Purpose: Hepatitis B virus (HBV) infection is a significant health issue with risk for a number of costly and debilitating disease complications. In industrialized nations such as the United States, there is a significant and disproportionate burden of chronic HBV infection among the foreign-born population. The purpose of this study was to determine the cost-effectiveness of universal screening for HBV infection among new immigrants to the United States.
Method: A Markov decision model was developed to compare screening and usual care strategies for a hypothetical cohort of immigrants entering the United States in one year. We considered direct health care costs and quality-adjusted life years (QALYs) for the immigrant cohort over a 20-year horizon. Patients could progress through the early stages of HBV infection to cirrhosis, hepatic decompensation, hepatocellular carcinoma (HCC), and death, as well as receive treatment or undergo liver transplant. We used prevalence of HBV infection among the foreign-born population from the National Health and Nutrition Examination Survey (NHANES) and obtained cost, utility, natural history and treatment effectiveness estimates from the literature. Costs and QALYs were discounted at 3% per year. Probabilistic sensitivity analyses were performed using 1,000 Monte Carlo simulations.
Results: The incremental cost-effectiveness ratio for the screening strategy compared to usual care was $45,570 per quality-adjusted life year (QALY) gained. For a willingness-to-pay (WTP) of $100,000/QALY, screening was cost-effective in 67% of Monte Carlo simulations. Our analysis identified key areas of uncertainty in the epidemiology and management of chronic HBV infection that could potentially benefit from future research.
Conclusion: Early detection and treatment of HBV infection through screening appears to substantially impact both health outcomes and health service utilization for new immigrants and their receiving country. Given the potential for health gains for the immigrant cohort as well as the economic attractiveness of the intervention, some consideration might be given to the introduction of a universal HBV screening program to the U.S. immigration medical exam.
Candidate for the Lee B. Lusted Student Prize Competition