Publications by authors named "Jagpreet Chhatwal"

102 Publications

Feasibility, effectiveness and cost of a decentralized HCV care model among the general population in Delhi, India.

Liver Int 2021 Nov 24. Epub 2021 Nov 24.

FIND, Geneva, Switzerland.

Background And Aims: India has a significant burden of hepatitis C virus (HCV) infection and has committed to achieving national elimination by 2030. This will require a substantial scale-up in testing and treatment. The "HEAD-Start Project Delhi" aimed to enhance HCV diagnosis and treatment pathways among the general population.

Methods: A prospective study was conducted at 5 district hospitals (Arm 1: one-stop shop), 15 polyclinics (Arm 2: referral for viral load (VL) testing and treatment) and 62 screening camps (Arm 3: referral for treatment). HCV prevalence, retention in the HCV care cascade, and turn-around time were measured.

Results: Between January and September 2019, 37 425 participants were screened for HCV. The median (IQR) age of participants was 35 (26-48) years, with 50.4% male and 49.6% female. A significantly higher proportion of participants in Arm 1 (93.7%) and Arm 3 (90.3%) received a VL test compared with Arm 2 (52.5%, P < .001). Of those confirmed positive, treatment was initiated at significantly higher rates for participants in both Arms 1 (85.6%) and 2 (73.7%) compared to Arm 3 (41.8%, P < .001). Arm 1 was found to be a cost-saving strategy compared to Arm 2, Arm 3, and no action.

Conclusions: Delivery of all services at a single site (district hospitals) resulted in a higher yield of HCV seropositive cases and retention compared with sites where participants were referred elsewhere for VL testing and/or treatment. The highest level of retention in the care cascade was also associated with the shortest turn-around times.
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http://dx.doi.org/10.1111/liv.15112DOI Listing
November 2021

Assessing cost-effectiveness of hepatitis C testing pathways in Georgia using the Hep C Testing Calculator.

Sci Rep 2021 Nov 1;11(1):21382. Epub 2021 Nov 1.

Massachusetts General Hospital, Boston, MA, USA.

The cost of testing can be a substantial contributor to hepatitis C virus (HCV) elimination program costs in many low- and middle-income countries such as Georgia, resulting in the need for innovative and cost-effective strategies for testing. Our objective was to investigate the most cost-effective testing pathways for scaling-up HCV testing in Georgia. We developed a Markov-based model with a lifetime horizon that simulates the natural history of HCV, and the cost of detection and treatment of HCV. We then created an interactive online tool that uses results from the Markov-based model to evaluate the cost-effectiveness of different HCV testing pathways. We compared the current standard-of-care (SoC) testing pathway and four innovative testing pathways for Georgia. The SoC testing was cost-saving compared to no testing, but all four new HCV testing pathways further increased QALYs and decreased costs. The pathway with the highest patient follow-up, due to on-site testing, resulted in the highest discounted QALYs (123 QALY more than the SoC) and lowest costs ($127,052 less than the SoC) per 10,000 persons screened. The current testing algorithm in Georgia can be replaced with a new pathway that is more effective while being cost-saving.
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http://dx.doi.org/10.1038/s41598-021-00362-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8560949PMC
November 2021

Comparative Clinical Effectiveness of Population-Based Atrial Fibrillation Screening Using Contemporary Modalities: A Decision-Analytic Model.

J Am Heart Assoc 2021 09 3;10(18):e020330. Epub 2021 Sep 3.

Cardiovascular Research Center and Cardiac Arrhythmia Service Division of Cardiology Massachusetts General Hospital Boston MA.

Background Atrial fibrillation (AF) screening is endorsed by certain guidelines for individuals aged ≥65 years. Yet many AF screening strategies exist, including the use of wrist-worn wearable devices, and their comparative effectiveness is not well-understood. Methods and Results We developed a decision-analytic model simulating 50 million individuals with an age, sex, and comorbidity profile matching the United States population aged ≥65 years (ie, with a guideline-based AF screening indication). We modeled no screening, in addition to 45 distinct AF screening strategies (comprising different modalities and screening intervals), each initiated at a clinical encounter. The primary effectiveness measure was quality-adjusted life-years, with incident stroke and major bleeding as secondary measures. We defined continuous or nearly continuous modalities as those capable of monitoring beyond a single time-point (eg, patch monitor), and discrete modalities as those capable of only instantaneous AF detection (eg, 12-lead ECG). In total, 10 AF screening strategies were effective compared with no screening (300-1500 quality-adjusted life-years gained/100 000 individuals screened). Nine (90%) effective strategies involved use of a continuous or nearly continuous modality such as patch monitor or wrist-worn wearable device, whereas 1 (10%) relied on discrete modalities alone. Effective strategies reduced stroke incidence (number needed to screen to prevent a stroke: 3087-4445) but increased major bleeding (number needed to screen to cause a major bleed: 1815-4049) and intracranial hemorrhage (number needed to screen to cause intracranial hemorrhage: 7693-16 950). The test specificity was a highly influential model parameter on screening effectiveness. Conclusions When modeled from a clinician-directed perspective, the comparative effectiveness of population-based AF screening varies substantially upon the specific strategy used. Future screening interventions and guidelines should consider the relative effectiveness of specific AF screening strategies.
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http://dx.doi.org/10.1161/JAHA.120.020330DOI Listing
September 2021

Association of Limited In-Person Attendance in US National Football League and National Collegiate Athletic Association Games With County-Level COVID-19 Cases.

JAMA Netw Open 2021 08 2;4(8):e2119621. Epub 2021 Aug 2.

Georgia Institute of Technology, Atlanta.

Importance: In 2020 and early 2021, the National Football League (NFL) and National Collegiate Athletic Association (NCAA) opted to host football games in stadiums across the country. The in-person attendance of games varied with time and from county to county. There is currently no evidence on whether limited in-person attendance of games is associated with COVID-19 case numbers on a county-level.

Objective: To assess whether NFL and NCAA football games with limited in-person attendance were associated with increased COVID-19 cases in the counties they were held compared with a matched set of counties.

Design, Setting, And Participants: In this time-series cross-sectional study, every county hosting NFL or NCAA games with in-person attendance (treated group) in 2020 and 2021 was matched with a county that that did not host a game on the corresponding day but had an identical game history for up to 14 days prior (control group). A standard matching method was used to further refine this matched set so that the treated and matched control counties had similar population size, nonpharmaceutical interventions in place, and COVID-19 trends. The association of hosting games with in-person attendance with COVID-19 cases was assessed using a difference-in-difference estimator. Data were analyzed from August 29 to December 28, 2020.

Exposures: Hosting NFL or NCAA games.

Main Outcomes And Measures: The main outcome was estimation of new COVID-19 cases per 100 000 residents at the county level reported up to 14 days after a game among counties with NFL and NCAA games with in-person attendance.

Results: A total of 528 games with in-person attendance (101 NFL games [19.1%]; 427 NCAA games [80.9%]) were included. The matching algorithm returned 361 matching sets of counties. The median (interquartile range [IQR]) number of attendance for NFL games was 9949 (6000 to 13 797) people. The median number of attendance for NCAA games was not available, and attendance was recorded as a binary variable. The median (IQR) daily new COVID-19 cases in treatment group counties hosting games was 26.14 (10.77-50.25) cases per 100 000 residents on game day. The median (IQR) daily new COVID-19 cases in control group counties where no games were played was 24.11 (9.64-48.55) cases per 100 000 residents on game day. The treatment effect size ranged from -5.17 to 4.72, with a mean (SD) of 1.21 (2.67) cases per 100 000 residents, within the 14-day period in all counties hosting the games, and the daily treatment effect trend remained relatively steady during this period.

Conclusions And Relevance: This cross-sectional study did not find a consistent increase in the daily COVID-19 cases per 100 000 residents in counties where NFL and NCAA games were held with limited in-person attendance. These findings suggest that NFL and NCAA football games hosted with limited in-person attendance were not associated with substantial risk for increased local COVID-19 cases.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.19621DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8371570PMC
August 2021

Comparative Effectiveness of Implantable Defibrillators for Asymptomatic Brugada Syndrome: A Decision-Analytic Model.

J Am Heart Assoc 2021 08 13;10(16):e021144. Epub 2021 Aug 13.

Cardiology Division Massachusetts General Hospital Boston MA.

Background Optimal management of asymptomatic Brugada syndrome (BrS) with spontaneous type I electrocardiographic pattern is uncertain. Methods and Results We developed an individual-level simulation comprising 2 000 000 average-risk individuals with asymptomatic BrS and spontaneous type I electrocardiographic pattern. We compared (1) observation, (2) electrophysiologic study (EPS)-guided implantable cardioverter-defibrillator (ICD), and (3) upfront ICD, each using either subcutaneous or transvenous ICD, resulting in 6 strategies tested. The primary outcome was quality-adjusted life years (QALYs), with cardiac deaths (arrest or procedural-related) as a secondary outcome. We varied BrS diagnosis age and underlying arrest rate. We assessed cost-effectiveness at $100 000/QALY. Compared with observation, EPS-guided subcutaneous ICD resulted in 0.35 QALY gain/individual and 4130 cardiac deaths avoided/100 000 individuals, and EPS-guided transvenous ICD resulted in 0.26 QALY gain and 3390 cardiac deaths avoided. Compared with observation, upfront ICD reduced cardiac deaths by a greater margin (subcutaneous ICD, 8950; transvenous ICD, 6050), but only subcutaneous ICD improved QALYs (subcutaneous ICD, 0.25 QALY gain; transvenous ICD, 0.01 QALY loss), and complications were higher. ICD-based strategies were more effective at younger ages and higher arrest rates (eg, using subcutaneous devices, upfront ICD was the most effective strategy at ages 20-39.4 years and arrest rates >1.37%/year; EPS-guided ICD was the most effective strategy at ages 39.5-51.3 years and arrest rates 0.47%-1.37%/year, and observation was the most effective strategy at ages >51.3 years and arrest rates <0.47%/year). EPS-guided subcutaneous ICD was cost-effective ($80 508/QALY). Conclusions Device-based approaches (with or without EPS risk stratification) can be more effective than observation among selected patients with asymptomatic BrS. BrS management should be tailored to patient characteristics.
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http://dx.doi.org/10.1161/JAHA.121.021144DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8475040PMC
August 2021

Health Economics of Interventions to Tackle the Coronavirus 2019 Pandemic.

Value Health 2021 05 16;24(5):605-606. Epub 2021 Apr 16.

Department of Health Sciences, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands and Department of Economics, Econometrics & Finance, University of Groningen, Faculty of Economics & Business, Groningen, The Netherlands.

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http://dx.doi.org/10.1016/j.jval.2021.03.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8049781PMC
May 2021

A Tool to Inform Hepatitis C Elimination: A Case for Hepatitis C Elimination in China.

Clin Liver Dis (Hoboken) 2021 Mar 13;17(3):99-106. Epub 2021 Apr 13.

Massachusetts General Hospital Institute for Technology Assessment Boston MA.

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http://dx.doi.org/10.1002/cld.1109DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8043698PMC
March 2021

Opioid Misuse: A Global Crisis.

Value Health 2021 02 13;24(2):145-146. Epub 2021 Jan 13.

Institute for Technology Assessment, Massachusetts General Hospital and Harvard Medical School, MA, USA.

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http://dx.doi.org/10.1016/j.jval.2020.12.003DOI Listing
February 2021

Reduction of COVID-19 Incidence and Nonpharmacologic Interventions: Analysis Using a US County-Level Policy Data Set.

J Med Internet Res 2020 12 21;22(12):e24614. Epub 2020 Dec 21.

Harvard Medical School, Boston, MA, United States.

Background: Worldwide, nonpharmacologic interventions (NPIs) have been the main tool used to mitigate the COVID-19 pandemic. This includes social distancing measures (closing businesses, closing schools, and quarantining symptomatic persons) and contact tracing (tracking and following exposed individuals). While preliminary research across the globe has shown these policies to be effective, there is currently a lack of information on the effectiveness of NPIs in the United States.

Objective: The purpose of this study was to create a granular NPI data set at the county level and then analyze the relationship between NPI policies and changes in reported COVID-19 cases.

Methods: Using a standardized crowdsourcing methodology, we collected time-series data on 7 key NPIs for 1320 US counties.

Results: This open-source data set is the largest and most comprehensive collection of county NPI policy data and meets the need for higher-resolution COVID-19 policy data. Our analysis revealed a wide variation in county-level policies both within and among states (P<.001). We identified a correlation between workplace closures and lower growth rates of COVID-19 cases (P=.004). We found weak correlations between shelter-in-place enforcement and measures of Democratic local voter proportion (R=0.21) and elected leadership (R=0.22).

Conclusions: This study is the first large-scale NPI analysis at the county level demonstrating a correlation between NPIs and decreased rates of COVID-19. Future work using this data set will explore the relationship between county-level policies and COVID-19 transmission to optimize real-time policy formulation.
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http://dx.doi.org/10.2196/24614DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7755429PMC
December 2020

A clash of epidemics: Impact of the COVID-19 pandemic response on opioid overdose.

J Subst Abuse Treat 2021 01 6;120:108158. Epub 2020 Oct 6.

Massachusetts General Hospital Institute for Technology Assessment, Harvard Medical School, Boston, MA, USA.

Coronavirus disease 2019 (COVID-19) will have a lasting impact on public health. In addition to the direct effects of COVID-19 infection, physical distancing and quarantine interventions have indirect effects on health. While necessary, physical distancing interventions to control the spread of COVID-19 could have multiple impacts on people living with opioid use disorder, including impacts on mental health that lead to greater substance use, the availability of drug supply, the ways that people use drugs, treatment-seeking behaviors, and retention in care. The degree to which COVID-19 will impact the opioid epidemic and through which of the possible mechanisms that we discuss is important to monitor. We employed simulation modeling to demonstrate the potential impact of physical distancing on overdose mortality.
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http://dx.doi.org/10.1016/j.jsat.2020.108158DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7536128PMC
January 2021

Trends in Thyroid Surgery and Guideline-Concordant Care in the United States, 2007-2018.

Thyroid 2021 06 18;31(6):941-949. Epub 2021 Jan 18.

Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA.

The American Thyroid Association (ATA) published the 2015 Management Guidelines for patients with thyroid nodules and differentiated thyroid cancer, recommending a shift to less aggressive diagnostic, surgical, and postoperative treatment strategies. At the same time and perhaps related to the new guidelines, there has been a shift to outpatient thyroid surgery. The aim of the current study was to assess physician adherence to these recommendations by identifying and quantifying temporal trends in the rates and indications for thyroid procedures in the inpatient and outpatient settings. Using the IBM MarketScan Commercial database, we identified employer-insured patients in the United States who underwent outpatient and inpatient thyroid surgery from 2007 to 2018. Thyroid surgery was classified as total thyroidectomy (TT), thyroid lobectomy (TL), or a completion thyroidectomy. The surgical indication diagnosis was also determined and classified as either benign or malignant thyroid disease. We compared outpatient and inpatient trends in surgery between benign and malignant thyroid disease both before and after the release of the 2015 ATA guidelines. A total of 220,088 patients who underwent thyroid surgery were included in the analysis. Approximately 80% of TLs were performed in the outpatient setting versus 70% of TTs. Longitudinal analysis showed a statistically significant changepoint for TT proportion occurring in November 2015. The proportion of TT as compared with TL decreased from 80% in September 2015 to 39% by December 2018. For thyroid cancer, there is an increasing trend in performing TL over TT, increasing from 17% in 2015 to 28% by the end of 2018. There was a significant changepoint occurring in November 2015 in the operative and management trends for benign and malignant thyroid disease.
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http://dx.doi.org/10.1089/thy.2020.0643DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8215427PMC
June 2021

Cost-Effectiveness of Testing and Treatment for Hepatitis B Virus and Hepatitis C Virus Infections: An Analysis by Scenarios, Regions, and Income.

Value Health 2020 12 9;23(12):1552-1560. Epub 2020 Oct 9.

World Health Organization Headquarters (Department of HIV and Global Hepatitis Programme and Department of Health Systems Governance and Financing), Geneva, Switzerland; Division of Universal Health Coverage, Communicable and Noncommunicable Diseases, World Health Organization, Geneva, Switzerland.

Objectives: Testing and treatment for hepatitis B virus (HBV) and hepatitis C virus (HCV) infection are highly effective, high-impact interventions. This article aims to estimate the cost-effectiveness of scaling up these interventions by scenarios, regions, and income groups.

Methods: We modeled costs and impacts of hepatitis elimination in 67 low- and middle-income countries from 2016 to 2030. Costs included testing and treatment commodities, healthcare consultations, and future savings from cirrhosis and hepatocellular carcinomas averted. We modeled disease progression to estimate disability-adjusted life-years (DALYs) averted. We estimated incremental cost-effectiveness ratios (ICERs) by regions and World Bank income groups, according to 3 scenarios: flatline (status quo), progress (testing/treatment according to World Health Organization guidelines), and ambitious (elimination).

Results: Compared with no action, current levels of testing and treatment had an ICER of $807/DALY for HBV and -$62/DALY (cost-saving) for HCV. Scaling up to progress scenario, both interventions had ICERs less than the average gross domestic product/capita of countries (HBV: $532/DALY; HCV: $613/DALY). Scaling up from flatline to elimination led to higher ICERs across countries (HBV: $927/DALY; HCV: $2528/DALY, respectively) that remained lower than the average gross domestic product/capita. Sensitivity analysis indicated discount rates and commodity costs were main factors driving results.

Conclusions: Scaling up testing and treatment for HBV and HCV infection as per World Health Organization guidelines is a cost-effective intervention. Elimination leads to a much larger impact though ICERs are higher. Price reduction strategies are needed to achieve elimination given the substantial budget impact at current commodity prices.
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http://dx.doi.org/10.1016/j.jval.2020.06.015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7806510PMC
December 2020

Assessment of Incidence of and Surveillance Burden for Hepatocellular Carcinoma Among Patients With Hepatitis C in the Era of Direct-Acting Antiviral Agents.

JAMA Netw Open 2020 11 2;3(11):e2021173. Epub 2020 Nov 2.

Institute for Technology Assessment, Massachusetts General Hospital, Harvard Medical School, Boston.

Importance: In the US, hepatocellular carcinoma (HCC), primarily associated with hepatitis C virus (HCV) infection, is the fastest rising cause of cancer-related death. Wider use of highly effective direct-acting antiviral agents (DAAs) substantially reduces the burden of chronic HCV infection, but the subsequent impacts with HCV-associated HCC remain unknown.

Objective: To assess projected changes in the incidence rate of and surveillance burden for HCC in the era of DAA treatment for HCV.

Design, Setting, And Participants: This decision analytical model study was performed from January 2019 to February 2020, using an individual-level state-transition simulation model to simulate disease progression, screening, and different waves of antiviral treatments for HCV in the US from 2012 to 2040.

Interventions: Current clinical management for chronic HCV infection.

Main Outcomes And Measures: Model outcomes were projected temporal trends and age distribution of incident HCC cases and candidates for HCC surveillance among patients with viremia and patients with virologically cured HCV.

Results: The simulation model projected that the annual incidence of HCC among patients with viremia and patients with virologically cured HCV will continue increasing to 24 000 (95% uncertainty interval [UI], 18 000-31 000) cases until 2021. In patients with virologically cured HCV, incident HCC cases are projected to increase from 1000 (95% UI, 500-2100) in 2012 to the peak of 7000 (95% UI, 5000-9600) in 2031 with a subsequent decrease to 6000 (95% UI, 4300-8300) by 2040. The proportion of incident HCC cases that occur in individuals with virologically cured HCV is estimated to increase from 5.3% in 2012 to 45.8% in 2040. The number of candidates for HCC surveillance in the population with virologically cured HCV is projected to increase from 106 000 (95% UI, 70 000-178 000) in 2012 to the peak of 649 000 (95% UI, 512 000-824 000) in 2030 and decrease to 539 000 (95% UI, 421 000-687 000) by 2040, while the proportion of all candidates for surveillance who are virologically cured is estimated to increase from 8.5% to 64.6% during the same period. The average age of HCC incidence and surveillance candidates is estimated to increase from 55 in 2012 to 72 and 71, respectively, by 2040.

Conclusions And Relevance: The results of this study suggest that the burden of HCC will shift from patients with viremia to patients with virologically cured HCV, and to older populations. Appropriate management may be warranted for early detection of HCC in patients who may no longer be receiving specialty care for liver conditions.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.21173DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7675109PMC
November 2020

Patient and Provider Risk in Managing ST-Elevation Myocardial Infarction During the COVID-19 Pandemic: A Decision Analysis.

Circ Cardiovasc Interv 2020 11 10;13(11):e010027. Epub 2020 Nov 10.

Division of Cardiology (N.B., N.P., E.P., M.A., R.S., A.R., S.E.), Massachusetts General Hospital, Boston.

Background: The optimal treatment strategy for treating ST-segment-elevation myocardial infarction (STEMI) in context of the coronavirus disease 2019 (COVID-19) pandemic is unclear given the potential risk of occupational exposure during primary percutaneous coronary intervention (PPCI). We quantified the impact of different STEMI treatment strategies on patient outcomes and provider risk in context of the COVID-19 pandemic.

Methods: Using a decision-analytic framework, we evaluated the effect of PPCI versus the pharmaco-invasive strategy for managing STEMI on 30-day patient mortality and individual provider infection risk based on presence of cardiogenic shock, suspected coronary territory, and presence of known or presumptive COVID-19 infection.

Results: For patients with low suspicion for COVID-19, PPCI had mortality benefit over the pharmaco-invasive strategy, and the risk of cardiac catheterization laboratory provider infection remained very low (<0.25%) across all subgroups. For patients with presumptive COVID-19 with cardiogenic shock, PPCI offered substantial mortality benefit to patients relative to the pharmaco-invasive strategy (7.9% absolute decrease in 30-day mortality), but also greater risk of provider infection (2.3% absolute increase in risk of provider infection). For patients with presumptive COVID-19 with nonanterior STEMI without cardiogenic shock, PPCI offered a 0.4% absolute mortality benefit over the pharmaco-invasive strategy with a 0.2% greater absolute risk of provider infection, and the tradeoff between patient and provider risk with PPCI became more apparent in sensitivity analysis with more severe COVID-19 infections.

Conclusions: Usual care with PPCI remains the appropriate treatment strategy in the majority of cases presenting with STEMI in the setting of the COVID-19 pandemic. However, utilization of a pharmaco-invasive strategy in selected patients with STEMI with presumptive COVID-19 and low likelihood of mortality from STEMI and use of preventive strategies such as preprocedural intubation in high risk patients when PPCI is the preferred strategy may be reasonable to reduce provider risk of COVID-19 infection.
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http://dx.doi.org/10.1161/CIRCINTERVENTIONS.120.010027DOI Listing
November 2020

Health economic design for cost, cost-effectiveness and simulation analyses in the HEALing Communities Study.

Drug Alcohol Depend 2020 12 3;217:108336. Epub 2020 Oct 3.

RTI International, 3040 East Cornwallis Road, RTP, NC, 27709, United States.

Background: The HEALing Communities Study (HCS) is designed to implement and evaluate the Communities That HEAL (CTH) intervention, a conceptually driven framework to assist communities in selecting and adopting evidence-based practices to reduce opioid overdose deaths. The goal of the HCS is to produce generalizable information for policy makers and community stakeholders seeking to implement CTH or a similar community intervention. To support this objective, one aim of the HCS is a health economics study (HES), the results of which will inform decisions around fiscal feasibility and sustainability relevant to other community settings.

Methods: The HES is integrated into the HCS design: an unblinded, multisite, parallel arm, cluster randomized, wait list-controlled trial of the CTH intervention implemented in 67 communities in four U.S. states: Kentucky, Massachusetts, New York, and Ohio. The objectives of the HES are to estimate the economic costs to communities of implementing and sustaining CTH; estimate broader societal costs associated with CTH; estimate the cost-effectiveness of CTH for overdose deaths avoided; and use simulation modeling to evaluate the short- and long-term health and economic impact of CTH, including future overdose deaths avoided and quality-adjusted life years saved, and to develop a simulation policy tool for communities that seek to implement CTH or a similar community intervention.

Discussion: The HCS offers an unprecedented opportunity to conduct health economics research on solutions to the opioid crisis and to increase understanding of the impact and value of complex, community-level interventions.
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http://dx.doi.org/10.1016/j.drugalcdep.2020.108336DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7532345PMC
December 2020

Incidence Trends and Burden of Human Papillomavirus-Associated Cancers Among Women in the United States, 2001-2017.

J Natl Cancer Inst 2021 Jun;113(6):792-796

Center for Health Services Research, Department of Management, Policy and Community Health, UTHealth School of Public Health, Houston, TX, USA.

Human papillomavirus (HPV)-associated anal and oropharyngeal cancer incidence has increased in recent years among US women. However, trends in incidence and burden (annual number of cases) of noncervical HPV-associated cancers relative to cervical cancer remain unclear. Using the 2001-2017 US cancer statistics dataset, we evaluated contemporary incidence trends and burden (annual number of cases) of HPV-associated cancers among women by anatomic site, race or ethnicity, and age. Overall, cervical cancer incidence plateaued among White women but continued to decline among Black and Hispanic women. Anal cancer incidence surpassed cervical cancer incidence among White women aged 65-74 years of age (8.6 and 8.2 per 100 000 in 2015) and 75 years or older (6.2 and 6.0 per 100 000 in 2014). The noncervical cancer burden (n  =  11 871) surpassed the cervical cancer burden (n  =  11 527) in 2013. Development of efficacious screening strategies for noncervical cancers and continued improvement in cervical cancer prevention are needed to combat HPV-associated cancers among women.
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http://dx.doi.org/10.1093/jnci/djaa128DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8168114PMC
June 2021

Projected prevalence and mortality associated with alcohol-related liver disease in the USA, 2019-40: a modelling study.

Lancet Public Health 2020 06;5(6):e316-e323

Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Liver Center and Gastrointestinal Division, Massachusetts General Hospital, Boston, MA, USA. Electronic address:

Background: Alcohol-related liver disease is the leading indication for liver transplantation in the USA. After remaining stable for over three decades, the number of deaths due to alcohol-related liver disease has been increasing as a result of increased high-risk drinking. We aimed to project trends in alcohol-related cirrhosis and deaths in the USA up to 2040 and assess the effect of potential changes in alcohol consumption on those trends.

Methods: In this modelling study, we developed a multicohort state-transition (Markov) model of high-risk alcohol drinking patterns and alcohol-related liver disease in high-risk drinking populations born in 1900-2016 in the USA projected up to 2040. We used data from the National Epidemiologic Survey on Alcohol and Related Conditions, National Institute of Alcohol Abuse and Alcoholism, US National Death Index, National Vital Statistics System, and published studies. We modelled trends in alcohol-related liver disease under three projected scenarios: the status quo scenario, in which current trends continued; a moderate intervention scenario, in which trends in high-risk drinking reduced to 2001 levels under some hypothetical moderate intervention; and a strong intervention, in which trends in high-risk drinking decreased by 3·5% per year under some hypothetical strong intervention. The primary outcome was to project deaths associated with alcohol-related liver disease from 2019 to 2040 for each pattern of alcohol consumption under the different scenarios.

Findings: Our model closely reproduced the observed trends in deaths due to alcohol-related liver disease from 2005 to 2018. Under the status quo scenario, age-standardised deaths due to alcohol-related liver disease are expected to increase from 8·23 (95% uncertainty interval [UI] 7·92-9·29) per 100 000 person-years in 2019 to 15·20 (13·93-16·19) per 100 000 person-years in 2040, and from 2019 to 2040, 1 003 400 (95% CI 896 800-1 036 200) people are projected to die from alcohol-related liver disease, resulting in 1 128 400 (1 113 200-1 308 400) DALYs by 2040. Under the moderate intervention scenario, age-standardised deaths due to alcohol-related liver disease would increase to 14·49 (95% UI 12·55-14·57) per 100 000 person-years by 2040, with 968 100 (95% UI 845 600-975 900) individuals projected to die between 2019 and 2040-35 300 fewer deaths than under the status quo scenario (a 3·5% decrease). Whereas, under the strong intervention scenario, age-standardised deaths due to alcohol-related liver disease would peak at 8·65 (95% UI 8·12-9·51) per 100 000 person-years in 2024 and decrease to 7·60 (6·96-8·10) per 100 000 person-years in 2040, with 704 300 (95% CI 632 700-731 500) individuals projected to die from alcohol-related liver disease in the USA between 2019 and 2040-299 100 fewer deaths than under the status quo scenario (a 29·8% decrease).

Interpretation: Without substantial changes in drinking culture or interventions to address high-risk drinking, the disease burden and deaths due to alcohol-related liver disease will worsen in the USA. Additional interventions are urgently needed to reduce mortality and morbidity associated with alcohol-related liver disease.

Funding: American Cancer Society and the Robert Wood Johnson Health Policy Research Fellowship.
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http://dx.doi.org/10.1016/S2468-2667(20)30062-1DOI Listing
June 2020

Estimating the price at which hepatitis C treatment with direct-acting antivirals would be cost-saving in Japan.

Sci Rep 2020 03 5;10(1):4089. Epub 2020 Mar 5.

Massachusetts General Hospital Institute for Technology Assessment, Boston, MA, USA.

In Japan, 1.5-2 million people are chronically infected with hepatitis C virus (HCV) infection. New direct-acting antiviral agents (DAA) offer an unprecedented opportunity to cure HCV. While the price of HCV treatment decreased recently in most countries, it remains one of the highest in Japan. Our objective was to evaluate the cost-effectiveness of HCV treatment in patients of different age groups and to estimate the price at which DAAs become cost-saving in Japan. A previously developed microsimulation model was adapted to the Japanese population and updated with Japan-specific health utilities and costs. Our model showed that compared with no treatment, the incremental cost-effectiveness ratio (ICER) of DAAs at a price USD 41,046 per treatment was USD 9,080 per quality-adjusted life year (QALY) gained in 60-year-old patients. HCV treatment became cost-effective after 9 years of starting treatment. However, if the price of DAAs is reduced by 55-85% (USD 6,730 to 17,720), HCV treatment would be cost-saving within a 5 to 20-year time horizon, which should serve to increase the uptake of DAA-based HCV treatment. The payers of health care in Japan could examine ways to procure DAAs at a price where they would be cost-saving.
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http://dx.doi.org/10.1038/s41598-020-60986-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7058050PMC
March 2020

We are Not Meeting the Needs of Pharmacoeconomic Models of Nonalcoholic Steatohepatitis, But We Can.

Pharmacoeconomics 2020 05;38(5):427-429

Massachusetts General Hospital Institute for Technology Assessment, Harvard Medical School, Boston, MA, USA.

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http://dx.doi.org/10.1007/s40273-020-00892-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7156303PMC
May 2020

Diagnostic Accuracy of Shear Wave Elastography as a Non-invasive Biomarker of High-Risk Non-alcoholic Steatohepatitis in Patients with Non-alcoholic Fatty Liver Disease.

Ultrasound Med Biol 2020 04 29;46(4):972-980. Epub 2020 Jan 29.

Center for Ultrasound Research & Translation, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA. Electronic address:

In this study, we evaluated the diagnostic accuracy of shear wave elastography (SWE) for differentiating high-risk non-alcoholic steatohepatitis (hrNASH) from non-alcoholic fatty liver and low-risk non-alcoholic steatohepatitis (NASH). Patients with non-alcoholic fatty liver disease scheduled for liver biopsy underwent pre-biopsy SWE. Ten SWE measurements were obtained. Biopsy samples were reviewed using the NASH Clinical Research Network Scoring System and patients with hrNASH were identified. Receiver operating characteristic curves for SWE-based hrNASH diagnosis were charted. One hundred sixteen adult patients underwent liver biopsy at our institution for the evaluation of non-alcoholic fatty liver disease. The area under the receiver operating characteristic curve of SWE for hrNASH diagnosis was 0.73 (95% confidence interval: 0.61-0.84, p < 0.001). The Youden index-based optimal stiffness cutoff value for hrNASH diagnosis was calculated as 8.4 kPa (1.67 m/s), with a sensitivity of 77% and specificity of 66%. SWE may be useful for the detection of NASH patients at risk of long-term liver-specific morbidity and mortality.
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http://dx.doi.org/10.1016/j.ultrasmedbio.2019.12.020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7034057PMC
April 2020

Prevalence of Human Papillomavirus Infection by Number of Vaccine Doses Among US Women.

JAMA Netw Open 2019 12 2;2(12):e1918571. Epub 2019 Dec 2.

Center for Health Services Research, Department of Management, Policy, and Community Health, UTHealth School of Public Health, Houston, Texas.

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http://dx.doi.org/10.1001/jamanetworkopen.2019.18571DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6986697PMC
December 2019

Securing sustainable funding for viral hepatitis elimination plans.

Liver Int 2020 02 5;40(2):260-270. Epub 2019 Dec 5.

Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School (MHH), Hannover, Germany.

The majority of people infected with chronic hepatitis C virus (HCV) in the European Union (EU) remain undiagnosed and untreated. During recent years, immigration to EU has further increased HCV prevalence. It has been estimated that, out of the 4.2 million adults affected by HCV infection in the 31 EU/ European Economic Area (EEA) countries, as many as 580 000 are migrants. Additionally, HCV is highly prevalent and under addressed in Eastern Europe. In 2013, the introduction of highly effective treatments for HCV with direct-acting antivirals created an unprecedented opportunity to cure almost all patients, reduce HCV transmission and eliminate the disease. However, in many settings, HCV elimination poses a serious challenge for countries' health spending. On 6 June 2018, the Hepatitis B and C Public Policy Association held the 2nd EU HCV Policy summit. It was emphasized that key stakeholders should work collaboratively since only a few countries in the EU are on track to achieve HCV elimination by 2030. In particular, more effort is needed for universal screening. The micro-elimination approach in specific populations is less complex and less costly than country-wide elimination programmes and is an important first step in many settings. Preliminary data suggest that implementation of the World Health Organization (WHO) Global Health Sector Strategy on Viral Hepatitis can be cost saving. However, innovative financing mechanisms are needed to raise funds upfront for scaling up screening, treatment and harm reduction interventions that can lead to HCV elimination by 2030, the stated goal of the WHO.
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http://dx.doi.org/10.1111/liv.14282DOI Listing
February 2020

Improved Health Outcomes from Hepatitis C Treatment Scale-Up in Spain's Prisons: A Cost-Effectiveness Study.

Sci Rep 2019 11 14;9(1):16849. Epub 2019 Nov 14.

Institute for Technology Assessment, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.

Hepatitis C virus (HCV) is 15 times more prevalent among persons in Spain's prisons than in the community. Recently, Spain initiated a pilot program, JAILFREE-C, to treat HCV in prisons using direct-acting antivirals (DAAs). Our aim was to identify a cost-effective strategy to scale-up HCV treatment in all prisons. Using a validated agent-based model, we simulated the HCV landscape in Spain's prisons considering disease transmission, screening, treatment, and prison-community dynamics. Costs and disease outcomes under status quo were compared with strategies to scale-up treatment in prisons considering prioritization (HCV fibrosis stage vs. HCV prevalence of prisons), treatment capacity (2,000/year vs. unlimited) and treatment initiation based on sentence lengths (>6 months vs. any). Scaling-up treatment by treating all incarcerated persons irrespective of their sentence length provided maximum health benefits-preventing 10,200 new cases of HCV, and 8,300 HCV-related deaths between 2019-2050; 90% deaths prevented would have occurred in the community. Compared with status quo, this strategy increased quality-adjusted life year (QALYs) by 69,700 and costs by €670 million, yielding an incremental cost-effectiveness ratio of €9,600/QALY. Scaling-up HCV treatment with DAAs for the entire Spanish prison population, irrespective of sentence length, is cost-effective and would reduce HCV burden.
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http://dx.doi.org/10.1038/s41598-019-52564-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6856347PMC
November 2019

Why should we apply ABM for decision analysis for infectious diseases?-An example for dengue interventions.

PLoS One 2019 27;14(8):e0221564. Epub 2019 Aug 27.

dwh Gmbh, Vienna, Austria.

For the evaluation of infectious-diseases interventions, the transmissible nature of such diseases plays a central role. Agent-based models (ABM) allow for dynamic transmission modeling but publications are limited. We aim to provide an overview of important characteristics of ABM for decision-analytic modeling of infectious diseases. A case study of dengue epidemics illustrates model characteristics, conceptualization, calibration and model analysis. First, major characteristics of ABM are outlined and discussed based on ISPOR and ISPOR-SMDM Good Practice guidelines. Second, in our case study, we modeled a dengue outbreak in Cebu City (Philippines) to assess the impact interventions to control the relative growth of the mosquito population. Model outcomes include prevalence and incidence of infected persons. The modular ABM simulates persons and mosquitoes over an annual time horizon considering daily time steps. The model was calibrated and validated. ABM is a dynamic, individual-level modeling approach that is capable to reproduce direct and indirect effects of interventions for infectious diseases. The ability to replicate emerging behavior and to include human behavior or the behavior of other agents is a distinguishing modeling characteristic (e.g., compared to Markov models). Modeling behavior may, however, require extensive calibration and validation. The analyzed hypothetical effectiveness of dengue interventions showed that a reduced human-mosquito ratio of 1:2.5 during rainy seasons leads already to a substantial decrease of infected persons. ABM can support decision-analyses for infectious diseases including disease dynamics, emerging behavior, and providing a high level of reusability due to modularity.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0221564PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6711507PMC
March 2020

Reply to L. Yaghjyan et al.

JNCI Cancer Spectr 2018 Jul 3;2(3):pky046. Epub 2018 Nov 3.

Department of Management Policy, and Community Health, The University of Texas Health Science Centre School of Public Health, Houston, TX (AAD, KS).

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http://dx.doi.org/10.1093/jncics/pky046DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6649707PMC
July 2018

Alternative Conversion Methods for Transition Probabilities in State-Transition Models: Validity and Impact on Comparative Effectiveness and Cost-Effectiveness.

Med Decis Making 2019 07 28;39(5):509-522. Epub 2019 Jun 28.

Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, UMIT-University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria.

. In state-transition models (STMs), decision problems are conceptualized using health states and transitions among those health states after predefined time cycles. The naive, commonly applied method (C) for cycle length conversion transforms all transition probabilities separately. In STMs with more than 2 health states, this method is not accurate. Therefore, we aim to describe and compare the performance of method C with that of alternative matrix transformation methods. . We compare 2 alternative matrix transformation methods (Eigenvalue method [E], Schure-Padé method [SP]) to method C applied in an STM of 3 different treatment strategies for women with breast cancer. We convert the given annual transition matrix into a monthly-cycle matrix and evaluate induced transformation errors for the transition matrices and the long-term outcomes: life years, quality-adjusted life-years, costs and incremental cost-effectiveness ratios, and the performance related to the decisions. In addition, we applied these transformation methods to randomly generated annual transition matrices with 4, 7, 10, and 20 health states. . In theory, there is no generally applicable correct transformation method. Based on our simulations, SP resulted in the smallest transformation-induced discrepancies for generated annual transition matrices for 2 treatment strategies. E showed slightly smaller discrepancies than SP in the strategy, where one of the direct transitions between health states was excluded. For long-term outcomes, the largest discrepancy occurred for estimated costs applying method C. For higher dimensional models, E performs best. . In our modeling examples, matrix transformations (E, SP) perform better than transforming all transition probabilities separately (C). Transition probabilities based on alternative conversion methods should therefore be applied in sensitivity analyses.
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http://dx.doi.org/10.1177/0272989X19851095DOI Listing
July 2019

Changes in hepatitis C burden and treatment trends in Europe during the era of direct-acting antivirals: a modelling study.

BMJ Open 2019 06 11;9(6):e026726. Epub 2019 Jun 11.

Institute for Technology Assessment, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.

Objectives: Oral direct-acting antivirals (DAAs) for hepatitis C virus (HCV) have dramatically changed the treatment paradigm. Our aim was to project temporal trends in HCV diagnosis, treatment and disease burden in France, Germany, Italy, Spain and the UK.

Design: A mathematical simulation model of natural history of HCV infection.

Participants: HCV-infected patients defined based on country-specific age, fibrosis and genotype distributions.

Interventions: HCV screening practice and availability of different waves of DAA treatment in each country.

Outcome Measures: Temporal trends in the number of patients who achieve sustained virological response (SVR), fail treatment (by drug regimen) and develop advanced sequelae from 2014 to 2030 in each country.

Results: We projected that 1 324 000 individuals would receive treatment from 2014 to 2030 in the five European countries and 12 000-37 000 of them would fail to achieve SVR. By 2021, the number of individuals cured of HCV would supersede the number of actively infected individuals in France, Germany, Spain and the UK. Under status quo, the diagnosis rate would reach between 65% and 75% and treatment coverage between 65% and 74% by 2030 in these countries. The number of patients who fail treatment would decrease over time, with the majority of those who fail treatment having been exposed to non-structural protein 5A inhibitors.

Conclusions: In the era of DAAs, the number of people with HCV who achieved a cure will exceed the number of viraemic patients, but many patients will remain undiagnosed, untreated, fail multiple treatments and develop advanced sequelae. Scaling-up screening and treatment capacity, and timely and effective retreatment are needed to avail the full benefits of DAAs and to meet HCV elimination targets set by WHO.
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http://dx.doi.org/10.1136/bmjopen-2018-026726DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6576109PMC
June 2019

The impact of direct-acting anti-virals on the hepatitis C care cascade: identifying progress and gaps towards hepatitis C elimination in the United States.

Aliment Pharmacol Ther 2019 07 22;50(1):66-74. Epub 2019 May 22.

Michael E. DeBakey Veterans Affairs Medical Center, and Baylor College of Medicine, Houston, Texas.

Background: The hepatitis C virus (HCV) care cascade has changed dramatically following the introduction of direct-acting anti-virals (DAAs). Up-to-date estimates of the cascade are needed to monitor progress, identify key gaps and inform policy.

Aim: To estimate the current and future HCV care cascade in the United States, nationally and in select subpopulations of interest.

Methods: We used a previously validated mathematical model to simulate the landscape of HCV in the United States from 2011 onwards, accounting for HCV screening policy updates, newer HCV treatments and rising HCV incidence.

Results: By the end of 2018, of 4.29 million HCV persons alive, 2.71 million (63%) were actively viremic, 2.24 million (52%) aware and 1.58 million (37%) cured. By 2030, under the status quo, of 3.65 million HCV persons alive, 1.88 million (51%) would be viremic, 2.25 million (62%) aware and 1.77 million (49%) cured. The HCV care cascade in 2018 differed substantially by subpopulation: of 1.34 million incarcerated HCV persons, 96% were viremic, 36% aware and 4% cured; of 0.87 million HCV persons in Medicare, 31% were viremic, 72% aware and 69% cured; and of 0.37 million HCV persons in Medicaid, 49% were viremic, 54% aware and 51% cured. Implementing universal screening, providing unrestricted treatment and controlling HCV incidence were factors found to have the largest effect on improving the HCV care cascade.

Conclusions: Since the launch of DAAs, the HCV care cascade has shifted towards higher awareness and treatment rates; however, additional interventions are needed to move towards HCV elimination.
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http://dx.doi.org/10.1111/apt.15291DOI Listing
July 2019

Assessment of the Feasibility and Cost of Hepatitis C Elimination in Pakistan.

JAMA Netw Open 2019 05 3;2(5):e193613. Epub 2019 May 3.

Houston Veterans Affairs Health Services Research and Development Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas.

Importance: Chronic hepatitis C virus (HCV) infection is a global health problem. The World Health Assembly recently pledged to eliminate HCV by 2030. However, in Pakistan, a country with one of the highest prevalence rates, the feasibility and cost of HCV elimination are not known.

Objectives: To investigate whether and under what conditions HCV elimination is feasible in Pakistan and to estimate the cost of such elimination.

Design, Setting, And Participants: This decision analytical model study used a microsimulation model of the HCV epidemic in Pakistan from 2015 to 2030. Using Pakistan-specific variables, the model simulated the landscape of HCV in Pakistan and evaluated the minimum required screening and treatment rates needed to eliminate HCV in Pakistan. The study used simulated individuals chronically infected with HCV from 2015 to 2030. The analysis was performed in 2018.

Interventions: The status quo and 7 scenarios that can lead to HCV elimination in Pakistan by 2030, which were defined by different combinations of tests for screening, detection of viremia before treatment, and confirmation of treatment response.

Main Outcomes And Measures: Temporal trends in HCV infection prevalence, mortality, and disability-adjusted life-years and total cost of HCV infection care under the status quo and scenarios that can eliminate HCV by 2030.

Results: Under the status quo, from 2015 to 2030, 1.44 million people are projected to die of HCV infection; 48% of deaths would be among people younger than 50 years. To achieve HCV elimination in Pakistan, HCV testing would need to be scaled up to at least 25 million people to diagnose 900 000 persons and treatment to 700 000 people per year. Compared with the status quo, the elimination scenario would avert 323 000 liver-related deaths and 13.0 million HCV-associated disability-adjusted life-years from 2015 to 2030. The elimination scenario was associated with cost savings of $2.6 billion from 2018 to 2030 with use of a point-of-care test for population-wide antibody screening and detection of viremia and treatment response.

Conclusions And Relevance: Substantial scale-up of HCV testing and treatment may be essential to eliminate HCV infection in Pakistan, and such a strategy may be associated with cost savings in the near future. Although HCV elimination in Pakistan may be ambitious, strategic planning and strong support from the government may aid in its elimination.
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http://dx.doi.org/10.1001/jamanetworkopen.2019.3613DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6512462PMC
May 2019
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