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Han C, Karamatic R, Hanson J. Chronic hepatitis B care in regional Australia: implications for clinical practice and public health policy. Intern Med J 2024; 54:1155-1163. [PMID: 38488685 DOI: 10.1111/imj.16364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 02/25/2024] [Indexed: 07/18/2024]
Abstract
BACKGROUND Australia is struggling to meet its National Hepatitis B Strategy care targets, particularly in nonmetropolitan settings. It is vital to engage priority populations and improve their access to recommended care to reach these targets. AIMS This retrospective study examined people living with chronic hepatitis B (CHB) in regional North Queensland, Australia, and determined whether their care adhered to current national CHB management guidelines. The analysis aimed to identify gaps in care that might be addressed to improve future outcomes. METHODS All individuals referred to the gastroenterology clinic at the Townsville University Hospital in regional North Queensland, Australia, for CHB care between January 2015 and December 2020 were identified. Their linkage to care, engagement in care and receipt of guideline-recommended CHB care were determined. RESULTS Of 255 individuals, 245 (96%) were linked to care; 108 (42%) remained engaged in care and 86 (38%) were receiving guideline-recommended care in 2021. There were 91/255 (36%) who identified as Indigenous Australians. Indigenous status was the only independent predictor of not being linked to care (odds ratio (OR): 0.13 (95% confidence interval (CI): 0.03-0.60), P = 0.01), not being engaged in care (OR: 0.19 (95% CI: 0.10-0.36), P < 0.0001), not receiving guideline-recommended CHB care (OR: 0.16 (95% CI: 0.08-0.31), P < 0.0001) or not being engaged in a hepatocellular carcinoma surveillance programme (OR: 0.08 (95% CI: 0.02-0.27), P < 0.0001). CONCLUSION Current approaches are failing to deliver optimal CHB care to Indigenous Australians in regional North Queensland. Targeted strategies to ensure that Indigenous Australians in the region receive equitable care are urgently needed.
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Affiliation(s)
- Chaw Han
- Department of Gastroenterology, Townsville University Hospital, Townsville, Queensland, Australia
- Department of Gastroenterology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Rozemary Karamatic
- Department of Gastroenterology, Townsville University Hospital, Townsville, Queensland, Australia
| | - Josh Hanson
- Department of Medicine, Cairns Hospital, Cairns, Queensland, Australia
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
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Hosking K, De Santis T, Vintour-Cesar E, Wilson PM, Bunn L, Garambaka Gurruwiwi G, Wurrawilya S, Bukulatjpi SM, Nelson S, Ross C, Stuart-Carter KA, Ngurruwuthun T, Dhagapan A, Binks P, Sullivan R, Ward L, Schroder P, Tate-Baker J, Davis JS, Connors C, Davies J. "Putting the power back into community": A mixed methods evaluation of a chronic hepatitis B training course for the Aboriginal health workforce of Australia's Northern Territory. PLoS One 2024; 19:e0288577. [PMID: 38266007 PMCID: PMC10807824 DOI: 10.1371/journal.pone.0288577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 12/20/2023] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND Chronic hepatitis B (CHB) is endemic in the Aboriginal and Torres Strait Islander population of Australia's Northern Territory. Progression to liver disease can be prevented if holistic care is provided. Low health literacy amongst health professionals is a known barrier to caring for people living with CHB. We co-designed and delivered a culturally safe "Managing hepatitis B" training course for the Aboriginal health workforce. Here, we present an evaluation of the course. OBJECTIVES 1. To improve course participants CHB-related knowledge, attitudes, and clinical practice. 2. To evaluate the "Managing hepatitis B" training course. 3. To enable participants to have the skills and confidence to be part of the care team. METHODS We used participatory action research and culturally safe principles. We used purpose-built quantitative and qualitative evaluation tools to evaluate our "Managing hepatitis B" training course. We integrated the two forms of data, deductively analysing codes, grouped into categories, and assessed pedagogical outcomes against Kirkpatrick's training evaluation framework. RESULTS Eight courses were delivered between 2019 and 2023, with 130 participants from 32 communities. Pre- and post-course questionnaires demonstrated statistically significant improvements in all domains, p<0.001 on 93 matched pairs. Thematic network analysis demonstrated high levels of course acceptability and significant knowledge acquisition. Other themes identified include cultural safety, shame, previous misinformation, and misconceptions about transmission. Observations demonstrate improvements in post-course engagement, a deep understanding of CHB as well as increased participation in clinical care teams. CONCLUSIONS The "Managing hepatitis B" training course led to a sustained improvement in the knowledge and attitudes of the Aboriginal health workforce, resulting in improved care and treatment uptake for people living with CHB. Important non-clinical outcomes included strengthening teaching and leadership skills, and empowerment.
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Affiliation(s)
- Kelly Hosking
- Public Health Directorate, Office of the Chief Health Officer, Northern Territory Health, Northern Territory, Australia
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
- Population and Primary Health Care Branch, Top End Health Service, Northern Territory Health, Northern Territory, Australia
| | - Teresa De Santis
- Population and Primary Health Care Branch, Top End Health Service, Northern Territory Health, Northern Territory, Australia
| | - Emily Vintour-Cesar
- Public Health Directorate, Office of the Chief Health Officer, Northern Territory Health, Northern Territory, Australia
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Phillip Merrdi Wilson
- Population and Primary Health Care Branch, Top End Health Service, Northern Territory Health, Northern Territory, Australia
| | - Linda Bunn
- Population and Primary Health Care Branch, Top End Health Service, Northern Territory Health, Northern Territory, Australia
| | - George Garambaka Gurruwiwi
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Shiraline Wurrawilya
- Population and Primary Health Care Branch, Top End Health Service, Northern Territory Health, Northern Territory, Australia
| | | | - Sandra Nelson
- Population and Primary Health Care Branch, Top End Health Service, Northern Territory Health, Northern Territory, Australia
| | - Cheryl Ross
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Kelly-Anne Stuart-Carter
- Centre for Disease Control, Northern Territory Health, Alice Springs, Northern Territory, Australia
| | - Terese Ngurruwuthun
- Miwatj Aboriginal Health Corporation, Nhulunbuy, East Arnhem Land, Northern Territory, Australia
| | - Amanda Dhagapan
- Miwatj Aboriginal Health Corporation, Nhulunbuy, East Arnhem Land, Northern Territory, Australia
| | - Paula Binks
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Richard Sullivan
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
- UNSW School of Clinical Medicine, St George & Sutherland Campus, Jannali, NSW, Australia
| | - Linda Ward
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Phoebe Schroder
- Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine, Sydney, NSW, Australia
| | - Jaclyn Tate-Baker
- Department of Infectious Diseases, Royal Darwin and Palmerston Hospital, Northern Territory Health, Darwin, Northern Territory, Australia
| | - Joshua S. Davis
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
| | - Christine Connors
- Public Health Directorate, Office of the Chief Health Officer, Northern Territory Health, Northern Territory, Australia
- Population and Primary Health Care Branch, Top End Health Service, Northern Territory Health, Northern Territory, Australia
| | - Jane Davies
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
- Department of Infectious Diseases, Royal Darwin and Palmerston Hospital, Northern Territory Health, Darwin, Northern Territory, Australia
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Cama E, Beadman M, Beadman K, Hopwood M, Treloar C. Health workers' perspectives of hepatitis B-related stigma among Aboriginal and Torres Strait Islander people in New South Wales, Australia. Harm Reduct J 2023; 20:116. [PMID: 37633903 PMCID: PMC10463284 DOI: 10.1186/s12954-023-00844-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 07/28/2023] [Indexed: 08/28/2023] Open
Abstract
BACKGROUND Experiences of stigma and discrimination can act as a significant barrier to testing, monitoring, and treatment for hepatitis B virus (HBV). Aboriginal and Torres Strait Islander Australians are a population disproportionately impacted by HBV and yet limited research has explored HBV-related stigma in these communities. To begin preliminary explorations of HBV-related stigma among Aboriginal and Torres Strait Islander people, we interviewed health workers about their perceptions regarding HBV infection and HBV-related stigma. METHODS Participants were recruited from staff involved in the Deadly Liver Mob (DLM) program which is a health promotion program that offers incentives for Aboriginal and Torres Strait Islander clients to be educated on viral hepatitis, recruit and educate peers, and receive screening and treatment for blood-borne viruses (BBVs) and sexually transmissible infections (STIs), and vaccination. Semi-structured interviews were conducted with 11 Aboriginal and Torres Strait Islander and non-Aboriginal or Torres Strait Islander health workers who have been involved in the development, implementation, and/or management of the DLM program within participating services in New South Wales, Australia. RESULTS Findings suggest that stigma is a barrier to accessing mainstream health care among Aboriginal and Torres Strait Islander clients, with stigma being complex and multi-layered. Aboriginal and Torres Strait Islander people contend with multiple and intersecting layers of stigma and discrimination in their lives, and thus HBV is just one dimension of those experiences. Health workers perceived that stigma is fuelled by multiple factors, including poor HBV health literacy within the health workforce broadly and among Aboriginal and Torres Strait Islander clients, shame about social practices associated with viral hepatitis, and fear of unknown transmission risks and health outcomes. The DLM program was viewed as helping to resist and reject stigma, improve health literacy among both health workers and clients, and build trust and confidence in mainstream health services. CONCLUSIONS Health promotion programs have the potential to reduce stigma by acting as a 'one stop shop' for BBVs and STIs through one-on-one support, yarning, and promotion of the HBV vaccine, monitoring for chronic HBV, and treatment (where required).
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Affiliation(s)
- Elena Cama
- Centre for Social Research in Health, UNSW Sydney, Sydney, NSW, 2052, Australia.
| | - Mitch Beadman
- Centre for Social Research in Health, UNSW Sydney, Sydney, NSW, 2052, Australia
| | - Kim Beadman
- Centre for Social Research in Health, UNSW Sydney, Sydney, NSW, 2052, Australia
| | - Max Hopwood
- Centre for Social Research in Health, UNSW Sydney, Sydney, NSW, 2052, Australia
| | - Carla Treloar
- Centre for Social Research in Health, UNSW Sydney, Sydney, NSW, 2052, Australia
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Nguyen ALT, Si L, Lubel JS, Shackel N, Yee KC, Wilson M, Bradshaw J, Hardy K, Palmer AJ, Blizzard CL, de Graaff B. Hepatocellular carcinoma surveillance based on the Australian Consensus Guidelines: a health economic modelling study. BMC Health Serv Res 2023; 23:378. [PMID: 37076870 PMCID: PMC10116722 DOI: 10.1186/s12913-023-09360-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 03/31/2023] [Indexed: 04/21/2023] Open
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) is the fastest increasing cause of cancer death in Australia. A recent Australian consensus guidelines recommended HCC surveillance for cirrhotic patients and non-cirrhotic chronic hepatitis B (CHB) patients at gender and age specific cut-offs. A cost-effectiveness model was then developed to assess surveillance strategies in Australia. METHODS A microsimulation model was used to evaluate three strategies: biannual ultrasound, biannual ultrasound with alpha-fetoprotein (AFP) and no formal surveillance for patients having one of the conditions: non-cirrhotic CHB, compensated cirrhosis or decompensated cirrhosis. One-way and probabilistic sensitivity analyses as well as scenario and threshold analyses were conducted to account for uncertainties: including exclusive surveillance of CHB, compensated cirrhosis or decompensated cirrhosis populations; impact of obesity on ultrasound sensitivity; real-world adherence rate; and different cohort's ranges of ages. RESULTS Sixty HCC surveillance scenarios were considered for the baseline population. The ultrasound + AFP strategy was the most cost-effective with incremental cost-effectiveness ratios (ICER) compared to no surveillance falling below the willingness-to-pay threshold of A$50,000 per quality-adjusted life year (QALY) at all age ranges. Ultrasound alone was also cost-effective, but the strategy was dominated by ultrasound + AFP. Surveillance was cost-effective in the compensated and decompensated cirrhosis populations alone (ICERs < $30,000), but not cost-effective in the CHB population (ICERs > $100,000). Obesity could decrease the diagnostic performance of ultrasound, which in turn, reduce the cost-effectiveness of ultrasound ± AFP, but the strategies remained cost-effective. CONCLUSIONS HCC surveillance based on Australian recommendations using biannual ultrasound ± AFP was cost-effective.
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Affiliation(s)
- Anh Le Tuan Nguyen
- Menzies Institute for Medical Research, University of Tasmania, 17 Liverpool Street, Hobart, TAS, 7000, Australia.
| | - Lei Si
- School of Health Sciences, Western Sydney University, Campbelltown, Australia
- Translational Health Research Institute, Western Sydney University, Penrith, Australia
| | - John S Lubel
- Alfred Health, Melbourne, VIC, Australia
- Monash University, Melbourne, VIC, Australia
| | | | - Kwang Chien Yee
- School of Medicine, University of Tasmania, Hobart, TAS, Australia
- Royal Hobart Hospital, Hobart, TAS, Australia
| | - Mark Wilson
- School of Medicine, University of Tasmania, Hobart, TAS, Australia
- Royal Hobart Hospital, Hobart, TAS, Australia
| | | | - Kerry Hardy
- Royal Hobart Hospital, Hobart, TAS, Australia
| | - Andrew John Palmer
- Menzies Institute for Medical Research, University of Tasmania, 17 Liverpool Street, Hobart, TAS, 7000, Australia
| | - Christopher Leigh Blizzard
- Menzies Institute for Medical Research, University of Tasmania, 17 Liverpool Street, Hobart, TAS, 7000, Australia
| | - Barbara de Graaff
- Menzies Institute for Medical Research, University of Tasmania, 17 Liverpool Street, Hobart, TAS, 7000, Australia
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Riddell J, Hempenstall A, Nakata Y, Gregson S, Hayes R, Smith S, Coates M, Charlie L, Perrett C, Newie V, Newie T, Radlof S, Hanson J. The high burden of comorbidities in Aboriginal and Torres Strait Islander Australians living with chronic hepatitis B in Far North Queensland, Australia, and the implications for patient management. PLoS One 2023; 18:e0284151. [PMID: 37023060 PMCID: PMC10079072 DOI: 10.1371/journal.pone.0284151] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 03/26/2023] [Indexed: 04/07/2023] Open
Abstract
BACKGROUND Aboriginal and Torres Strait Islander Australians living with chronic hepatitis B virus (HBV) infection have a significant burden of hepatocellular carcinoma (HCC). The prevalence of comorbidities that increase the risk of HCC in this population is incompletely defined. METHODS This cross-sectional study was performed in remote tropical Queensland, Australia in January 2021. All individuals living with chronic HBV in the region were identified; the prevalence of relevant comorbidities was determined by reviewing medical records. RESULTS All 236 individuals in the cohort identified as Aboriginal and Torres Strait Islander Australians; their median (interquartile range (IQR)) age was 48 (40-62) years; 120/236 (50.9%) were female. Of the 194/236 (82.2%) engaged in HBV care, 61 (31.4%) met criteria for HBV therapy and 38 (62.2%) were receiving it. However, 142/236 (60.2%) were obese, 73/236 (30.9%) were current smokers and 57/236 (24.2%) were drinking alcohol hazardously; 70/236 (29.7%) had ≥2 of these additional risk factors for HCC, only 43/236 (18.2%) had none. Among the 19 patients with confirmed cirrhosis, 9 (47%) were obese, 8 (42%) were currently-or had a history of-drinking alcohol hazardously and 5 (26.3%) were current smokers. Patients also had a median (IQR) of 3 (2-4) cardiovascular risk factors (cigarette smoking, hypertension, impaired glucose tolerance, dyslipidaemia, renal impairment/proteinuria). Only 9/236 (3.8%) did not have one of these 5 comorbidities. CONCLUSIONS Aboriginal and Torres Strait Islander Australians living with chronic HBV in this region of remote Australia have a high engagement with HBV care and the majority of individuals eligible for antiviral therapy are receiving it. However, a significant comorbidity burden increases their risk of cirrhosis, HCC, and premature death. It is essential to integrate chronic HBV care with management of these comorbidities-rather than focusing on HBV alone-to achieve optimal health outcomes.
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Affiliation(s)
- Jordan Riddell
- Department of Medicine, Cairns Hospital, Cairns, Queensland, Australia
| | | | - Yoko Nakata
- Torres and Cape Hospital and Health Service, Queensland, Australia
| | - Sandra Gregson
- Torres and Cape Hospital and Health Service, Queensland, Australia
| | - Richard Hayes
- Torres and Cape Hospital and Health Service, Queensland, Australia
| | - Simon Smith
- Department of Medicine, Cairns Hospital, Cairns, Queensland, Australia
| | - Marlow Coates
- Torres and Cape Hospital and Health Service, Queensland, Australia
| | - Lizzie Charlie
- Torres and Cape Hospital and Health Service, Queensland, Australia
| | | | - Victoria Newie
- Torres and Cape Hospital and Health Service, Queensland, Australia
| | - Tomi Newie
- Torres and Cape Hospital and Health Service, Queensland, Australia
| | - Sharna Radlof
- Department of Medicine, Cairns Hospital, Cairns, Queensland, Australia
| | - Josh Hanson
- Department of Medicine, Cairns Hospital, Cairns, Queensland, Australia
- Kirby Institute, University of New South Wales, Sydney, Australia
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Sachar Y, Brahmania M, Dhanasekaran R, Congly SE. Screening for Hepatocellular Carcinoma in Patients with Hepatitis B. Viruses 2021; 13:1318. [PMID: 34372524 PMCID: PMC8310362 DOI: 10.3390/v13071318] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 07/05/2021] [Accepted: 07/05/2021] [Indexed: 12/18/2022] Open
Abstract
Chronic hepatitis B (CHB) infection is a significant risk factor for developing hepatocellular carcinoma (HCC). As HCC is associated with significant morbidity and mortality, screening patients with CHB at a high risk for HCC is recommended in an attempt to improve these outcomes. However, the screening recommendations on who to screen and how often are not uniform. Identifying patients at the highest risk of HCC would allow for the best use of health resources. In this review, we evaluate the literature on screening patients with CHB for HCC, strategies for optimizing adherence to screening, and potential risk stratification tools to identify patients with CHB at a high risk of developing HCC.
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Affiliation(s)
- Yashasavi Sachar
- London Health Sciences Center, Department of Medicine, Division of Gastroenterology, Western University, London, ON N6A 5A5, Canada; (Y.S.); (M.B.)
| | - Mayur Brahmania
- London Health Sciences Center, Department of Medicine, Division of Gastroenterology, Western University, London, ON N6A 5A5, Canada; (Y.S.); (M.B.)
- Centre for Quality, Innovation and Safety, Schulich School of Medicine & Dentistry, Western University, London, ON N6A 5W9, Canada
| | - Renumathy Dhanasekaran
- Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University, Stanford, CA 94305, USA;
| | - Stephen E. Congly
- Department of Medicine, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada
- O’Brien Institute of Public Health, University of Calgary, Calgary, AB T2N 4Z6, Canada
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Allard NL, MacLachlan JH, Tran L, Yussf N, Cowie BC. Time for universal hepatitis B screening for Australian adults. Med J Aust 2021; 215:103-105.e1. [PMID: 34120343 PMCID: PMC9290936 DOI: 10.5694/mja2.51114] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Nicole L Allard
- WHO Collaborating Centre for Viral Hepatitis, Peter Doherty Institute for Infection and Immunity, Melbourne, VIC.,University of Melbourne, Melbourne, VIC
| | - Jennifer H MacLachlan
- WHO Collaborating Centre for Viral Hepatitis, Peter Doherty Institute for Infection and Immunity, Melbourne, VIC.,University of Melbourne, Melbourne, VIC
| | - Lien Tran
- WHO Collaborating Centre for Viral Hepatitis, Peter Doherty Institute for Infection and Immunity, Melbourne, VIC.,University of Melbourne, Melbourne, VIC
| | - Nafisa Yussf
- WHO Collaborating Centre for Viral Hepatitis, Peter Doherty Institute for Infection and Immunity, Melbourne, VIC
| | - Benjamin C Cowie
- WHO Collaborating Centre for Viral Hepatitis, Peter Doherty Institute for Infection and Immunity, Melbourne, VIC.,Royal Melbourne Hospital, Melbourne, VIC
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Nguyen ALT, Nguyen HTT, Yee KC, Palmer AJ, Blizzard CL, de Graaff B. A Systematic Review and Narrative Synthesis of Health Economic Evaluations of Hepatocellular Carcinoma Screening Strategies. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:733-743. [PMID: 33933243 DOI: 10.1016/j.jval.2020.11.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 09/24/2020] [Accepted: 11/17/2020] [Indexed: 05/02/2023]
Abstract
OBJECTIVES Many economic evaluations of hepatocellular carcinoma (HCC) screenings have been conducted; however, these vary substantially with regards to screening strategies, patient group, and setting. This review aims to report the current knowledge of the cost-effectiveness of screening and describe the published data. METHODS We conducted a search of biomedical and health economic databases up to July 2020. We included full and partial health economic studies if they evaluated the costs or outcomes of HCC screening strategies. RESULTS The review included 43 studies. Due to significant heterogeneity in key aspects across the studies, a narrative synthesis was conducted. Most studies reported using ultrasound or alpha fetoprotein as screening strategies. Screening intervals were mostly annual or biannual. Incidence, diagnostic performance, and health state utility values were the most critical parameters affecting the cost-effectiveness of screening. The majority of studies reported HCC screening to be cost-effective, with the biannual ultrasound + alpha fetoprotein standing out as the most cost-effective strategy. However, few studies considered the utilization rate, and none considered the diagnostic performance of ultrasound in the context of central adiposity. Computed tomography and magnetic resonance imaging were also evaluated, but its cost-effectiveness was still controversial. CONCLUSIONS Although many studies suggested HCC screening was cost-effective, substantial limitations of the quality of these studies means the results should be interpreted with caution. Future modeling studies should consider the impact of central adiposity on the precision of ultrasound, real-world utilization rates and projections of increased HCC incidence.
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Affiliation(s)
- Anh Le Tuan Nguyen
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - Hoa Thi Thu Nguyen
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - Kwang Chien Yee
- School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Andrew J Palmer
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia; Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | | | - Barbara de Graaff
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia.
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Hanson J, Fox M, Anderson A, Fox P, Webster K, Williams C, Nield B, Bagshaw R, Hempenstall A, Smith S, Solomon N, Boyd P. Chronic hepatitis B in remote, tropical Australia; successes and challenges. PLoS One 2020; 15:e0238719. [PMID: 32881958 PMCID: PMC7470305 DOI: 10.1371/journal.pone.0238719] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 08/22/2020] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Aboriginal and Torres Strait Islander Australians living in remote locations suffer disproportionately from chronic hepatitis B (CHB). Defining the temporospatial epidemiology of the disease-and assessing the ability of local clinicians to deliver optimal care-is crucial to improving patient outcomes in these settings. METHODS The demographic, laboratory and radiology findings in all patients diagnosed with CHB after 1990, and presently residing in remote Far North Queensland (FNQ), tropical Australia, were correlated with their management and clinical course. RESULTS Of the 602 patients, 514 (85%) identified as Aboriginal and Torres Strait Islander Australians, 417 (69%) of whom had Torres Strait Islander heritage. Among the 514 Aboriginal and Torres Strait Islander Australians, there were only 61 (12%) born after universal postnatal vaccination was introduced in 1985. Community CHB prevalence varied significantly across the region from 7/1707 (0.4%) in western Cape York to 55/806 (6.8%) in the Eastern Torres Strait Islands. Although 240/602 (40%) are engaged in care, with 65 (27%) meeting criteria for antiviral therapy, only 43 (66%) were receiving this treatment. Among 537 with complete data, 32 (6%) were cirrhotic, of whom 15 (47%) were engaged in care and 10 (33%) were receiving antiviral therapy. Only 64/251 (26%) in whom national guidelines would recommend hepatocellular carcinoma (HCC) surveillance are receiving screening, however, only 20 patients have been diagnosed with HCC since 1999. CONCLUSION Vaccination has had a dramatic effect on CHB prevalence in FNQ in only a generation. However, although engagement in care is the highest in Australia, this is not translating into initiation of antiviral therapy in all those that should be receiving it, increasing their risk of developing cirrhosis and HCC. New strategies are necessary to improve the care of Indigenous Australians living with CHB to reduce the morbidity and mortality of this preventable disease.
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Affiliation(s)
- Josh Hanson
- The Director’s Unit, The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
- Division of Medicine, Cairns Hospital, Cairns, Queensland, Australia
| | - Melissa Fox
- Division of Medicine, Cairns Hospital, Cairns, Queensland, Australia
| | - Adam Anderson
- Division of Medicine, Cairns Hospital, Cairns, Queensland, Australia
| | - Penny Fox
- Division of Medicine, Cairns Hospital, Cairns, Queensland, Australia
| | - Kate Webster
- Division of Medicine, Cairns Hospital, Cairns, Queensland, Australia
| | - Charlie Williams
- Department of Medicine, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Blake Nield
- Department of Microbiology, St George Hospital, Sydney, New South Wales, Australia
| | - Richard Bagshaw
- Division of Medicine, Cairns Hospital, Cairns, Queensland, Australia
| | | | - Simon Smith
- Division of Medicine, Cairns Hospital, Cairns, Queensland, Australia
| | - Norma Solomon
- Division of Medicine, Cairns Hospital, Cairns, Queensland, Australia
| | - Peter Boyd
- Division of Medicine, Cairns Hospital, Cairns, Queensland, Australia
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10
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Hosking K, Stewart G, Mobsby M, Skov S, Zhao Y, Su JY, Tong S, Nihill P, Davis J, Connors C, Davies J. Data linkage and computerised algorithmic coding to enhance individual clinical care for Aboriginal people living with chronic hepatitis B in the Northern Territory of Australia - Is it feasible? PLoS One 2020; 15:e0232207. [PMID: 32343712 PMCID: PMC7188233 DOI: 10.1371/journal.pone.0232207] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 04/09/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Chronic hepatitis B (CHB) is endemic in the Aboriginal population of Australia's Northern Territory (NT). However, many people's hepatitis B virus (HBV) status remains unknown. OBJECTIVE 1. To maximise the utility of existing HBV test and vaccination data in the NT by creating a linked dataset and computerised algorithmic coding. 2. To undertake rigorous quality assurance processes to establish feasibility of using the linked dataset and computerised algorithmic coding for individual care for people living with CHB. METHODS Step 1: We used deterministic data linkage to merge information from three separate patient databases. HBV testing and vaccination data from 2008-2016 was linked and extracted for 19,314 people from 21 remote Aboriginal communities in the Top End of the NT. Step 2: A computerised algorithm was developed to allocate one of ten HBV codes to each individual. Step 3: A quality assurance process was undertaken by a clinician, using standardised processes, manually reviewing all three databases, for a subset of 5,293 Aboriginal people from five communities to check the accuracy of each allocated code. RESULTS The process of data linking individuals was highly accurate at 99.9%. The quality assurance process detected an overall error rate of 17.7% on the HBV code generated by the computerised algorithm. Errors occurred in source documentation, primarily from the historical upload of paper-based records to electronic health records. An overall HBV prevalence of 2.6% in five communities was found, which included ten cases of CHB who were previously unaware of infection and not engaged in care. CONCLUSIONS Data linkage of individuals was highly accurate. Data quality issues and poor sensitivity in the codes produced by the computerised algorithm were uncovered in the quality assurance process. By systematically, manually reviewing all available data we were able to allocate a HBV status to 91% of the study population.
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Affiliation(s)
- Kelly Hosking
- Primary Health Care Branch, Top End Health Service, Northern Territory Government, Darwin, Northern Territory, Australia
- Global and Tropical Health Division, Menzies School of Health Research, Darwin, Northern Territory, Australia
| | - Geoffrey Stewart
- Primary Health Care Branch, Top End Health Service, Northern Territory Government, Darwin, Northern Territory, Australia
- Centre for Disease Control, Northern Territory Government, Darwin, Northern Territory, Australia
| | - Mikaela Mobsby
- Primary Health Care Branch, Top End Health Service, Northern Territory Government, Darwin, Northern Territory, Australia
| | - Steven Skov
- Centre for Disease Control, Northern Territory Government, Darwin, Northern Territory, Australia
| | - Yuejen Zhao
- Innovation & Research, Northern Territory Government, Darwin, Northern Territory, Australia
| | - Jiunn-Yih Su
- Global and Tropical Health Division, Menzies School of Health Research, Darwin, Northern Territory, Australia
- Centre for Disease Control, Northern Territory Government, Darwin, Northern Territory, Australia
| | - Steven Tong
- Global and Tropical Health Division, Menzies School of Health Research, Darwin, Northern Territory, Australia
- Victorian Infectious Disease Service, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Peter Nihill
- Primary Health Care Branch, Top End Health Service, Northern Territory Government, Darwin, Northern Territory, Australia
| | - Joshua Davis
- Global and Tropical Health Division, Menzies School of Health Research, Darwin, Northern Territory, Australia
- Department of Infectious Diseases, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Christine Connors
- Primary Health Care Branch, Top End Health Service, Northern Territory Government, Darwin, Northern Territory, Australia
| | - Jane Davies
- Primary Health Care Branch, Top End Health Service, Northern Territory Government, Darwin, Northern Territory, Australia
- Global and Tropical Health Division, Menzies School of Health Research, Darwin, Northern Territory, Australia
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11
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MacLachlan JH, Cowie BC. Bridging the access gap: Medicare ineligibility in people living with chronic hepatitis B. Intern Med J 2019; 49:122-125. [PMID: 30680906 DOI: 10.1111/imj.14175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 05/16/2018] [Accepted: 06/07/2018] [Indexed: 12/01/2022]
Abstract
People living in Australia on temporary student or work visas are excluded from Medicare access and can face barriers to adequate healthcare, even if they are privately insured. This analysis aimed to quantify this issue in relation to people living with chronic hepatitis B, the majority of whom in Australia were born overseas. The data suggest that an estimated 25 000 people living with chronic hepatitis B in Australia are ineligible for Medicare, 10% of the total number affected, with considerable potential impact in access to effective healthcare and prevention of adverse outcomes.
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Affiliation(s)
- Jennifer H MacLachlan
- WHO Collaborating Centre for Viral Hepatitis, The Doherty Institute, Melbourne, Victoria, Australia.,Department of Medicine, Dentistry, and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Benjamin C Cowie
- WHO Collaborating Centre for Viral Hepatitis, The Doherty Institute, Melbourne, Victoria, Australia.,Department of Medicine, Dentistry, and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia.,Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne, Victoria, Australia
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12
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Hong TP, Gow PJ, Fink M, Dev A, Roberts SK, Nicoll A, Lubel JS, Kronborg I, Arachchi N, Ryan M, Kemp WW, Knight V, Sundararajan V, Desmond P, Thompson AJ, Bell SJ. Surveillance improves survival of patients with hepatocellular carcinoma: a prospective population-based study. Med J Aust 2019; 209:348-354. [PMID: 30309301 DOI: 10.5694/mja18.00373] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Accepted: 08/23/2018] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To determine the factors associated with survival of patients with hepatocellular carcinoma (HCC) and the effect of HCC surveillance on survival. DESIGN, SETTING AND PARTICIPANTS Prospective population-based cohort study of patients newly diagnosed with HCC in seven tertiary hospitals in Melbourne, 1 July 2012 - 30 June 2013. MAIN OUTCOME MEASURES Overall survival (maximum follow-up, 24 months); factors associated with HCC surveillance participation and survival. RESULTS 272 people were diagnosed with incident HCC during the study period; the most common risk factors were hepatitis C virus infection (41%), alcohol-related liver disease (39%), and hepatitis B virus infection (22%). Only 40% of patients participated in HCC surveillance at the time of diagnosis; participation was significantly higher among patients with smaller median tumour size (participants, 2.8 cm; non-participants, 6.0 cm; P < 0.001) and earlier Barcelona Clinic Liver Cancer (BCLC) stage disease (A/B, 59%; C/D, 25%; P < 0.001). Participation was higher among patients with compensated cirrhosis or hepatitis C infections; it was lower among those with alcohol-related liver disease or decompensated liver disease. Median overall survival time was 20.8 months; mean survival time was 18.1 months (95% CI, 16.6-19.6 months). Participation in HCC surveillance was associated with significantly lower mortality (adjusted hazard ratio [aHR], 0.60; 95% CI, 0.38-0.93; P = 0.021), as were curative therapies (aHR, 0.33; 95% CI, 0.19-0.58). Conversely, higher Child-Pugh class, alpha-fetoprotein levels over 400 kU/L, and later BCLC disease stages were each associated with higher mortality. CONCLUSIONS Survival for patients with HCC is poor, but may be improved by surveillance, associated with the identification of earlier stage tumours, enabling curative therapies to be initiated.
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Affiliation(s)
- Thai P Hong
- St Vincent's Hospital Melbourne, Melbourne, VIC
| | | | | | | | | | | | | | | | | | - Marno Ryan
- St Vincent's Hospital Melbourne, Melbourne, VIC
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13
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Carville KS, MacLachlan JH, Thursfield V, Cowie BC. Hepatocellular carcinoma over three decades in Victoria, Australia: epidemiology, diagnosis and trends, 1984-2013. Intern Med J 2018; 48:835-844. [PMID: 29604152 DOI: 10.1111/imj.13823] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 03/22/2018] [Accepted: 03/28/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Liver cancer continues to be a health priority in Australia, with the majority attributable to preventable causes, and certain populations at higher risk. AIMS Epidemiological assessment of incidence, trends and distribution to inform prevention, and reassessment of data in light of recent changes to registry case definitions. METHODS Reported cases of hepatocellular carcinoma (HCC) in Victoria, Australia, 1984-2013, were obtained from the Victorian Cancer Registry. Demographic characteristics were examined, incidence and survival assessed using Poisson and Cox regression, and geographic distribution mapped. Incidence was compared before and after inclusion of non-histologically confirmed cases in Registry data to assess impacts on incidence trends. RESULTS Diagnoses of HCC rose substantially between 1984 and 2013, increasing sixfold from 0.9 to 5.9 per 100 000. The rate of increase per year accelerated from 5.3% between 1984 and 2003 to 9.5% between 2004 and 2013. Cases were disproportionately male (80%), median age at diagnosis was 66 years and 53% were born overseas. Even during 2004-2013, 5-year survival was only 16%, although higher among younger people, metropolitan residents and people born overseas. Incidence showed strong geographic clustering. The proportion of cases diagnosed clinically increased from 1% during 1984-2004 to 43% in 2009-2013. The revised case definition added 993 cases (27.3% of total). CONCLUSION Cases of HCC are becoming increasingly common, and revised incidence estimates highlight the impact of case definitions in the context of changing diagnostic approaches. The ongoing burden, disproportionate population distribution and low survival emphasise the importance of prevention and early detection as a public health imperative.
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Affiliation(s)
- Kylie S Carville
- Epidemiology Unit, The Doherty Institute, Melbourne, Victoria, Australia
| | - Jennifer H MacLachlan
- Epidemiology Unit, The Doherty Institute, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Vicky Thursfield
- Victorian Cancer Registry, Cancer Council Victoria, Melbourne, Victoria, Australia
| | - Benjamin C Cowie
- Epidemiology Unit, The Doherty Institute, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne, Victoria, Australia
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14
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Robotin MC, Masgoret X, Porwal M, Goldsbury D, Khoo C, George J. Using a chronic hepatitis B Registry to support population-level liver cancer prevention in Sydney, Australia. Clin Epidemiol 2018; 10:41-49. [PMID: 29339926 PMCID: PMC5745153 DOI: 10.2147/clep.s146275] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background Approximately 1% of Australians have chronic hepatitis B (CHB), which disproportionately affects people born in hepatitis B-endemic countries. Currently, approximately half of the people affected remain undiagnosed and antiviral treatment uptake is suboptimal (~5%). This increases the likelihood of developing end-stage disease complications, particularly hepatocellular cancer (HCC), and largely accounts for the significant increases in HCC incidence and mortality in Australia over the last decades. As our previous economic modeling suggested that CHB screening and treatment is cost-effective, we tested the feasibility of a primary care-based model of CHB diagnosis and management to prevent HCC. Materials and methods From 2009 to 2016, the B Positive program trialed a CHB screening and management program in an area of high disease prevalence in Sydney, Australia. Trained local primary care providers (general practitioners) screened and managed their CHB patients using a purpose-built CHB Registry and a risk stratification algorithm, which allocated patients to ongoing primary care-based management or specialist referral. Results The program enrolled and followed up >1,500 people (25% of the target population). Their median age was 48 years, with most participants being born in China (50%) or Vietnam (32%). The risk stratification algorithm allocated most Registry participants (n=847 or 79%) to primary care-based management, reducing unnecessary specialist referrals. The level of antiviral treatment uptake in Registry patients was 18%, which was the optimal level in this population group. Conclusion This pilot program demonstrated that primary care-based hepatitis B diagnosis and management is acceptable to patients and their care providers and significantly increases compliance with treatment guidelines. This would suggest that scaling up access to hepatitis B treatment is achievable and can provide a means to operationalize a population-level approach to CHB management and liver cancer prevention.
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Affiliation(s)
- Monica C Robotin
- School of Medicine, The University of Notre Dame Australia, Darlinghurst.,Faculty of Medicine, University of Sydney, Camperdown.,Storr Liver Center, Westmead Institute for Medical Research, Westmead Hospital, Westmead
| | - Ximena Masgoret
- School of Medicine, The University of Notre Dame Australia, Darlinghurst
| | - Mamta Porwal
- Australian School of Graduate Management, University of New South Wales, Kensington
| | | | - Chee Khoo
- Royal Australasian College of General Practitioners, Sydney.,University of Western Sydney, Macarthur, NSW, Australia
| | - Jacob George
- Faculty of Medicine, University of Sydney, Camperdown.,Storr Liver Center, Westmead Institute for Medical Research, Westmead Hospital, Westmead
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15
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Najjar Z, Gupta L, Pritchard-Jones J, Strasser SI, Levy MT, Liaw ST, Cowie BC. A survey of Sydney general practitioners' management of patients with chronic hepatitis B. Med J Aust 2016; 204:74. [PMID: 26821107 DOI: 10.5694/mja15.00524] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 10/07/2015] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To examine the chronic hepatitis B (CHB) assessment and management practices of general practitioners in the Sydney and South Western Sydney Local Health Districts, areas with a high prevalence of CHB, and to obtain their views on alternative models of care. DESIGN, SETTING AND PARTICIPANTS We used a descriptive, cross-sectional study design to survey GPs who had seen at least one patient aged 18 years or over who had been notified as having CHB to the Public Health Unit between 1 June 2012 and 31 May 2013. There were 213 eligible GPs; the response rate was 57.7%. MAIN OUTCOME MEASURES The CHB assessment, management and referral practices of the GPs, and their opinions about different models of care. RESULTS Most GPs (78.9%) were at least reasonably confident about managing CHB. GPs were generally most comfortable with a model of care that involved initial referral to a specialist; managing CHB without specialist input or with only review by a specialised nurse practitioner were less popular. CONCLUSION These results suggest that barriers, including dependence on specialist input, still hinder the appropriate assessment and management of CHB patients by GPs. Well designed and targeted support programs that include specialist support are needed if there is to be a successful shift to an increased role for GPs in the model of care for managing CHB.
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Affiliation(s)
- Zeina Najjar
- Public Health Unit, Sydney Local Health District, Sydney, NSW
| | - Leena Gupta
- Public Health Unit, Sydney Local Health District, Sydney, NSW
| | | | - Simone I Strasser
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, NSW
| | | | - Siaw-Teng Liaw
- General Practice Unit, South West Sydney Local Health District, Sydney, NSW
| | - Benjamin C Cowie
- WHO Collaborating Centre for Viral Hepatitis, VIDRL, Doherty Institute, Melbourne, VIC
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16
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Woodland L, Kang M, Elliot C, Perry A, Eagar S, Zwi K. Evaluation of a school screening programme for young people from refugee backgrounds. J Paediatr Child Health 2016; 52:72-9. [PMID: 26416315 DOI: 10.1111/jpc.12989] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/14/2015] [Indexed: 11/28/2022]
Abstract
AIM To describe the development of the Optimising Health and Learning Program, guided by the only available published framework for the delivery of health services to newly arrived refugee children and report on the evaluation of the programme. METHODS We conducted process and impact evaluation using a mixed methods approach. The sample was 294 refugee young people enrolled in two Intensive English Centres in New South Wales. We collected quantitative data (demographic and clinical information) as well as qualitative data via focus groups, key informant interviews, surveys and programme documentation. Qualitative data were subjected to thematic analysis; programme documents underwent document review. RESULTS There were high levels of programme participation (90%), and the yield from routine health screening was high (80% of participants screened positive for two or more health conditions). All identified programme development strategies were implemented; programme partners and participants reported satisfaction with the programme. Sixteen programme partners were identified with a high level of intersectoral collaboration reported. Significant in-kind contributions and seed funding enabled the uptake of the programme to increase from one to five Intensive English Centres over a 4-year period. CONCLUSION Process and impact evaluation identified that the programme was well implemented and met its stated objectives of increasing the detection of health conditions likely to impact on student health and learning; linkage of newly arrived students and their families with primary health care; and coordination of care across primary health and specialist services.
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Affiliation(s)
- Lisa Woodland
- Multicultural Health Service, South Eastern Sydney Local Health District, Sydney, New South Wales, Australia
| | - Melissa Kang
- General Practice, University of Sydney, Sydney, New South Wales, Australia
| | - Christopher Elliot
- Community Child Health, Sydney Children's Hospitals Network, Sydney, New South Wales, Australia
| | - Astrid Perry
- Multicultural Health Service, South Eastern Sydney Local Health District, Sydney, New South Wales, Australia
| | - Sandy Eagar
- New South Wales Refugee Health Service, Sydney, New South Wales, Australia
| | - Karen Zwi
- Community Child Health, Sydney Children's Hospitals Network, Sydney, New South Wales, Australia.,Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
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17
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Pritchard-Jones J, Stevens C, McCaughan G, Strasser S. Feasibility, acceptability and safety of a nurse led hepatitis B clinic based in the community. Collegian 2015; 22:233-40. [PMID: 26281412 DOI: 10.1016/j.colegn.2015.03.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
AIM The aim of this study was to investigate if a community based hepatitis B (HBV) nurse clinic is a feasible, acceptable and safe strategy to improve access to best practice chronic hepatitis B care (CHB) in Sydney Local Health District. METHODS The weekly clinic commenced in an Inner West Sydney Health Centre in November 2012. The CNC responsibilities included patient assessment, management, education, triage, the development of care plans for GPs and GP support. Nursing practice was guided by recommendations from internationally and nationally endorsed CHB Guidelines. Information on patient demographics, clinical findings, triage decisions and sources of referral were collected and used to assess the feasibility, acceptability and safety of the nurse clinic. Patients were also invited to complete a self-administered survey. The survey included questions on attitudes towards the clinic and opinions on barriers to accessing treatment and care. Data was collated and analysed in both Excel and SPPS. RESULTS In the first 18 months of the clinic 66 people attended, 56 (80%) had CHB, 51 (77%) were born in an Asian country. An equal number of males and females attended. 11 (17%) required further management at a hospital based liver clinic and were referred. 5 (8%) have commenced anti-viral treatment. 24 (36%) met the criteria for six monthly HCC screening and were commenced on HCC surveillance. Twenty-two GPs referred patients. 11 (17%) patients returned the survey and they reported a high level of satisfaction with the clinic and willingness to engage in future CHB care. CONCLUSIONS This study of a community based CHB nurse clinic shows it is a feasible, acceptable, and safe initiative. The nurse improved access to best practice care and supported patients to effectively manage their CHB. We have confirmed a nurse can have a central role in triage, case management and GP support. Given the high CHB prevalence in our LHD a higher number of GP referrals were expected. Further research on how to increase engagement with GPs and people living with CHB is needed. We plan to expand our model with the CHB nurse conducting assessments and education in GP practices.
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18
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Anderson E, Ellard J, Wallace J. Torres Strait Islanders' understandings of chronic hepatitis B and attitudes to treatment. Aust J Prim Health 2015; 22:316-319. [PMID: 26329779 DOI: 10.1071/py14130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Accepted: 02/11/2015] [Indexed: 11/23/2022]
Abstract
Indigenous Australians are disproportionally affected by hepatitis B compared with non-Indigenous Australians. The higher prevalence of hepatitis B among Indigenous Australians has been linked to an increased incidence of liver cancer in this population. There is evidence that comprehensive programs of hepatitis B virus management, which include liver cancer surveillance and appropriate antiviral therapy, offer a cost-effective approach to reduce the incidence of liver cancer in Australia. This paper reports on data from the first study investigating understandings of hepatitis B and attitudes to treatment among Torres Strait Islanders living with chronic hepatitis B. Forty-two participants completed an interview questionnaire. Participants typically had an unclear understanding of hepatitis B and reported significant gaps in monitoring and follow up. A majority of participants indicated a willingness to use treatment if required. The findings of this study suggest the need for a new service delivery model that is appropriate to remote communities such as the Torres Strait Islands, to improve hepatitis B follow up, disease monitoring and management, and where appropriate, the uptake of treatment.
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Affiliation(s)
- Elayne Anderson
- James Cook University, School of Medicine and Dentistry, 1 James Cook Drive, Townsville City, Qld 4811, Australia
| | - Jeanne Ellard
- La Trobe University, Australian Centre in Sex, Health and Society, 255 Franklin Street, Melbourne, Vic. 3000, Australia
| | - Jack Wallace
- La Trobe University, Australian Centre in Sex, Health and Society, 255 Franklin Street, Melbourne, Vic. 3000, Australia
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19
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Farag I, Howard K, Ferreira ML, Sherrington C. Economic modelling of a public health programme for fall prevention. Age Ageing 2015; 44:409-14. [PMID: 25523025 DOI: 10.1093/ageing/afu195] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Accepted: 11/12/2014] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND despite evidence on what works in falls prevention, falls in older people remain an important public health problem. AIMS the purpose of this study was to model the impact and cost-effectiveness of a public health falls prevention programme, from the perspective of the health funder. METHODS a decision analytic Markov model compared the health benefits in quality-adjusted life years (QALYs) and costs of treatment and residential aged care with and without a population heath falls prevention programme. Different intervention costs, uptake levels and programme effectiveness were modelled in sensitivity analyses. Uncertainty was explored using univariate and probabilistic sensitivity analysis. RESULTS widespread rollout of a public health fall prevention programme could result in an incremental cost-effectiveness ratio (ICER) of $A28,931 per QALY gained, assuming a programme cost of $700 per person and at a fall prevention risk ratio of 0.75. This ICER would be considered cost-effective at a threshold value of $A50,000 per QALY gained. Sensitivity analyses for programme cost and effectiveness indicated that the public health programme produced greater health outcomes and was less costly than no programme when programme costs were $A500 or lower and risk ratio for falls was 0.70 or lower. At a cost of $A2,500, the public health falls prevention programme ceases to be a cost-effective option. CONCLUSION serious consideration should be given to implementation of a public health programme of falls prevention as a cost-effective option that enables population-wide access to the intervention strategies.
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Affiliation(s)
- Inez Farag
- Musculoskeletal Divison, The George Institute, Level 7, 341 George Street, Sydney, New South Wales, Australia
| | - Kirsten Howard
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Manuela L Ferreira
- The George Institute for Global Health, University of Sydney, Sydney, New South Wales, Australia
| | - Catherine Sherrington
- Musculoskeletal Division, The George Institute for Global Health, Sydney, New South Wales, Australia
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20
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Allard NL, MacLachlan JH, Cowie BC. The cascade of care for Australians living with chronic hepatitis B: measuring access to diagnosis, management and treatment. Aust N Z J Public Health 2015; 39:255-9. [PMID: 25716519 DOI: 10.1111/1753-6405.12345] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2014] [Revised: 08/01/2014] [Accepted: 10/01/2014] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE To estimate the level of access to diagnosis, management and treatment for people living with chronic hepatitis B (CHB) in Australia, and to identify the gaps in clinical care for people living with CHB. METHODS Analysis of publicly available population level data including infectious disease notifications, Medicare and Pharmaceutical Benefits Scheme utilisation data, census-based estimates of CHB prevalence and burden, and mathematical modelling. RESULTS In 2012, of the estimated 218,567 Australians living with CHB, 57% had been diagnosed, 17,367 people (8%) received recommended HBV DNA viral load testing (without treatment) and 10,987 (5%) received antiviral therapy. CONCLUSIONS This analysis reveals substantial gaps in the cascade of care for CHB in Australia, most notably in diagnosis (with 43% undiagnosed) and in recommended yearly monitoring (87% not in care). The number receiving therapy represents only one-third of those estimated to require treatment to prevent progressive liver disease and liver cancer. IMPLICATIONS These findings demonstrate that the majority of those affected are not receiving guideline-based care; highlight the need for improvements in opportunistic screening, engagement in care, and access to therapy; and provide a method to assess the impact of public health and clinical interventions in response to CHB over time.
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Affiliation(s)
- Nicole L Allard
- Epidemiology Unit VIDRL, The Doherty Institute, Victoria.,Department of Medicine, University of Melbourne, Victoria
| | - Jennifer H MacLachlan
- Epidemiology Unit VIDRL, The Doherty Institute, Victoria.,Department of Medicine, University of Melbourne, Victoria
| | - Benjamin C Cowie
- Epidemiology Unit VIDRL, The Doherty Institute, Victoria.,Department of Medicine, University of Melbourne, Victoria
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21
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Parker C, Tong SY, Dempsey K, Condon J, Sharma SK, Chen JW, Sievert W, Davis JS. Hepatocellular carcinoma in Australia's Northern Territory: high incidence and poor outcome. Med J Aust 2014; 201:470-4. [DOI: 10.5694/mja13.11117] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Accepted: 02/24/2014] [Indexed: 12/13/2022]
Affiliation(s)
| | | | - Karen Dempsey
- Health Gains Planning Unit, Northern Territory Government, Darwin, NT
| | - John Condon
- Menzies School of Health Research, Darwin, NT
| | | | - John W C Chen
- South Australian Liver Transplant Unit, Flinders Medical Centre, Adelaide, SA
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22
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Abstract
INTRODUCTION Chronic hepatitis B (CHB) affects over 350 million people worldwide and can lead to life-threatening complications, including liver failure and hepatocellular cancer (HCC). Modern antiviral therapies could stem the rising tide of hepatitis B-related HCC, provided that individuals and populations at risk can be reliably identified through hepatitis B screening and appropriately linked to care. Opportunistic disease screening cannot deliver population-level outcomes, given the large number of undiagnosed people, but they may be achievable through well-organized and targeted community-based screening interventions. MATERIAL AND METHODS This review summarizes the experience with community-based CHB screening programs published in the English-language literature over the last 30 years. RESULTS They include experiences from Taiwan, the USA, The Netherlands, New Zealand, and Australia. Despite great variability in program setting and design, successful programs shared common features, including effective community engagement incorporating the target population's cultural values and the ability to provide low-cost or free access to care, including antiviral treatment. CONCLUSION While many questions still remain about the best funding mechanisms to ensure program sustainability and what the most effective strategies are to ensure program reach, linkage to care, and access to treatment, the evidence suggests scope for cautious optimism. A number of successful, large-scale initiatives in the USA, Asia-Pacific, and Europe demonstrated the feasibility of community-based interventions in effectively screening large numbers of people with CHB. By providing an effective mechanism for community outreach, scaling up these interventions could deliver population-level outcomes in liver cancer prevention relevant for many countries with a large burden of disease.
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Affiliation(s)
| | - Jacob George
- Storr Liver Unit, Westmead Millennium Institute and Westmead Hospital, University of Sydney, Westmead, Sydney, NSW Australia
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23
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Toy M, Demirci U, So S. Preventing hepatocellular carcinoma: the crucial role of chronic hepatitis B monitoring and antiviral treatment. Hepat Oncol 2014; 1:255-257. [PMID: 30190959 DOI: 10.2217/hep.14.10] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Affiliation(s)
- Mehlika Toy
- Asian Liver Center, Department of Surgery, Stanford School of Medicine, Stanford, CA 94305, USA.,Asian Liver Center, Department of Surgery, Stanford School of Medicine, Stanford, CA 94305, USA
| | - Utkan Demirci
- Canary Center for Early Detection of Cancer, Radiology, Stanford School of Medicine, Stanford, CA 94305, USA.,Canary Center for Early Detection of Cancer, Radiology, Stanford School of Medicine, Stanford, CA 94305, USA
| | - Samuel So
- Asian Liver Center, Department of Surgery, Stanford School of Medicine, Stanford, CA 94305, USA.,Asian Liver Center, Department of Surgery, Stanford School of Medicine, Stanford, CA 94305, USA
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Robotin MC, Kansil MQ, Porwal M, Penman AG, George J. Community-based prevention of hepatitis-B-related liver cancer: Australian insights. Bull World Health Organ 2014; 92:374-9. [PMID: 24839327 DOI: 10.2471/blt.13.130344] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2013] [Revised: 12/14/2013] [Accepted: 01/02/2014] [Indexed: 02/06/2023] Open
Abstract
PROBLEM Although most primary hepatocellular cancers (HCCs) are attributable to chronic viral hepatitis and largely preventable, such cancers remain a leading cause of cancer-related mortality wherever chronic hepatitis B is endemic. APPROACH Many HCCs could be prevented by increasing awareness and knowledge of hepatitis B, optimizing the monitoring of chronic hepatitis B and using antiviral treatments - but there are gaps in the implementation of such strategies. LOCAL SETTING The "B Positive" programme, based in Sydney, Australia, is designed to improve hepatitis-B-related health outcomes among immigrants from countries with endemic hepatitis B. The programme offers information about disease screening, vaccination and treatment options, as well as optimized access to care. RELEVANT CHANGES The B Positive programme has been informed by economic modelling. The programme offers culturally tailored education on chronic hepatitis B to target communities and their health practitioners and regular follow-up through a population-based registry of cases. LESSONS LEARNT As the costs of screening for chronic hepatitis B and follow-up are relatively low and less than one in every four cases may require antiviral drugs, optimizing access to treatment seems an appropriate and cost-effective management option. The identification and accurate staging of cases and the judicious use of antiviral medications are predicated upon an informed and educated health workforce. As establishing community trust is a lengthy process, delaying the implementation of programmes against chronic hepatitis B until antiviral drugs become cheaper is unwarranted.
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Affiliation(s)
- Monica C Robotin
- Cancer Council New South Wales, 153 Dowling Street, Woolloomooloo, Sydney, New South Wales, 2011, Australia
| | | | - Mamta Porwal
- Cancer Council New South Wales, 153 Dowling Street, Woolloomooloo, Sydney, New South Wales, 2011, Australia
| | - Andrew G Penman
- Cancer Council New South Wales, 153 Dowling Street, Woolloomooloo, Sydney, New South Wales, 2011, Australia
| | - Jacob George
- University of Sydney School of Medicine, Sydney, Australia
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MacLachlan JH, Wang YJ, Cowie BC. A validation of the use of names to screen for risk of chronic hepatitis B in Victoria, Australia, 2001 to 2010. ACTA ACUST UNITED AC 2013; 18. [PMID: 24300885 DOI: 10.2807/1560-7917.es2013.18.47.20638] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The burden of chronic hepatitis B (CHB) is increasing in Australia, particularly in those born in the Asia-Pacific region, and nearly half are undiagnosed. Primary care clinicians have a key role in diagnosing CHB, however identification of patients at risk is hindered by lack of awareness and limited information on country of birth in patient records. This study evaluates the potential of a validated list of names associated with Asian country of birth as a screening tool to predict risk of CHB, by comparing it with surveillance records for all people diagnosed with CHB or salmonellosis in Victoria from 2001 to 2010, and analysed using standard screening tools. Name list match was associated with CHB notification, with over 60% of cases having one name matching the list (sensitivity), and nearly one third matching both given name and surname; less than 15% and 2% of salmonellosis notifications matched for one name and both names, respectively (false positives). These results show that more than half of notified cases of CHB would have been identified by this name list, and that it could be used in support of initiatives to improve diagnosis of patients with diseases associated with country of birth when limited information is available.
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Affiliation(s)
- J H MacLachlan
- World Health Organisation Regional Reference Laboratory for Hepatitis B, Victorian Infectious Diseases Reference Laboratory, Victoria, Australia
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Deng Y, Du Y, Zhang Q, Han X, Cao G. Human cytidine deaminases facilitate hepatitis B virus evolution and link inflammation and hepatocellular carcinoma. Cancer Lett 2013; 343:161-71. [PMID: 24120759 DOI: 10.1016/j.canlet.2013.09.041] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Revised: 09/27/2013] [Accepted: 09/27/2013] [Indexed: 12/13/2022]
Abstract
During hepatitis B virus (HBV)-induced hepatocarcinogenesis, chronic inflammation facilitates the evolution of hepatocellular carcinoma (HCC)-promoting HBV mutants. Cytidine deaminases, whose expression is stimulated by inflammatory cytokines and/or chemokines, play an important role in bridging inflammation and HCC. Through G-to-A hypermutation, cytidine deaminases inhibit HBV replication and facilitate the generation of HCC-promoting HBV mutants including C-terminal-truncated HBx. Cytidine deaminases also promote cancer-related somatic mutations including TP53 mutations. Their editing efficiency is counteracted by uracil-DNA glycosylase. Understanding the effects of cytidine deaminases in HBV-induced hepatocarcinogenesis and HCC progression will aid in developing efficient prophylactic and therapeutic strategies against HCC in HBV-infected population.
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Affiliation(s)
- Yang Deng
- Department of Epidemiology, Second Military Medical University, Shanghai, China
| | - Yan Du
- Department of Epidemiology, Second Military Medical University, Shanghai, China
| | - Qi Zhang
- Department of Epidemiology, Second Military Medical University, Shanghai, China
| | - Xue Han
- Division of Chronic Diseases, Center for Disease Control and Prevention of Yangpu District, Shanghai, China
| | - Guangwen Cao
- Department of Epidemiology, Second Military Medical University, Shanghai, China.
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MacLachlan JH, Allard N, Towell V, Cowie BC. The burden of chronic hepatitis B virus infection in Australia, 2011. Aust N Z J Public Health 2013; 37:416-22. [PMID: 24090323 DOI: 10.1111/1753-6405.12049] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE The number of Australians living with chronic hepatitis B (CHB) is thought to be increasing, as are adverse outcomes including cirrhosis and liver cancer, however, robust, up-to-date estimates of this burden are limited. Contemporary estimates of the prevalence of CHB in Australia are essential to guide appropriate public health and clinical responses. METHODS This study used census-based methodology attributing risk of CHB by country of birth and Aboriginal and Torres Strait Islander status, augmented with priority risk-group based estimates. Deterministic mathematical modelling was used for comparison and for validation of census-derived estimates. RESULTS An estimated 218,000 Australians (plausible range 192,000-284,000) are living with CHB, a significant increase over previous estimates. The prevalence derived using mathematical modelling was similar, at 204,000. Notable differences were observed by geographic area in both prevalence and the populations predominantly affected. It is estimated that only 56% of people living with CHB in Australia have been diagnosed and notified. CONCLUSIONS The prevalence of CHB in Australia is increasing, with 1% of the population now estimated to be affected. The majority of the burden is experienced by people born overseas in endemic areas, with more than 95% of new cases of CHB entering the population through migration. IMPLICATIONS It is imperative that more attention and greater resources are devoted to addressing CHB in Australia; to increase the proportion of Australians affected who have been diagnosed and who are on treatment, in accordance with the First National Hepatitis B Strategy.
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Affiliation(s)
- Jennifer H MacLachlan
- Epidemiology Unit, WHO Regional Reference Laboratory for Hepatitis B, Victorian Infectious Diseases Reference Laboratory; University of Melbourne, Victoria National Policy and Education Division, Australasian Society for HIV Medicine, New South Wales Epidemiology Unit, WHO Regional Reference Laboratory for Hepatitis B, Victorian Infectious Diseases Reference Laboratory; University of Melbourne, Victoria
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Graham S, Guy RJ, Cowie B, Wand HC, Donovan B, Akre SP, Ward JS. Chronic hepatitis B prevalence among Aboriginal and Torres Strait Islander Australians since universal vaccination: a systematic review and meta-analysis. BMC Infect Dis 2013; 13:403. [PMID: 24004727 PMCID: PMC3846608 DOI: 10.1186/1471-2334-13-403] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Accepted: 08/27/2013] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND In Australia, higher rates of chronic hepatitis B (HBsAg) have been reported among Aboriginal and Torres Strait Islander (Indigenous) compared with non-Indigenous people. In 2000, the Australian government implemented a universal infant/adolescent hepatitis B vaccination program. We undertook a systematic review and meta-analysis to assess the disparity of HBsAg prevalence between Indigenous and non-Indigenous people, particularly since 2000. METHODS We searched Medline, Embase and public health bulletins up to March 2011. We used meta-analysis methods to estimate HBsAg prevalence by Indigenous status and time period (before and since 2000). RESULTS There were 15 HBsAg prevalence estimates (from 12 studies) among Indigenous and non-Indigenous people; adults and pregnant women (n = 9), adolescents (n = 3), prisoners (n = 2), and infants (n = 1). Of these, only one subgroup (adults/pregnant women) involved studies before and since 2000 and formed the basis of the meta-analysis. Before 2000, the pooled HBsAg prevalence estimate was 6.47% (95% CI: 4.56-8.39); 16.72% (95%CI: 7.38-26.06) among Indigenous and 0.36% (95%CI:-0.14-0.86) in non-Indigenous adults/pregnant women. Since 2000, the pooled HBsAg prevalence was 2.25% (95% CI: 1.26-3.23); 3.96% (95%CI: 3.15-4.77) among Indigenous and 0.90% (95% CI: 0.53-1.28) in non-Indigenous adults/pregnant women. CONCLUSIONS The disparity of HBsAg prevalence between Indigenous and non-Indigenous people has decreased over time; particularly since the HBV vaccination program in 2000. However HBsAg prevalence remains four times higher among Indigenous compared with non-Indigenous people. The findings highlight the need for opportunistic HBV screening of Indigenous people to identify people who would benefit from vaccination or treatment.
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Affiliation(s)
- Simon Graham
- The Kirby Institute, University of New South Wales, Sydney, Australia
| | - Rebecca J Guy
- The Kirby Institute, University of New South Wales, Sydney, Australia
| | - Benjamin Cowie
- The Victorian Infectious Diseases Reference Laboratory (VIDRL), Melbourne, Australia
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne, Australia
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Handan C Wand
- The Kirby Institute, University of New South Wales, Sydney, Australia
| | - Basil Donovan
- The Kirby Institute, University of New South Wales, Sydney, Australia
- Sydney Sexual Health Centre, Sydney Hospital, Sydney, Australia
| | - Snehal P Akre
- The Kirby Institute, University of New South Wales, Sydney, Australia
| | - James S Ward
- Baker IDI Heart and Diabetes Institute, Sydney, Alice Springs, Australia
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Guirgis M, Nusair F, Bu YM, Yan K, Zekry AT. Barriers faced by migrants in accessing healthcare for viral hepatitis infection. Intern Med J 2013; 42:491-6. [PMID: 22151101 DOI: 10.1111/j.1445-5994.2011.02647.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The morbidity and mortality of hepatitis B virus- and hepatitis C virus-related complications are disproportionately higher in the culturally and linguistically diverse population (CALD) when compared with Australian-born individuals. AIM This project aims to elucidate the barriers faced by the CALD population in accessing viral hepatitis management. METHOD CALD outpatients attending a viral hepatitis clinic in a tertiary teaching hospital were invited to participate in interviews. Questions pertained to: reason for screening for viral hepatitis, barriers to healthcare, perceived community view of viral hepatitis, main source of information of viral hepatitis and suggestions to engage members of CALD to seek healthcare. RESULTS The total number of participants was 60. The two major countries of birth included China (40%) and Egypt (17%). In 40% of the cohort, viral hepatitis was identified through screening programmes. Importantly, 37% were diagnosed as a result of complications of hepatitis infection, presenting late in the stage of disease. Forty-five per cent of participants perceived language to be a chief barrier. twenty-two per cent reported cultural barriers to accessing healthcare. Of these, 53% reported fear of discrimination/stigma. The lack of knowledge of available treatments/options was stated as a major obstacle in 40%. The two prevailing recommendations were greater education and awareness (85%) and changes in the health system itself (11%). CONCLUSION Substantial hurdles identified by participants include cultural differences, language difficulties, cultural beliefs, stigma and misinformation. These data demonstrate the need for the greater dissemination of information in culturally and linguistically appropriate mediums to raise awareness about viral hepatitis, pathogenesis and available treatments.
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Affiliation(s)
- M Guirgis
- Gastroenterology and Hepatology Department, St George Hospital, Australia.
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Subramaniam K, Flexman J, Tarquinio L, Thambiran A, Hopkins S, Cheng W. Hepatitis B status in migrants and refugees: increasing health burden in Western Australia. Intern Med J 2013; 42:880-6. [PMID: 22212294 DOI: 10.1111/j.1445-5994.2011.02711.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND In light of increasing migration from endemic countries with chronic hepatitis B (CHB), this study describes the changing epidemiology of CHB patients born outside Australia referred to a tertiary hospital in Western Australia. It aims to stratify risk and progression to cirrhosis and hepatocellular carcinoma according to viral factors and to provide an indication of the growing burden of disease and current and future treatment costs. METHODS Demographic, serological and biochemical data were obtained from patients with CHB between July 2002 and December 2008. Hepatitis B virus DNA quantification was performed to assess baseline viral loads in the patients. Total cost estimates for surveillance and treatment are based on probabilities of the population anticipated to be at a given stage of the disease in a given year. RESULTS There is a progressive increase in referrals (n=478) with the majority coming from Asia (57%) and Africa (35%). The mean age of Africans is 11 years less than that of Asians, with a lower proportion of Africans having hepatitis B virus DNA>2000 IU/mL compared with Asians (36.7% vs 54.3%). Approximately 50% of CHB patients referred are at risk of cirrhosis and hepatocellular carcinoma unless treated. Without treatment, a substantial increase in cost over 10 years (from $401,460 to $2,027,078) is estimated at 400%. CONCLUSION This study highlights the increasing burden of CHB in Western Australia, from people born in endemic countries, in particular, the direct costs of treatment. It will help to develop strategies that can be tailored to Western Australia with appropriate allocation of resources.
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Affiliation(s)
- K Subramaniam
- Department of Gastroenterology & Hepatology, Royal Perth Hospital, Perth, Western Australia, Australia.
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MacLachlan JH, Cowie BC. Liver cancer is the fastest increasing cause of cancer death in Australians. Med J Aust 2013; 197:492-3. [PMID: 23121582 DOI: 10.5694/mja12.11481] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Mahady SE, Wong G, Craig JC, George J. Pioglitazone and vitamin E for nonalcoholic steatohepatitis: a cost utility analysis. Hepatology 2012; 56:2172-9. [PMID: 22707355 DOI: 10.1002/hep.25887] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Accepted: 05/25/2012] [Indexed: 12/20/2022]
Abstract
UNLABELLED Nonalcoholic steatohepatitis (NASH) is the commonest liver disease in developed countries. However, there are no current data on the cost-effectiveness of therapeutic options such as lifestyle modification, pioglitazone, or vitamin E. We undertook a cost utility analysis to compare these strategies. Using a third-party payer perspective, a deterministic Markov model was developed to compare costs and health benefits of lifestyle modification alone or with pioglitazone or vitamin E in a cohort of patients aged 50 years with biopsy-proven NASH and fibrosis level 3 or greater. We assumed an annual cycle length over a lifetime horizon. Probability and utility estimates were derived from a systematic literature review, and uncertainties in parameter estimates were tested using one- and two-way sensitivity analyses. Our outcome measure was the incremental cost-effectiveness ratio (ICER), with $A50,000 or less considered cost-effective. In comparison with lifestyle modification alone, treatment with either pioglitazone or vitamin E in addition to lifestyle modification was cost-effective, with incremental cost-effectiveness ratios of $A2748 and $A8475 per quality-adjusted life year (QALY) gained, respectively. In a direct comparison, pioglitazone was more cost-effective than vitamin E (ICER $A2,056/QALY gained). Sensitivity analyses indicated that pioglitazone was not cost-effective if either the total drug cost was greater than $A16,000 per annum, or the annual probability of developing cirrhosis in advanced fibrosis was less than 2%. CONCLUSION Our modeled analyses suggest that in patients with advanced fibrosis due to NASH, pharmacological treatment in addition to standard lifestyle modification is likely to be cost-effective.
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Affiliation(s)
- Suzanne E Mahady
- School of Public Health, University of Sydney, Sydney, Australia.
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Robotin M, Patton Y, Kansil M, Penman A, George J. Cost of treating chronic hepatitis B: Comparison of current treatment guidelines. World J Gastroenterol 2012; 18:6106-13. [PMID: 23155339 PMCID: PMC3496887 DOI: 10.3748/wjg.v18.i42.6106] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2012] [Revised: 08/01/2012] [Accepted: 08/26/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare program costs of chronic hepatitis B (CHB) screening and treatment using Australian and other published CHB treatment guidelines.
METHODS: Economic modeling demonstrated that in Australia a strategy of hepatocellular cancer (HCC) prevention in patients with CHB is more cost-effective than current standard care, or HCC screening. Based upon this model, we developed the B positive program to optimize CHB management of Australians born in countries of high CHB prevalence. We estimated CHB program costs using the B positive program algorithm and compared them to estimated costs of using the CHB treatment guidelines published by the Asian-Pacific, American and European Associations for the Study of Liver Disease (APASL, AASLD, EASL) and those suggested by an independent United States hepatology panel. We used a Markov model that factored in the costs of CHB screening and treatment, individualized by viral load and alanine aminotransferase levels, and calculated the relative costs of program components. Costs were discounted by 5% and calculated in Australian dollars (AUD).
RESULTS: Using the B positive algorithm, total program costs amount to 13 979 224 AUD, or 9634 AUD per patient. The least costly strategy is based upon using the AASLD guidelines, which would cost 34% less than our B positive algorithm. Using the EASL and the United States Expert Group guidelines would increase program costs by 46%. The largest expenditure relates to the cost of drug treatment (66.9% of total program costs). The contribution of CHB surveillance (20.2%) and HCC screening and surveillance (6.6%) is small - and together they represent only approximately a quarter of the total program costs.
CONCLUSION: 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.
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Canadian patients with chronic hepatitis B cannot access appropriate drug treatments: a call for change. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2011; 25:538-41. [PMID: 22059156 DOI: 10.1155/2011/864046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Walter SR, Thein HH, Gidding HF, Amin J, Law MG, George J, Dore GJ. Risk factors for hepatocellular carcinoma in a cohort infected with hepatitis B or C. J Gastroenterol Hepatol 2011; 26:1757-64. [PMID: 21615789 DOI: 10.1111/j.1440-1746.2011.06785.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND AIM The incidence of hepatocellular carcinoma (HCC) has increased in Australia in recent decades, a large and growing proportion of which occurs among a population chronically infected with hepatitis B virus (HBV) or hepatitis C virus (HCV). However, risk factors for HCC among these high-risk groups require further characterization. METHODS We conducted a population-based cohort study using HBV and HCV cases notified to the New South Wales Health Department between 2000 and 2007. These were linked to cause of death data, HIV/AIDS notifications, and hospital records. Proportional hazards regression was used to identify significant risk factors for developing HCC. RESULTS A total of 242 and 339 HCC cases were linked to HBV (n = 43 892) and HCV (n = 83 817) notifications, respectively. For both HBV and HCV groups, being male and increasing age were significantly associated with risk of HCC. Increasing comorbidity score indicated high risk, while living outside urban areas was associated with lower risk. Hazard ratios for males were two to three times those of females. For both HBV and HCV groups, cirrhosis, alcoholic liver disease, and the interaction between the two were associated with significantly and considerably elevated risk. CONCLUSION This large population-based study confirms known risk factors for HCC. The association with older age highlights the potential impact of HBV and HCV screening of at-risk groups and early clinical assessment. Additional research is required to evaluate the impact of improving antiviral therapy on HCC risk.
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Affiliation(s)
- Scott R Walter
- The Kirby Institute, The University of New South Wales, Australia
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Robotin MC. Hepatitis B prevention and control: Lessons from the East and the West. World J Hepatol 2011; 3:31-7. [PMID: 21423912 PMCID: PMC3060417 DOI: 10.4254/wjh.v3.i2.31] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2010] [Revised: 12/13/2010] [Accepted: 12/20/2010] [Indexed: 02/06/2023] Open
Abstract
Despite being ten times more common than HIV infection, viral hepatitis has so far not commanded the same public health response worldwide, so a global viral hepatitis treatment program is still a long way from becoming a reality. However, much progress has occurred over the last few decades, with the screening of blood products, sound infection control practices and the introduction of disposable needles and syringes leading to significant reductions in nosocomial hepatitis B transmission in the developed world and increasingly in other countries. The introduction of hepatitis B vaccination in the 1980s and its integration into the Expanded Immunization Program have led to substantial reductions in chronic hepatitis B infection rates in children and to millions of lives saved. The availability of effective antiviral treatment has revolutionized treatment prospects, although access to treatment remains a significant challenge for most developed countries and remains out of reach for developing nations. Some of these breakthroughs have occurred in Asian countries, others in the West, but their unifying features are innovative research, timely clinical translation and a commitment to apply their findings to improve the health of populations, not just individuals. This paper reviews some of the challenges and opportunities for hepatitis B control at the end of the first decade of the third millennium and argues for closer East - West collaborations, to bring in fresh perspectives, avoid duplications of effort and in order to help answer many of the remaining challenges in making hepatitis B history.
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Affiliation(s)
- Monica C Robotin
- Monica C Robotin, NSW Cancer Council, School of Public Health University of Sydney, Sydney, NSW 2011, Australia
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Cowie B. The linguistic demography of Australians living with chronic hepatitis B. Aust N Z J Public Health 2010; 35:12-5. [PMID: 21299694 DOI: 10.1111/j.1753-6405.2010.00634.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE The prevalence of chronic hepatitis B virus (HBV) infection is increasing in Australia, and most affected individuals were born overseas. Estimating the English literacy of predominantly affected populations and determining the languages other than English (LOTE) spoken is essential for the development of appropriate resources. METHOD Data from the Australian Bureau of Statistics and Department of Immigration and Citizenship were used to estimate the number of Australian residents by birth country, English literacy and LOTE spoken, with a focus on those arriving in the past two decades. Prevalence of chronic HBV infection was estimated using source country seroprevalence. The results were compared to Victorian surveillance notification data and published Australian epidemiological and clinical studies. RESULTS Chinese languages and Vietnamese are the dominant languages spoken by Australians living with chronic HBV infection who speak limited or no English. Estimates of predominant source countries for people living with chronic HBV infection derived from Census data were generally coherent with existing epidemiological and clinical studies but differences exist, particularly for groups targeted for screening such as humanitarian entrants. CONCLUSIONS This study emphasises the need for LOTE resources for Australians living with chronic HBV infection and suggests priority languages. The notable differences observed between Census-derived estimates and surveillance data suggest there are particularly under-diagnosed groups within the community. IMPLICATIONS This study has clear implications for prioritising the translation of resources targeting Australians living with chronic HBV infection.
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Affiliation(s)
- Benjamin Cowie
- Victorian Infectious Diseases Reference Laboratory, Victorian Infectious Diseases Service, Royal Melbourne Hospital, Victoria.
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Williams S, Vally H, Fielding J, Cowie B. Chronic hepatitis B surveillance in Victoria, 1998-2008: instituting a 21st Century approach to an old disease. Aust N Z J Public Health 2010; 35:16-21. [DOI: 10.1111/j.1753-6405.2010.00611.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Robotin MC, Kansil MQ, George J, Howard K, Tipper S, Levy M, Phung N, Penman AG. Using a population-based approach to prevent hepatocellular cancer in New South Wales, Australia: effects on health services utilisation. BMC Health Serv Res 2010; 10:215. [PMID: 20663140 PMCID: PMC2918596 DOI: 10.1186/1472-6963-10-215] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2009] [Accepted: 07/21/2010] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Australians 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. METHODS Estimated 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. RESULTS Assuming 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. CONCLUSIONS While 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.
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Affiliation(s)
- Monica C Robotin
- School of Public Health, University of Sydney NSW, Sydney, Australia
- Cancer Council NSW, Woolloomooloo NSW, Australia
| | | | - Jacob George
- Storr Liver Unit, Millennium Institute, Westmead NSW, Australia
- School of Medicine, University of Sydney NSW, Sydney, Australia
| | - Kirsten Howard
- School of Public Health, University of Sydney NSW, Sydney, Australia
| | | | - Miriam Levy
- Department of Gastroenterology, Liverpool Hospital, Liverpool NSW, Australia
- University of New South Wales, Sydney NSW, Australia
| | - Nghi Phung
- Departments of Gastroenterology and Addiction Medicine, Westmead Hospital, Westmead NSW, Australia
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Veldhuijzen IK, Toy M, Hahné SJM, De Wit GA, Schalm SW, de Man RA, Richardus JH. Screening and early treatment of migrants for chronic hepatitis B virus infection is cost-effective. Gastroenterology 2010; 138:522-30. [PMID: 19879275 DOI: 10.1053/j.gastro.2009.10.039] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2009] [Revised: 10/09/2009] [Accepted: 10/19/2009] [Indexed: 12/17/2022]
Abstract
BACKGROUND & AIMS Persons with chronic hepatitis B virus (HBV) infection are at risk of developing cirrhosis and hepatocellular carcinoma. Early detection of chronic HBV infection through screening and treatment of eligible patients has the potential to prevent these sequelae. We assessed the cost-effectiveness in The Netherlands of systematically screening migrants from countries that have high and intermediate HBV infection levels. METHODS Epidemiologic data of the expected numbers of patients with active chronic HBV infection in the target population and information about the costs of a screening program were used in a Markov model and used to determine costs and quality-adjusted life years (QALY) for patients who were and were not treated. RESULTS Compared with the status quo, a 1-time screen for HBV infection can reduce mortality of liver-related diseases by 10%. Using base case estimates, the incremental cost-effectiveness ratio (ICER) of screening, compared with not screening, is euros (euro) 8966 per QALY gained. The ICER ranged from euro7936 to euro11,705 based on univariate sensitivity analysis, varying parameter values of HBV prevalence, participation rate, success in referral, and treatment compliance. Using multivariate sensitivity analysis for treatment effectiveness, the ICER ranged from euro7222 to euro15,694; for disease progression, it ranged from euro5568 to euro60,418. CONCLUSIONS Early detection and treatment of people with HBV infection can have a large impact on liver-related health outcomes. Systematic screening for chronic HBV infection among migrants is likely to be cost-effective, even using low estimates for HBV prevalence, participation, referral, and treatment compliance.
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Affiliation(s)
- Irene K Veldhuijzen
- Division of Infectious Disease Control, Municipal Public Health Service Rotterdam-Rijnmond, Rotterdam, The Netherlands.
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