Using a population-based approach to prevent hepatocellular cancer in New South Wales, Australia: effects on health services utilisation.

Monica C Robotin,Melanie Q Kansil,Miriam Levy,Andrew G Penman,Kirsten Howard,Jacob George,Steven Tipper,Nghi Phung

doi:10.1186/1472-6963-10-215

Abstract

BackgroundAustralians born in countries where hepatitis B infection is endemic are 6-12 times more likely to develop hepatocellular cancer (HCC) than Australian-born individuals. However, a program of screening, surveillance and treatment of chronic hepatitis B (CHB) in high risk populations could significantly reduce disease progression and death related to end-stage liver disease and HCC. Consequently we are implementing the B Positive pilot project, aiming to optimise the management of CHB in at-risk populations in south-west Sydney. Program participants receive routine care, enhanced disease surveillance or specialist referral, according to their stage of CHB infection, level of viral load and extent of liver injury. In this paper we examine the program's potential impact on health services utilisation in the study area.MethodsEstimated numbers of CHB infections were derived from Australian Bureau of Statistics data and applying estimates of HBV prevalence rates from migrants' countries of birth. These figures were entered into a Markov model of disease progression, constructing a hypothetical cohort of Asian-born adults with CHB infection. We calculated the number of participants in different CHB disease states and estimated the numbers of GP and specialist consultations and liver ultrasound examinations the cohort would require annually over the life of the program.ResultsAssuming a 25% participation rate among the 5,800 local residents estimated to have chronic hepatitis B infection, approximately 750 people would require routine follow up, 260 enhanced disease surveillance and 210 specialist care during the first year after recruitment is completed. This translates into 5 additional appointments per year for each local GP, 25 for each specialist and 420 additional liver ultrasound examinations.ConclusionsWhile the program will not greatly affect the volume of local GP consultations, it will lead to a significant increase in demand for specialist services. New models of CHB care may be required to aid program implementation and up scaling the program will need to factor in additional demands on health care utilisation in areas of high hepatitis B sero-prevalence.

Highlights

Australians born in countries where hepatitis B infection is endemic are 6-12 times more likely to develop hepatocellular cancer (HCC) than Australian-born individuals
People born in China and Vietnam represent a small proportion of the total Australian population, but carry a disproportionate burden of chronic hepatitis B (CHB)-related disease, as > 50% of the total number of CHB cases in Australia are diagnosed in migrants born in one of these countries [6]
They are enrolled in a program of routine CHB surveillance, consisting of six-monthly general practitioner (GP) follow up, comprising a clinical examination and a review of blood test results for hepatitis B surface antigen (HBsAg), hepatitis B e antigen (HBeAg), viral load (VL) and alanine amino transferase (ALT) levels

Summary

Introduction

Australians born in countries where hepatitis B infection is endemic are 6-12 times more likely to develop hepatocellular cancer (HCC) than Australian-born individuals. A program of screening, surveillance and treatment of chronic hepatitis B (CHB) in high risk populations could significantly reduce disease progression and death related to end-stage liver disease and HCC. People with chronic viral hepatitis are at a significantly greater risk (20 to 200-fold) of developing HCC than those not infected [2,3] and worldwide, chronic infection with the hepatitis B virus (HBV) is responsible for approximately 50-55% of all liver cancers [4]. People born in China and Vietnam represent a small proportion (approximately 5%) of the total Australian population, but carry a disproportionate burden of CHB-related disease, as > 50% of the total number of CHB cases in Australia are diagnosed in migrants born in one of these countries [6]. Men born in Vietnam, Hong Kong, Macau, Korea, Indonesia and China and women born in Vietnam and China are 6-12 times more likely to develop HCC than non-Indigenous, Australian-born individuals [8]

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Conclusion