Author information

¹Department of Medicine, Section of Infectious Diseases, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA.

²Department of Pediatrics, Section of Infectious Diseases, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA.

³Section of Infectious Diseases, Boston Medical Center, Boston, Massachusetts, USA.

⁴Department of Pharmacy Practice and Clinical Research, University of Rhode Island, Kingston, Rhode Island, USA.

⁵Department of Primary Care, HealthFirst Family Care Center Inc., Fall River, Massachusetts, USA.

⁶Toronto Centre for Liver Disease, University Health Network, University of Toronto, Toronto, Ontario, Canada.

⁷Department of Hepatology, Beaujon Hospital, Assistance Publique-Hopitaux de Paris, Université Paris Cité, Clichy, France.

⁸Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University, Richmond, Virginia, USA.

⁹Rhode Island Department of Health, Providence, Rhode Island, USA.

¹⁰Department of Medicine, Brown University, Providence, Rhode Island, USA.

Abstract

Background: Liver disease assessment is a key aspect of chronic hepatitis C virus (HCV) infection pre-treatment evaluation but guidelines differ on the optimal testing modality given trade-offs in availability and accuracy. We compared clinical outcomes and cost-effectiveness of common fibrosis staging strategies.

Methods: We simulated adults with chronic HCV receiving care at US health centers through a lifetime microsimulation across five strategies: (1) no staging or treatment (comparator), (2) indirect serum biomarker testing (Fibrosis-4 index [FIB-4]) only, (3) transient elastography (TE) only, (4) staged approach: FIB-4 for all, TE only for intermediate FIB-4 scores (1.45-3.25), and (5) both tests for all. Outcomes included infections cured, cirrhosis cases, liver-related deaths, costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs). We used literature-informed loss to follow-up (LTFU) rates and 2021 Medicaid perspective and costs.

Results: FIB-4 alone generated the best clinical outcomes: 87.7% cured, 8.7% developed cirrhosis, and 4.6% had liver-related deaths. TE strategies cured 58.5%-76.6%, 16.8%-29.4% developed cirrhosis, and 11.6%-22.6% had liver-related deaths. All TE strategies yielded worse clinical outcomes at higher costs per QALY than FIB-4 only, which had an ICER of $12 869 per QALY gained compared with no staging or treatment. LTFU drove these findings: TE strategies were only cost-effective with no LTFU. In a point-of-care HCV test-and-treat scenario, treatment without any staging was most clinically and cost-effective.

Conclusions: FIB-4 staging alone resulted in optimal clinical outcomes and was cost-effective. Treatment for chronic HCV should not be delayed while awaiting fibrosis staging with TE.