The direct cost of managing patients with chronic hepatitis B infection in Australia

Real-World Epidemiology, Clinical and Economic Burden of Chronic Hepatitis B in Japan: A Retrospective Study Using JMDC Claims Database

INTRODUCTION

Chronic hepatitis B (CHB) is one of the world's major healthcare problems, especially in the Western Pacific regions. This study describes the prevalence, incidence, treatment profiles and clinical and economic burden of chronic hepatitis B patients in Japan using the Japan Medical Data Center (JMDC) Claims Database.

METHODS

This is a retrospective observational study. Prevalence cases were identified as patients with ≥ 1 inpatient or ≥ 2 outpatient CHB diagnoses and ≥ 2 records for hepatitis B tests or ≥ 1 prescription for CHB treatment between January 2010 and December 2019. Newly diagnosed CHB patients were defined as patients diagnosed from 2010 to 2018 with no history of the disease up to 2 years prior to the diagnosis. The index date is defined as the first CHB diagnosis day. We only used patients' data with ≥ 1-year post-index date.

RESULTS

We identified 13,061 CHB prevalent cases (2010-2019), yielding a crude period prevalence of 0.32%. Newly diagnosed CHB patients (n = 1973; median age 52 years) were followed for a median period of 3.1 years, during which 15% received a CHB treatment. Entecavir was the most common first treatment (66%). During this period, 3.4% of the patients developed compensated cirrhosis (CC), 1.5% decompensated cirrhosis (DC) and 3.0% hepatocellular carcinoma (HCC). Around 43.3% of CHB patients were hospitalized at least once. Hospitalizations, treatment rates, serologic testing and screening for liver diseases increased as the severity of the disease progressed. The average total healthcare cost was 870,568 JPY (7779 USD) per person per year. DC and HCC resulted in the highest management costs.

CONCLUSIONS

Chronic hepatitis B represents a high clinical and economic burden for patients and caregivers, given its morbidity and associated costs.

Health care costs related to hepatitis B in Finland are mostly due to chronic infections: a register-based study

BACKGROUND

Finland is among the countries with low hepatitis B endemicity. We evaluate the hepatitis B-related disease and economic burden needed for evidence-based immunisation policy decision-making.

METHODS

Hepatitis B-related cases in 2004-2012 were retrieved from population-based nationwide registers. We evaluated the incidence, health care resource use, health care costs, and life years lost due to hepatitis B-related outcomes. An episode of care was constructed from each individual's hepatitis B-related events retrieved from individually linkable registers.

RESULTS

The mean health care costs per an acute hepatitis B case were €450 (SD 240), €2030 (SD 350), and €5400 (SD 3370) in those aged 0-14, 15-64, and ≥65 years, respectively. For chronic infection, the mean cost per case among Finnish-born individuals was €990 and among foreign-born €1360. The costs per case of liver cirrhosis were €15,350 and liver cancer €19,080. In addition, the annual antiviral medication costs per case receiving antiviral medication were €4710 to €5530. Annually <10% of the chronic and approximately 20% of liver cirrhosis cases received antiviral medication. We identified annually 21 acute, 264 chronic, three liver cirrhosis, and four liver cancer cases and 63.7 life years lost due to hepatitis B per 5.3 million inhabitants. The total annual health care costs were €1.2 million of which 60% were antiviral medication costs and 86% accounted for chronic hepatitis B.

CONCLUSIONS

When planning prevention of hepatitis B infection, it is pivotal to notice that the overall disease and economic burden due to hepatitis B is mostly due to chronic infection.

"B in IT" - a community-based model for the management of hepatitis B patients in primary care clinics using a novel web-based clinical tool

Background

The current model of care for the treatment of chronic hepatitis B (CHB) in Australia is through specialist Hepatology or Infectious Diseases clinics, and limited accredited primary care practices. Capacity is limited, and less than 5% of Australians living with CHB currently access therapy. Increasing treatment uptake is an urgent area of clinical need. Nucleos(t)ide analogue therapy is safe and effective treatment for CHB that is suitable for community prescribing. We have evaluated the success of a community-based model for the management of CHB in primary care clinics using a novel web-based clinical tool.

Methods

Using guidelines set out by the Gastroenterological Society of Australia, we developed an interactive online clinical management tool for the shared care of patients with CHB in primary care clinics, with remote oversight from tertiary hospital-based hepatologists and a project officer. We call this model of care the “B in IT” program. Suitable patients were referred from the specialist liver clinic back to primary care for ongoing management. Compliance with recommended appointments, pathology tests and ultrasounds of patients enrolled in “B in IT” was assessed and compared to that of the same patients prior to community discharge, as well as a matched control group of CHB outpatients continuing to attend a specialist clinic.

Results

Thirty patients with CHB were enrolled in the “B in IT” program. Compliance with attending scheduled appointments within 1 month of the suggested date was 87% across all 115 visits scheduled. Compliance with completing recommended pathology within 1 month of the suggested date was 94% and compliance with completing recommended liver ultrasounds for cancer screening within 1 month of the suggested date was 89%. The compliance rates for visit attendance and ultrasound completion were significantly higher than the control patient group (p < 0.0001) and the “B in IT” patients prior to community discharge (p = 0.002 and p = 0.039, respectively).

Conclusions

The “B in IT” program’s novel web-based clinical tool supports primary care physicians to treat and monitor patients with CHB. This program promotes community-based care and increases system capacity for the clinical care of people living with CHB.

Assessing the clinical and economic impact of increasing treatment uptake in chronic hepatitis B infection using a Markov model

Treatment uptake in chronic hepatitis B virus (HBV) infection is low in South Australia, and the cost-effectiveness of increasing treatment uptake rates in this population has not been assessed.

AIMS AND METHODS

Using a cohort Markov model, cost-effectiveness was assessed for three different treatment uptake scenarios: 2.9% (current level-scenario 1), 10% (scenario 2), and 15% (scenario 3). The initial HBV population included 2550 treatment eligible patients who transitioned between six different health states over a 10-year period. Treatment transition probabilities were based on tenofovir therapy, while those not assigned to treatment followed the natural history transition probabilities. We estimated the incremental cost per quality adjusted life year gained using the prevented number of deaths, hepatocellular carcinoma, and liver transplants.

RESULTS

Scenario 3 was associated with the lowest mean cost/person over 10 years (AU$60 133), compared with scenario 2 (AU$61 964) and scenario 1 (AU$64 597). Scenario 3 was also associated with the highest quality adjusted life year gained (8.196) compared with scenario 2 (7.985) and scenario 1 (7.684). Scenario 3 would result in 50% reduction in hepatocellular carcinoma and 30% reduction in HBV-related mortality compared with scenario 1, over a 10-year period. Higher treatment uptake was found to be cost-effective with at least 2 years of treatment at either 10% or 15% of the target population.

CONCLUSION

Maximizing the treatment uptake in the existing HBV population from 2.9% to 15% was cost-effective for periods of 2 years or more. This was due to a reduction in the number of expected clinical events.

Economic evaluation of HBV vaccination: A systematic review of recent publications (2000-2013)

AIM

To conduct a systematic review of the economic evaluations (EE) of HBV vaccination, taking also into account the studies published in the new millennium.

METHODS

An extensive scientific literature review was conducted using two electronic medical journal databases: Scopus and PubMed engines for published studies on EE of HBV vaccination.

RESULTS

22 articles were reviewed, 9, 5 and 8 cost-effectiveness, cost-benefit and cost-utility analysis, respectively. Studies were mainly concerning EE of universal vaccination (UV), mostly with regards to low or low-medium income countries. For high income countries, EE were focused on the possible implementation of HBV vaccination in particular settings, such as diabetic, renal and other chronic conditions care, as well as infectious diseasesUV has usually a very good cost-effectiveness ratio (80%), ranging from cost-saving (China) or few Euro per LY/QALY gained (in Thailand, and Vietnam) to 630.00$/QALY in USA (Asian and Pacific Islands) Moreover, EE of HBV vaccination are favorable in the infectious diseases field as well as for chronic conditions. In relation to diabetes the studies gave controversial results.

CONCLUSION

This systematic review highlighted the importance of introducing HBV vaccination not only for infant UV program but also for other settings in which patients are people affected by communicable and non-communicable diseases.

Annual economic burden of hepatitis B virus-related diseases among hospitalized patients in twelve cities in China

A nationwide survey of hepatitis B virus (HBV)-associated economic burden has not previously been performed in China. The purpose of this study was to examine the direct, indirect, and intangible costs of HBV-related diseases within the span of one year. A random sample was taken from specialty and general hospitals across 12 cities in six provinces of China. Intangible costs were estimated based on willingness to pay or open-ended answers provided by patients. The results showed that 27 hospitals were enrolled, with a sample population of 4726 patients (77.7% response rate). The average annual costs were $4454.0 (direct), $924.3 (indirect), and $6611.10 (intangible), corresponding to 37.3%, 7.7%, and 55.1% of the total costs, respectively. The direct medical fees were substantially greater than the non-medical fees. Annual indirect costs were divided into outpatient ($112.9) and inpatient ($811.40) loss of income. The intangible costs of chronic HBV were notably higher than either the direct or indirect costs, consistent with the social stigma in China. The comparison amongst individual cities for the average ratio of direct to indirect costs revealed that the sizes of ratios were negatively correlated with the socioeconomic status of the regions. This study suggested that as a whole in China, the HBV-related diseases caused a heavy financial burden which was positively associated with disease severity. Although the intangible costs coincided with a high prevalence of discrimination against CHB patients in Chinese society, our study may serve as future reference for detailed exploration.

Hepatitis B status in migrants and refugees: increasing health burden in Western Australia

BACKGROUND

In light of increasing migration from endemic countries with chronic hepatitis B (CHB), this study describes the changing epidemiology of CHB patients born outside Australia referred to a tertiary hospital in Western Australia. It aims to stratify risk and progression to cirrhosis and hepatocellular carcinoma according to viral factors and to provide an indication of the growing burden of disease and current and future treatment costs.

METHODS

Demographic, serological and biochemical data were obtained from patients with CHB between July 2002 and December 2008. Hepatitis B virus DNA quantification was performed to assess baseline viral loads in the patients. Total cost estimates for surveillance and treatment are based on probabilities of the population anticipated to be at a given stage of the disease in a given year.

RESULTS

There is a progressive increase in referrals (n=478) with the majority coming from Asia (57%) and Africa (35%). The mean age of Africans is 11 years less than that of Asians, with a lower proportion of Africans having hepatitis B virus DNA>2000 IU/mL compared with Asians (36.7% vs 54.3%). Approximately 50% of CHB patients referred are at risk of cirrhosis and hepatocellular carcinoma unless treated. Without treatment, a substantial increase in cost over 10 years (from $401,460 to $2,027,078) is estimated at 400%.

CONCLUSION

This study highlights the increasing burden of CHB in Western Australia, from people born in endemic countries, in particular, the direct costs of treatment. It will help to develop strategies that can be tailored to Western Australia with appropriate allocation of resources.

Pioglitazone and vitamin E for nonalcoholic steatohepatitis: a cost utility analysis

Nonalcoholic steatohepatitis (NASH) is the commonest liver disease in developed countries. However, there are no current data on the cost-effectiveness of therapeutic options such as lifestyle modification, pioglitazone, or vitamin E. We undertook a cost utility analysis to compare these strategies. Using a third-party payer perspective, a deterministic Markov model was developed to compare costs and health benefits of lifestyle modification alone or with pioglitazone or vitamin E in a cohort of patients aged 50 years with biopsy-proven NASH and fibrosis level 3 or greater. We assumed an annual cycle length over a lifetime horizon. Probability and utility estimates were derived from a systematic literature review, and uncertainties in parameter estimates were tested using one- and two-way sensitivity analyses. Our outcome measure was the incremental cost-effectiveness ratio (ICER), with $A50,000 or less considered cost-effective. In comparison with lifestyle modification alone, treatment with either pioglitazone or vitamin E in addition to lifestyle modification was cost-effective, with incremental cost-effectiveness ratios of $A2748 and $A8475 per quality-adjusted life year (QALY) gained, respectively. In a direct comparison, pioglitazone was more cost-effective than vitamin E (ICER $A2,056/QALY gained). Sensitivity analyses indicated that pioglitazone was not cost-effective if either the total drug cost was greater than $A16,000 per annum, or the annual probability of developing cirrhosis in advanced fibrosis was less than 2%.

CONCLUSION

Our modeled analyses suggest that in patients with advanced fibrosis due to NASH, pharmacological treatment in addition to standard lifestyle modification is likely to be cost-effective.

Postoperative adjuvant transarterial chemoembolization for participants with hepatocellular carcinoma: A meta-analysis

AIM

  The efficacy of transarterial chemoembolization (TACE) for inoperable hepatocellular carcinoma (HCC) is positive, but for postoperative HCC, many studies have reported controversial results. The present study aimed to evaluate the efficacy of postoperative adjuvant TACE for participants with HCC.

METHODS

  Electronic and manual searches were conducted to identify randomized controlled trials (RCT) evaluating postoperative adjuvant TACE for participants with HCC.

RESULTS

  Six RCT totaling 659 participants, of whom almost all were of stage IIIA HCC, were included. For the 1-year tumor recurrence rate, hepatectomy plus TACE showed statistically significant less incidence of recurrence, with a pooled risk ratio (RR) of 0.68 (95% confidence interval [CI] = 0.55-0.84, P = 0.0003). For 1-year mortality, the trials were favorable for TACE with a pooled risk ratio of 0.48 (95% CI = 0.35-0.65, P < 0.00001). For 3-year mortality, the trials also revealed statistically significant less incidence, with a pooled risk ratio of 0.76 (95% CI = 0.64-0.90, P = 0.002). However, for 5-year mortality, TACE did not demonstrate statistically significant less incidence (RR = 0.94, 95% CI = 0.81-1.08, P = 0.36). Transient fever and nausea/vomiting were reported as side-effects of TACE but were well tolerated by most participants.

CONCLUSION

  Postoperative adjuvant TACE seems promising for participants with HCC with risk factors (multiple nodules of >5 cm or vascular invasion) but requires further trial.

New data concerning the epidemiology of Hepatitis B virus infection in Greece

There is an obvious, significant, and diachronic reduction of the prevalence of HBV infection in Greece, concerning the general population as well as some traditionally high-risk groups, mainly as a result of constant informing and the widespread initiation of preventive and prophylactic measures, as well as the improvement of health care services. Nevertheless, there are special groups and populations (economical refugees, religious minorities, HIV-positive patients, abroad pregnant women, prostitutes, etc.) who represent sacs of high HBV endemicity and need epidemiological supervision and intervention, in order to limit the spread of the infection and to further improve the existing epidemiological data.

Antiviral therapy of chronic hepatitis B: opportunities and challenges in Asia

Asia comprises more than 40 countries encompassing a wide geographic area with a very large population. Many of these countries have low-income economies together with high endemicity of chronic hepatitis B virus (HBV) infection, which is usually acquired perinatally or during early childhood. The well elucidated natural history of chronic HBV infection, together with the extensive research and the longest experience in the use of therapeutic agents in Asia have provided a great opportunity for Asian patients to benefit from recent advancements. However, treatment of chronic HBV infection is a complex task that requires individualized assessment, thus representing a great challenge for general physicians. The inherent problems of the drugs currently available, together with a lack of awareness of the disease among patients, government, and healthcare practitioners are obstacles to proper management of HBV. The most critical challenge and obstacle is the high cost of medical care and antiviral drugs. Lack of adequate reimbursement for treatment and diagnostic testing makes adherence to treatment guidelines impossible. Hence lamivudine is still widely used in Asia. To address these challenges, the ongoing awareness campaigns, active screening programs, educational activities are needed but must be enhanced. Cost-cutting measures and international support are essential to improve the difficult situation in this part of the world.

Hepatitis B-related hepatocellular carcinoma: epidemiological characteristics and disease burden

Worldwide, 350 million people are chronically infected with hepatitis B virus (HBV) who are at greater risk of hepatocellular carcinoma (HCC) compared with uninfected people. The relative risks of HCC among people infected with HBV ranges from 5 to 49 in case-control studies and from 7 to 98 in cohort studies. More than 50% of HCC cases worldwide and 70-80% of HCC cases in highly HBV endemic regions are attributable to HBV. Incidence of HCC (per 100,000 person/year) among people with chronic HBV infection ranges from 400 to 800 in male and from 120 to 180 in female. Factors associated with increased risk of HCC include demographic characteristics (male sex and older age), lifestyles (heavy alcohol consumption and smoking), viral factors (genotype C, D F, high level of HBV DNA, core/precore mutation) and clinical factors (cirrhosis, elevated alpha-fetoprotein (AFP) and alanine aminotransferase (ALT)). HBV-related HCC has extremely poor prognosis with median survival less than 16 months. Survival rates of HBV-related HCC ranged from 36% to 67% after 1 year and from 15% to 26% after 5 year of diagnosis. Older age, liver function impairment, vascular invasion, tumour aggressiveness and elevated AFP are associated with HCC survival. Global burden of HBV-related liver disease is still a major challenge for public health in the 21st century. While decreases in incidence of HBV infection have been observed in birth cohorts following the introduction of universal infant HBV vaccination programme, HBV-related HCC incidence in is projected to increase for at least two decades because of the high prevalence of chronic HBV infection and prolonged latency to HCC development. To reduce HBV-related HCC continued expansion of universal infant HBV vaccination is required along with antiviral therapy targeted to those individuals at highest risk of HCC. Broad public health strategies should include routine testing to identify chronic HBV infection, improved health infrastructures including human resource to provide diagnosis and treatment assessment.

The impact of chronic hepatitis B on quality of life: a multinational study of utilities from infected and uninfected persons

OBJECTIVES

Chronic hepatitis B (CHB) is a condition that results in substantial morbidity and mortality worldwide because of progressive liver damage. Investigators undertaking economic evaluations of new therapeutic agents require estimates of health-related quality of life (HRQOL). Recently, evidence has begun to accumulate that differences in cultural backgrounds have a quantifiable impact on perceptions of health. The objective was to elicit utilities for six health states that occur after infection with the hepatitis B virus from infected and uninfected respondents living in jurisdictions with low and with high CHB endemicity.

METHODS

Standard gamble utilities were elicited from hepatitis patients and uninfected respondents using an interviewer-administered survey in the United States, Canada, United Kingdom, Spain, Hong Kong, and mainland China. Generalized linear models were used to the effect on utilities of current health, age and sex, jurisdiction and, for infected respondents, current disease state.

RESULTS

The sample included 534 CHB-infected patients and 600 uninfected respondents. CHB and compensated cirrhosis had a moderate impact on HRQOL with utilities ranging from 0.68 to 0.80. Decompensated cirrhosis and hepatocellular carcinoma had a stronger impact with utilities ranging from 0.35 to 0.41. Significant variation was observed between countries, with both types of respondents in mainland China and Hong Kong reporting systematically lower utilities.

CONCLUSIONS

Health states related to CHB infection have substantial reductions in HRQOL and the utilities reported in this study provide valuable information for comparing new treatment options. The observed intercountry differences suggest that economic evaluations may benefit from country-specific utility estimates. The extent that systematic intercountry differences in utilities hold true for other infectious and chronic diseases remains an open question and has considerable implications for the proper conduct and interpretation of economic evaluations.

An enormous hepatitis B virus-related liver disease burden projected in Vietnam by 2025

BACKGROUND

Hepatitis B virus (HBV) is the major cause of chronic liver disease in Vietnam. This study aimed to estimate and project chronic HBV prevalence and HBV-related liver cirrhosis (LC) and hepatocellular carcinoma (HCC) for the period 1990-2025.

METHOD

The Vietnamese population for the period 1990-1999 was derived from census data to 1999 and from 2000 to 2025 based on projection data from the United States Census Bureau. Population chronic HBV prevalence for males and females was estimated based on age-specific HBV prevalence from Vietnamese community-based studies. Universal infant HBV vaccination from 2003 was assumed to reduce HBV infection by 90% in subsequent birth cohorts. Incidences of HBV-related LC and HCC by HBV DNA levels from the Taiwanese REVEAL studies were applied to the chronic HBV population to estimate and project HBV-related liver disease burden.

RESULTS

Estimated chronic HBV prevalence increased from 6.4 million cases in 1990 to around 8.4 million cases in 2005 and was projected to decrease to 8.0 million by 2025. Estimated HBV-related LC and HCC incidence increased linearly from 21,900 and 9400 in 1990 to 58,650 and 25,000 in 2025. Estimated HBV-related mortality increased from 12,600 in 1990 to 40,000 in 2025.

CONCLUSION

Over the next two decades, universal infant HBV vaccination will reduce chronic HBV prevalence in Vietnam but HBV-related liver disease burden will continue to rise. A national HBV strategy is required to address this expanding burden of liver disease.

Cost-effectiveness analysis of entecavir versus lamivudine in the first-line treatment of Australian patients with chronic hepatitis B

BACKGROUND

Chronic hepatitis B (CHB) virus infection is a major global healthcare problem. The recent introduction of entecavir in Australia for the treatment of CHB patients in the naive treatment setting has triggered significant optimism with regards to improved clinical outcomes for CHB patients.

OBJECTIVE

To estimate, from an Australian healthcare perspective, the cost effectiveness of entecavir 0.5 mg/day versus lamivudine 100 mg/day in the treatment of CHB patients naive to nucleos(t)ide therapy.

METHODS

A cost-utility analysis to project the clinical and economic outcomes associated with CHB disease and treatment was conducted by developing two decision-tree models specific to hepatitis B e antigen-positive (HBeAg+ve) and HBeAg-ve CHB patient subsets. This analysis was constructed using the Australian payer perspective of direct costs and outcomes, with indirect medical costs and lost productivity not being included. The study population comprised a hypothetical cohort of 1000 antiviral treatment-naive CHB patients who received either entecavir 0.5 mg/day or lamivudine 100 mg/day at model entry. The population of patients used in this analysis was representative of those patients likely to receive initial antiviral therapy in clinical practice in Australia. The long-term cost effectiveness of entecavir compared with lamivudine in the first-line treatment of CHB patients was expressed as an incremental cost per life-year gained (LYG) or QALY gained.

RESULTS

Results revealed that the availability of entecavir 0.5 mg/day as part of the Australian hepatologist's treatment armamentarium should result in significantly lower future rates of compensated cirrhosis (CC), decompensated cirrhosis (DC), and hepatocellular carcinoma (HCC) events (i.e. 54 fewer cases of CC, seven fewer cases of DC, and 20 fewer cases of HCC over the model's timeframe for HBeAg+ve CHB patients, and 69 fewer cases of CC, eight fewer cases of DC and 25 fewer cases of HCC over the model's timeframe for HBeAg-ve CHB patients). Compared with lamivudine 100 mg/day, entecavir 0.5 mg/day generated an estimated incremental cost per LYG of Australian dollars ($A, year 2006 values) 5046 and an estimated incremental cost per QALY of $A5952 in the HBeAg+ve CHB patient population, an estimated incremental cost per LYG of $A7063 and an estimated incremental cost per QALY of $A8003 in the HBeAg-ve CHB patient population, and an overall estimated incremental cost per LYG of $A5853 and an estimated incremental cost per QALY of $A6772 in the general CHB population.

CONCLUSION

The availability of entecavir in Australian clinical practice should make long-term suppression of hepatitis B virus replication increasingly attainable, resulting in fewer CHB sequelae, at an acceptable financial cost.

Blood-borne viral and sexually transmissible infections among psychiatric populations: what are we doing about them?

OBJECTIVE

To discuss the prevalence of blood-borne viral and sexually transmissible infections among psychiatric populations, as well as current treatment approaches, both locally and internationally.

METHOD

In this paper, we outline available epidemiological data, as well as interventions designed to target infectious disease risk among those with serious mental illness.

RESULTS

Within Australia, the prevalence of blood-borne viral and sexually transmissible infections among at-risk populations remains unacceptably high despite a number of successful harm reduction and prevention strategies. Although the highest rates of new infections occur among young people aged 15-29 years, recent research suggests that psychiatric populations are also at significant risk. However, despite increased rates, there is currently no coordinated strategy to educate, test and reduce disease risk among people suffering with mental illness within Australia.

CONCLUSIONS

Although further epidemiological research at a local level is needed, interventions specifically targeting psychiatric populations and younger cohorts in particular, are essential. This will require multidisciplinary, collaborative service development, incorporating mental health, substance use and infectious disease specialists.