A threshold analysis of the cost-effectiveness of hepatitis C testing in emergency departments in the U

Author: Williams J, Vickerman P, Douthwaite S, Nebbia G, Hunter L, Wong T, Ruf M, Miners A

Theme: Epidemiology & Public Health Research Year: 2019

The prevalence of blood borne viruses is higher in emergency department (ED) attendees compared
to the general population, due to higher attendance of marginalised populations, such as people
who inject drugs (PWIDs) and homeless populations. Studies have found prevalence up to 3% for
hepatitis C (HCV) in EDs in England. HIV testing in EDs in the UK is recommended in high prevalence
areas (≥0.2%), but there is no defined threshold for HCV testing.
A Markov model was developed to analyse the impact of opt-out HCV testing in EDs in the UK. The
model used data from studies of ED testing in the UK to parameterise test costs and intervention
effects (contact rates and linkage to care). We used an antibody test cost of £3.64 and RNA test cost
of £68.38, and assumed a direct acting antiviral (DAA) treatment cost of £10,000. An estimated
61.5% of positive tests were PWIDs. We considered what prevalence of HCV RNA would be required
to make ED testing cost-effective at a threshold of £20,000 willingness to pay (WTP) per quality
adjusted life year (QALY) gained.
The prevalence required for ED testing to be cost-effective was 0.26% HCV RNA prevalence under
the base case parameters. In probabilistic analyses, at a HCV RNA prevalence of 0.5%, testing was
97% likely to be cost-effectiveness. The results were sensitive to the cost of the diagnostic tests and
the linkage to care achieved (proportion of patients contacted, attending referral, and receiving
treatment), the proportion of PWIDs, and DAA treatment costs.
Early evidence suggests that ED testing and ED based linkage to care for HCV is likely to be costeffective in many geographical areas across the UK. Additional studies are required to evaluate ED
testing across regions, and this can inform HCV testing guidelines in the UK.
Disclosure of Interest Statement:
The research was funded by the National Institute for Health Research Health Protection Research
Unit (NIHR HPRU) in Blood Borne and Sexually Transmitted Infections at University College London in
partnership with Public Health England (PHE), in collaboration with London School of Hygiene &
Tropical Medicine (LSHTM) and the University of Bristol. The views expressed are those of the
authors and not necessarily those of the NIHR, the Department of Health and Social Care or Public
Health England. We acknowledge members of the NIHR HPRU in BBSTI Steering Committee: Caroline
Sabin (Director), John Saunders (PHE Lead), Catherine H. Mercer, Gwenda Hughes, Greta Rait, Jackie
Cassell, William Rosenberg, Tim Rhodes, Kholoud Porter, Samreen Ijaz and Sema Mandal.
PV and the University of Bristol have received funding from Gilead to perform the economic analysis.
SD, GN and LH have received, technical expertise, project management and funding of tests as part
of a joint working initiative between Guy’s & St Thomas’ NHS Foundation Trust and Gilead.

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