Health care costs associated with chronic hepatitis B

Prevalence estimates of diagnosed viral hepatitis B, liver condition outcomes and hospitalization costs: a population record-linkage study in Tayside, Scotland

We estimated prevalence and incidence of liver condition outcomes, and costs to the health service of diagnosed hepatitis B virus (HBV) in Tayside, UK. HBV patients were identified from electronic virology data between 1989 and 2003. The health resource costs of HBV for surface antigen-positive (HBsAg+) patients and HBV (HBsAg+ or immune, i.e. recovered) patients were calculated. A total of 633 patients had HBV (275 HBsAg+), and were more likely to be male (62% vs. 48%), older (mean age 42.6 vs. 39 . 2 years) and deprived than the general population. The prevalence of immune individuals increased steadily. Post-HBV diagnosis, 24% of immune and 13% of HBsAg+ patients were diagnosed with a liver condition. The median cost per immune patient (£3023) was greater than per HBsAg+ patient (£1498) (P=0.02). While increasing prevalence of immune HBV patients highlights an increase in screening and treatment, the costs associated with this group are high.

Online survey: knowledge about risks, prevention and consequences of infections with HBV among travellers from four European countries

OBJECTIVE

To evaluate knowledge about risks, prevention and consequences of infection with hepatitis B virus (HBV) among travellers from four low HBV risk, European countries.

METHODS

Individuals from an internet panel and based in the Czech Republic, the Netherlands, Spain and Sweden were invited to take part in an online survey. A total of 4203 respondents met the inclusion criteria and completed the survey.

RESULTS

The majority (62.3%) of respondents did not know the main travel destinations with moderate or high prevalence for HBV. Also, 20.1% were somewhat or very unaware of the ways in which HBV can be caught and travellers aged 18-35 years were significantly more likely (p < 0.01) to have participated in at least one risky activity abroad. Three-quarters (74.9%) thought they were somewhat or very aware of the health implications of contracting HBV, but only 11.8% of participants selected more than three out of the six correct answers relating to conditions caused by HBV. Only 39.3% of those who knew their vaccination status had received vaccination against HBV within the previous 5 years, although some patients may have been vaccinated prior to this period.

CONCLUSIONS

As country-specific variables were not analysed in this study, the results do not allow interpretation by country. A high proportion of the respondents were at an elevated risk of HBV infection while visiting moderate or high prevalence countries. They were unlikely to be immunised or take appropriate precautions; participation in risk activities abroad was high, and knowledge of HBV was limited. These findings indicate there is a need for healthcare professionals and the travel industry to educate travellers on the risks of HBV infections while abroad and the importance of preventing infection through vaccination.

Hepatitis B virus infection among refugees resettled in the U.S.: high prevalence and challenges in access to health care

Hepatitis B virus infection (HBV) remains highly endemic in many parts of the world. Refugees resettling in their host countries may carry a significant burden of disease due to HBV and may require long-term medical care. A retrospective descriptive study was conducted to assess the epidemiology of HBV and entry into medical care in refugee communities resettled in the State of Georgia over a five-year period: 2003-2007. Among 6,347 refugees (89.7% of those resettled) screened for HBV infection, six hundred and eighty (10.7%) were found to be HBsAg seropositive. Those between the ages of 10-39 years of age contributed to the majority of cases; and most originated from Africa (71%). All HBsAg positive cases were adequately referred to a primary care physician for further management but there are no formal feedback mechanisms in place to learn if those who tested positive for HBsAg accessed the primary healthcare system. HBV infection is a frequent infection among refugees resettled in the US. but their entry into healthcare to treat those with chronic infection is often unknown. Further efforts are required to assure their entry into the healthcare system. Primary care physicians caring for refugee patients should think about verifying HBV-infection status as part of health maintenance protocols.

Non-invasive diagnosis of large oesophageal varices with FibroTest in patients with cirrhosis: a preliminary retrospective study

BACKGROUND AND AIMS

Primary prevention of variceal bleeding with beta-blockers improves survival in patients with large oesophageal varices (LOV). Therefore, cirrhotic patients frequently undergo screening endoscopy. As portal hypertension is related to liver fibrosis, this study aimed to assess the predictive value of FibroTest, a non-invasive marker of liver fibrosis, for the diagnosis of LOV in cirrhotic patients.

METHODS

Ninety-nine cirrhotic patients had clinical examination, blood sample (liver function tests, platelet count, FibroTest) and upper endoscopy. Measurements of endoscopic and biochemical parameters were made blindly. Sensitivity, specificity, predictive values and area under the receiver operating characteristic curves were assessed for FibroTest, platelet count and Child-Pugh score. The main endpoint was the presence of LOV.

RESULTS

Platelet count, prothrombin time, ascites, FibroTest and Child-Pugh class were significantly different among patients with or without LOV. FibroTest had the highest discriminative power with an area under receiver operating characteristics curves of 0.77 (SE=0.06), compared with 0.64 (0.08) and 0.68 (0.08) for platelet count and Child-Pugh score, respectively (P=0.08). A cut-off at 0.80 had a 86% negative predictive value for the diagnosis of LOV (Se=92%, Sp=21%).

CONCLUSION

FibroTest could aid in the diagnosis of LOV and may therefore reduce the indication of endoscopic screening in cirrhotic patients.

Cost-of-illness studies : a review of current methods

The number of cost-of-illness (COI) studies has expanded considerably over time. One outcome of this growth is that the reported COI estimates are inconsistent across studies, thereby raising concerns over the validity of the estimates and methods. Several factors have been identified in the literature as reasons for the observed variation in COI estimates. To date, the variation in the methods used to calculate costs has not been examined in great detail even though the variations in methods are a major driver of variation in COI estimates. The objective of this review was to document the variation in the methodologies employed in COI studies and to highlight the benefits and limitations of these methods. The review of COI studies was implemented following a four-step procedure: (i) a structured literature search of MEDLINE, JSTOR and EconLit; (ii) a review of abstracts using pre-defined inclusion and exclusion criteria; (iii) a full-text review using pre-defined inclusion and exclusion criteria; and (iv) classification of articles according to the methods used to calculate costs. This review identified four COI estimation methods (Sum_All Medical, Sum_Diagnosis Specific, Matched Control and Regression) that were used in categorising articles. Also, six components of direct medical costs and five components of indirect/non-medical costs were identified and used in categorising articles.365 full-length articles were reflected in the current review following the structured literature search. The top five cost components were emergency room/inpatient hospital costs, outpatient physician costs, drug costs, productivity losses and laboratory costs. The dominant method, Sum_Diagnosis Specific, was a total costing approach that restricted the summation of medical expenditures to those related to a diagnosis of the disease of interest. There was considerable variation in the methods used within disease subcategories. In several disease subcategories (e.g. asthma, dementia, diabetes mellitus), all four estimation methods were represented, and in other cases (e.g. HIV/AIDS, obesity, stroke, urinary incontinence, schizophrenia), three of the four estimation methods were represented. There was also evidence to suggest that the strengths and weaknesses of each method were considered when applying a method to a specific illness. Comparisons and assessments of COI estimates should consider the method used to estimate costs both as an important source of variation in the reported COI estimates and as a marker of the reliability of the COI estimate.

A cost comparison of management of chronic hepatitis B and its associated complications in Hong Kong and Singapore

GOALS

To estimate and compare the direct medical cost in the management of chronic hepatitis B (CHB) infection and its complications from the perspective of public health organizations in Hong Kong and Singapore.

BACKGROUND

Hong Kong and Singapore are endemic hepatitis B virus areas with about 10% and 5%, respectively, of the population estimated as hepatitis B virus infected.

STUDY

The medical histories of 660 patients with CHB who received medical services over 5 years from three major public hospitals in Hong Kong and Singapore were studied retrospectively. Costs were analyzed according to the five disease states and estimated in Hong Kong dollars (HKD) and Singapore dollars (SGD).

RESULTS

In both Hong Kong and Singapore, the per-patient total annual cost increased with the severity of the disease. CHB cost HKD 6318 (US 810 dollars) in Hong Kong and SGD 718.15 (US 410.37 dollars) in Singapore. Compensated cirrhosis cost HKD 10,304 (US 1321 dollars) in Hong Kong and SGD 1,175.34 (US 671.62 dollars) in Singapore. Decompensated cirrhosis cost HKD 58,428 (US 7490 dollars) in Hong Kong and SGD 15,389.84 (US 8794.19 dollars) in Singapore. Hepatocellular carcinoma cost HKD 121,822 (US 15,618 dollars) in Hong Kong and SGD 12314.04 (US 7036.59 dollars) in Singapore. Each case of liver transplant was estimated to cost HKD 514,498 (US 65,961 dollars) in Hong Kong and SGD 86,369.28 (US 49,353.87 dollars) in Singapore. CHB in Hong Kong accounted for about 4% of the healthcare expenditure.

CONCLUSION

This study confirms that CHB and its liver disease complications are a significant economic burden to the healthcare budgets of Hong Kong and Singapore, and indicates that effective therapy that arrests or reverses the progression of liver disease would be highly cost-effective.

Hepatitis B virus epidemiology, disease burden, treatment, and current and emerging prevention and control measures

Hepatitis B virus (HBV) infection is a serious global health problem, with 2 billion people infected worldwide, and 350 million suffering from chronic HBV infection. The 10th leading cause of death worldwide, HBV infections result in 500 000 to 1.2 million deaths per year caused by chronic hepatitis, cirrhosis, and hepatocellular carcinoma; the last accounts for 320 000 deaths per year. In Western countries, the disease is relatively rare and acquired primarily in adulthood, whereas in Asia and most of Africa, chronic HBV infection is common and usually acquired perinatally or in childhood. More efficacious treatments, mass immunization programs, and safe injection techniques are essential for eliminating HBV infection and reducing global HBV-related morbidity and mortality. Safe and effective vaccines against HBV infection have been available since 1982. The implementation of mass immunization programs, which have been recommended by the World Health Organization since 1991, have dramatically decreased the incidence of HBV infection among infants, children, and adolescents in many countries. However, not all countries have adopted these recommendations and there remains a large number of persons that were infected with HBV prior to the implementation of immunization programs. Antiviral treatment is the only way to reduce morbidity and mortality from chronic HBV infection. Conventional interferon alfa and lamivudine have been the primary treatments to date. Conventional interferon alfa produces a durable response in a moderate proportion of patients but has undesirable side-effects and must be administered subcutaneously three times per week. Lamivudine also produces a response in a modest proportion of patients and causes few side-effects. However, prolonged treatment is often necessary to prevent relapse on cessation of therapy, and continuous treatment can lead to the development of lamivudine resistance. Promising emerging new treatments include adefovir, entecavir and peginterferon alfa-2a (40 kDa).