrosis-4; advanced Fibrosis-4; hepatocellular carcinoma; liver transplant; and post-liver transplant. The former two stages were ascertained using laboratory result data; the latter stages were ascertained using administrative data. Costs were obtained from the Veterans Health Administration’s activity-based cost accounting system and more closely represent the actual costs of providing care, an improvement on the charge data that generally characterizes the hepatitis C virus cost literature. Generalized estimating equations were used to estimate and predict costs per liver disease stage. Missing data were multiply imputed.

Results

Annual costs of care increased as patients progressed from non-advanced Fibrosis-4 to advanced Fibrosis-4, hepatocellular carcinoma, and liver transplant (all p < 0.001). Post-liver transplant, costs decreased significantly (p < 0.001). In simulations, patients were estimated to incur the following annual costs: US $17,556 for non-advanced Fibrosis-4; US $20,791 for advanced Fibrosis-4; US $46,089 for liver cancer; US $261,959 in the year of the liver transplant; and US $18,643 per year after the liver transplant.

Conclusions

Cost differences of treating non-advanced and advanced Fibrosis-4 are relatively small. The greatest cost savings would be realized from avoiding progression to liver cancer and transplant.

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Author information

Authors and Affiliations

  1. VA Health Economics Resource Center, VA Palo Alto Health Care System, 795 Willow Rd. (152 MPD), Menlo Park, CA, 94025, USA

    Risha Gidwani-Marszowski, Jeanie Lo & Paul G. Barnett

  2. VA Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA

    Risha Gidwani-Marszowski, Douglas K. Owens, Steven M. Asch & Paul G. Barnett

  3. Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA

    Risha Gidwani-Marszowski & Steven M. Asch

  4. Center for Primary Care and Outcomes Research/Center for Health Policy, Department of Medicine, Stanford University, Stanford, CA, USA

    Douglas K. Owens, Jeremy D. Goldhaber-Fiebert & Paul G. Barnett

Authors
  1. Risha Gidwani-Marszowski
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  2. Douglas K. Owens
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  4. Jeremy D. Goldhaber-Fiebert
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  6. Paul G. Barnett
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Contributions

RGM contributed to the study design, data interpretation, and writing of the manuscript, and is the overall guarantor of this work. PB contributed to the study conceptualization and design, data interpretation, and writing of the manuscript. JL contributed to the data acquisition and analyses, and writing of the manuscript. DO contributed to the funding, study conceptualization, and data interpretation. SA and JGF contributed to the data interpretation.

Corresponding author

Correspondence to Risha Gidwani-Marszowski.

Ethics declarations

Funding

This work was supported by Merit Review Award no. I01 HX000889-1A1 from the US Department of Veterans Affairs Health Services Research and Development Program. Jeremy D. Goldhaber-Fiebert was supported by Grant R01 DA15612-016 from the National Institutes of Health and the National Institute on Aging Career Development Award K01 AG037593-01A1. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US Government.

Ethics Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. For this type of study, formal consent is not required.

Conflict of interest

Risha Gidwani-Marszowski, Douglas K. Owens, Jeanie Lo, Jeremy D. Goldhaber-Fiebert, Steven M. Asch, and Paul G. Barnett have no conflicts of interest that are directly relevant to the content of this article.

Data Sharing

The datasets generated during and/or analyzed during the current study are not publicly available because of Veterans Health Administration regulations. Persons who are not approved by the project’s institutional review board are prohibited by the Veterans Health Administration from viewing the underlying data. Additionally, the Veterans Health Administration requires all its data to remain on its own secure servers.

Appendix

Appendix

Comorbidity International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9 CM) diagnosis codes

Comorbidities

ICD-9 CM diagnosis codes

Alcohol problem: drinking, abuse, or dependence

291.x, 303.0x, 303.9x, 305.0x, and where the fifth digit is not equal to ‘3’

Any drug dependency/abuse

292.x, 304.0x–304.9x, 305.2x–305.9x, and where the fifth digit is not equal to ‘3’

Arthritis

725.x, 446.5x, 710.0x–710.4x, 714.0x–714.2x, 714.8x

Bipolar disorder

296.0x, 296.4x–296.8x

Cancer (excluding hepatocellular carcinoma)

140.x–172.x, 174.x–194.x, 195.0x–195.8x, 200.x–208.x, 238.6x, and excluding 155.x

Cancer (metastatic solid tumor)

196.x–199.x

Congestive heart failure

428.x, 398.91, 402.01, 402.11, 402.91, 404.01, 404.03, 404.11, 404.13, 404.91, 404.93, 425.4x–425.9x

Chronic obstructive pulmonary disease

490.x–505.x, 416.8x, 416.9x, 506.4x, 508.1x, 508.8x

Dementia

290.x, 294.1x, 331.2x

Depression

311.x, 296.2x, 296.3x, 298.0x, 300.4x, 309.0x, 309.1x, 293.83, 296.90, 296.99, 301.12

Diabetes

250.0x–250.9x

Hepatitis B

070.22, 070.23, 070.32, 070.33

Kidney transplant, history of

V42.0x, 996.81

Myocardial infarction

410.x, 412.x

Paralysis

342.x, 343.x, 334.1x, 344.0x–344.6x, 344.9x

Peripheral vascular disease

440.x, 441.x, 093.0x, 437.3x, 447.1x, 557.1x, 557.9x, V43.4x, 443.1x–443.9x

Psychosis, other

297.0x–297.3x, 297.8x–298.4x, 298.8x, 298.9x

Post-traumatic stress disorder

309.81x

Renal failure

582.x, 585.x, 586.x, 403.01, 403.11, 403.91, 404.02, 404.03, 404.12, 404.13, 404.92, 404.93, 583.0x–583.7x, 588.0x, V42.0x, V45.1x, V56.x

Schizophrenia

295.x

Seizure

345.01, 345.11, 345.41, 345.51, 345.61, 345.71, 345.81, 345.91

Stroke

430.x–438.x, 362.34

Suicide attempt

E950.x–E959.x

Transplant (other than kidney or liver)

996.83–996.87, V42.84

Liver disease stage

 Non-advanced FIB-4

FIB-4 score < 3.25

 Advanced FIB-4

FIB-4 score ≥ 3.25

 Hepatocellular carcinoma

155.0x

 Liver transplant

50.51x, 50.59x

 History of liver transplant

V42.7x

  1. FIB-4 Fibrosis 4

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Gidwani-Marszowski, R., Owens, D.K., Lo, J. et al. The Costs of Hepatitis C by Liver Disease Stage: Estimates from the Veterans Health Administration. Appl Health Econ Health Policy 17, 513–521 (2019). https://doi.org/10.1007/s40258-019-00468-5

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