COST-EFFECTIVENESS OF SCREENING FOR CHRONIC HEPATITIS B INFECTION IN THE UNITED STATES

Purpose: Hepatitis B continues to be a major cause of morbidity and mortality in the United States despite strategies developed to eliminate its transmission. We examined the cost-effectiveness of screening strategies followed by treatment in those found to have chronic hepatitis B viral (HBV) infection versus not screening a representative United States population.

Method: We used a Markov state transition decision model.  Effectiveness and costs were measured in quality-adjusted life years (QALYs) and 2008 U.S. dollars, respectively. Data sources included the English language literature using MEDLINE searches and bibliographies from selected articles. The setting involved asymptomatic outpatients, and the base case focused on a hypothetical population of 35-year-old white men. Interventions were: Screening for HBsAg followed by treatment in appropriate patients with: a) pegylated interferon-α2a for 48 weeks, b) treatment with a 48-week course of a “low-cost” nucleos(t)ide agent with high rate of developing viral resistance, c) indefinite treatment with “low-cost, high-resistance” nucleos(t)ide, or indefinite treatment with a “high-cost” nucleos(t)ide with a low rate of developing viral resistance; versus no screening. Deterministic and probabilistic sensitivity analyses were performed examining 10,000 iterations in a second order Monte Carlo version of the model.

Result: In the base-case, not screening was least expensive, however, screening followed by treatment with a “low-cost, high-resistance” nucleos(t)ide was “cost-effective” ($21,500 per QALY) and had a 64% chance of costing less than $50,000 per QALY in probabilistic sensitivity analyses. Screening followed by treatment with a “high-cost, low-resistance nucleos(t)ide was more effective, but also more expensive, costing almost $221,300 per QALY. Deterministic sensitivity analyses revealed that the cost of screening followed by treatment with a “low-cost” nucleos(t)ide might exceed $50,000 per QALY in extremely low risk populations with a prevalence of chronic HBV infection less than 0.22%, or if the annual rate of spontaneous HBeAg seroconversion exceeded 13% per year. Screening followed by a “high-cost, low-resistance” nucleos(t)ide might be cost-effective if the monthly medication cost were less than $414.

Conclusion: Although current guidelines do not support universal screening for chronic HBV infection, general population screening of adults in the United States is likely to be “cost-effective”.