Chronic Hepatitis B Is Associated with Higher Inpatient Resource Utilization and Mortality Versus Chronic Hepatitis C

Hepatitis C Virus Infection and Hospital-Related Outcomes: A Systematic Review

Background

People living with hepatitis C infection (HCV) have a significant impact on the global healthcare system, with high rates of inpatient service use. Direct-acting antivirals (DAAs) have the potential to alleviate this burden; however, the evidence on the impact of HCV infection and hospital outcomes is undetermined. This systematic review aims to assess this research gap, including how DAAs may modify the relationship between HCV infection and hospital-related outcomes.

Methods

We searched five databases up to August 2022 to identify relevant studies evaluating the impact of HCV infection on hospital-related outcomes. We created an electronic database of potentially eligible articles, removed duplicates, and then independently screened titles, abstracts, and full-text articles.

Results

A total of 57 studies were included. Analysis of the included studies found an association between HCV infection and increased number of hospitalizations, length of stay, and readmissions. There was less consistent evidence of a relationship between HCV and in-hospital mortality. Only four studies examined the impact of DAAs, which showed that DAAs were associated with a reduction in hospitalizations and mortality. In the 14 studies available among people living with HIV, HCV coinfection similarly increased hospitalization, but there was less evidence for the other hospital-related outcomes.

Conclusions

There is good to high-quality evidence that HCV negatively impacts hospital-related outcomes, primarily through increased hospitalizations, length of stay, and readmissions. Given the paucity of studies on the effect of DAAs on hospital outcomes, future research is needed to understand their impact on hospital-related outcomes.

Epidemiology and Prevention of Tuberculosis and Chronic Hepatitis B Virus Infection in the United States

Tuberculosis (TB) and chronic hepatitis B virus (CHB) infection can be prevented with treatment and vaccination, respectively. We reviewed epidemiology and guidelines for TB and CHB to inform strategies for reducing United States (U.S.) burden of both infections. Non-U.S.-born, compared to U.S.-born, persons have a 15-, 6-, and 8-fold higher TB incidence and latent TB infection (LTBI) and CHB prevalence, respectively; all infections disproportionately impact non-U.S.-born Asians. TB and CHB each are associated with ~ 10% mortality that results in 7- and 14-years per life lost, respectively. LTBI and CHB have significant gaps in their care cascade as 40% of LTBI and 20% of CHB patients are diagnosed, and 20% of LTBI and CHB diagnosed patients receive treatment. Reducing TB and CHB burden will require healthcare provider-, system-, and policy-level interventions, and increased funding and collaboration between public health departments and healthcare systems.Institutional Review Board Statement: Since this review article did not include primary data on patients and only focused on reviewing published data, approval by an institutional review board was not needed.

Cost-Effectiveness Analysis of Screening for Hepatitis B Virus Infection in Patients With Solid Tumors Before Initiating Chemotherapy

BACKGROUND & AIMS

Patients with solid tumors who undergo chemotherapy have an increased risk of hepatitis B virus (HBV) reactivation, but a low proportion of these patients are screened for HBV infection and guidelines make conflicting recommendations. Further, the cost-effectiveness of newer treatments for HBV prophylaxis has not been examined for this population. We aimed to analyze the cost-effectiveness of HBV screening before chemotherapy for patients with solid tumors.

METHODS

We compared 3 HBV screening strategies (screen all, screen only high-risk patients, or screen none) using a Markov model of a population of adults in the United States who initiated chemotherapy for a solid tumor. We modeled use of entecavir prophylaxis for HB surface antigen (HBsAg)-positive patients and surveillance for HBsAg-negative patients who are positive for HBV core antibody. The Markov cycle length was 1 year, with model simulation for up to 5 years.

RESULTS

The screen all strategy was the most cost effective, with an incremental cost-effectiveness ratio of $42,761 compared to screening only high-risk patients. The screen none strategy was less effective and less costly than screening all patients or only high-risk patients. The screen-all strategy was the most cost effective for all estimates of prevalence of HBsAg-positive patients and estimates of HBV reactivation in HBsAg-positive patients. Screening only high-risk patients was the most cost-effective strategy when more than 25% of high-risk patients were screened for HBV infection.

CONCLUSIONS

In a Markov model analysis, we found screening all patients with solid tumors for HBV infection before chemotherapy to be the most cost-effective strategy. Guidelines should consider recommending HBV tests for patients initiating chemotherapy.

Resource Utilization and Outcomes of Medicare Recipients With Chronic Hepatitis B in the United States

GOALS

To assess the outcomes and resource utilization of chronic hepatitis B (CH-B) among Medicare beneficiaries.

BACKGROUND

CH-B is highly prevalent among immigrants from endemic areas. Although incidence of CH-B is stable in the United States, CH-B patients have become Medicare eligible.

STUDY

We used the inpatient and outpatient Medicare database (2005 to 2014). Adult patients with CH-B diagnosis were included. One-year mortality and resource utilization were assessed. Independent associations with resource utilization and mortality were determined using multivariate analysis.

RESULTS

Study cohort included 18,603 Medicare recipients with CH-B. Between 2005 and 2014, number of Medicare beneficiaries with CH-B increased by 4.4% annually. The proportion of beneficiaries with CH-B who were whites decreased while those who were Asians increased (P<0.05). Furthermore, 7.4% of CH-B Medicare cohort experienced decompensated cirrhosis, 2.9% hepatocellular carcinoma (HCC) and 11.9% 1-year mortality. Although the number of inpatients with CH-B remained stable, the number of outpatient encounters increased. Annual total inpatient charges increased from $66,610 to $94,221 while these charges for outpatient increased from $9257 to $47,863. In multivariate analysis, age [odds ratio (OR), 1.05; 95% confidence interval (CI), 1.04-1.05], male gender [OR, 1.24 (95% CI, 1.12-1.38)], decompensated cirrhosis [OR, 3.02 (95% CI, 2.63-3.48)], HCC [OR, 2.64 (95% CI, 2.10-3.32)], and higher Charlson comorbidity index [OR, 1.24 (95% CI, 1.21-1.27)] were independently associated with increased 1-year mortality. HCC and higher Charlson comorbidity index were also associated with higher inpatient and outpatient charges, and inpatient length of stay (all P<0.001).

CONCLUSIONS

CH-B infection has been rising in Medicare population and is responsible for significant mortality and resource utilization.

NASH Is the Most Rapidly Growing Etiology for Acute-on-Chronic Liver Failure-Related Hospitalization and Disease Burden in the United States: A Population-Based Study

Acute-on-chronic liver failure (ACLF) is characterized by multiple organ failure (OF) with high short-term mortality. There is lack of population-based data on trends on etiology specific ACLF related burden. National Inpatient Sample (2006-2014) was queried using ICD-09 codes for admissions with cirrhosis and ACLF (≥2 extrahepatic OF). Of 1,928,764 admissions for cirrhosis between 2006 and 2014, 112,174 (5.9%) had ACLF (4.5%, 1.2%, and 0.2% with ACLF 1, 2, and 3, respectively). The brain was the most common OF in 11.9%, followed by respiratory failure in 7.7%, cardiac failure in 6.3%, and renal failure in 5.6%. ACLF increased by 24% between 2006 and 2014 with a 63% increase in 179,104 patients with nonalcoholic steatohepatitis (NASH) cirrhosis (3.5% to 5.7%); a 28% increase in patients with 429,306 alcoholic cirrhosis (5.6% to 7.2%); a 25% increase in patients with 1,091,053 with other etiologies (5.2% to 6.5%); and no significant change in 229,301 patients with viral hepatitis (VH) (4.0% to 4.1%). In-hospital mortality was higher among ACLF patients compared with patients without ACLF (44% versus 4.7%; P < 0.0001). Each NASH-related ACLF patient compared with other etiologies had a longer mean length of stay (14 versus 12 days), was associated with higher median total charges (US $151,196 versus US $134,597), and had more frequent use of dialysis (45% versus 36%) and longterm care (32% versus 26%; P < 0.0001 for all). Results remained similar in a subgroup analysis after including half of admissions with cryptogenic cirrhosis as NASH. In conclusion, NASH cirrhosis is the most rapidly growing indication for ACLF-related hospitalization and use of hospital resources. In the setting of improved treatment options for chronic hepatitis, the health care burden of chronic viral-related liver disease remains stable. Population-based strategies are needed to reduce the health care burden of cirrhosis, particularly related to NASH.

Prevalence of Undetectable Vaccine-Induced Immunity Against Hepatitis B Virus in US Adults at High Risk for Infection

In 2015, the Centers for Disease Control and Prevention reported a substantial increase in the number of acute hepatitis B virus (HBV) infections in the United States. Although national guidelines recommend vaccination of adults at high risk for HBV infection, the prevalence of undetectable immunity (i.e., susceptibility) in this population remains unknown. In this study, we analyzed a nationally representative sample using the National Health and Nutrition Examination Survey to evaluate the prevalence, trend, and predictors of undetectable vaccine-induced antibodies against HBV surface antigen (<10 mIU/mL) among high-risk adults from 2003-2014. Among adults at high risk for HBV infection, the prevalence of undetectable immunity decreased from 83.2% in 2003-2004 (95% confidence interval [CI]: 81.3-85.0) to 69.4% (about 64 million) in 2013-2014 (95% CI: 66.0-72.6). The prevalence decreased significantly in individuals with multiple sex partners or sexually transmitted disease and in pregnant women. However, there were no significant changes in men who have sex with men (MSMs), intravenous drug users (IDUs), hepatitis C virus (HCV)-infected and patients with diabetes, and those with elevated aspartate aminotransferase/alanine aminotransferase (AST/ALT). Mexican Americans had the highest prevalence of undetectable immunity (77.6%, 95% CI: 72.6-81.9), followed by non-Hispanic whites (70.1%, 95% CI: 66.9-73.1). Older age, lower socioeconomic status, and having at least 1 high-risk factor were associated with a higher risk of undetectable immunity, whereas an increased risk among the foreign-born disappeared after multivariable adjustment. Conclusion: Approximately 64 million high-risk adults in the United States remain susceptible to HBV infection, especially MSMs, IDUs, diabetics, HCV patients, and populations with elevated AST/ALT. To eliminate HBV, efforts should be made to increase screening and vaccination in high-risk adults.

Advancing Age and Comorbidity in a US Insured Population-Based Cohort of Patients With Chronic Hepatitis B

Chronic hepatitis B (CHB) comorbidity data are limited. Using insurance claims databases, our aims were to determine the prevalence and incidence of nonliver comorbidities in CHB patients over time and the predictors of select comorbidities in CHB patients. Patients were adults with continuous coverage (commercial/Medicare or Medicaid) 6 months prior to and after the first CHB diagnosis and matched non-CHB patients. Deyo-Charlson Comorbidity Index (DCCI) and comorbidities were analyzed (cardiovascular disease [CVD], carcinoma, diabetes mellitus [DM], obesity, hypertension [HTN], hyperlipidemia, alcohol use, renal impairment, chronic kidney disease [CKD], and osteoporosis/fracture [OF]). The study population included 44,026 CHB cases and 121,568 matched controls. CHB patient mean age increased from 48.1 ± 11.9 years in 2006 to 51.8 ± 12.4 years in 2015 for commercial/Medicare and from 44.1 ± 11.1 years to 50.2 ± 10.2 years for Medicaid (P < 0.001 for both). The Medicaid CHB cohort was the sickest (DCCI, 2.6, P < 0.001). The commercial/Medicare 2006 CKD prevalence rate was 36.1/1,000 in CHB patients and 10.2/1,000 in controls, increasing to 97.6 and 38.8 in 2015, respectively. The 2006 CKD incidence (per 1,000 person-years) was 10.3 and 4.8 and 15.2 and 11.3 by 2015, respectively (P < 0.05 for all). The strongest predictors for CKD were DM (hazard ratio [HR], 2.48), HTN (HR, 3.29), and CVD (HR, 2.61) (all P < 0.0001). Similar prevalence and incidence changes were observed for OF. The strongest predictors for OF were female gender (HR, 2.22), alcohol use (HR, 2.02), and viral coinfection (HR, 1.37) (all P < 0.0001). Conclusion: Insured CHB patients were older, had more comorbidities, and experienced higher incidence and prevalence of CKD and OF than controls.

Healthcare resource utilization and costs by disease severity in an insured national sample of US patients with chronic hepatitis B

BACKGROUND & AIMS

Chronic hepatitis B (CHB) affects over 2 million people in the US, with little reported on healthcare utilization and cost. We aimed to quantify annual CHB utilization and costs by disease severity and payer type.

METHODS

Using Commercial, Medicare, and Medicaid databases from 2004 to 2015 and ICD9 codes, we retrospectively identified adults with CHB, analyzing all-cause inpatient, outpatient, and pharmaceutical utilization and costs by disease severity. We compared healthcare utilization and costs between patients with CHB, without advanced liver disease, and matched non-CHB controls. All-cause inpatient, outpatient, and pharmaceutical utilization and costs were reported for each year and adjusted to 2015 dollars.

RESULTS

Our sample consisted of 33,904 CHB cases and 86,072 non-CHB controls. All-cause inpatient admissions (average stay 6-10 days) were more frequent in advanced liver disease states. Across all payers, patients with decompensated cirrhosis had the highest emergency department utilization (1.6-2.8 annual visits) and highest mean annual costs. The largest all-cause cost components for Commercial and Medicaid were inpatient costs for all advanced liver disease groups (Commercial: 62%, 47%, 68%; Medicaid: 81%, 72%, 74%, respectively), and decompensated cirrhosis and hepatocellular carcinoma groups for Medicare (Medicare 49% and 48%). In addition, patients with compensated liver disease incurred costs 3 times higher than non-CHB controls.

CONCLUSION

Patients with CHB, regardless of payer, who experienced decompensated cirrhosis, hepatocellular carcinoma, or a liver transplant incurred the highest annual costs and utilization of healthcare resources, but even patients with CHB and compensated liver disease incurred higher costs than those without CHB. All stakeholders in disease management need to combine efforts to prevent infection and advanced liver disease through improved vaccination rates, earlier diagnosis, and treatment.

LAY SUMMARY

Hepatitis B virus can be a progressive disease leading to cirrhosis, hepatocellular carcinoma, liver transplant, and death. These progressive disease states are associated with a higher rate of hospitalizations, emergency room visits, outpatient visits, and costs compared to similar patients without hepatitis B. The most ill patients have the highest costs, but even patients who are less sick experience higher costs than patients without hepatitis B.

Economic and clinical burden of viral hepatitis in California: A population-based study with longitudinal analysis

BACKGROUND

Economic burden of HBV and HCV infection are trending upwards.

AIMS

Compare hepatitis B virus (HBV) and hepatitis C virus (HCV) related hospital admission rates, charges, mortality rates, causes of death in a US population-based study.

METHODS

Retrospective cohort analysis of HBV and HCV patients from the California Office of Statewide Health Planning and Development (2006-2013) database.

RESULTS

A total of 23,891 HBV and 148,229 HCV patients were identified. Across the 8-year period, the mean increase for all-cause ($1,863 vs $1,388) and liver-related hospitalization charges ($1,175 vs $675) were significantly higher for the HBV cohort compared to the HCV cohort. HBV patients had significantly higher liver-related hospital charges per person per year than HCV patients after controlling for covariates ($123,239 vs $111,837; p = 0.002). Compared to HCV patients, adjusted mortality hazard ratio was slightly lower in HBV patients (relative risk = 0.96; 95% CI 0.94-0.99). The major causes and places of death were different. The three major causes of death for HBV were: other malignant neoplasms (35%), cardiovascular disease/other circulatory disorders (17%), and liver-related disease (15%) whereas for HCV patients were: liver-related disease (22%), other malignant neoplasms (20%), and cardiovascular disease (16%). Regarding the place of death, 53% of HBV patients and 44% of HCV patients died in hospital inpatient, respectively.

CONCLUSIONS

HBV patients incurred higher liver-related hospital charges and higher mean increase for all-cause and liver-related hospitalization charges over the 8-year period compared to HCV patients. HBV patients had slightly lower mortality rate and their major causes and places of death were noticeably different from HCV patients.