Cost of treating chronic hepatitis B: Comparison of current treatment guidelines

Table 1 General assumptions of the Markov model of the B positive hepatocellular cancer prevention program

Assumption	How addressed and rationale
Participant recruitment	Target population age ≥ 35 yr, HBsAg +ve for ≥ 6 mo, born in China, Hong Kong, Vietnam
Contact testing and immunisation	Not factored into the model
Seroprevalence in target populations	10.7% for people born in China
	10.5% for people born in Vietnam
	7.7% for people born in Hong Kong (Nguyen et al[16])
Initial testing to confirm chronic hepatitis B	Not factored in the GP consultation calculations
Program participation rates	Base case assumption: 25% of eligible people are enrolled
HCC screening	All participants have AFP and liver US at enrolment
	Participants receiving enhanced surveillance have 6-monthly AFP and US
	Participants receiving treatment also have liver biopsy
Follow up requirements	Routine surveillance arm: 2 GP appointments/yr
	Enhanced HCC surveillance arm: 2 GP appointments/yr
	Interferon treatment: 6 specialist appointments/yr
	Entecavir treatment: 4 specialist appointments/yr
	Patients with HCC: assumed two monthly follow up
Viral load distribution	Based upon Risk Evaluation of Viral Load Elevation and Associated Liver Disease study data (Chen et al[20])
ALT level distribution	Based upon Hong Kong data (Yuen et al[18])
Progression rates through different disease stages	Constant
Treatment protocol	30% receive first line interferon (weekly for 12 mo); 30% seroconvert and receive no further treatment; 70% commence entecavir the following year 70% receive entecavir as first-line treatment; 20% seroconvert in first year and receive no further treatment; 80% continue lifelong entecavir
Patients with liver failure	Receive lifelong entecavir

Lists the general assumptions used in building the model, including treatment protocols and follow up and other relevant elements and data sources. HBsAg: Hepatitis B surface antigen; GP: General practitioner; AFP: α fetoprotein; ALT: Alanine aminotransferase; HCC: Hepatocellular cancer; US: Ultrasound.

Table 2 Participant distribution by disease stage at initial enrolment and management pathways, according to the B positive algorithm and hepatitis B treatment published guidelines n (%)

Treatment guideline	B positive	Modified B positive	EASL, United States experts	APASL	AASLD
HBV DNA level to treat	> 2000 if > 50	> 2000	> 2000	> 2000	> 20 000
	> 20 000 if < 50
ALT (ULN)	> 1.5	> 1.5	> 1	> 2	> 2
Number receiving interferon	61 (4)	81 (6)	108 (8)	54 (4)	33 (2)
Number receiving entecavir	143 (10)	190 (13)	253 (17)	126 (9)	76 (5)
Total on treatment	204 (14)	271 (19)	361 (25)	181 (12)	109 (8)
Total under enhanced surveillance	340 (23)	452 (31)	361 (25)	542 (37)	326 (23)
Total under routine surveillance	907 (63)	728 (50)	728 (50)	728 (50)	1016 (70)
Total	1451 (100)	1451 (100)	1451 (100)	1451 (100)	1451 (100)

Tabulates the estimated number of participants undergoing different monitoring strategies and treatment options, according to recommendations put forward by Australian, Asia-Pacific, United States and European chronic hepatitis B treatment guidelines. ULN: Upper limit of normal; HBV: Hepatitis B virus; EASL: European Associations for the Study of Liver Disease; APASL: Asia-Pacific Associations for the Study of Liver Disease; AASLD: American Associations for the Study of Liver Disease.

Table 3 Calculated costs (in Australian dollars) of implementing a program of chronic hepatitis B management in hepatitis B e antigen-negative patients according to the B positive algorithms and published hepatitis B treatment guidelines, n (%)

Discounted costs of management strategies	B positive	Modified B positive	APASL	EASL, United States experts	AASLD
Cost/QALY (discounted)	13 465	15 770	11 746	19 622	8867
Total program cost (discounted)	13 979 224	16 372 320	12 194 905	20 371 117	9 205 680
Cost components
Initial CHB screening cost	767 728 (5.5)	800 792 (4.9)	755 971 (6.2)	845 613 (4.2)	720 357 (7.8)
Drug treatment costs	9 347 662 (66.9)	11 493 535 (70.2)	7 360 940 (60.4)	15 447 510 (75.8)	4 951 419 (53.8)
CHB surveillance costs	2 827 093 (20.2)	2 866 053 (17.5)	2 866 053 (23.5)	2 866 053 (14.1)	2 767 073 (30.1)
HCC surveillance costs	917 783 (6.6)	1 092 983 (6.7)	1 092 983 (9.0)	1 092 983 (5.4)	647 874 (7.0)
Total cost per person in the program	9634	11 283	8404	14 039	6344
% change with equivalent unit costs/QALY	100	117	87	146	66

Tabulates the costs of chronic hepatitis B screening, surveillance and treatment as per Australian, Asia-Pacific, United States and European treatment guidelines scenarios. Costs are discounted by 5% and calculated in Australian dollars (AUD). EASL: European Associations for the Study of Liver Disease; APASL: Asia-Pacific Associations for the Study of Liver Disease; AASLD: American Associations for the Study of Liver Disease; HCC: Hepatocellular cancer; CHB: Chronic hepatitis B; QALY: Quality-adjusted life year.