Characteristics and Management of Patients with Chronic Hepatitis B in an Integrated Care Setting

Abstract

Background Few population-based studies have described characteristics and management of patients with chronic hepatitis B (CHB) in the USA. Methods We retrospectively studied adults with CHB in the Northern California Kaiser Permanente Medical Care Program (KPNC) from July 2009 to December 2010 (n = 12,016). Laboratory tests, treatment patterns, and hepatocellular carcinoma (HCC) surveillance were ascertained during a “recent” 18-month study window (July 2009–December 2010), or as “ever” based on records dating to 1995. Results The mean age was 49 years; 51 % were men, 83 % Asian, and 87 % KPNC members >5 years. Overall, 51 % had ≥1 liver-related visit, 14 % with gastroenterology or infectious disease specialists, and 37 % with primary care providers (PCP) only. Less than 40 % of patients had both hepatitis B virus (HBV) DNA and ALT testing conducted recently, while 56 % of eligible patients had received HCC surveillance. Recent laboratory testing and HCC surveillance were more frequent in patients seen by a specialist versus PCP only (90 vs. 47 % and 92 vs. 73 %, respectively, p values <0.001). During the study period, 1,649 (14 %) received HBV treatment, while 5 % of untreated patients had evidence of treatment eligibility. Among 599 patients newly initiated on HBV therapy, 76 % had guideline-based indications for treatment. Conclusions Most patients initiated on HBV treatment met eligibility, and very few patients with evidence of needing treatment were left untreated. However, monitoring of ALT and HBV DNA levels, as well as HCC surveillance, were not frequent, underestimating the proportion of patients that warranted HBV therapy. Viral monitoring and cancer surveillance are therefore important targets for improving the scope of CHB care in the community setting.

Care delivery and outcomes among US veterans with hepatitis B: A national cohort study

“…Similar to previous studies, we found low adherence to recommended laboratory testing and significant gaps in the clinical recognition of HBV diagnosis and subsequent follow-up care. (8)(9)(10)(11) A minority of patients had the HBV diagnosis code entered into the medical record by providers, and fewer than half had confirmatory testing 6 months after the initial HBsAg result. Although patients with confirmed chronic HBV infection had higher rates of recommended laboratory testing, testing rates were still suboptimal.…”

“…These results are consistent with recently published studies that have found rates of antiviral initiation ranging from 14% to 72%. (8,9,28,29) Although increased rates of HBV DNA testing and receipt of specialty care were noted following the most recent 2009 AASLD guidelines, rates of appropriate confirmatory testing dropped slightly and rates of antiviral therapy initiation remained stable at about 40%, suggesting that guidelines do not necessarily result in changes in clinical practice. The findings that treatment with antiviral therapy and one-time liver imaging were independently associated with lower all-cause mortality need to be prospectively confirmed.…”

“…(6,7) Significant gaps in care were noted across large integrated systems of care such as Kaiser Permanente and academic practices alike. (8)(9)(10) In addition, poor monitoring of chronic HBV patients has led to the delayed initiation of antiviral therapy, leaving patients at risk for disease progression. (11) Similar patterns have been recognized in the community setting, where a minority of HBV patients, including those with cirrhosis, had low rates of antiviral therapy initiation and HCC screening.…”

“…In contrast to the predominantly Asian-born individuals infected by vertical transmission included in most prior US studies, the majority of Veterans Administration (VA) patients are US-born individuals infected by horizontal transmission, thus representing a unique and understudied population. (1,8,9) The study objectives were to evaluate the delivery of care among US veterans with chronic HBV infection and examine the prevalence and risk factors for adverse clinical outcomes. We also examined potential changes in care patterns after the publication of the 2009 HBV management guidelines released by the American Association for the Study of Liver Diseases (AASLD).…”

Capsule Commentary on Mukhtar et al., Assessment of HBV Preventive Services in a Medically Underserved Asian and Pacific Islander Population Using Provider and Patient Data

“…Currently, fewer than half of the estimated 2 million cases of hepatitis B have been diagnosed and only a fraction of those infected are being adequately managed. 1,2 The study by Mukhtar and colleagues highlights some of the barriers to hepatitis B screening. 3 Not surprisingly, testing rates for hepatitis B were positively associated with provider attitudes and negatively associated with providers' perceived barriers to testing.…”