Hepatitis B Evaluation and Linkage to Care for Newly Arrived Refugees: A Multisite Quality Improvement Initiative

Abstract

A quality improvement collaborative evaluated Hepatitis B virus (HBV) care for resettled refugees and identified strategies to enhance care. 682 of the 12,934 refugees from five refugee health clinics in Colorado, Minnesota, and Pennsylvania had chronic HBV. Timely care was defined relative to a HBsAg + result: staging (HBV DNA, hepatitis Be antigen, hepatitis Be antibody, alanine transaminase testing) within 14 days, comorbid infection screening (hepatitis C virus and HIV) within 14 days, and linkage to care (HBV specialist referral within 30 days and visit within 6 months). Completed labs included: HBV DNA (93%), hepatitis Be antigen (94%), hepatitis Be antibody (92%), alanine transaminase (92%), hepatitis C screening (86%), HIV screening (97%). 20% had HBV specialist referrals within 30 days; 36% were seen within 6 months. Standardized reflex HBV testing and specialist referral should be prioritized at the initial screening due to the association with timely care.

Leveraging a community-based participatory approach to improve linkage to care for HBV

“…Known barriers to HBV LTC include sociocultural and linguistic factors (ie, stigma, provider-patient language discordance, etc. ), limited health literacy, inadequate provider-to-patient education, and navigation of insurance health care landscape 4,11–13…”

“…), limited health literacy, inadequate provider-to-patient education, and navigation of insurance health care landscape. [4,[11][12][13] Stigma plays a crucial role in why patients initially refuse or would rather not seek care. [11] This can involve fears of losing employment, losing insurance, and increasing the burden of treatment on the family.…”

“…and cultural events, to disseminate high-quality information. [13,17,19,21] For patients who were receiving explanations of their HBV screening results, multilingual staff have provided timely counseling and have mailed letters in patients' respective languages with explanations, along with contact information for further a Success was defined as a patient consenting to receiving HBV education and specifically, the importance of encouraging family to also be screened and adhering to antiviral treatment (if applicable), laboratory monitoring, and ultrasound screening.…”

“…[11] This can involve fears of losing employment, losing insurance, and increasing the burden of treatment on the family. [14,15] Language discordance and limited acculturation to Western society can also manifest as mistrust in the health care system [11,13] and hinder patient understanding of the importance of routine HCC surveillance and laboratory monitoring. [4,11,12] For instance, one study consisting of patients primarily from immigrant communities reported that 20% of HBV patients did not believe HBV was a treatable disease, and only 47.7% believed they could develop any liver complications or transmit HBV to others during their lifetime.…”

“…In partnership with CBOs, they have also been used to identify culturally appropriate venues, such as media outlets (eg, radio, television, etc.) and cultural events, to disseminate high-quality information 13,17,19,21. For patients who were receiving explanations of their HBV screening results, multilingual staff have provided timely counseling and have mailed letters in patients’ respective languages with explanations, along with contact information for further questions 18,21.…”