Using a population-based approach to prevent hepatocellular cancer in New South Wales, Australia: effects on health services utilisation

Abstract

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.

Getting it right: the impact of a continuing medical education program on hepatitis B knowledge of Australian primary care providers

“…In the state of New South Wales, 25% of the population is born overseas and HCC incidence rates are highest in Southwest Sydney, where approximately 6000 residents born in Vietnam or China are estimated to have CHB,13 yet many remain unaware of their status and are therefore unable to access appropriate care 14. To reduce the burden of hepatitis B-related liver disease in this population, the Cancer Council of New South Wales developed the B Positive program, which seeks to support local general practitioners (GPs) in southwest Sydney to identify and manage their patients with CHB 15…”

The cascade of care for Australians living with chronic hepatitis B: measuring access to diagnosis, management and treatment

“…Evidence of ongoing liver damage with persistently raised alanine transaminase (ALT) over a 3-6 month period and/or evidence of cirrhosis are indicators for initiation of therapy. 9,10 Past modelling of cost effectiveness of antiviral treatment has used 15% as a lower end estimate of the population proportion that would benefit from treatment, [17][18][19] and this is the treatment target in Australia's Second National Hepatitis B Strategy 2014-2017. 20 In Australia, it is not known what proportion of people living with CHB are being appropriately monitored or receiving antiviral therapy.…”

Using a chronic hepatitis B Registry to support population-level liver cancer prevention in Sydney, Australia

“… 19 Furthermore, the Registry data validated the role of economic modeling in informing policy. Our economic model had predicted that assuming a 25% program uptake, 271 patients (19%) would require antiviral therapy, 22 2 would be diagnosed with HCC at enrollment 20 and 81% could continue to be cared for by their GP through routine hepatitis care (50%) or enhanced HCC surveillance (31%). 22 These predictions proved extremely accurate: in this cohort, 270 patients (18%) were receiving antiviral treatment and 3 patients were diagnosed with HCC at enrollment.…”

“… 19 In the Fairfield Local Government Area, overall CHB prevalence is estimated at 2.7%, and 76.5% of those affected were born overseas, mostly in Vietnam and China. 15 Our economic model estimated that of local residents with CHB, ~5,800 were born in China or Vietnam and were aged >35 years, 20 when the likelihood of developing disease complications increases significantly. 21 Using Australian CHB management guidelines, our economic model predicted that 19% of this patient group were candidates for antiviral treatment.…”