Uptake of hepatitis B antiviral treatment: A panel data analysis of 31 provinces in China (2013-2020)

Effect of Health Literacy on Antiviral Treatment of Hepatitis B: Instrumental Variable Analysis

Background

China is a country with a high burden of hepatitis B (Hep B) but a low treatment rate. One of the key reasons for the low treatment rate is the inadequate health literacy (HL) of the people, which may affect the awareness and knowledge of Hep B and its treatment, as well as the ability to actively and correctly seek medical resources.

Objective

This study analyzed how HL contributed to the scale-up of antiviral treatment of Hep B in China. We expect that the findings of this study could be used to inform resource allocation for health education and other approaches intending to improve the HL of the Chinese population, thus facilitating the nationwide scale-up of Hep B treatment and contributing to the achievement of the 2030 goal of eliminating viral hepatitis as a major public health threat in China.

Methods

We used the two-stage least squares regression method and adopted the mobile phone penetration rate as the instrumental variable to estimate the effect of improved HL on the number of 12-month standard Hep B antiviral treatments in China based on the panel data of 31 provinces from 2013 to 2020.

Results

In the cross-sectional dimension, the higher the HL, the higher the number of treatments in the provinces in a specific year. In the time series dimension, the number of treatments in a specific province increased with the improvement of HL over time. After controlling the time-invariant inherent attributes of provinces, the instrumental variable estimation with two-stage least squares regression based on the province fixed effect model found that for every 1% increase of HL in each province, the number of treatments increased by 7.15% (0.0715 = e0.0691 - 1; P<.001). Such an increase turned to 5.19% (0.0519 = e0.0506 - 1; P<.001) for the analysis targeting the observation time from 2013 to 2019, as the data of 2020 were removed when the COVID-19 pandemic started. The study found no statistically significant effect of HL on the number of Hep B treatments in the provinces with higher newly reported Hep B incidence and lower gross domestic product per capita.

Conclusions

Our findings suggest that improved HL of the population is an important favorable facilitator for the scale-up of Hep B treatment in China. Building awareness and knowledge of Hep B and its treatment can help individuals understand their health status, ensuring a healthier lifestyle and appropriate health care-seeking behaviors and health care service utilization, so that people can be diagnosed and treated timely and appropriately. Enhancing resource allocation to improve the overall HL of the population and sending Hep B-specific messages to the infected people would be a feasible and effective approach to scale-up the treatment of Hep B in low- and middle-income settings with limited resources, and contribute to achieving the 2030 global goal of eliminating viral hepatitis as a major public health threat.

Economic evaluation of hepatocellular carcinoma surveillance in chronic hepatitis B patients with virological remission

BACKGROUND

Subsequent risk of hepatocellular carcinoma (HCC) persists in chronic hepatitis B (CHB) patients with virological remission. We aimed to assess the cost-effectiveness of HCC surveillance in those patients and determine appropriate age to commence or discontinue surveillance.

METHODS

We developed an individual-based state transition model, simulating the advancement of HCC in CHB patients with virological remission. We used this model to compare the incremental cost-effectiveness ratio (ICER) and long-term health outcomes of biannual or annual HCC surveillance for varying durations with no surveillance.

RESULTS

For compensated cirrhosis patients with CHB, biannual surveillance was not cost-effective for all age groups, while annual surveillance was cost-effective for patients aged 55 to 70 (ICER USD 28,076 / quality-adjusted life years [QALY] gained), which detected 176 additional early HCC cases in a 100,000-person cohort compared to no surveillance. In CHB patients with advanced fibrosis, annual surveillance for patients aged 40 to 75 was the most cost-effective strategy (ICER USD 4,984/QALY gained), which detected 289 additional early HCC per 100,000 patients.

CONCLUSIONS

Annual surveillance for patients with compensated cirrhosis or advanced fibrosis was a more cost-effective option that demonstrated substantial economic benefits, being slightly less effective than biannual surveillance at a significantly lower cost, providing insights for professionals in evaluating HCC surveillance among high-risk patients in China.

Characteristics of patients with chronic hepatitis B infection in China: A retrospective claims database study

Chronic hepatitis B (CHB) infection affects approximately 90 million people in China, where there are profoundly unmet clinical and public health needs. This study evaluated patient demographics, disease progression, and treatment management using national administrative claims data. This retrospective, observational study used anonymized data from the China Health Insurance Research Association claims database (January 1-December 31, 2016); data that could not be validated, or from duplicate entries, were excluded. Patients were identified using the International Classification of Diseases, 10th Revision diagnostic code for CHB (B18.0 and B18.1), using keyword searches for "CHB or HBV" and free-text descriptions of CHB treatments including nucleos(t)ide analogues. Primary objectives included evaluation of: demographics and clinical characteristics of patients with CHB, overall and by presence or absence of cirrhosis and hospital tier; proportion of patients prescribed CHB treatment; and healthcare costs and utilization overall and by presence or absence of cirrhosis and hospital tier. Most identified patients with CHB were male, aged 25 to 65 years, resided in East China, and had employee health insurance. Cirrhosis was common (16.20%) and associated with male preponderance, older age, hepatitis C virus coinfection, and higher hospital care demands and costs. The most frequently visited hospitals were Tier III; patients visiting Tier III generally required more hospital care compared with those visiting Tier I/II hospitals. Only two-thirds of patients were prescribed antiviral therapy for CHB (most commonly nucleos(t)ide analogues). Results from this study highlight a substantial need to improve access to appropriate CHB treatment in China.

Global burden of hepatitis B virus: current status, missed opportunities and a call for action

Chronic hepatitis B virus (HBV) infection affects about 296 million people worldwide and is the leading aetiology of cirrhosis and liver cancer globally. Major medical complications also include acute flares and extrahepatic manifestations. In addition, people living with HBV infection also experience stigma. HBV-related cirrhosis resulted in an estimated 331,000 deaths in 2019, and it is estimated that the number of deaths from HBV-related liver cancer in 2019 was 192,000, an increase from 156,000 in 2010. Meanwhile, HBV remains severely underdiagnosed and effective measures that can prevent infection and disease progression are underutilized. Birth dose coverage for HBV vaccines remains low, particularly in low-income countries or regions where HBV burden is high. Patients with HBV infection are inadequately evaluated and linked to care and are undertreated worldwide, even in high-income countries or regions. Despite the goal of the World Health Organization to eliminate viral hepatitis as a public health problem by 2030, the annual global deaths from HBV are projected to increase by 39% from 2015 to 2030 if the status quo remains. In this Review, we discuss the current status and future projections of the global burden of HBV infection. We also discuss gaps in the current care cascade and propose future directions.