Poor Adherence to AASLD Guidelines for Chronic Hepatitis B Management and Treatment in a Large Academic Medical Center

Abstract

Objectives Adherence to the American Association for the Study of Liver Disease (AASLD) guidelines for the management of chronic hepatitis B (CHB) has not been systematically assessed. We sought to comprehensively evaluate adherence to five key areas of these guidelines. We also evaluated physician and patient factors underlying nonadherence, and predictors of nonadherence such as physician type, patient demographic factors, and phase of CHB infection. Methods Nine hundred and sixty-two adult patients were retrospectively identified. Each patient chart was reviewed in detail. The primary outcome was adherence to five areas of the AASLD guidelines: (i) timely alanine aminotransferase (ALT)/hepatitis B virus DNA level checks needed to monitor inactive carrier and immune-tolerant phases; (ii) liver biopsy to guide decisions on initiating treatment; (iii) treatment initiation when indicated; (iv) hepatocellular carcinoma (HCC) screening; (v) testing for hepatitis A virus (HAV) immunity, HIV, and hepatitis C virus (HCV) co-infections. Results Sixty percent did not undergo clinically indicated liver biopsies, largely owing to physician nonadherence. Eighty-nine percent of these missed biopsies were needed to further assess possible e-antigen-negative CHB. A high treatment initiation rate was found for the treatment eligible, but 121 patients had unclear treatment eligibility as they warranted, but did not undergo, liver biopsy. Forty-five percent did not have timely HCC screening, although gastroenterology physicians had the highest odds of adherence, and 29% did not have timely CHB lab assessment; patients seen by gastroenterologists had twice the odds compared with primary care physicians of undergoing timely lab monitoring. Thirty-five, 24, and 54% were not tested for HAV, HCV, and HIV co-infections. Conclusions Our findings show remarkably poor adherence to AASLD guidelines, particularly in the areas of liver biopsy, timely HCC and ALT monitoring, and testing for co-infection. These findings call for greater efforts to meet physician knowledge gaps, incorporation of decision support tools, and improved communication among providers.

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.…”