Reimbursement policies in the Asia-Pacific for chronic hepatitis B.

BACKGROUND: There is considerable variation in reimbursement policies in Asian countries and this is likely to have an impact on treatment practice for chronic hepatitis B (CHB). Consequently a survey of leading hepatologists was performed to evaluate such policies and their impact on management of CHB in the Asia Pacific region. METHODS: A questionnaire was sent to key hepatologists in Asia Pacific for information on CHB reimbursement policy-its nature, coverage, funding source, duration, review strategy and impact on Asia Pacific Association for the Study of the Liver (APASL) CHB guidelines. The results were analysed and described. RESULTS: Leading hepatologists from 16 Asia Pacific countries responded. Almost all of the countries have reimbursement policies but eligibility varied from only a limited group (e.g. civil servants only) to universal access. In most instances reimbursement was from the central government (except China, Pakistan and Hong Kong). Reimbursement policies were usually created by Ministry of Health committees, who received input from medical professionals, although they may not be aware of the APASL guidelines. Policies were limited by available resources, funds and prioritization. Where there was a regular review this occurred between 1 and 5 years. The quantum of reimbursement varied from 50% in Singapore to 100% in the majority of other countries. The criteria for treatment reimbursement were based on doctor's opinion alone (Bangladesh, India, Pakistan, Philippines, Singapore and Vietnam) or specific clinical/laboratory criteria in the rest of the countries. In general, most countries offered unlimited duration for reimbursement except Taiwan, Indonesia and Pakistan. Monitoring tests for treatment response were reimbursed in all countries other than Vietnam. Viral resistance was diagnosed by viral or biochemical breakthrough, and viral resistance testing was uncommon. The main rescue therapy was adefovir. CONCLUSION: Reimbursement policies differed from country to country, the quantum and the proportion of patients who received reimbursement also varied significantly. Asia Pacific countries were able to follow APASL guidelines with variable success based on their reimbursement policies.

Oral ß-blockade in relation to energy expenditure in clinically stable patients with liver cirrhosis: a double-blind randomized cross-over trial.

Elevated resting energy expenditure (REE) is seen in liver cirrhosis and is associated with reduced transplant-free survival. Non-selective ß-blockers reduce REE in acute hypermetabolic conditions. We examined whether non-selective ß-blockers reduce REE in patients with stable liver cirrhosis. Twenty-two stable cirrhotic patients (Child-Pugh grading: 19A, 2B, 1C) were randomized to 3-month treatment with nadolol (titrated to decrease resting pulse rate by 20%) or placebo and after a 1-month washout period crossed to the alternative treatment for a further 3 months. REE was measured by indirect calorimetry and total body protein by neutron activation analysis at the beginning and end of each 3-month period of treatment. A predicted REE was calculated for each patient based on total body protein. A measured to predicted REE ratio >1.22 indicated significantly elevated REE. The primary outcome was REE at the end of 3-month treatment with nadolol compared with placebo. Elevated REE was seen in one patient at study entry. After 3 months on placebo REE was 1506±40 (SEM) kcal/d and on nadolol, 1476±40 kcal/d, a mean reduction of 31±16 kcal/d (P=.076). Total body protein changes were not significant. Nadolol was well tolerated with no increase in the rate of adverse events. In stable cirrhotic patients, nadolol was not associated with reduction in REE. A larger, longer-term study with different eligibility criteria is required to investigate whether this treatment offers benefits additional to its use for prevention of variceal hemorrhage.

Body composition, muscle function, and energy expenditure in patients with liver cirrhosis: a comprehensive study.

BACKGROUND: Data describing the nutritional status of patients with liver cirrhosis of diverse origin, as assessed by direct body-composition methods, are limited. OBJECTIVE: We sought to provide a comprehensive assessment of nutritional status and metabolic activity in patients with liver cirrhosis by using the most accurate direct methods available. DESIGN: Two hundred sixty-eight patients (179 M, 89 F; x +/- SEM age: 50.1 +/- 0.6 y) with liver cirrhosis underwent measurements of total body protein by neutron activation analysis, of total body fat and bone mineral by dual-energy X-ray absorptiometry, of resting energy expenditure by indirect calorimetry, of grip strength by dynamometry, and of respiratory muscle strength by using a pressure transducer. Dietary intakes of energy and protein were assessed and indexed to resting energy expenditure and energy intake, respectively. RESULTS: Significant protein depletion, seen in 51% of patients, was significantly (P<0.0001) more prevalent in men (63%) than in women (28%). This sex difference occurred irrespective of disease severity or origin. The prevalence of protein depletion increased significantly (P<0.0001) with disease severity. Protein depletion was associated with decreased muscle function but not with lower energy and protein intake. Energy intake was significantly (P=0.002) higher in men than in women, whereas protein intakes did not differ significantly (P=0.12). Hypermetabolism, seen in 15% of patients, was not associated with sex, origin or severity of disease, protein depletion, ascites, or presence of tumor. CONCLUSIONS: Poor nutritional status with protein depletion and reduced muscle function was a common finding, particularly in men, and was not related to the presence of hypermetabolism or reduced energy and protein intakes. The greater conservation of protein stores in women than in men warrants further investigation.