gms | German Medical Science

Background: The advent of sofosbuvir heralded a new period in the therapy of hepatitis C, creating novel therapeutic possibilities while at the same time taxing the financial possibilities of social health care nationally and internationally. It has been hypothesized that the new therapies would first be applied to more severe cases, i.e., patients in higher need. This may have had an influence on the uptake of the new therapies by doctors.

Materials and Methods: Secondary data on prescription records for all AOK insurees between 2012 and mid-2015 have been analysed for prescription volume (DDD) and cost of both the new hepatitis C drugs and for the previous standard therapy, i.e., interferone plus ribavirin plus possibly boceprevir or telaprevir.

For assessing changes in the length of treatment, patients in the first half of 2014 and 2015, respectively, were identified. Additional prescriptions during the previous six and the subsequent two months were taken into account for these patients, giving a maximum observed time of 14 months for each patient. Duration of treatment was estimated by DDD.

Results: There are substantial differences between regions in the use of the new hepatitis C drugs, but also in the prevalence of hepatitis C. Taking the pre-existing therapy of 2012 as the baseline, the rate of conversion to the new therapy differs more than five-fold between regions.

Comparing the initial phase (first six months of 2014) with the corresponding period in 2015, a noticeable shift towards older patients can be observed, and also towards female patients.

In the same period, the average length of therapy increases slightly from 94.5 to 100.6 days, while the median stays the same at 84. The increase in the average length is due to an increasing number of patients with highly prolonged treatment: While the maximum length in 2014 was 224 days (corresponding to 8 packs of 28 DDD each), the maximum in 2015 was double that amount, with peaks at 84, 168, and 336 days. Recalculating a trimmed average, where patients with more than 2000 DDDs are excluded, the average duration of therapy decreased slightly from 94.3 to 85.4 days. 75% of patients from the latter period received treatment of 84 days or less, another 17% were treated for up to 168 days. The rest were treated substantially longer.

Conclusion: The regional differences, even after accounting for differences in prevalence, show substantial differences, but no clear geographic pattern. It must be assumed that regional policies have an impact on the conversion to new therapies.

The shifts in therapy lengths do not give strong evidence to the hypothesis that initially the more severe cases have been treated, in a conscious effort by doctors to stretch resources without withholding needed therapy. The increasing spread of therapy lengths shows that fast successes can be achieved for the majority of patients, but there is a relevant share requiring longer treatment. This needs to be taken into account for financing access to hepatitis C treatment and in particular for risk-sharing or P4P agreements.