Evaluating costs and benefits of expanding access to comprehensive care for chronic hepatitis B infection

Background: Chronic hepatitis B (CHB) infection, a major cause of cirrhosis of the liver and hepatocellular carcinoma (HCC) worldwide, infects between 1.5 and 2 million individuals in the U.S. Even as new treatments have become available that could reduce the incidence of serious outcomes, many infected people have little or no health insurance and are ineligible for publicly-subsidized insurance.

Methods: We constructed a Markov state transition model to evaluate costs, benefits and cost-effectiveness of providing early-stage care for CHB, comparing no treatment, full enrollment and limited enrollment scenarios. Utility values were assigned for each individual in the model such that each year of life lost represents one quality-adjusted life-year (QALY) lost, and each year in any unfavorable health state represents some fraction of a lost QALY (to account for decreased quality of life).

Results: Increasing coverage helps prevent long-term health problems even within a short time frame. For instance, cumulative mortality rates for the identical initial populations diverge substantially: after twenty years, rates per 100,000 are 13,914 in the no-treatment scenario, versus 8,344 in the intermediate scenario and just 3,922 under full enrollment.

In addition to generating substantial health status gains, our results indicate that expanding access to treatment can be highly cost-effective, and even cost-saving, as money spent on early-stage treatment helps prevent expensive complications. Even after five years, the incremental cost-effectiveness of full enrollment is between approximately $40,000 and $85,000 per QALY. After twenty years, the cost per QALY gained by full enrollment is just under $7,000.

Conclusions: Our analysis indicates that providing additional care for individuals with CHB is highly cost-effective and would lead to greatly reduced morbidity and mortality for these individuals. Expanding coverage for CHB treatment and care could set an important precedent of the possibility of managing chronic diseases by providing early-stage interventions.

By making it possible to evaluate a wide variety of CHB-related scenarios among different target populations, our model provides a valuable tool for evaluating different policy options, including proposed government-sponsored expansions of health coverage. We advocate analyzing potential costs and impact among specific patient populations and investigating the political feasibility of implementing expanded access to care.