Care quality and outcomes among US veterans with chronic hepatitis B in the hepatitis C direct‐acting antiviral era

Abstract

Adherence to guideline‐recommended hepatitis B virus (HBV) care is suboptimal. We hypothesized that national hepatitis C eradication efforts during the era from 2015 to 2017 would improve the quality of care for cHBV given increased recognition and specialty referrals for liver disease. The study described herein is a retrospective cohort study of veterans with at least one positive HBsAg (HBsAg+) result from 1 January 2003 to 31 December 2017 using the VA Corporate Data Warehouse (CDW) analysed by era (2003‐2004, 2005‐2009, 2010‐2014, 2015‐2017). Relevant covariates such as HCV co‐infection, demographics, cirrhosis and baseline laboratory testing were obtained through previously validated approaches. We evaluated completion of process measures within 2 years of the index HBsAg + result: specialty care referral; testing of ALT, HBV‐DNA, HBeAg and anti‐HBe; testing for co‐infection and/or vaccination for HAV, HCV, HDV and HIV; and hepatocellular carcinoma (HCC) surveillance among those meeting criteria. We also measured use of antiviral therapy in appropriate candidates (ALT ≥ 2 × ULN, HBV‐DNA ≥ 2000 IU/mL). Of the 16 673 individuals with HBsAg + test results, 9,521 were confirmed as chronic HBV. Era‐related (Era 3:2010‐2014 vs Era 4:2015‐2017) increases in guideline‐recommended process measures included the following: outpatient visits with GI/ID specialists (78%‐89%), HBV‐DNA testing (73%‐79%), HDV testing (27%‐35%), appropriate HBV antiviral utilization (55%‐70%) and HCC surveillance (40%‐43%); all P < .0001. In the subset of HBV/HCV‐co‐infected patients, HCV DAA therapy was associated with a trend towards improved overall survival. In conclusion, the overall quality of care for HBV has significantly improved in the era of widespread HCV DAA therapy in an integrated health system possibly due to increased recognition and referral for liver disease.

Low Prevalence of Vaccination or Documented Immunity to Hepatitis A and Hepatitis B Viruses Among Individuals with Chronic Liver Disease

“…5,6 Increasing rates of hepatitis A infections and related outbreaks observed in the United States emphasize the importance of effective vaccination programs, particularly among individuals with greater behavioral and socioeconomic risk factors such as homelessness, injection drug use, and unsafe sex practices. 23 Our study adds to existing literature highlighting low rates of hepatitis A immunity or vaccination in patients with chronic viral hepatitis infections, 10,13,15,16 and further contributes new data reporting similarly low rates in nonalcoholic fatty liver disease and alcoholic liver disease patients. Using the 2014-2015 National Health Interview Survey, self-reported rates of completing hepatitis A and hepatitis B vaccination among adults with chronic liver disease was 11.5% and 29.1%, respectively.…”

“…[7][8][9][10][11][12][13][14] Among 9,521 US veterans with chronic hepatitis B, only 24% of patients not immune to hepatitis A virus received vaccination. 15 Similarly, among 88,456 US veterans with chronic hepatitis C, only 21.9% and 20.7% received vaccinations for hepatitis A and hepatitis B, respectively. 9 Data from the US Chronic Hepatitis Cohort Study observed that over 40% of chronic hepatitis B and chronic hepatitis C patients did not have any evidence of documented vaccination or immunity to hepatitis A and hepatitis B.…”

Hepatitis delta testing trends in a US national cohort: An analysis of patient and provider-level predictive factors

“…The results are consistent with other findings in VA health care that suggest suboptimal adherence to guideline-recommended HBV care. 17 In another study, Kaplan et al 18 reported increases in guideline-recommended process measures over time, yet it also highlighted the need for improvement in HBV DNA testing and HCC surveillance among Veterans. The differences in follow-up care represent a significant concern and an opportunity for systemic improvement.…”