No abstract

No abstract

The significant cost variations in CHB screening and treatment using different guidelines are relevant for clinicians and policy makers involved in designing population-based disease control programs.

BackgroundAustralians born in countries where hepatitis B infection is endemic are 6-12 times more likely to develop hepatocellular cancer (HCC) than Australian-born individuals. However, a program of screening, surveillance and treatment of chronic hepatitis B (CHB) in high risk populations could significantly reduce disease progression and death related to end-stage liver disease and HCC. Consequently we are implementing the B Positive pilot project, aiming to optimise the management of CHB in at-risk populations in south-west Sydney. Program participants receive routine care, enhanced disease surveillance or specialist referral, according to their stage of CHB infection, level of viral load and extent of liver injury. In this paper we examine the program's potential impact on health services utilisation in the study area.MethodsEstimated numbers of CHB infections were derived from Australian Bureau of Statistics data and applying estimates of HBV prevalence rates from migrants' countries of birth. These figures were entered into a Markov model of disease progression, constructing a hypothetical cohort of Asian-born adults with CHB infection. We calculated the number of participants in different CHB disease states and estimated the numbers of GP and specialist consultations and liver ultrasound examinations the cohort would require annually over the life of the program.ResultsAssuming a 25% participation rate among the 5,800 local residents estimated to have chronic hepatitis B infection, approximately 750 people would require routine follow up, 260 enhanced disease surveillance and 210 specialist care during the first year after recruitment is completed. This translates into 5 additional appointments per year for each local GP, 25 for each specialist and 420 additional liver ultrasound examinations.ConclusionsWhile the program will not greatly affect the volume of local GP consultations, it will lead to a significant increase in demand for specialist services. New models of CHB care may be required to aid program implementation and up scaling the program will need to factor in additional demands on health care utilisation in areas of high hepatitis B sero-prevalence.

193 Background: Hepatitis B (HBV) infection is endemic in many Asian and Pacific Island countries, with 25-40% of chronic hepatitis B (CHB) patients developing cirrhosis or hepatocellular cancer (HCC). Increased migration from high HBV prevalence countries leads to Vietnamese-born Americans and Australians 11-13 times more likely to develop HCC than other groups. As antiviral therapy is more cost-effective than HCC screening, we developed a program of hepatitis B screening, monitoring and treatment targeting high–risk populations in Sydney aged >35 years (the median age for HBeAg sero-conversion in Asian populations). Here we compare estimated program costs using guidelines for HBV treatment in hepatitis B e antigen negative populations. Methods: Using a Markov model, we modelled CHB disease progression and management costs using guidelines published by the American, European and Asian Pacific Associations for the Study of Liver Disease (AASLD, EASL and APASL) and algorithms created by US hepatology experts and our B Positive program, using different levels of alanine aminotransferase (ALT) for treatment initiation. We factored in costs for CHB screening and surveillance for liver damage provided by specialists and/or primary care providers, including CHB and HCC treatment, individualised by viral load and ALT levels. Costs were discounted by 5% and calculated in Australian dollars (AUD); incremental costs used AASLD guidelines as a baseline. Results: Assuming a 25% enrolment in our target population of patients with CHB in South West Sydney followed up for 50 years, total program costs would amount to 9,205,680 AUD. Using AASLD guidelines, estimated cost would amount to 6,344 AUD per patient. APASL guidelines lead to a 132% cost rise, the B Positive program costs 152% more, while the US algorithm and EASL are associated with a 221% cost increment to achieve the equivalent cost/QALY. Conclusions: While the AASLD guidelines appear to be the least costly, uncertainties about “ideal” ALT and viral load levels for treatment initiation and the extent of the benefit conferred in terms of HCC cases averted will need to be resolved to inform large-scale prevention programs.