Background Chronic hepatitis C virus (HCV) infection causes substantial health and economic burden in the United States (US). With the availability of direct-acting antiviral agents (DAAs), recently approved and other therapies under development and 1-time birth-cohort screening, the burden of HCV disease is expected to decrease. Objective To predict the impact of new therapies and screening on chronic HCV cases and associated disease outcomes. Design Individual-level state-transition model. Setting Existing and anticipated HCV therapies and screening in the US. Patients Total HCV-infected population in the US. Measurements Chronic HCV cases and advanced-stage HCV outcomes. Results The number of chronic HCV cases decreased from 3.2 million in 2001 to 2.3 million in 2013. One-time birth-cohort screening beginning in 2013 is expected to identify 487 000 HCV cases in the next 10 years. In contrast, 1-time universal screening could identify 933 700 HCV cases. With the availability of highly effective therapies, HCV could become a rare disease in the next 22 years. The adoption of recently approved HCV therapies and one-time birth-cohort screening can prevent approximately 124 200 cases of decompensated cirrhosis, 78 800 cases of hepatocellular carcinoma, 126 500 liver-related deaths and 9900 liver transplants by 2050. Increasing the treatment capacity would further reduce the burden of HCV-related disease. Limitations Empirical data on the effectiveness of the future HCV therapies, on the future annual incidence of HCV, and on HCV treatment capacity are lacking. Conclusions New HCV therapies along with widespread implementation of screening and treatment will play an important role in reducing the burden of HCV disease. More aggressive screening recommendations are needed to identify a large pool of infected patients. Funding source National Institutes of Health.

Oral direct-acting antivirals (DAAs) represent a major advance in hepatitis C virus (HCV) treatment. Along with recent updates in HCV screening policy and expansions in insurance coverage, the treatment demand in the United States is changing rapidly. Our objective was to project the characteristics and number of people needing antiviral treatment, and HCV- associated disease burden in the era of oral DAAs. We used a previously developed and validated Hepatitis C Disease Burden Simulation model (HEP-SIM). HEP-SIM simulated the actual clinical management of HCV from 2001 onwards, which included antiviral treatment with peginterferon-based therapies as well as the recent oral DAAs, risk-based and birth-cohort HCV screening, and the impact of the Affordable Care Act. We also simulated two hypothetical scenarios—no treatment and treatment with peginterferon-based therapies only. We estimated that in 2010, 2.5 (95% CI: 1.9–3.1) million non-institutionalized people were viremic, which dropped to 1.9 (95% CI: 1.4–2.6) million in 2015, and projected to drop below 1 million by 2020. A total of 1.8 million HCV patients will receive HCV treatment from the launch of oral DAAs in 2014 until 2030. Based on current HCV management practices, it will take 4–6 years to treat the majority of patients aware of their disease. However, 560,000 patients would still remain unaware by 2020. Even in the oral DAA era, 320,000 patients will die, 157,000 will develop hepatocellular carcinoma, and 203,000 will develop decompensated cirrhosis in the next 35 years. Conclusions HCV-associated disease burden will still remain substantial in the era of oral DAAs. Increasing HCV screening and treatment capacity is essential to further decreasing HCV burden in the United States.

Introduction: Mobility impairments have substantial physical and mental health consequences, resulting in diminished quality of life. Whereas most studies on the health economic consequences of mobility limitations focus on short-term implications, this study examines the long-term value of improving mobility in older adults. Methods: Our six-step approach used clinical trial data to calibrate mobility improvements and estimate health economic outcomes using a microsimulation model. First, we measured improvement in steps per day calibrated with clinical trial data examining hylan G-F20 viscosupplementation treatment. Second, we created a cohort of osteoarthritis patients aged ≥51. In the third step, we estimated their baseline quality of life (QoL). Fourth, we translated steps per day improvements to changes in QoL using estimates from the literature. Fifth, we calibrated QoL in this cohort to match those in the trial. Lastly, we incorporated these data and parameters into The Health Economic Medical Innovation Simulation (THEMIS) model to estimate how mobility improvements affect functional status limitations, medical expenditures, nursing home utilization, employment, and earnings between 2012 and 2030. Results: In our sample of 12.6 million patients, 66.7% were female and 70% had BMI>25 kg/m2. Our model predicted that a 554-steps-per-day increase in mobility would reduce functional status limitations by 5.9%, total medical expenditures by 0.9%, and nursing home utilization by 2.8%, and increase employment by 2.9%, earnings by 10.3% and monetized QoL by 3.2% over this 18-year period. Conclusions: Interventions that improve mobility are likely to reduce long-run medical expenditures and nursing home utilization, and increase employment.

Objective Obesity and its complications place an enormous burden on society. Yet antiobesity medications (AOM) are prescribed to only 2% of the eligible population, even though few individuals can sustain weight loss using other strategies alone. This study estimated the societal value of greater access to AOM. Methods By using a well‐established simulation model (The Health Economics Medical Innovation Simulation), the societal value of AOM for the cohort of Americans aged ≥ 25 years in 2019 was quantified. Four scenarios with differential uptake among the eligible population (15% and 30%) were modeled, with efficacy from current and next‐generation AOM. Societal value was measured as monetized quality of life, productivity gains, and savings in medical spending, subtracting the costs of AOM. Results For the 217 million Americans aged ≥ 25 years, AOM generated $1.2 trillion in lifetime societal value under a conservative scenario (15% annual uptake using currently available AOM). The introduction of next‐generation AOM increased societal value to $1.9 to $2.5 trillion, depending on uptake. Finally, societal value was higher for younger individuals and Black and Hispanic individuals compared with White individuals. Conclusions This study suggests that AOM provide substantial gains to patients and society. Policies promoting broader clinical access to and use of AOM warrant consideration to reach national goals to reduce obesity.

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Pre-exposure prophylaxis (PrEP) effectively reduces human immunodeficiency virus (HIV) transmission. We aimed to estimate the impact of different PrEP prioritization strategies among Black and Latino men who have sex with men (MSM) in the United States, populations most disproportionately affected by HIV. We developed an agent-based simulation to model the HIV epidemic among MSM. Individuals were assigned an HIV incidence risk index (HIRI-MSM) based on their sexual behavior. Prioritization strategies included PrEP use for individuals with HIRI-MSM ≥10 among all MSM, all Black MSM, young (≤25 years) Black MSM, Latino MSM, and young Latino MSM. We estimated the number needed to treat (NNT) to prevent one HIV infection, reductions in prevalence and incidence, and subsequent infections in non-PrEP users avoided under these strategies over 5 years (2016–2020). Young Black MSM eligible for PrEP had the lowest NNT (NNT = 10) followed by all Black MSM (NNT = 33) and young Latino MSM (NNT = 35). All Latino MSM and all MSM had NNT values of 63 and 70, respectively. Secondary infection reduction with PrEP was the highest among young Latino MSM (53.2%) followed by young Black MSM (37.8%). Targeting all MSM had the greatest reduction in prevalence (14.7% versus 2.9%–3.9% in other strategies) and incidence (49.4% versus 9.4%–13.9% in other groups). Using data representative of the United States MSM population, we found that a strategy of universal PrEP use by MSM was most effective in reducing HIV prevalence and incidence of MSM. Targeted use of PrEP by Black and Latino MSM, however, especially those ≤25 years, had the greatest impact on HIV prevention.

Background People living with obesity have been among those most disproportionately impacted by the COVID-19 pandemic, highlighting the urgent need for increased provision of bariatric and metabolic surgery (BMS). Objectives To evaluate the possible clinical and economic benefits of BMS compared with non-surgical treatment options in the UK, considering the broader impact that COVID-19 has on people living with obesity. Methods A Markov model compared lifetime costs and outcomes of BMS and conventional treatment, from the UK perspective, amongst patients with BMI ≥40 kg/m 2 , or BMI ≥35 kg/m 2 with obesity-related comorbidities (Group A), or BMI ≥35 kg/m 2 with type 2 diabetes mellitus (T2DM; Group B). Inputs were sourced from clinical audit data and literature sources; direct and indirect costs were considered. Model outputs included costs and quality-adjusted life years (QALYs). Scenario analyses whereby patients experienced COVID-19 infection, BMS was delayed by five years, and BMS patients underwent endoscopy were conducted. Results In both groups, BMS was dominant versus conventional treatment, at a willingness-to-pay threshold of £25,000/QALY. When COVID-19 infections were considered, BMS remained dominant and, over 1,000 patients, prevented 117 deaths, 124 hospitalizations and 161 ICU admissions in Group A, and 64 deaths, 65 hospitalizations and 90 ICU admissions in Group B. Delaying BMS by 5 years resulted in higher costs and lower QALYs in both groups compared to not delaying treatment. Conclusions Increased provision of BMS would be expected to reduce COVID-19-related morbidity and mortality, as well as obesity-related comorbidities, ultimately reducing the clinical and economic burden of obesity.

Background Several highly effective but costly therapies for hepatitis C virus (HCV) are available. As a consequence of their high price, thirty-five state Medicaid programs limited treatment coverage to patients with more advanced HCV stages. States have only limited information available to predict the long-term impact of these decisions. Methods We adapted a validated hepatitis C microsimulation model to the Pennsylvania Medicaid population to estimate the existing HCV prevalence in Pennsylvania Medicaid and estimate the impact of various HCV drug coverage policies on disease outcomes and costs. Outcome measures included rates of advanced-stage HCV outcomes and treatment and disease costs in both Medicaid and Medicare. Results We estimated that 46,700 individuals in Pennsylvania Medicaid were infected with HCV in 2015, 33% of whom were still undiagnosed. By expanding treatment to include mild fibrosis stage (Metavir F2), Pennsylvania Medicaid will spend an additional $274 million on medications in the next decade with no substantial reduction in the incidence of liver cancer or liver-related death. Medicaid patients who are not eligible for treatment under restricted policies would get treatment once they transition to the Medicare program, which would experience 10% reduction in disease-related costs due to early treatment in Medicaid. Further expanding treatment to patients with early fibrosis stages (F0 or F1) would cost Medicaid an additional $693 million during the next decade but would reduce the number of individuals in need of treatment in Medicare by 46% and decrease Medicare treatment costs by 23%. In some scenarios, outcomes could worsen with eligibility expansion if there is inadequate capacity to treat all patients. Conclusions and Relevance Expansion of HCV treatment coverage to less severe stages of liver disease may not substantially improve liver related outcomes for patients in Pennsylvania Medicaid in scenarios in which coverage through Medicare is widely available.