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Gillespie IA, Barnes E, Wong ICK, Matthews PC, Cooke GS, Tipple C, Elston RC, Liu Y, Smith DA, Wang T, Davies J, Várnai KA, Freeman O, Man KKC, Lau WCY, Glampson B, Meng X, Morais E, Liu S, Mercuri L, Boxall N, Jenner S, Kendrick S, Dong J, Theodore D. Patient Biochemistry and Treatment Need in Chronic Hepatitis B Virus Infection Across Three Continents: Retrospective Cross-Sectional Cohort Studies. Infect Dis Ther 2023; 12:2513-2532. [PMID: 37432642 PMCID: PMC10651815 DOI: 10.1007/s40121-023-00824-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 05/16/2023] [Indexed: 07/12/2023] Open
Abstract
INTRODUCTION Chronic hepatitis B virus (HBV) infection is associated with significant global morbidity and mortality. Low treatment rates are observed in patients living with HBV; the reasons for this are unclear. This study sought to describe patients' demographic, clinical and biochemical characteristics across three continents and their associated treatment need. METHODS This retrospective cross-sectional post hoc analysis of real-world data used four large electronic databases from the United States, United Kingdom and China (specifically Hong Kong and Fuzhou). Patients were identified by first evidence of chronic HBV infection in a given year (their index date) and characterized. An algorithm was designed and applied, wherein patients were categorized as treated, untreated but indicated for treatment and untreated and not indicated for treatment based on treatment status and demographic, clinical, biochemical and virological characteristics (age; evidence of fibrosis/cirrhosis; alanine aminotransferase [ALT] levels, HCV/HIV coinfection and HBV virology markers). RESULTS In total, 12,614 US patients, 503 UK patients, 34,135 patients from Hong Kong and 21,614 from Fuzhou were included. Adults (99.4%) and males (59.0%) predominated. Overall, 34.5% of patients were treated at index (range 15.9-49.6%), with nucleos(t)ide analogue monotherapy most commonly prescribed. The proportion of untreated-but-indicated patients ranged from 12.9% in Hong Kong to 18.2% in the UK; almost two-thirds of these patients (range 61.3-66.7%) had evidence of fibrosis/cirrhosis. A quarter (25.3%) of untreated-but-indicated patients were aged ≥ 65 years. CONCLUSION This large real-world dataset demonstrates that chronic hepatitis B infection remains a global health concern; despite the availability of effective suppressive therapy, a considerable proportion of predominantly adult patients apparently indicated for treatment are currently untreated, including many patients with fibrosis/cirrhosis. Causes of disparity in treatment status warrant further investigation.
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Affiliation(s)
| | - Eleanor Barnes
- Nuffield Department of Medicine, University of Oxford, Old Road, Oxford, OX3 7BN, UK
- NIHR Health Informatics Collaborative, Oxford University Hospitals NHS Foundation Trust, Headley Way, Headington, Oxford, OX3 9DU, UK
| | - Ian C K Wong
- Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, The University of Hong Kong, 21 Sassoon Road, Pokfulam, Hong Kong
- Research Department of Practice and Policy, UCL School of Pharmacy, 29-39 Brunswick Square, London, WC1N 1AX, UK
| | - Philippa C Matthews
- Nuffield Department of Medicine, University of Oxford, Old Road, Oxford, OX3 7BN, UK
- NIHR Health Informatics Collaborative, Oxford University Hospitals NHS Foundation Trust, Headley Way, Headington, Oxford, OX3 9DU, UK
- The Francis Crick Institute, 1 Midland Road, London, NW1 1AT, UK
- University College London, Gower St, London, WC1E 6BT, UK
| | - Graham S Cooke
- Faculty of Medicine, Department of Infectious Disease, Imperial College London, South Kensington Campus, London, SW7 2AZ, UK
- NIHR Health Informatics Collaborative, Imperial College Healthcare NHS Trust, The Bays, S Wharf Rd, London, W2 1NY, UK
| | - Craig Tipple
- GSK, Gunnels Wood Road, Stevenage, SG1 2NY, Hertfordshire, UK
| | - Robert C Elston
- GSK, Gunnels Wood Road, Stevenage, SG1 2NY, Hertfordshire, UK
| | - Yunhao Liu
- GSK, 1250 S Collegeville Rd, Collegeville, PA, 19426, USA
| | - David A Smith
- NIHR Health Informatics Collaborative, Oxford University Hospitals NHS Foundation Trust, Headley Way, Headington, Oxford, OX3 9DU, UK
| | - Tingyan Wang
- Nuffield Department of Medicine, University of Oxford, Old Road, Oxford, OX3 7BN, UK
| | - Jim Davies
- Department of Computer Science, University of Oxford, 7 Parks Rd, Oxford, OX1 3QG, UK
| | - Kinga A Várnai
- NIHR Health Informatics Collaborative, Oxford University Hospitals NHS Foundation Trust, Headley Way, Headington, Oxford, OX3 9DU, UK
| | - Oliver Freeman
- Nuffield Department of Population Health, University of Oxford, University of Oxford Richard Doll Building, Old Road Campus, Headington, Oxford, OX3 7LF, UK
| | - Kenneth K C Man
- Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, The University of Hong Kong, 21 Sassoon Road, Pokfulam, Hong Kong
- Research Department of Practice and Policy, UCL School of Pharmacy, 29-39 Brunswick Square, London, WC1N 1AX, UK
| | - Wallis C Y Lau
- Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, The University of Hong Kong, 21 Sassoon Road, Pokfulam, Hong Kong
- Research Department of Practice and Policy, UCL School of Pharmacy, 29-39 Brunswick Square, London, WC1N 1AX, UK
| | - Ben Glampson
- NIHR Health Informatics Collaborative, Imperial College Healthcare NHS Trust, The Bays, S Wharf Rd, London, W2 1NY, UK
| | - Xing Meng
- GSK Institute for Infectious Diseases and Public Health, 11F, Bldg 2, Shuangqing Plaza, No. 77, Shuangqing Road, Beijing, China
| | | | - Sen Liu
- GSK Institute for Infectious Diseases and Public Health, 11F, Bldg 2, Shuangqing Plaza, No. 77, Shuangqing Road, Beijing, China
| | - Luca Mercuri
- NIHR Health Informatics Collaborative, Imperial College Healthcare NHS Trust, The Bays, S Wharf Rd, London, W2 1NY, UK
| | - Naomi Boxall
- IQVIA, The Point, 37 N Wharf Rd, London, W2 1AF, UK
| | - Sarah Jenner
- IQVIA, The Point, 37 N Wharf Rd, London, W2 1AF, UK
| | - Stuart Kendrick
- GSK, Gunnels Wood Road, Stevenage, SG1 2NY, Hertfordshire, UK
| | - Jane Dong
- GSK Institute for Infectious Diseases and Public Health, 11F, Bldg 2, Shuangqing Plaza, No. 77, Shuangqing Road, Beijing, China
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Gillespie IA, Chan KA, Liu Y, Hsieh SF, Schindler C, Cheng W, Chang R, Kap E, Morais E, Duh MS, Park S, Ketz M, Jenner S, Boxall N, Kendrick S, Theodore D. Characteristics, Treatment Patterns, and Clinical Outcomes of Chronic Hepatitis B Across 3 Continents: Retrospective Database Study. Adv Ther 2023; 40:425-444. [PMID: 36350533 PMCID: PMC9898346 DOI: 10.1007/s12325-022-02284-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 07/25/2022] [Indexed: 11/11/2022]
Abstract
INTRODUCTION The prevalence of chronic hepatitis B virus (HBV) infection is high in many countries; however, robust, real-world epidemiological data are lacking. This study describes the prevalence, characteristics, treatment patterns, and long-term clinical outcomes of patients with chronic HBV infection in the US, Germany, and Taiwan. METHODS This was a retrospective cohort analysis of three healthcare/insurance claims databases. Individuals were identified as patients with chronic HBV infection if their records contained HBV diagnostic codes from 1 January 2010 to 31 December 2012 (Germany and Taiwan) or 1 January 2013 (USA). Included patients were indexed on 1 January 2013. Patients' demographics, clinical characteristics, and healthcare utilisation were described. Treatment patterns and long-term clinical outcomes over follow-up (to 31 December 2016 or loss to follow-up) were estimated. RESULTS The prevalence of chronic HBV infection was 0.10%, 0.17%, and 2.39% in the US, Germany, and Taiwan respectively. Prevalence was very low in children, increased rapidly in adulthood, and peaked in 50- < 65 year olds before declining in the elderly. More US (16.6%) and German (15.4%) patients were HIV ± HCV coinfected than in Taiwan (4.1%). Baseline clinical characteristics and healthcare utilisation were broadly similar between countries. In total, 19.2%, 11.1%, and 5.9% of non-coinfected adult patients received treatment at index in the US, Germany, and Taiwan, respectively; most frequently with nucleos(t)ide analogue monotherapy (94.4%, 97.2%, 99.8% of treated patients, respectively) and rarely with interferons (0.27%, 1.63%, and 0.06%, respectively). Untreated Taiwanese patients were more likely to remain untreated than elsewhere, and treated Taiwanese patients were less likely to persist with therapy. Generally, the cumulative incidence of long-term clinical outcomes was lowest in Germany. CONCLUSION This study provides a contemporary, real-world, intercontinental snapshot of chronic HBV infection. Long-term sequelae occurred in all populations, and treatment levels were low, suggesting an unmet need for (or access to) effective treatments.
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Affiliation(s)
- Iain A. Gillespie
- Epidemiology, Value Evidence and Outcomes, GSK, Gunnels Wood Road, Stevenage, UK
| | - K. Arnold Chan
- Health Data Research Center, National Taiwan University, Taipei, Taiwan ,College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yunhao Liu
- VEO Data, Methods, and Analytics, GSK, Collegeville, PA USA
| | - Shu-Feng Hsieh
- Health Data Research Center, National Taiwan University, Taipei, Taiwan
| | - Christian Schindler
- WIG2 Scientific Institute for Health Economics and Health System Research, Leipzig, Germany
| | | | | | | | - Eleonora Morais
- Epidemiology, Value Evidence and Outcomes, GSK, Gunnels Wood Road, Stevenage, UK
| | | | - Suna Park
- Analysis Group, Inc., Boston, MA USA
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Scarponi CFO, Pedrosa MAF, Mol MPG, Greco DB. Noncompliance with Therapeutic Guidelines for Chronic Hepatitis B Patients in Minas Gerais, Brazil. Infect Dis Rep 2022; 14:955-966. [PMID: 36547240 PMCID: PMC9778473 DOI: 10.3390/idr14060094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 11/17/2022] [Accepted: 11/22/2022] [Indexed: 11/29/2022] Open
Abstract
Standardized treatment regimens for chronic hepatitis B (CHB) are crucial in suppressing viral replication, disease progression and the development of complications. However, information on routine compliance with such therapeutic recommendations in medical practice is rare. Aim: To evaluate the application of Brazilian therapeutic guidelines for CHB within the scope of the Unified Health System in Minas Gerais state. Four key recommendations from the national guidelines were compared with data from treated patients: (i) eligibility to start treatment; (ii) type of treatment applied; (iii) rescue antiviral therapy; and (iv) monitoring of virological response. Most physicians (69.8%) declared to adopt these guidelines, while 10 of them were unaware. However, according to the criteria established by the guidelines, only 39.5% of treated patients should have been considered "truly" eligible to start treatment and only 67.6% of these underwent the recommended pharmacological treatment. The virological response was laboratory monitored in just over a third of patients. Rescue therapy was adequately supplanted in 41.2% of patients previously treated with lamivudine. There was low compliance with national guidelines by public service physicians in Brazil, highlighting the need to raise awareness of the importance of its adherence to expand the control of CHB. Thus, increasing the adherence of health professionals to this tool is a current challenge for health institutions and managers.
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Affiliation(s)
| | | | - Marcos Paulo Gomes Mol
- Research and Development Board, Ezequiel Dias Foundation, Belo Horizonte CEP 31510-010, MG, Brazil
| | - Dirceu Bartolomeu Greco
- Faculty of Medicine, Federal University of Minas Gerais, Av. Prof. Alfredo Balena 190, Santa Efigênia, Belo Horizonte CEP 30130-100, MG, Brazil
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Scarponi CFO, Pedrosa MAF, Mol MPG, Hardman MJM, Greco DB. Low eligibility for hepatitis B treatment in the Brazilian public health system. Rev Soc Bras Med Trop 2022; 55:e02972021. [PMID: 35416869 PMCID: PMC9009889 DOI: 10.1590/0037-8682-0297-2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 02/16/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Chronic hepatitis B (CHB) affects 257 million people worldwide. However, the proportion of patients eligible for treatment in the public health system has not been established. This study describes the clinical and laboratory profiles of untreated CHB patients and estimates the eligibility rate for antiviral therapy in accordance with the Brazilian Clinical Protocol and Therapeutic Guidelines. METHODS Records of 670 CHB patients were collected from May 2012 to September 2013 in Minas Gerais. Data from each patient were analyzed by hepatitis B virus (HBV) management. RESULTS 461 CHB patients were treatment-naive. Of these, 23 were HBeAg-positive, 352 were HBeAg-negative, and 14 were clinically diagnosed with cirrhosis. Periodic monitoring was performed in only three patients. However, 9.3% of untreated patients met the eligibility criteria for HBV treatment. CONCLUSIONS Few CHB patients were active carriers and eligible candidates for antiviral therapy. This study revealed inadequate pre-treatment conduct in the Brazilian public health system, emphasizing the need for regular laboratory follow-up for patients initially not eligible for treatment. Such information may indirectly subsidize the planning and improvement of actions and services related to optimal HBV management in the public sphere.
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Affiliation(s)
| | | | | | | | - Dirceu Bartolomeu Greco
- Universidade Federal de Minas Gerais, Programa de Pós-Graduação em Ciência da Saúde: Infectologia e Medicina Tropical, Belo Horizonte, MG, Brasil
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Patients with suboptimal hepatitis B virus diagnostic characterization are at risk of liver fibrosis progression. Eur J Gastroenterol Hepatol 2020; 32:426-432. [PMID: 31490418 DOI: 10.1097/meg.0000000000001527] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Many patients with chronic hepatitis B virus infection remain infradiagnosed and untreated. In a national health system with unrestricted access to treatment, our aims were to assess the level of compliance with clinical guidelines and the characteristics and risk of fibrosis progression in patients with suboptimal diagnosis. METHODS In a cohort of patients with positive hepatitis B surface antigen from January 2011 to December 2013, data were registered to assess characteristics and compliance with guidelines. For assessing the risk of liver fibrosis, positive hepatitis B surface antigen patients from January 2008 to December 2013 were grouped depending on DNA request. Liver fibrosis was estimated by serological scores. RESULTS Of 41 158 subjects with hepatitis B surface antigen request, 351 (0.9%) tested positive, and DNA was not available from 110 patients (66.4% male, mean 42.4 ± 14.5 years) after a median of 25.6 months (range 12.0-43.5). Most of these patients (76%) were assessed by primary care. Half of the patients (47.2%) showed hypertransaminasemia, at least significant fibrosis, or both conditions. After long follow-up (mean 90.1 ± 45.2 months), these patients had a higher risk of achieving at least significant fibrosis during follow-up (log-rank 8.73; P = 0.003). CONCLUSION In more than one-third of patients with positive hepatitis B surface antigen, DNA was not requested despite showing hypertransaminasemia and significant fibrosis. Patients without DNA request are at high risk of liver fibrosis progression. Thus, educational measures and other strategies are necessary, especially targeting primary care, to improve access to treatment.
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Cindolo L, De Francesco P, Petragnani N, Simiele F, Marchioni M, Logreco A, Di Fabio C, De Tursi M, Tinari N, Schips L. Persistence and adherence to androgen deprivation therapy in men with prostate cancer: an administrative database study. MINERVA UROL NEFROL 2019; 72:615-621. [PMID: 31833723 DOI: 10.23736/s0393-2249.19.03595-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND The aim of this study was to assess adherence to and persistence with androgen deprivation therapy (ADT) in a large cohort of prostate cancer (PCa) patients selected from an administrative database, with special attention to elderly patients. METHODS Patients treated with LHRH analogues, LHRH antagonists, the novel androgen antagonist enzalutamide, and the CYP17 inhibitor abiraterone were included spanning the years 2011-2017. Descriptive statistics were used to analyze persistence and adherence in older patients stratified by age (46-55, 56-65, 66-75, 76-85, and >85 years). The effect of persistence duration on overall survival in super-elderly patients was analyzed by the Kaplan-Meier method, together with the influence of multiple prescriptions on overall survival. RESULTS A total of 1160 male patients were treated with ADT. Of these, 1075 were given LHRH analogues, 80 LHRH antagonists, 14 novel androgen antagonists, and 109 the CYP17 inhibitor. Median adherence values were 0.93, 0.97, 0.95, and 0.99 respectively. The highest persistence was recorded for LHRH analogues/antagonists (24 months), followed enzalutamide and abiraterone (8 months). A total of 107 patients (9.2%) were classified as super-elderly (age range 85-97 years). Median persistence and OS in this group were 13 months and 29 months, respectively. The adherence was 0.92. Overall survival was significantly associated with additional prescriptions for other conditions-indications (P=0.0047) but not with differences in adherence rates (P=0.98). CONCLUSIONS Our data showed high adherence and persistence rates in men on ADT. The overall survival in the super-elderly is not influenced by persistence and/or adherence but rather by coprescriptions.
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Affiliation(s)
- Luca Cindolo
- Department of Urology, ASL Abruzzo 02, Chieti, Italy
| | | | | | - Felice Simiele
- Department of Hospital Pharmacy, ASL Abruzzo 02, Chieti, Italy
| | - Michele Marchioni
- Department of Urology, SS Annunziata Hospital, G. D'Annunzio University, Chieti, Italy
| | - Andrea Logreco
- Department of Hospital Pharmacy, ASL Abruzzo 02, Chieti, Italy
| | | | - Michele De Tursi
- Department of Medical, Oral and Biotechnological Sciences, Centro Scienze dell'Invecchiamento e Medicina Traslazionale (CeSI-MeT), G. D'Annunzio University, Chieti, Italy
| | - Nicola Tinari
- Department of Medical, Oral and Biotechnological Sciences, Centro Scienze dell'Invecchiamento e Medicina Traslazionale (CeSI-MeT), G. D'Annunzio University, Chieti, Italy
| | - Luigi Schips
- Department of Urology, ASL Abruzzo 02, Chieti, Italy.,Department of Urology, SS Annunziata Hospital, G. D'Annunzio University, Chieti, Italy.,Department of Medical, Oral and Biotechnological Sciences, Centro Scienze dell'Invecchiamento e Medicina Traslazionale (CeSI-MeT), G. D'Annunzio University, Chieti, Italy
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Ford N, Scourse R, Lemoine M, Hutin Y, Bulterys M, Shubber Z, Donchuk D, Wandeler G. Adherence to Nucleos(t)ide Analogue Therapies for Chronic Hepatitis B Infection: A Systematic Review and Meta-Analysis. Hepatol Commun 2018; 2:1160-1167. [PMID: 30288470 PMCID: PMC6167073 DOI: 10.1002/hep4.1247] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 07/15/2018] [Indexed: 01/06/2023] Open
Abstract
Successful treatment outcomes for chronic hepatitis B virus (HBV) infection requires high levels of adherence to treatment. We searched three databases and abstracts from two conferences up to January 2018 for studies reporting the proportion of patients who were adherent to HBV antiviral therapy and pooled data using random effects meta-analysis. We included 30 studies, providing data for 23,823 patients. Overall, adherence to treatment was 74.6% (95% confidence interval [CI] 67.1%-82.1%). Adherence was similar in high-income settings (75.1%; 95% CI, 65.4%-85.0%) and in low-income and middle-income settings (72.9%; 95% CI, 57.8%-88.0%). Reported barriers to adherence included forgetting, limited understanding of the importance of adherence, and change to routine. Conclusion : There is a need to reinforce assessment and reporting of adherence as a routine part of HBV care and to assess the extent to which evidence-based interventions to improve adherence to medication for human immunodeficiency virus [HIV] and other chronic diseases are effective for HBV infection.
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Affiliation(s)
- Nathan Ford
- Department of HIV and Global Hepatitis Program World Health Organization Geneva Switzerland
| | - Roz Scourse
- Médecins Sans Frontières Access Campaign Geneva Switzerland
| | - Maud Lemoine
- Department of Surgery and Cancer St Mary's Hospital, Imperial College London London United Kingdom
| | - Yvan Hutin
- Department of HIV and Global Hepatitis Program World Health Organization Geneva Switzerland
| | - Marc Bulterys
- Department of HIV and Global Hepatitis Program World Health Organization Geneva Switzerland
| | - Zara Shubber
- Department of Infectious Disease Epidemiology Imperial College London London United Kingdom
| | | | - Gilles Wandeler
- Department of Infectious Diseases and Institute of Social and Preventive Medicine University of Berne Berne Switzerland
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Borrego Izquierdo Y, Gómez Fernández E, Monje Agudo P, Jiménez Galán R, Almeida-González CV, Ferrit Martín M, Morillo Verdugo R. Persistence profile to nucleos(t)ide analogue treatment for patients with chronic hepatitis B. Eur J Hosp Pharm 2016; 23:278-282. [DOI: 10.1136/ejhpharm-2015-000822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2015] [Revised: 01/09/2016] [Accepted: 01/21/2016] [Indexed: 11/11/2022] Open
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Egger ME, Myers JA, Arnold FW, Pass LA, Ramirez JA, Brock GN. Cost effectiveness of adherence to IDSA/ATS guidelines in elderly patients hospitalized for Community-Aquired Pneumonia. BMC Med Inform Decis Mak 2016; 16:34. [PMID: 26976388 PMCID: PMC4791973 DOI: 10.1186/s12911-016-0270-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 02/29/2016] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Adherence to guidelines for the treatment of hospitalized elderly patients with community-acquired pneumonia (CAP) has been associated with improved clinical outcomes. This study evaluated the cost-effectiveness of adherence to guidelines for the treatment of CAP in an elderly hospitalized patient cohort. METHODS Data from an international, multicenter observational study for patients age 65 years or older hospitalized with CAP from 2001 to 2007 were used to estimate transition probabilities for a multi-state Markov model traversing multiple health states during hospitalization for CAP. Empiric antibiotic therapy was classified as adherent, over-treated, and under-treated according to 2007 Infectious Disease Society of America/American Thoracic Society IDSA/ATS guidelines. Utilities were estimated from an expert panel of active clinicians. Costs were estimated from a tertiary referral hospital and adjusted for inflation to 2013 US dollars. Costs, utilities, and transition probabilities were all modeled using probability distributions to handle their inherit uncertainty. Cost-effectiveness analysis was based on the first 14 days of hospitalization. Patients admitted to the intensive care unit (ICU) were analyzed separately from those admitted to the ward. Sensitivity analyses with regards to time frame (out to 30 days hospitalization), cost estimates, and willingness to pay values were performed. RESULTS The model parameters were estimated using data from 1635 patients (1438 admitted to the ward and 197 admitted to the ICU). For the ward model, adherence to antibiotic guidelines was the dominant strategy and associated with lower costs (-$1379 and -$799) and improved quality of life compared to over- and under-treatment. In the ICU model, however, adherence to guidelines was associated with greater costs (+$13,854 and + $3461 vs. over- and under-treatment, respectively) and lower quality of life. Acceptance rates across the willingness to pay ranges evaluated were 42-48 % for guideline adherence on the ward and 61-64 % for over-treatment on the ICU. Results were robust over sensitivity analyses concerning cost and utility estimates. CONCLUSIONS While adherence to antibiotic guidelines was the most cost-effective strategy for elderly patients hospitalized with CAP and admitted to the ward, in the ICU over-treatment of patients relative to the guidelines was the most cost-effective strategy.
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Affiliation(s)
- Michael E. Egger
- />The Hiram C. Polk, Jr., MD Department of Surgery, University of Louisville, School of Medicine, Louisville, KY USA
- />Present Affiliation: Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX USA
| | - John A. Myers
- />Department of Pediatrics, University of Louisville, School of Medicine, Louisville, KY USA
| | - Forest W. Arnold
- />Department of Medicine, Division of Infectious Diseases, University of Louisville, School of Medicine, Louisville, KY USA
| | - Leigh Ann Pass
- />Pharmacy Department, University of Louisville Health Care, Louisville, KY USA
| | - Julio A. Ramirez
- />Department of Medicine, Division of Infectious Diseases, University of Louisville, School of Medicine, Louisville, KY USA
| | - Guy N. Brock
- />Department of Bioinformatics and Biostatistics, University of Louisville, School of Public Health, Louisville, KY USA
- />Present Affiliation: Department of Biomedical Informatics, The Ohio State University, College of Medicine, Columbus, OH USA
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Chang ML, Liaw YF, Hadziyannis SJ. Systematic review: cessation of long-term nucleos(t)ide analogue therapy in patients with hepatitis B e antigen-negative chronic hepatitis B. Aliment Pharmacol Ther 2015; 42:243-57. [PMID: 26151841 DOI: 10.1111/apt.13272] [Citation(s) in RCA: 100] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 04/08/2015] [Accepted: 05/20/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND It has been debated whether finite nucleos(t)ide analogue therapy is feasible in HBeAg-negative chronic hepatitis B. AIM To review this issue systematically. METHODS Using text terms HBsAg and various nucleos(t)ide analogues, PubMed was searched between 1995 and 2014 to find studies on therapy >6 months in adult HBeAg-negative chronic hepatitis B patients with off-therapy follow-up >6 months. RESULTS Twenty-two studies with a total of 1732 patients were identified and included. The median duration of therapy, consolidation therapy and off-therapy follow-up ranged from 6 months to 8 years, 4 to 96 weeks and 6 to 80 months respectively. Patients were monitored with serum ALT and HBV DNA monthly in the first 1-3 months and every 3-6 months afterwards in most studies. The 1-year off-therapy 'virological relapse' (HBV DNA >2000 IU/mL) and 'clinical relapse' (HBV DNA > 2000 IU/mL + ALT elevation) occurred in <70% and <50% of the patients, respectively, and <40% of the patients received re-treatment. These rates were higher in patients with shorter treatment, shorter consolidation therapy and those treated with less potent nucleos(t)ide analogues. Off-therapy severe flares were rare and hepatic decompensation was reported in only one patient with cirrhosis. Biochemical relapse reflecting enhanced immune-mediated hepatocyte killing may lead to a higher chance for off-therapy HBsAg seroclearance and be possibly desirable. CONCLUSION With an appropriate stopping rule and a proper off-therapy monitoring plan, cessation of long-term nucleos(t)ide analogue therapy prior to HBsAg seroclearance in HBeAg-negative chronic hepatitis B is a feasible alternative to indefinite treatment.
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Affiliation(s)
- M-L Chang
- Liver Research Unit, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taipei, Taiwan
| | - Y-F Liaw
- Liver Research Unit, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taipei, Taiwan
| | - S J Hadziyannis
- Second Department of Medicine at Hippokration Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Jeng WJ, Sheen IS, Chen YC, Hsu CW, Chien RN, Chu CM, Liaw YF. Off-therapy durability of response to entecavir therapy in hepatitis B e antigen-negative chronic hepatitis B patients. Hepatology 2013; 58:1888-96. [PMID: 23744454 DOI: 10.1002/hep.26549] [Citation(s) in RCA: 175] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Accepted: 05/22/2013] [Indexed: 12/12/2022]
Abstract
UNLABELLED The optimal duration of nucelos(t)ide analog (Nuc) treatment in hepatitis B e antigen (HBeAg)-negative patients with chronic hepatitis B virus (HBV) infection is unknown. The Asian Pacific Association for the Study of the Liver (APASL) guidelines recommend that treatment can be discontinued if undetectable HBV-DNA has been documented on three occasions ≥ 6 months apart. This study aimed to test this stopping rule in HBeAg-negative chronic hepatitis B (CHB) patients treated with entecavir (ETV). Ninety-five patients (39 cirrhosis) were treated with ETV for a median of 721 (395-1,762) days before stopping therapy and were then monitored with serum HBV DNA and alanine aminotransferase (ALT) at least every 3 months. Within 1 year after stopping ETV therapy, "clinical relapse" (an episode of ALT elevation >2 × upper limit of normal plus HBV-DNA >2,000 IU/mL) occurred in 43 (45.3%) of the 95 patients. Of the 39 cirrhosis patients, 17 (43.6%) relapsed and one (2.6%) developed decompensation. The median duration until relapse was 230 days (74.4% >6 months). Logistic regression analysis showed that baseline HBV-DNA ≤ 2 × 10(5) IU/mL was the only significant independent factor for sustained response. The 1-year relapse rate was 29% in patients with a baseline HBV DNA ≤ 2 × 10(5) IU/mL versus 53% in those with HBV DNA >2 × 10(5) IU/mL (P = 0.027). For the latter, consolidation therapy >64 weeks reduced the relapse rate to 33.3% in patients without cirrhosis. CONCLUSION With an overall 1-year relapse rate of 45% and 29% in those with a baseline serum HBV DNA ≤ 2 × 10(5) IU/mL, the APASL stopping rule for HBeAg-negative CHB patients with proper off-therapy monitoring is adequate even in patients with cirrhosis. Consolidation therapy >64 weeks seems more appropriate for those with higher baseline HBV DNA.
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Affiliation(s)
- Wen-Juei Jeng
- Liver Research Unit, Linkou Medical Center, Chang Gung Memorial Hospital, Taipei, Taiwan; College of Medicine, Chang Gung University, Taipei, Taiwan
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