A Microsimulation Study of the Cost-Effectiveness of Hepatitis C Virus Screening Frequencies in Hemodialysis Centers
Authors: Epstein Rachel L. , Pramanick Tannishtha , Baptiste Dimitri , Buzzee Benjamin , Reese Peter P. , Linas Benjamin P. , Sawinski Deirdre 
Published: December 2022

Significance Statement
Studies examining the cost-effectiveness of hepatitis C virus (HCV) screening methods or frequencies are lacking. The authors examined the cost-effectiveness of the Kidney Disease Improving Global Outcomes (KDIGO) 2018 guidelines' recommendation to test in-center hemodialysis patients for HCV every 6 months. They demonstrated that with current HCV prevalence, incidence, and treatment practices in patients receiving hemodialysis, screening for HCV every 6 months is not cost-effective under a willingness-to-pay threshold of US$150,000, even if baseline survival rates doubled or all patients received treatment on diagnosis. Screening only at dialysis initiation or every 2 years are cost-effective approaches, however, with incremental cost-effectiveness ratios of $82,739 and $140,193, respectively, per quality-adjusted life-year saved compared with no screening. These data suggest that reevaluation of HCV screening guidelines in hemodialysis patients should be considered.

Background
National guidelines recommend twice-yearly hepatitis C virus (HCV) screening for patients receiving in-center hemodialysis. However, studies examining the cost-effectiveness of HCV screening methods or frequencies are lacking.

Methods
We populated an HCV screening, treatment, and disease microsimulation model with a cohort representative of the US in-center hemodialysis population. Clinical outcomes, costs, and cost-effectiveness of the Kidney Disease Improving Global Outcomes (KDIGO) 2018 guidelines–endorsed HCV screening frequency (every 6 months) were compared with less frequent periodic screening (yearly, every 2 years), screening only at hemodialysis initiation, and no screening. We estimated expected quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICERs) between each screening strategy and the next less expensive alternative strategy, from a health care sector perspective, in 2019 US dollars. For each strategy, we modeled an HCV outbreak occurring in 1% of centers. In sensitivity analyses, we varied mortality, linkage to HCV cure, screening method (ribonucleic acid versus antibody testing), test sensitivity, HCV infection rates, and outbreak frequencies.

Results
Screening only at hemodialysis initiation yielded HCV cure rates of 79%, with an ICER of $82,739 per QALY saved compared with no testing. Compared with screening at hemodialysis entry only, screening every 2 years increased cure rates to 88% and decreased liver-related deaths by 52%, with an ICER of $140,193. Screening every 6 months had an ICER of $934,757; in sensitivity analyses using a willingness-to-pay threshold of $150,000 per QALY gained, screening every 6 months was never cost-effective.

Conclusions
The KDIGO-recommended HCV screening interval (every 6 months) does not seem to be a cost-effective use of health care resources, suggesting that re-evaluation of less-frequent screening strategies should be considered.