Treatment of Chronic Hepatitis C in the Aged - Does It Impact Life Expectancy? A Decision Analysis.

BACKGROUND AND AIMS: Recent studies have demonstrated that the efficacy of interferon-free direct-acting antiviral agents (DAAs) in patients over 70 is similar to that of younger age groups. Evidence continues to mount that life expectancy (LE) increases with successful treatment of hepatitis C (HCV) patients with advanced fibrosis. The evidence in older people is more limited. Our aim was to estimate the life year (LY) and quality-adjusted life year (QALY) gained by treatment of naïve patients with HCV as a function of patient's age and fibrosis stage. METHODS: We constructed a Markov model of HCV progression toward advanced liver disease. The primary outcome was LY and QALY saved. The model and the sustained virological response of HCV infected subjects treated with a fixed-dose combination of the NS5B polymerase inhibitor Sofosbuvir and the NS5A replication complex inhibitor Ledipasvir were based on the published literature and expert opinion. RESULTS: Generally, both the number of LY gained and QALY gained gradually decreased with advancing age but the rate of decline was slower with more advanced fibrosis stage. For patients with fibrosis stage F1, F2 and F3, LY gained dropped below six months if treated by the age of 55, 65 or 70 years, respectively, while for a patient with fibrosis stage F4, the gain was one LY if treated by the age of 75. The QALY gained for treated over untreated elderly were reasonably high even for those treated at early fibrosis stage. CONCLUSIONS: There is a significant life expectancy benefit to HCV treatment in patients up to age 75 with advanced-stage fibrosis.

A cost-effective method for reducing the volume of laboratory tests in a university-associated teaching hospital.

BACKGROUND: Laboratory tests comprise a significant portion of hospital expenditure. Attempts to reduce their use have had mixed results. OBJECTIVE: To investigate the effect of an intervention based on a simple form-based system for ordering laboratory tests by physicians, on both use of laboratory resources and diagnostic accuracy. DESIGN: At Kaplan Medical Center in Rehovot , Israel , there are 4 similar Internal Medicine departments. In one department (C), the new system was initiated, whereas in the other 3 departments (A, B and D), the traditional method of ordering blood tests was continued. The intervention used was a requirement for tests to be specifically requested by residents following unbundling of test panels, with hands-on supervision by a senior physician. In addition, the residents attended a series of lectures on the economic implications of laboratory testing. The intervention study lasted for 3 years. MEASUREMENTS: Total number of tests performed in each department, number of tests per admission and total cost of each test at Medicare reimbursement prices. RESULTS: The number of tests per admission prior to the intervention was 1.91 +/- 0.89; it decreased for each of the next 3 years: 0.76 +/- 0.61, 0.80 +/- 0.62 and 0.78 +/- 0.63 respectively. There was a total decrease of 97,365 tests during the 3-year period, saving 1,914,149 dollars. There was no difference in the readmission rate or in the number of diagnoses of conditions based primarily on blood tests such as hypokalemia or hyponatremia, between department C and the other departments. CONCLUSIONS: The intervention developed here produced significant and sustained reduction of financial savings in the number of laboratory tests ordered, without negatively impacting diagnostic capability or patient care.