Assessing the Value of New Treatments for Hepatitis C: Are International Decision Makers Getting this Right?

Health systems worldwide are facing difficult choices about the use of a series of highly effective but costly new treatments for hepatitis C. In this paper we discuss how the National Institute for Health and Care Excellence in England and Wales, the Common Drug Review in Canada and the Pharmaceutical Benefits Advisory Committee (PBAC) in Australia have approached the appraisal of these drugs. We argue that with the exception of the PBAC, assessments of the new drugs have not adequately accounted for their large financial burden. Given the potential health system impact of reimbursing these drugs, the use of lower cost-effectiveness thresholds should be considered. None of the decision-making processes included a comparison of the full range of treatment pathways. In particular, comparisons of using the new drugs as first- versus second-line drugs were omitted from all appraisals, as were comparisons with delayed treatment strategies whereby treatment is withheld until more severe disease stages. Omission of comparators leads to inaccurate estimates of cost effectiveness and potentially sub-optimal decision making. Lessons learned from these appraisals should be considered in future appraisals, particularly the upcoming assessments of the 'blockbuster' PCSK9 inhibitors for hypercholesterolaemia.