SHOULD CHRONIC HEPATITIS B BE TREATED AS EARLY AS POSSIBLE?

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.

Burden and impacts of chronic hepatitis B infection in rural Senegal: study protocol of a cross-sectional survey in the area of Niakhar (AmBASS ANRS 12356)

INTRODUCTION

Though Senegal has one of the highest estimated prevalence rates of chronic hepatitis B virus (HBV) infection worldwide, epidemiological data in the general population are lacking and consequences of the infection remain undocumented. The ANRS-12356 AmBASS study aims at evaluating the health and socioeconomic burden of chronic HBV infection at the individual, household and population level. Its specific objectives are (1) to document the epidemiology of chronic HBV infection, including prevalence and risk factors; (2) to assess the acceptability of home-based testing and first clinic visit; (3) to investigate the repercussions of chronic HBV infection on living conditions; and (4) to estimate the public health impact of chronic HBV infection at the population level and the feasibility of a decentralised model of HBV test and treat.

METHODS AND ANALYSIS

This multidisciplinary cross-sectional survey includes a twofold data collection: (1) home-based screening using dried blood spot (DBS) sampling and collection of sociodemographic, economic and behavioural data, and (2) additional clinical and biological data collection in chronic HBV carriers at the first clinic visit. The prevalence of chronic HBV infection will be estimated in the general population and in key subgroups. Risk factors for HBV acquisition in children will be explored using case-control analysis. HBV burden will be assessed through comparisons of health and economic outcomes between households affected by the disease versus non-affected households. Last, an economic evaluation will assess costs and health benefits of scaling-up HBV care.

ETHICS AND DISSEMINATION

This study was approved by the Senegalese National Ethical Committee for Research in Health, and received authorisation from the Senegalese Ministry of Health and the French Commission on Information Technology and Liberties (Senegalese Protocol Number: SEN17/15). The study results will be presented in peer-review journals, international conferences and at a workshop with national stakeholders in order to contribute to the design of programmes to address the HBV pandemic.

TRIAL REGISTRATION NUMBER

NCT03215732; Pre-results.

Real-World Data for the Evaluation of Transarterial Radioembolization versus Sorafenib in Hepatocellular Carcinoma: A Cost-Effectiveness Analysis

OBJECTIVES

To perform a cost-effectiveness analysis comparing the use of transarterial radioembolization (TARE) with that of sorafenib in the treatment of patients with intermediate or advanced hepatocellular carcinoma (HCC) according to the Barcelona Clinic Liver Cancer staging system.

METHODS

Patient-level data were consecutively recorded and collected at three oncology centers in Italy. A propensity score matching was performed to compare patients with similar clinical characteristics who underwent TARE or sorafenib treatment. Clinical data from the matched cohorts were used to populate a Markov model to project, on a lifetime horizon, life years, quality-adjusted life years, and economic outcomes associated with TARE and sorafenib for both intermediate and advanced HCC stages.

RESULTS

Starting from data covering 389 and 241 patients who underwent TARE and sorafenib treatment, respectively, the propensity score matching yielded a total of 308 matched patients. For intermediate-stage patients, the model estimated for TARE versus sorafenib an incremental cost-utility ratio of €3,302/QALY (incremental cost-effectiveness ratio of €1,865 per life year gained), whereas for patients in advanced stage TARE dominated (lower costs and greater health improvements) compared with sorafenib.

CONCLUSIONS

From an Italian health care service perspective, TARE could be a cost-effective strategy in comparison with sorafenib for patients with intermediate or advanced HCC. The results from forthcoming randomized controlled trials comparing TARE with sorafenib will be able to confirm or reject the validity of this preliminary evaluation. In the meantime, decision makers can use these results to control and coordinate the diffusion of the technology.

Recognizing the impact of endemic hepatitis D virus on hepatitis B virus eradication

BACKGROUND

Hepatitis delta virus (HDV) in conjunction with hepatitis B virus (HBV) increases adult morbidity and mortality. A number of studies have performed cost-benefit analyses for HBV interventions, but they have ignored the impact of HDV on these outcomes.

METHODS

Using a mathematical model of HBV-HDV epidemiology, we compare health benefits and cost outcomes of four interventions: testing with HBV adult vaccination (diagnosis), diagnosis with antiviral treatment for HBV infections (mono-infections), diagnosis with antiviral treatment for HBV-HDV infections (dual-infections), and awareness programs. The relationship between optimal levels and outcomes of each of these interventions and HDV prevalence in HBV infected individuals ranging from 0 to 50% is determined.

RESULTS

Over a 50 year period under no intervention, HBV prevalence, per capita total cost and death toll increase by 2.25%, -$11 and 2.6-fold respectively in moderate HDV endemic regions compared to mono-infected regions; the corresponding values for high HDV endemic regions are 4.2%, -$21 and 3.9-fold. Optimal interventions can be strategized similarly in mono and dually endemic regions. Only implementation of all four interventions achieves a very low HBV prevalence of around 1.5% in a moderate HDV endemic region such as China, with 2.8 million fewer deaths compared to no intervention. Although the policy of implementation of all four interventions costs additional $382 billion compared to no intervention, it still remains cost-effective with an incremental cost-effectiveness ratio of $1400/QALY. Very high efficacy awareness programs achieve less prevalence with fewer deaths at a lower cost compared to treatment and/or vaccination programs.

CONCLUSION

HDV substantially affects the performance of any HBV-related intervention. Its exclusion results in over-estimation of the effectiveness of HBV interventions.

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.

Cost-effectiveness of viral hepatitis B & C treatment

With the availability of effective antiviral therapies for chronic viral hepatitis B and C, cost-effectiveness studies have been performed to assess the outcomes and costs of these therapies to support health policy. It is now accepted that treatment of active CHB is cost-effective versus no treatment, although there are a variety of options. And with the new developments around CHC treatment and diagnostic tools it is of interest to both the clinician and policy makers to know both the costs and effects of these choices. The purpose of this article is to provide the reader with an insight into the recent treatment developments and cost-effectiveness issues related to chronic hepatitis B and C treatment, and an overview of recent cost-effectiveness studies evolving around HBV and HCV therapy.