Health Economic Evaluation On A Strategy For Preventing Mother-to-child Transmission Of Hepatitis B

ObjectiveHepatitis B virus(HBV)infection is a global public health challenge.The prevalence of HBV has caused great losses to health,community and health system.China is a middle-high endemic area of hepatitis B,and mother-to-child transmission has become the most important route for hepatitis B infection.Preventing mother-to-child transmission(PMTCT)of hepatitis B is an effective strategy to block perinatal transmission.A reliable economic assessment helps decision makers choose the optimal hepatitis B prevention and treatment program,which is of great significance for the elimination of hepatitis B.Taking Zhejiang Province as an example,this study used the method of health economics to measure the economic burden of hepatitis B-related diseases and the health utility value of hepatitis B patients.Besides,the economic value of current strategies for prevention of mother-to-child transmission of hepatitis B from the perspective of payers,health care and the society was evaluated quantitatively,so as to provide a basis for improving the strategy of hepatitis B immunization prevention in China.MethodFirstly,the economic burden of hepatitis B-related disease and the quality of life of patients was estimated by a multi-stage stratified sampling survey in Zhejiang Province.Secondly,a decision tree-Markov model is constructed to simulate the health or infection outcomes under different immunization strategies by using the data obtained from the survey,the monitoring data of the information system of Zhejiang CDC and the data of literature review.Furthermore,by using a hypothetical birth cohort in 2016 in Zhejiang Province,the long-term benefits,effects and utilities among the PMTCT strategy,universal strategy and non-vaccination were compared during the life expectancy year of the cohort.Benefits were defined as savings on the economic burden of HBV related disease treatment;effectiveness were measured according to the number of measles cases and deaths averted and utilities were expressed as the life years saved and the quality-adjusted life years(QALY)gained.In addtional,the net present benefit value(NPV),benefit cost ratio(BCR),and incremental cost-effectiveness ratio(ICER)of PMTCT were calculated,and thus the long-term economic value of PMTCT was estimated.A one-way sensitivity analysis and a probabilistic sensitivity analysis(PSA)were performed to assess parameter uncertainties.Results(1)The survey included 8 county and municipal hospitals in Jinhua,Jiaxing and Taizhou,Zhejiang Province.There were 626 outpatient cases,including 1 acute hepatitis B,39 hepatitis B carriers,442 chronic hepatitis B(CHB)(including 301 HBeAg-positive cases,136 HBeAg-negative cases and 5 HBeAg undetected cases),97 compensated cirrhosis(CC)cases,28 decompensated cirrhosis(DC)cases and 19 cases of hepatocellular carcinoma(HCC).There were 523 inpatient cases,including 10 cases of acute hepatitis B,270 cases of CHB(including 178 cases of HBeAg-positive and 92 cases of HBeAg-negative),46 cases of CC,145 cases of DC and 52 cases of HCC.(2)The results of the economic burden survey showed that the average annual outpatient visits were 9.95 times.The total burden of outpatients was 641.01 yuan,with direct and indirect economic burden accounted for 553.78 yuan(86.40%)and 87.23 yuan(13.60%)respectively.The average number of hospitalization time were 1.32,and the average hospitalization stay were 12.87 days.The average economic burden of hospitalized patients was 14955.94 yuan,including the direct burden and indirect burden which were 13041.95 yuan(87.20%)and 1913.99 yuan(12.80%)respectively.The annual average direct,indirect and intangible burdens of patients with hepatitis B-related diseases were 23423.93 yuan,3394.41 yuan and 30,000.00 yuan,respectively,and the total cost was 56,818.34 yuan.The sum of direct and indirect economic burden accounts for 26.45%of annual household income and 92.34%of annual per capita income.(3)The average of health utility of patients with hepatitis B-related diseases was 0.68.The average of health utility of acute hepatitis B,HBsAg-positive CHB,HBsAg-negative CHB,CC,DC and HCC were 0.75,0.77,0.77,0.66,0.56 and 0.58,respectively.These utilities decreased as the disease became more aggravation.(4)The cost-benefit analysis showed that the BCR of the PMTCT strategy was 22.84 and 21.10 from the perspective of health care and society respectively.NPV was 31295.52 and 38323.78 per capita,respectively.The BCR and NPV were both higher than universal strategy;the cost-effectiveness analysis shows that 182 cases of acute hepatitis B,2215 cases of CHB,872 cases of cirrhosis,595 cases of HCC and 1349 deaths would be further avoided by the PMTCT strategy compared to universal vaccination.The ICER was 6293 yuan and 11175 yuan per additional case and deaths avoided from the perspective of payers,respectively,which were both lower than the per capita GDP of Zhejiang Province;while from the perspective of health care and society,the PMTCT strategy not only reduced the morbidity and mortality of diseases,but also further saved costs.The cost-utility analysis shows that the PMTCT strategy resulted in an addition 0.01 life years saved and 0.04 QALY gained per capita.The ICER of the PMTCT strategy were 560.18 yuan per QALY gained,-18372.74 yuan perQALY gained and-22787.07 yuan per QALY gained,from the perspective of payers,health care and society,respectively.Which indicted the PMTCT strategy have preferable economic values.The results remained robust over a wide range of parameter inputs.However,the vaccination rate,the efficacy rate of combination of hepatitis B vaccine and HBIG,the discount rate and economic burden of hepatitis B-related diseases were the most important parameters that could affect BCR and ICER.Conclusion(1)The economic burden of patients with hepatitis B-related diseases was huge,contributing to a heavy burden to patients and society.Preventing HBV infecting is still very important to further decrease burden.(2)Tremendous economic benefits can be achieved from the investment of health resources.The strategy of PMTCT of hepatitis B received a preferable benefit-cost ratio,showing that the benefit of 22.87 yuan can be obtained by investing 1 yuan.(3)The strategy of the PMTCT of hepatitis B is superior to the conventional universal strategy with substantial social benefits.The PMTCT of hepatitis B further reduced the morbidity and mortality of hepatitis B-related diseases,saved life years and led to more QALY gained.Besides,it further reduced the consumption of medical resources and saved social costs,indicting an attractive economic value.(4)The results remained robust over a wide range of epidemiological and cost parameter inputs,indicting that results obtained from the baseline study were reliable.