Department of Global Health and Population, Harvard School of Public Health, Boston, MA, USA; Department of Public Health, Erasmus Medical Centre, Rotterdam, the Netherlands.
Hepatology. 2014 Jul;60(1):46-55. doi: 10.1002/hep.26934. Epub 2014 May 27.
Inactive chronic hepatitis B (CHB) carriers make up the largest group of hepatitis B virus-infected patients, and China bears the largest total CHB burden of any country. We therefore assessed the population health impact and cost-effectiveness of a strategy of lifelong monitoring for inactive CHB and treatment of eligible patients in Shanghai, China. We used a computer simulation model to project health outcomes among a population cohort of CHB based on age-specific prevalence of hepatitis B surface antigen (HBsAg), hepatitis B e antigen (HBeAg), and cirrhosis. Using a Markov model we simulated patients' progression through a discrete series of health states, and compared current practice to a monitor and treat (M&T) strategy. We measured lifetime costs and quality-adjusted life years (QALYs) (both discounted at 3% per year), incremental cost-effectiveness ratios (ICERs), and clinical outcomes such as development of hepatocellular carcinoma (HCC). We estimated that there are 1.5 million CHB-infected persons in Shanghai. The M&T strategy costs US$20,730 per patient and yields a discounted QALY of 15.45, which represents incremental costs and health benefits of US$275 and 0.10 QALYs compared to current practice, and an ICER of US$2,996 per QALY gained. In the base case, we estimated that the M&T strategy will reduce HCC and CHB-related mortality by only around 1%. If variables such as adherence to monitoring and treatment could be substantially improved the M&T strategy could reduce HCC by 70% and CHB-related mortality by 83%.
Lifelong monitoring of inactive CHB carriers is cost-effective in Shanghai according to typical benchmarks for value for money, but achieving substantial population-level health gains depends on identifying more CHB-infected cases in the population, and increasing rates of treatment, monitoring, and treatment adherence.
未活动慢性乙型肝炎（CHB）携带者构成了最大的乙型肝炎病毒感染患者群体，而中国承担着全球最大的 CHB 负担。因此，我们评估了在中国上海对未活动 CHB 进行终身监测和对符合条件的患者进行治疗的策略对人群健康的影响和成本效益。我们使用计算机模拟模型，根据乙型肝炎表面抗原（HBsAg）、乙型肝炎 e 抗原（HBeAg）和肝硬化的特定年龄患病率，预测 CHB 人群的健康结果。我们使用马尔可夫模型模拟患者在一系列离散健康状态中的进展，并将当前实践与监测和治疗（M&T）策略进行比较。我们衡量了终身成本和质量调整生命年（QALY）（均以每年 3%贴现）、增量成本效益比（ICER）以及临床结果，如肝细胞癌（HCC）的发展。我们估计上海有 150 万乙型肝炎病毒感染者。M&T 策略的每位患者成本为 20730 美元，贴现后的 QALY 为 15.45，与当前实践相比，增量成本和健康收益分别为 275 美元和 0.10 QALY，ICER 为每获得一个 QALY 花费 2996 美元。在基本情况下，我们估计 M&T 策略只会将 HCC 和 CHB 相关死亡率降低约 1%。如果可以大大提高监测和治疗的依从性等变量，M&T 策略可以将 HCC 降低 70%，将 CHB 相关死亡率降低 83%。
根据典型的物有所值基准，上海对未活动 CHB 携带者进行终身监测具有成本效益，但要实现人群健康的显著改善，取决于在人群中发现更多的乙型肝炎病毒感染者，并提高治疗、监测和治疗依从率。
