基于社区慢性乙型肝炎抗病毒治疗策略成本效果分析

张顺祥; 杨品超; 蔡亚丽; 林莹; 邹宇华

Abstract

张顺祥,杨品超,蔡亚丽,林莹,邹宇华.基于社区慢性乙型肝炎抗病毒治疗策略成本效果分析[J].Chinese journal of Epidemiology,2017,38(7):860-867

基于社区慢性乙型肝炎抗病毒治疗策略成本效果分析

Cost-effectiveness of community-based treatment of chronic hepatitis B in China

Received:January 13, 2017

DOI：10.3760/cma.j.issn.0254-6450.2017.07.004

KeyWord: 慢性乙型肝炎治疗预防乙型肝炎疫苗接种成本效果分析可支付性

English Key Word: Chronic hepatitis B Prevention Treatment Hepatitis B vaccination Cost-effectiveness analysis Affordability

FundProject:深圳市国家科技重大专项配套项目（GJHS20120628150832769）；国家科技重大专项（2008ZX10002-001）

Author Name	Affiliation	E-mail
Zhang Shunxiang	Shenzhen Center for Disease Control and Prevention, Shenzhen 518055, China	zhangsx@szcdc.net
Yang Pinchao	Shenzhen Center for Disease Control and Prevention, Shenzhen 518055, China Guangdong Pharmaceutical University, Guangzhou 510006, China
Cai Yali	Shenzhen Center for Disease Control and Prevention, Shenzhen 518055, China
Lin Ying	Shenzhen Center for Disease Control and Prevention, Shenzhen 518055, China Guangdong Pharmaceutical University, Guangzhou 510006, China
Zou Yuhua	Guangdong Pharmaceutical University, Guangzhou 510006, China

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Abstract:

目的我国消除乙型肝炎（乙肝）将会承受巨量的公共卫生资源，基于社区慢性乙肝（chronic hepatitis B，CHB）抗病毒治疗策略的经济学问题凸显，本研究对该策略的成本效果和可支付性做出评价。方法以WHO有关规划和我国重大传染病社区综合防治方案为策略依据，按照我国CHB防治指南确定抗病毒药物治疗和监测内容，遵循成本效果分析理论和方法构建决策分析马尔科夫模型，参数主要采用全国调查或Meta分析结果，利用TreeAge Pro 2015软件实现模型构建和运行。以我国20~59岁社区人群为研究对象，分别从全社会和支付者角度计算成本，效果用质量调整生命年（QALYs），策略间比较采用增量成本效果比（ICER）或成本效果比（CER）。通过敏感性分析明确模型中各参数的不确定性，绘制成本效果可支付曲线评价策略的可支付性。结果我国20~59岁社区人群CHB抗病毒治疗策略的ICER为37 598.6元/QALYs，低年龄组人群ICER较小，即每多获得一个QALYs需要增加投入但具有成本效果价值，抗病毒治疗应优先在低年龄人群中实施。乙肝疫苗接种策略的ICER为-64 000.0元/QALYs，即该策略每多获得一个QALYs可节省成本，最具成本效果价值。人群CHB抗病毒治疗与乙肝疫苗接种策略对比，CER变动在731.8元和1 813.3元/QALYs之间，各年龄人群乙肝疫苗接种的CER均低于抗病毒治疗策略，表明乙肝疫苗接种策略的经济学价值高于抗病毒治疗策略。恩替卡韦成本降低可提高抗病毒治疗策略的成本效果价值，当成本降至一半时，抗病毒治疗成为节省费用的策略。概率敏感性分析表明，抗病毒治疗策略的经济学评价结果可靠，该策略的成本效果价值受公众支付意愿的影响不能忽视。可支付分析发现，按照10万人计算，总预算小于0.3亿元，抗病毒治疗策略无法实现；总预算增加到1.27亿元时，该策略实现的概率为42.6%；只有当总预算达到2.69亿元，该策略才可以完全实现。结论我国20~59岁社区人群CHB抗病毒治疗策略虽然符合成本效果价值，但作为公共卫生措施将耗资较多。对该人群易感者接种乙肝疫苗，再实施CHB抗病毒治疗，成本效果价值更高，印证了消除乙肝目标的合理性。

English Abstract:

Objective Since eliminating hepatitis B in China would need considerable public health resources, the economics problem of the strategy of community-based antiviral treatment for chronic hepatitis B (CHB) has become an important issue. The cost-effectiveness and affordability of the strategy were evaluated in this study. Methods According to the advocacy on eliminating hepatitis B by WHO and the comprehensive protocol of community based prevention of major infectious diseases and the guideline for CHB prevention and treatment in China, the decision analytic Markov model was constructed with the parameters from national surveys or Meta-analysis. A cohort population aged 20-59 years was used as study subjects. The strategy of CHB antiviral treatment was compared with the strategies of hepatitis B vaccination and non-intervention, respectively. The costs and disability-adjusted life years (QALYs) of the strategies were calculated from the societal and payer perspectives. The incremental cost-effectiveness ratio (ICER) and the cost-effectiveness ratio (CER) were calculated for the comparison of the strategies. One-way and probability sensitivity analysis were performed for uncertainty of the results. And the cost-effectiveness and affordability curves were introduced to estimate the budget impact on the strategies. Results In the Chinese aged 20-59 years, the ICER of CHB antiviral treatment was 37 598.6 yuan (RMB) per QALYs and the ICERs were smaller in the low age groups, indicating that the antiviral treatment strategy is cost-effective and low age groups should be the priority population. The ICER of hepatitis B vaccination was -64 000.0 yuan (RMB) per QALYs, indicating that hepatitis B vaccination is cost saving. The CER of CHB antiviral treatment ranged from 731.8 to 1 813.3 yuan (RMB) per QALYs compared with hepatitis B vaccination, and the CER of CHB antiviral treatment was higher than that of hepatitis B vaccination in all age groups, indicating that hepatitis B vaccination would be more cost-effective than CHB antiviral treatment. The price of antiviral drug, entercavir, can influence the cost effectiveness of CHB antiviral treatment. If the price of entercavir declined half, CHB antiviral treatment would be cost-saving. The probability sensitivity analysis showed that people's willing to pay for CHB antiviral treatment should not be ignored, although the results of economics evaluation of CHB antiviral treatment were reliable. The results of affordability analysis indicated that the antiviral treatment strategy could not be implemented with the budget lower than 30 million yuan (RMB), the probability of implementing the strategy was 42.6% if the budget reaches 127 million yuan (RMB), and only when the budget reaches 269 million yuan (RMB), the goal of CHB antiviral treatment strategy can be fully realized. Conclusions Although the strategy of CHB antiviral treatment as prevention in Chinese aged 20-59 years is cost-effective, it is not an appropriate public health measure due to the high cost. The cost effectiveness would be higher by conducting hepatitis B vaccination and then antiviral treatment in susceptible population.

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