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Abstract

We read the letter from Liu et al regarding our recent publication and appreciate their interests and insightful comments.1Liu X. et al.Clin Gastroenterol Hepatol. 2017; Google Scholar, 2Yang J.D. et al.Clin Gastroenterol Hepatol. 2017; 15: 767-775Abstract Full Text Full Text PDF Scopus (87) Google Scholar As the authors mentioned, policies on the coverage of direct-acting antiviral agents (DAA) from Medicare/Medicaid and private or commercial insurance companies have changed rapidly over the past few years. This is a highly relevant point in the interpretation of the study finding because effectiveness of DAA treatment at the population level is a product of efficacy of treatment in eradicating hepatitis C virus (HCV) and its availability to the general population. In other words, effectiveness of DAA treatment may not be high in the general population if access is limited. We agree that impact of DAA on pre– or post–liver transplant outcome could have been underestimated in HCV-infected recipients. The magnitude of benefit might be even higher than what was reported in our study because DAA treatments are now even more effective, and to some degree more accessible, particularly in patients with HCV with advanced-stage liver disease or in post-transplant setting. Barriers to access deserve continued focus and improvement. We expect that post-transplant outcomes may be as good in patients with HCV as it is in patients with other etiologies of liver disease, as HCV treatment becomes more accessible in the post–liver transplant setting, regardless of fibrosis stage of liver graft.3Saxena V. et al.Hepatology. 2017; Google Scholar Interrupted time series analysis could potentially be an excellent analytical tool to investigate the impact of DAA treatment on pre– or post–liver transplant outcome specifically for the HCV subgroup, taking into account the availability/affordability of DAA treatment in the general population. However, interrupted time series analysis with few time points as in the current study (pre-DAA era vs DAA era) can underpower statistical analysis.4Lopez Bernal J. et al.Int J Epidemiol. 2017; 46: 348-355Google Scholar Furthermore, the scope of our work was to evaluate the time trend of all subgroups of patients with different liver disease etiologies, which would not be impacted by the access to DAA treatments. More Benefits From Interrupted Time Series in Evaluating the Recent Market Release of Direct-Acting Antiviral Agents and State Medicaid Reimbursement ProgramsClinical Gastroenterology and HepatologyVol. 15Issue 11PreviewWe read with interest the study by Yang et al1 that assessed the epidemiologic trends of pretransplant and post-transplant outcomes for patients with hepatitis C virus (HCV) infection before and after the introduction of direct-acting antiviral agents (DAAs). The investigators identified that the post-DAA era (2011–2014) was associated with a decreased risk of graft loss or death, with the largest effect seen in HCV-infected recipients. However, according to Chhatwal et al,2 DAAs were cost effective when they cost less than $227,200. Full-Text PDF