Impact of partial reimbursement on hepatitis B antiviral utilization and adherence

Comprehensive approach to controlling chronic hepatitis B in China

Hepatitis B virus (HBV) infection was highly endemic in China, where the prevalence of HBsAg was 9.7% in 1992. Comprehensive strategies, including universal infant hepatitis B vaccination with emphasis on timely birth-dose and 3-dose coverage, dramatically reduced the mother-to-infant transmission and early childhood acquisition of HBV, resulting in estimated HBsAg prevalence rates of 5.6% and 0.1% in the general population and among children aged <5 years in 2022, respectively. Clinical guidelines on the prevention and treatment of chronic hepatitis B have been periodically updated based on emerging evidence from clinical research. The continuously improved reimbursement policy and the massively reduced price of antiviral drugs through government negotiation and central procurement have increased treatment accessibility and affordability. However, due to the low rates of diagnosis and treatment, China still faces a large challenge in achieving the 2030 goal of lowering HBV-related mortality by 65%. A public health approach involving concerted efforts from the government, medical community, industry, and society as a whole would be necessary to increase the uptake of HBV tests and treatment to achieve the global goal of eliminating viral hepatitis as a public health threat by 2030.

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

BACKGROUND

China has made substantial efforts aimed to promote the uptake of antiviral treatment of hepatitis B (HB). It is unclear whether these policies achieved the desired impact. This study adopted medicines procurement data from 31 provinces to generate the first evidence about the number of standard antiviral treatment of HB overtime at both national and provincial levels in China.

METHODS

We performed the panel data analyses and quasi-experimental design with the time-varying difference-in-difference method combined with the event study approach to estimate the uptake of HB antiviral treatment before and after national policy changes.

RESULTS

The overall trends in HB antiviral treatment at the national level increased incrementally during 2013-2020. There was 2.8862 million 12-month (person-year) antiviral standard treatment in 2020, which was only 8.93% of the eligible people estimated to need treatment. The number of monthly antiviral standard treatment increased by 42.4% (p = .001) overall following the nationwide adoption of the '4 + 7' pilot-pooled procurement prices in 2019, which brought substantial price reduction of core antivirals.

CONCLUSIONS

A low treatment rate is a critical issue in reaching the elimination of viral hepatitis as a public health threat in China. Affordability is an important but not the only factor that determines the uptake of hepatitis treatment. Further scaling up and acceleration of treatment uptake will need strategies improving public awareness of HB, strengthening diagnosis, linking people who are infected to chronic care, reducing loss to follow-up, and ensuring people who are eligible get timely treatment.

Changing clinical care cascade of patients with chronic hepatitis B in Beijing, China

Background

High uptake of hepatitis B virus (HBV) tests and antiviral therapy are required to improve the clinical outcomes of patients with chronic hepatitis B (CHB) at the population level. In the current study, we used the Basic Medical Care Insurance for Employees (BMCIE) to investigate the changes of clinical care cascade of CHB in Beijing, China.

Methods

Records for medical service of CHB patients from January 1, 2010 to December 31, 2018 were retrieved from the BMCIE database. The annual and cumulative rates of CHB patients in care, receiving HBV tests and on antiviral therapy were calculated. The trends of annual percentage changes (APCs) were estimated using Joinpoint regression model.

Findings

Among estimated HBsAg positive employees, the rate of CHB patients in care increased from 4•77% in 2010 to 18•61% in 2018 (APC=17•3, 95%CI: 14•4-20•4). The rate of HBV tests increased from 4•41% in 2010 to 16•39% in 2018. Among the estimated eligible employees for treatment, the rate of antiviral therapy increased from 3•92% in 2010 to 30•88% in 2018. The proportion of hospital visits for HBV≥4 times per year had increased from 47•07% in 2010 to 65•31% in 2018. By 2018, entecavir (65•07%) and tenofovir (12•98%) had become the predominantly prescribed antiviral agents.

Interpretation

The rates of CHB patients in care, receiving HBV tests and on antiviral therapy substantially increased in Beijing, China. However, more efforts are still needed to increase the uptake of HBV tests and treatment for achieving the goal of HBV elimination by 2030.

Funding

Beijing Municipal Science and Technology Commission (No.D161100002716003), National Science and Technology Major Special Project for Infectious Diseases (No.Z191100007619037, No.2018ZX10302204), and Digestive Medical Coordinated Development Center of Beijing Municipal Administration of Hospitals (No. XXX 0104).

Long-term virological and adherence outcomes to antiviral treatment in a 4-year cohort chronic HBV study

BACKGROUND

Chronic hepatitis B (CHB) treatment adherence has been poorly studied worldwide. We evaluated long-term virological and adherence outcomes to antiviral treatment in CHB patients.

METHODS

A prospective 183 Brazilian CHB patient cohort treated with monotherapy or combination adefovir dipivoxil, entecavir, lamivudine and/or tenofovir disoproxil fumarate was studied in a reference tertiary centre. Treatment adherence was evaluated by a validated questionnaire named 'Assessment of Adherence to Antiviral Therapy Questionnaire' (CEAT-HBV) within three yearly periods (2010/2011, 2013/2014 and 2014/2015).

RESULTS

CEAT-HBV identified 43% (79/183) patients with non-adherence to antiviral treatment and among them, 67% (53/79) were viral load positive. The main causes associated with non-response to antiviral treatment were drug resistance variants followed by non-adherence, insufficient treatment duration and other causes. Single-dose pharmacokinetics demonstrated 35% (23/65) antiviral non-adherence. 2 years after the first assessment, the CEAT-HBV indicated that 71% (101/143) of subjects adhered to treatment (per-protocol population). However, 21% (40/183) of the patients could not be evaluated and were excluded. The main reasons for exclusion were death (20/183), 11 out 20 deaths due to hepatocellular carcinoma. HBV booklet was used for medical education. The third CEAT-HBV assessment (2014/2015) showed that 83% (112/135) patients were compliant with treatment adherence (per-protocol population). Long-term evaluation showed that adherence rate based on CEAT-HBV continue to increase after 4-years (P<0.001).

CONCLUSIONS

The results highlight the importance of CHB therapy adherence assessment monitoring. Long-term adherence outcomes were dynamic and it is possible to increase the migration rate to adherence/HBV-DNA-negative group.

Antiviral drug utilization and annual expenditures for patients with chronic HBV infection in Guangzhou, China, in 2008-2015

BACKGROUND

The aims of this study were to describe antiviral drug (AD) utilization and costs in patients with chronic HBV infection.

METHODS

We conducted a retrospective study of patients in the hospital and calculated annual proportions of AD utilization and costs among patients. A two-part model was used to estimate adjusted odds ratio (OR) for antiviral therapy and cost ratios for antiviral costs associated with demographics.

RESULTS

Of a total of 14,920 records, 143,658 records were involved in the analysis. The annual proportions of AD utilization were 56.99% (45.65%) for inpatients (outpatients) during 2008-2015 and increased annually. Entecavir (ETV), in particular, increased from 11.08% to 70.26% (11.05% to 49.35%) for inpatients (outpatients). The patients with medical insurance were more likely to use AD than patients without insurance, and the adjusted OR was 1.11 (95% CI: 1.03, 1.19) for inpatients and 1.66 (1.59, 1.73) for outpatients. With the disease progressing, the proportion of antiviral costs in total direct medical costs decreased from 13.91% to 4.07% (71.29% to 49.29%) for inpatients (outpatients).

CONCLUSIONS

The use of AD for chronic HBV infection was less than expected based on established guidelines, and only half of patients received antiviral treatment. However, the AD utilization, especially ETV, increased annually. Reimbursement policy was the most important factor affecting antiviral treatment. Antiviral therapy was an important part of the direct medical costs, especially in the early stage of disease.

Impact of reimbursement program on liver-related mortality in patients with chronic hepatitis B in Beijing, China

OBJECTIVE

Since July 1, 2011 antiviral therapy for hepatitis B virus infection has been listed as a reimbursable expense for medical insurance in Beijing. This study aimed to assess the impact of this program on liver-related death for patients with chronic hepatitis B (CHB).

METHODS

Profiles of patients with CHB discharged between January 2008 and December 2015 were retrieved from the Beijing hospital discharge database. Liver-related deaths in these patients occurring between January 2008 and December 2017 were retrieved by linking them to the death certification database. Liver-related mortality (number of deaths divided by the observed person-years) before and after this program was launched was calculated and compared. A Poisson regression was performed to assess the strength of association (risk ratio [RR]) between the reimbursement program and liver-related mortality.

RESULTS

Information on 35 943 discharged patients (17 114 patients with non-cirrhotic and 18 829 with compensated cirrhotic CHB) was retrieved. Altogether 3 832 liver-related deaths during the 190 695 person-years were observed. After the reimbursement program was launched, liver-related mortality per 100 person-years dropped from 0.38% to 0.16% for patients with non-cirrhotic CHB, and from 4.03% to 3.39% for those with compensated cirrhosis. The program was associated with a lower risk of developing liver-related death for patients with non-cirrhotic CHB (RR 0.40, 95% confidence interval [CI] 0.30-0.52) and those with compensated cirrhosis (RR 0.84, 95% CI 0.78-0.89).

CONCLUSION

Coverage of antiviral therapy by basic medical insurance reduced the risk of developing liver-related death for patients with non-cirrhotic and with compensated cirrhotic CHB.

Cost-effectiveness of antiviral treatment after resection in hepatitis B virus-related hepatocellular carcinoma patients with compensated cirrhosis

Hepatocellular carcinoma (HCC) imposes a heavy disease burden on China due to its high morbidity and mortality. China accounts for about 50% of the total new cases and deaths worldwide. Most cases are related to hepatitis B virus (HBV) infection and are associated with cirrhosis at diagnosis. Antiviral treatment with nucleos(t)ide analogues (NAs) after resection in HBV-related HCC can reduce recurrence and improve survival. Such treatment is in fact recommended by Chinese guidelines. However, cost-effectiveness studies regarding this treatment are rare. The objective of this study was to estimate the cost-effectiveness of NA treatment after resection in HBV-related HCC patients with compensated cirrhosis. A Markov model was constructed to simulate HBV-related HCC patients with compensated cirrhosis and detectable HBV DNA, with or without NA treatment after resection, followed up over their lifetime. Costs, life expectancy, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICER) were calculated for each strategy from the societal perspective. The parameters of the model were derived from published studies, government documents, and our surveys. Sensitivity analyses were used to explore the impact of parameters on the uncertainty of the results. NA treatment produced 4.22 QALYs, costing $39,898, while non-NA treatment achieved 2.80 QALYs, costing $16,048. The ICER of NA treatment versus non-NA treatment was $16,848/QALY, which was between 2 and 3 times gross domestic product per capita and was therefore deemed cost-effective. Probabilistic sensitivity analysis confirmed that NA treatment was cost-effective, with a probability of 0.852.

CONCLUSION

NA treatment after liver resection was likely cost-effective in HBV-related HCC patients with compensated cirrhosis. (Hepatology 2018).

Adherence to Nucleos(t)ide Analogue Therapies for Chronic Hepatitis B Infection: A Systematic Review and Meta-Analysis

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.

Interrupted time-series analysis of the impact of generic market entry of antineoplastic products in China

OBJECTIVES

The rapid growth of pharmaceutical costs is a major healthcare issue all over the world. The high prices of new drugs, especially those for cancer, are also a concern for stakeholders. Generic drugs are a major price-reducing opportunity and provide more societal value. The aim of this research is to analyse the impact of generic entry on the volume and cost of antineoplastic agents in China.

METHODS

An interrupted time-series design examined monthly sales of three antineoplastic drugs (capecitabine, decitabine, imatinib) from 699 public hospitals during January 2011 to June 2016. The first generic entry times (December 2013, December 2012, August 2013, respectively) were regarded as the intervention time points. We estimated changes in volume and cost following the generic entry.

RESULTS

We found that generic entry was associated with increases in the volume of three antineoplastic agents and decreases in their costs. In terms of volume, generic entry was associated with increases in use of capecitabine, decitabine and imatinib by 815.0 (95% CI -66.5 to 1696.5, p>0.05), 11.0 (95% CI 3.7 to 18.3, p=0.004) and 2145.5 (95% CI 1784.1 to 2506.9, p<0.001) units. The entry of generic antineoplastic drugs reduced the monthly cost trend of three agents by ¥3.1 (95% CI -¥3.6 to -¥2.6, p<0.001), ¥84.7 (95% CI -¥104.7 to -¥64.6, p<0.001) and ¥21.3 (95% CI -¥24.2 to -¥18.4, p<0.001), respectively. The entry of generic drugs attenuated the upward trend in volume of three brand-name drugs and even triggered reductions in the volume of brand-name capecitabine. The entry of generics was accompanied by significant increase of ¥2.6 in monthly brand-name decitabine cost (95% CI ¥0.2 to ¥5.1, p=0.04).

CONCLUSION

Our findings suggested that entry of generic drugs impacted use and cost of antineoplastic medicines in China. Generic drugs may improve the availability and the affordability of antineoplastic agents, which would benefit more patients.

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.