Cost-effectiveness in hepatitis B

The cost-effectiveness of screening for chronic hepatitis B infection in the United States

BACKGROUND

Hepatitis B virus (HBV) continues to cause significant morbidity and mortality in the United States. Current guidelines suggest screening populations with a prevalence of ≥2%. Our objective was to determine whether this screening threshold is cost-effective and whether screening lower-prevalence populations might also be cost-effective.

METHODS

We developed a Markov state transition model to examine screening of asymptomatic outpatients in the United States. The base case was a 35-year-old man living in a region with an HBV infection prevalence of 2%. Interventions (versus no screening) included screening for Hepatitis B surface antigen followed by treatment of appropriate patients with (1) pegylated interferon-α2a for 48 weeks, (2) a low-cost nucleoside or nucleotide agent with a high rate of developing viral resistance for 48 weeks, (3) prolonged treatment with low-cost, high-resistance nucleoside or nucleotide, or (4) prolonged treatment with a high-cost nucleoside or nucleotide with a low rate of developing viral resistance. Effectiveness was measured in quality-adjusted life years (QALYs) and costs in 2008 US dollars.

RESULTS

Screening followed by treatment with a low-cost, high-resistance nucleoside or nucleotide was cost-effective ($29,230 per QALY). Sensitivity analyses revealed that screening costs <$50,000 per QALY in extremely low-risk populations unless the prevalence of chronic HBV infection is <.3%.

CONCLUSIONS

The 2% threshold for prevalence of chronic HBV infection in current Centers for Disease Control and Prevention/US Public Health Service screening guidelines is cost-effective. Furthermore, screening of adults in the United States in lower-prevalence populations (eg, as low as .3%) also is likely to be cost-effective, suggesting that current health policy should be reconsidered.

Economic evaluation of chronic hepatitis B treatments in Taiwan

BACKGROUND AND AIMS

Chronic hepatitis B (CHB) and its sequelae are major health problems in Taiwan. The purpose of the present study was the economic evaluation of short-duration treatments of CHB and longer duration antiviral treatment for up to 5 years.

METHODS

Ten-health state CHB disease progression Markov models were used for hepatitis B e antigen (HBeAg)-positive and HBeAg-negative CHB patients, respectively, that included the emergence of antiviral resistance. The perspective of this economic evaluation was the Taiwan health-care system. Costs and benefits were discounted at 3% per annum.

RESULTS

Short-course therapies of up to 1-year treatment had limited impact on improving patient survival. Long-term viral suppression with lamivudine and adefovir sequential rescue therapies (including add-on therapies) for up to 5 years were found to be highly cost-effective by international standards (estimated to be NT$580,000 per quality adjusted life year [QALY] for Taiwan). When Taiwan-specific model inputs were used for HBeAg-positive CHB, the cost per QALY for lamivudine plus adefovir sequential antiviral therapy increased by approximately 100% over the base-case estimate, but was still well within the estimated NT$580,000 per QALY threshold.

CONCLUSIONS

In Taiwan, treatment of CHB patients with lamivudine and adefovir sequential antiviral therapies for up to 5 years results in survival benefits and is highly cost-effective.

The cost-effectiveness of long-term antiviral therapy in the management of HBeAg-positive and HBeAg-negative chronic hepatitis B in Singapore

The purpose of this study was the economic evaluation of short-duration treatments of chronic hepatitis B (CHB) and longer duration antiviral treatment for up to 5 years. Two 10-health state Markov models were developed for hepatitis B e antigen (HBeAg)-positive and HBeAg-negative CHB patients respectively. The perspective of this economic evaluation was the Singapore healthcare system and CHB patient. The models followed cohorts of HBeAg-positive and HBeAg-negative CHB patients, respectively, over a period of 40 years, by which time the majority of the cohorts would have died if left untreated. Costs and benefits were discounted at 5% per annum. Annual rates of disease progression and the magnitude of treatment effects were obtained from the literature, with a focus on data obtained in Asian patients and meeting the criteria for therapy as described in internationally recognized management guidelines. Short-course therapy with alpha-interferon, or 1-year treatment with pegylated interferon alpha-2a, lamivudine or adefovir had limited impact on disease progression. In contrast, treatment of CHB with antiviral therapy for 5 years substantially decreased the rate of disease progression. Treatment with lamivudine for 1-year is highly cost-effective compared with no treatment of CHB but has limited effect on reducing the rate of disease progression. Compared with 1-year treatment with lamivudine, sequential antiviral therapies for up to 5 years (i.e. lamivudine plus adefovir on emergence of lamivudine resistance or adefovir plus lamivudine on emergence of adefovir resistance) are highly cost-effective by international standards. These conclusions are robust to uncertainties in model inputs and are consistent with the findings of other recently published studies.