Cost-effectiveness analysis of antiviral therapies for hepatitis B e antigen-positive chronic hepatitis B patients in China

Quality of Health Economic Evaluations in Mainland China: A Comparison of Peer-Reviewed Articles in Chinese and in English

OBJECTIVE

Our objective was to assess the incidence and quality of reporting of published health economic evaluations in mainland China and compare the quality of peer-reviewed articles in Chinese and English.

METHODS

A comprehensive search was conducted for economic evaluations pertaining to China published from 2006 to 2015 using the PubMed, CBM, CMCC, CNKI, VIP, and Wanfang databases. All studies in English that met the inclusion criteria were included. For studies in Chinese, 200 sampled studies were included according to the random seeds method, and the same number of the most-cited studies in Chinese as those in English were included according to the number of citations and journal grades. Researchers independently assessed the quality of the studies using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist.

RESULTS

After literature search and screening, a total of 310 studies were identified. The majority of these studies were cost-effectiveness studies (82.26%). Scores among different CHEERS items varied greatly. There was a gap between the average quality scores of the studies published in Chinese and those published in English (49.78 ± 9.31 vs. 82.48 ± 17.69) and between the average quality scores of the included most-cited studies in Chinese and English, which was slightly smaller (54.08 ± 10.27 vs. 82.48 ± 17.69). The methods, results, and discussion sections of studies published in Chinese were of low quality.

CONCLUSION

The quality of reporting of health economic evaluations in mainland China has developed slowly. Most of the included studies were incomplete in the presentation of content, making the results less reliable. It is important to standardize and improve the quality of Chinese health economic research.

Optimal Voluntary Vaccination of Adults and Adolescents Can Help Eradicate Hepatitis B in China

Hepatitis B (HBV) is one of the most common infectious diseases, with a worldwide annual incidence of over 250 million people. About one-third of the cases are in China. While China made significant efforts to implement a nationwide HBV vaccination program for newborns, a significant number of susceptible adults and teens remain. In this paper, we analyze a game-theoretical model of HBV dynamics that incorporates government-provided vaccination at birth coupled with voluntary vaccinations of susceptible adults and teens. We show that the optimal voluntary vaccination brings the disease incidence to very low levels. This result is robust and, in particular, due to a high HBV treatment cost, essentially independent from the vaccine cost.

Are Published Health Economic Models for Chronic Hepatitis B Appropriately Capturing the Benefits of HBsAg Loss? A Systematic Literature Review

OBJECTIVES

Sustained hepatitis B surface antigen (HBsAg) loss or 'functional cure' (FC) is considered an optimal treatment endpoint by international clinical guidelines for chronic hepatitis B (CHB), yet rarely is this achieved with current standard of care (SoC). This leads to an under-reporting of FC in clinical trials, observational studies and health economic (HE) models. This paper systematically identifies and assesses how FC is incorporated in published HE models of CHB.

METHODS

A systematic literature review was conducted in PubMed and Embase (conducted February 2019) to review how HBsAg loss is captured in HE models. The following items were extracted: rate of (and transition probabilities to) HBsAg loss, HBsAg loss health state costs, and HBsAg loss health state utilities.

RESULTS

Sixty-five economics evaluations were identified, and < 50% of these (27/65) incorporated HBsAg loss in their models. Only 15/27 stated HBsAg loss health state costs, 15/27 stated HBsAg loss health state utilities, and 11/27 mentioned treatment-specific transition probabilities to HBsAg loss. The majority of sources these inputs were derived from are not transparent.

CONCLUSIONS

The benefits of FC in current HE models are not well captured, as FC is often not reported or not directly related to modelled treatments. This has the potential for novel agents with higher efficacy compared with SoC to be overlooked and undervalued if their worth is not appropriately communicated. In order to ensure optimal access for patients to new and effective therapies, it is important that the benefits of FC are better assessed and captured within HE models.

Cost-Effectiveness Comparison Between the Response-Guided Therapies and Monotherapies of Nucleos(t)ide Analogues for Chronic Hepatitis B Patients in China

BACKGROUND AND OBJECTIVE

Nucleos(t)ide analogue (NA) monotherapies are typically used as the primary treatment for chronic hepatitis B (CHB) patients, including lamivudine (LAM), telbivudine (TBV), adefovir (ADV), entecavir (ETV) and tenofovir (TDF). For high-resistance NAs (LAM, TBV, ADV), they can generate excellent clinical outcomes by using response-guided therapy; however, their pharmacoeconomic profiles remain unclear in China. We aimed to evaluate the cost effectiveness between response-guided therapies and monotherapies of NAs for Chinese hepatitis B e-antigen (HBeAg)-positive and -negative CHB patients.

METHODS

We constructed a Markov model to simulate CHB progression associated with 12 treatment strategies using effectiveness and cost data from the published literature. We measured the lifetime costs, quality adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICERs). One-way sensitivity (especially to extend the range of the TDF price) and probabilistic sensitivity analyses were used to explore the uncertainties of the model.

RESULTS

For both HBeAg-positive and -negative patients, no treatment strategy generated the lowest lifetime costs (US$31,185-US$31,338) and QALYs (7.54-7.58). ETV and TDF monotherapies were not dominated by other treatments, whereas, the ICER of ETV monotherapy was the lowest (US$6112/QALY-US$8533/QALY). For each high-resistance NA, compared with its monotherapy, the ICERs of its response-guided therapies were below the willingness-to-pay threshold of US$22,833/QALY. Additionally, TDF monotherapy was the preferred treatment when its price dropped to US$1820/year or lower.

CONCLUSION

Among 12 treatment strategies evaluated, ETV monotherapy is the most cost-effective treatment for treatment-naive CHB patients in China. The response-guided therapies of high-resistance NAs are more cost-effective than their monotherapies.

Estimating cost-effectiveness associated with all-oral regimen for chronic hepatitis C in China

Background

All-oral regimens are associated with higher effectiveness and shorter treatment duration for chronic hepatitis C. Given its superior effect and enormous patients in China, clinicians or patients may be compelled to consider delaying treatment for all-oral regimen.

Objective

To estimate cost-effectiveness of delaying treatment for all-oral regimen in the subsequent years under different assumptions about their price and efficacy compared with standard of care in China.

Methods

A state-transition Markov model was developed to estimate lifetime costs and quality-adjusted life years (QALYs). Incremental cost-effectiveness ratio (ICER) and net monetary benefit (NB) were calculated. And sensitivity analyses were also performed to assess the impact of uncertainty.

Results

For treatment naive patients with Genotype 1, immediate treatment with all-oral regimen under assumed cost and efficacy at present was cost-effective compared with peginterferon α-2a (PegIFN) regimen at present with an ICER of $12536 per QALY gained and a positive NB of $6832 at a willingness-to-pay threshold of $21209. And it was more than 95% likely to be cost-effective if weekly drug cost was less than $1000. Moreover, patients delaying treatment for all-oral regimen in the 1^st year were associated with increase in QALYs of 0.62 and increase in cost of $10114 compared with initiating PegIFN regimen at present, which resulted in a positive NB of $3115.

Conclusion

From a payer perspective, all-oral regimen is associated with good long-term health and economic benefit for treatment-naive patients infected with HCV genotype 1. Particularly, if all-oral regimen would become available at lower price in the future, delaying treatment for all-oral regimen may be a good choice for patients in China.

Cost-effectiveness analysis of antiviral therapy in patients with advanced hepatitis B virus-related hepatocellular carcinoma treated with sorafenib

BACKGROUND AND AIM

Antiviral therapy has been demonstrated to significantly improve the survival in patients with advanced hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC). The aim of the study was to investigate the cost-effectiveness of antiviral therapy in patients with advanced HBV-related HCC treated with sorafenib.

METHODS

To conduct the analysis, a Markov model comprising three health states (progression-free survival, progressive disease, and death) was created. The efficacy data were derived from medical records. Cost data were collected based on the Chinese national drug prices. Utility data came from the previously published studies. One-way sensitivity analyses as well as probabilistic sensitivity analyses were performed to explore model uncertainties.

RESULTS

In the base-case analysis, addition of antiviral therapy to sorafenib generated an effectiveness of 0.68 quality-adjusted life years (QALYs) at a cost of $25 026.04, while sorafenib monotherapy gained an effectiveness of 0.42 QALYs at a cost of $20 249.64. The incremental cost-effectiveness ratio (ICER) was $18 370.77/QALY for antiviral therapy group versus non-antiviral therapy group. On the other hand, the ICER between the two groups in patients with high or low HBV-DNA load, with or without cirrhosis, normal or elevated alanine aminotransferase/aspartate aminotransferase were $16 613.97/QALY, $19 774.16/QALY, $14 587.66/QALY, $19 873.84/QALY, $17 947.07/QALY, and $18 785.58/QALY, respectively.

CONCLUSIONS

Based on the cost-effectiveness threshold ($20 301.00/QALY in China), addition of antiviral therapy to sorafenib is considered to be a cost-effective option compared with sorafenib monotherapy in patients with advanced HBV-related HCC in China from the patient's perspective.

Telbivudine for the treatment of chronic hepatitis B in HBeAg-positive patients in China: a health economic analysis

BACKGROUND

Nucleos(t)ide analogs (NUCs) are the standard of care for chronic hepatitis B (CHB). The present analysis aimed to determine the cost effectiveness of NUCs in Chinese healthcare settings.

METHODS

A Markov model was used to simulate two therapeutic strategies for a hypothetical patient cohort diagnosed with hepatitis B e antigen-positive CHB, unwilling or unable to receive interferon therapy, and about to start treatment with any NUC. The first strategy included NUC monotherapy without sequencing (telbivudine [LDT], entecavir [ETV], tenofovir [TDF], lamivudine [LAM], adefovir dipivoxil [ADV], and combination therapies of either LDT and ADV or LDT and TDF, followed by best supportive care [BSC]). The second strategy included sequential therapies of individual NUCs: LAM → ADV, ADV → LAM, LDT → ADV, and ETV → ADV, followed by BSC. The analysis included two scenarios: with and without costs due to nephrotoxicity. Renal impact was quantified as costs alone, without consideration for quality of life decrements.

RESULTS

When renal impact was not considered, without treatment sequencing, LDT was cost effective compared with other NUCs. Amongst the strategies with sequencing, LDT → ADV was cost effective. The results were similar when renal impact was considered. However, LDT strategy demonstrated better cost effectiveness. In probabilistic sensitivity analysis, in both scenarios, LDT → ADV sequence was cost effective with 51 % probability even at willingness to pay of $20,000.

CONCLUSION

Use of LDT, as compared with other NUCs, is cost effective in CHB treatment in Chinese healthcare settings. Considering the detrimental renal impact, overall costs for all treatment options were increased. However, the increase for LDT was comparatively small.