Use of Healthcare Resources and Drug Expenditure Before and After Treatment of Chronic Hepatitis C With Direct Antiviral Agents

Mercedes Vergara; Mireia Miquel; Emili Vela; Montserrat Cleries; Caridad Pontes; Alba Prat; Montse Rué


J Viral Hepat. 2021;28(5):728-738. 

In This Article

Abstract and Introduction


The aim of this study was to analyse the impact of treating chronic hepatitis C (CHC) with direct-acting agents (DAA) on the use of healthcare resources. We included all patients treated with DAA for CHC from January 2015 to December 2017 in Catalonia whose medical records from 12 months before to 24 months after treatment were available. Data were obtained from the Catalan Health Surveillance System. A total of 12,199 patients in Catalonia were treated with DAA for CHC. Of these, 11.3% had no-minimal fibrosis (F0–F1), 24.0% had moderate fibrosis (F2), 50.3% had significant fibrosis or cirrhosis (F3–F4), and 14.4% had decompensated cirrhosis. Use of healthcare resources decreased from the pre-treatment period to the post-treatment period for the following: hospital admissions due to complications of cirrhosis, from 0.19 to 0.12 per month per 100 patients (RR 0.57; 95% CI 0.47–0.68); length of hospital stay, from 12.9 to 12.2 days (RR 0.93; 95% CI 0.91–0.94); outpatient visits, from 65.0 to 49.2 (RR 0.75; 95% CI 0.74–0.75); and number of medication containers per patient per month, from 13.9 to 12.5 (RR 0.837; 95% CI 0.835–0.838). However, the number of invoices for antineoplastic treatment increased after DAA treatment, especially for patients with high morbidity or advanced fibrosis stage. In conclusion, a decrease in health resource use was seen in CHC patients treated with DAA, as measured by length of hospital stay, number of admissions due to cirrhosis complications, outpatient visits and overall drug invoicing. However, use of antineoplastic drugs increased significantly, especially in patients with cirrhosis and high morbidity.


The current prevalence of hepatitis C infection is an estimated 71 million infected people worldwide. The incidence of new cases in 2015 was estimated to be 1.75 million per year.[1] Progression to cirrhosis is variable and depends on the severity of liver damage at the time of diagnosis,[2] and other cofactors including alcohol intake,[3] iron overload,[4] steatosis[5] or co-infection such as hepatitis B or human immunodeficiency virus (HIV).[6–8] Approximately 20% of untreated chronic hepatitis C (CHC) patients progress to liver cirrhosis and its associated complications such as portal hypertension, ascites, variceal bleeding or hepatocellular carcinoma.[9] In addition, up to 74% of patients may experience extrahepatic manifestations,[10] increasing the cost of the disease.[11] However, with a sustained virological response, the use of healthcare resources seems to diminish.[12]

Since 2014, direct antiviral agents (DAA) have changed the prognosis of CHC, achieving cure rates above 95%. Almost all patients with active infection are eligible for treatment, the only exception being those with poor short-term prognosis.[1,13–15] DAA treatment reduces the complications of liver cirrhosis and the rate of liver transplant due to CHC and improves extrahepatic manifestations.[12,16,17] Some studies have demonstrated that DAA treatment also increases the perceived quality of life and work productivity.[18]

Initially, the high cost of DAA limited access to these drugs, which were prioritized for patients with significant fibrosis or cirrhosis.[19] However, the progressive emergence of new DAA has reduced the cost. Since September 2017, in Spain, all patients with CHC can be treated regardless of fibrosis severity.[15]

Complications of liver cirrhosis may require repeated hospital admissions over the disease course;[20–22] improved management of these complications has led to an increase in survival,[21] but with an increase in health expenditure.[23] Higher costs have been described for patients with decompensated cirrhosis than for those with compensated disease, mainly due to hospitalization costs.[24]

Pharmacoeconomic studies support the cost-effectiveness of DAA treatment even when drug prices are high, and even in patients with mild CHC disease, thus supporting this treatment option regardless of the stage of liver disease.[13] Considering the costs of complications and extrahepatic manifestations, therefore, improved prognosis due to treatment with DAA should theoretically translate to a reduced use of healthcare resources.

The aim of our study was to analyse the use of healthcare resources in patients with CHC before and after DAA treatment in our area. Secondary objectives were to compare, for the periods before and after DAA treatment, the rate of hospitalization due to cirrhosis complications, the length of hospital stay, the rate of visits to outpatient clinics and to primary care and the type and number of medications administered.