Advertisement

Digestive Diseases and Sciences

, Volume 59, Issue 1, pp 46–56 | Cite as

Hepatitis B Management in Vulnerable Populations: Gaps in Disease Monitoring and Opportunities for Improved Care

  • Blaire E. Burman
  • Nizar A. Mukhtar
  • Brian C. Toy
  • Tung T. Nguyen
  • Alice Hm Chen
  • Albert Yu
  • Peter Berman
  • Hali Hammer
  • Daniel Chan
  • Charles E. McCulloch
  • Mandana Khalili
Original Article

Abstract

Background

Hepatitis B (HBV) is prevalent in certain US populations and regular HBV disease monitoring is critical to reducing associated morbidity and mortality. Adherence to established HBV monitoring guidelines among primary care providers is unknown.

Aims

The purpose of this study was to evaluate HBV disease monitoring patterns and factors associated with adherence to HBV management guidelines in the primary care setting.

Methods

Primary providers within the San Francisco safety net healthcare system were surveyed for HBV management practices, knowledge, attitudes, and barriers to HBV care. Medical records from 1,727 HBV-infected patients were also reviewed retrospectively.

Results

Of 148 (45 %) responding providers, 79 % reported ALT and 44 % reported HBV viral load testing every 6–12 months. Most providers were knowledgeable about HBV but 43 % were unfamiliar with HBV management guidelines. Patient characteristics included: mean age 51 years, 54 % male and 67 % Asian. Within the past year, 75 % had ALT, 24 % viral load, 21 % HBeAg tested, and 40 % of at-risk patients had abdominal imaging for HCC. Provider familiarity with guidelines (OR 1.02, 95 % CI 1.00–1.03), Asian patient race (OR 4.18, 95 % CI 2.40–7.27), and patient age were associated with recommended HBV monitoring. Provider HBV knowledge and attitudes were positively associated, while provider age and perceived barriers were negatively associated with HCC surveillance.

Conclusions

Comprehensive HBV disease monitoring including HCC screening with imaging were suboptimal. While familiarity with AASLD guidelines and patient factors were associated with HBV monitoring, only provider and practice factors were associated with HCC surveillance. These findings highlight the importance of targeted provider education to improve HBV care.

Keywords

Hepatitis B Hepatocellular carcinoma Primary care Provider education Practice guidelines Health disparities 

Abbreviations

ALT

Alanine aminotransferase

HBV

Hepatitis B virus

HBsAg

Hepatitis B surface antigen

HBeAg

Hepatitis B e antigen

HAV

Hepatitis A virus

HCV

Hepatitis C virus

HIV

Human immunodeficiency virus

HCC

Hepatocellular carcinoma

AASLD

American Association for the Study of Liver Diseases

Notes

Acknowledgments

This work was in part supported by Hepatology Training Grant DK060414 (B.B.), San Francisco General Hospital Foundation Grant (M.K.), K24AA022523 (M.K.) and P30 DK026743 (UCSF Liver Center).

Conflict of interest

None.

References

  1. 1.
    Lok AS, McMahon BJ. Chronic hepatitis B: update 2009. Hepatology. 2009;50:661–662.PubMedCrossRefGoogle Scholar
  2. 2.
    Weinbaum CM, Williams I, Mast EE, et al. Recommendations for identification and public health management of persons with chronic hepatitis B virus infection. MMWR Recomm Rep. 2008;57:1–20.PubMedGoogle Scholar
  3. 3.
    Mitchell T, Armstrong GL, Hu DJ, et al. The increasing burden of imported chronic hepatitis B-United States, 1974–2008. PLoS One. 2011;6:e27717.PubMedCentralPubMedCrossRefGoogle Scholar
  4. 4.
    Lin SY, Chang ET, So SK. Why we should routinely screen Asian American adults for hepatitis B: a cross-sectional study of Asians in California. Hepatology. 2007;46:1034–1040.PubMedCrossRefGoogle Scholar
  5. 5.
    Hu KQ, Pan CQ, Goodwin D. Barriers to screening for hepatitis B virus infection in Asian Americans. Dig Dis Sci. 2011;56:3163–3171.PubMedCrossRefGoogle Scholar
  6. 6.
    Cohen C, Holmberg SD, McMahon BJ, et al. Is chronic hepatitis B being undertreated in the United States? J Viral Hepat. 2011;18:377–383.PubMedCrossRefGoogle Scholar
  7. 7.
    Chen CJ, Iloeje UH, Yang HI. Long-term outcomes in hepatitis B: the REVEAL-HBV study. Clin Liver Dis 2007;11:797–816, viii.Google Scholar
  8. 8.
    Scaglione SJ, Lok AS. Effectiveness of hepatitis B treatment in clinical practice. Gastroenterology. 2012;142:1360e1–1368e1.CrossRefGoogle Scholar
  9. 9.
    Liaw YF, Sung JJ, Chow WC, et al. Lamivudine for patients with chronic hepatitis B and advanced liver disease. N Engl J Med. 2004;351:1521–1531.PubMedCrossRefGoogle Scholar
  10. 10.
    Post SE, Sodhi NK, Peng CH, et al. A simulation shows that early treatment of chronic hepatitis B infection can cut deaths and be cost-effective. Health Aff (Millwood). 2011;30:340–348.CrossRefGoogle Scholar
  11. 11.
    Rajendra A, Wong JB. Economics of chronic hepatitis B and hepatitis C. J Hepatol. 2007;47:608–617.PubMedCrossRefGoogle Scholar
  12. 12.
    Zhang S, Ristau JT, Trinh HN, et al. Undertreatment of Asian chronic hepatitis B patients on the basis of standard guidelines: a community-based study. Dig Dis Sci. 2012;57:1373–1383.PubMedCrossRefGoogle Scholar
  13. 13.
    Jung CW, Tan J, Tan N, et al. Evidence for the insufficient evaluation and undertreatment of chronic hepatitis B infection in a predominantly low-income and immigrant population. J Gastroenterol Hepatol. 2010;25:369–375.PubMedCrossRefGoogle Scholar
  14. 14.
    Mitchell AE, Colvin HM, Palmer Beasley R. Institute of Medicine recommendations for the prevention and control of hepatitis B and C. Hepatology. 2010;51:729–733.PubMedCrossRefGoogle Scholar
  15. 15.
    Pollack H, Wang S, Wyatt L, et al. A comprehensive screening and treatment model for reducing disparities in hepatitis B. Health Aff (Millwood). 2011;30:1974–1983.CrossRefGoogle Scholar
  16. 16.
    El-Serag H, McGlynn KA, Graham GN, et al. Achieving health equity to eliminate racial, ethnic, and socioeconomic disparities in HBV- and HCV-associated liver disease. J Fam Pract. 2010;59:S37–S42.PubMedGoogle Scholar
  17. 17.
    Guy J, Yee HF Jr. Health disparities in liver disease: time to take notice and take action. Hepatology. 2009;50:309–313.PubMedCentralPubMedCrossRefGoogle Scholar
  18. 18.
    Bruix J, Sherman M. American Association for the Study of Liver D. Management of hepatocellular carcinoma: an update. Hepatology. 2011;53:1020–1022.PubMedCentralPubMedCrossRefGoogle Scholar
  19. 19.
    Lai CJ, Nguyen TT, Hwang J, et al. Provider knowledge and practice regarding hepatitis B screening in Chinese-speaking patients. J Cancer Educ. 2007;22:37–41.PubMedCrossRefGoogle Scholar
  20. 20.
    Ferrante JM, Winston DG, Chen PH, et al. Family physicians’ knowledge and screening of chronic hepatitis and liver cancer. Fam Med. 2008;40:345–351.PubMedGoogle Scholar
  21. 21.
    Khalili M, Guy J, Yu A, et al. Hepatitis B and hepatocellular carcinoma screening among Asian Americans: survey of safety net healthcare providers. Dig Dis Sci. 2011;56:1516–1523.PubMedCentralPubMedCrossRefGoogle Scholar
  22. 22.
    Upadhyaya N, Chang R, Davis C, et al. Chronic hepatitis B: perceptions in Asian American communities and diagnosis and management practices among primary care physicians. Postgrad Med. 2010;122:165–175.PubMedCrossRefGoogle Scholar
  23. 23.
    Bindman AB, Chen A, Fraser JS, et al. Healthcare reform with a safety net: lessons from San Francisco. Am J Manag Care. 2009;15:747–750.PubMedGoogle Scholar
  24. 24.
    Advisory Committee on Immunization P, Fiore AE, Wasley A, et al. Prevention of hepatitis A through active or passive immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2006;55:1–23.Google Scholar
  25. 25.
    Smith BD, Morgan RL, Beckett GA, et al. Recommendations for the identification of chronic hepatitis C virus infection among persons born during 1945–1965. MMWR Recomm Rep. 2012;61:1–32.PubMedGoogle Scholar
  26. 26.
    Hu KQ, Schiff ER, Kowdley KV, et al. Histologic evidence of active liver injury in chronic hepatitis B patients with normal range or minimally elevated alanine aminotransferase levels. J Clin Gastroenterol. 2010;44:510–516.PubMedGoogle Scholar
  27. 27.
    El-Serag HB, Marrero JA, Rudolph L, et al. Diagnosis and treatment of hepatocellular carcinoma. Gastroenterology. 2008;134:1752–1763.PubMedCrossRefGoogle Scholar
  28. 28.
    Nguyen VT, Law MG, Dore GJ. Hepatitis B-related hepatocellular carcinoma: epidemiological characteristics and disease burden. J Viral Hepat. 2009;16:453–463.PubMedCrossRefGoogle Scholar
  29. 29.
    Altekruse SF, McGlynn KA, Reichman ME. Hepatocellular carcinoma incidence, mortality, and survival trends in the United States from 1975 to 2005. J Clin Oncol. 2009;27:1485–1491.PubMedCrossRefGoogle Scholar
  30. 30.
    Sarkar M, Stewart S, Yu A, et al. Hepatocellular carcinoma screening practices and impact on survival among hepatitis B-infected Asian Americans. J Viral Hepat. 2012;19:594–600.PubMedCentralPubMedCrossRefGoogle Scholar
  31. 31.
    Bruix J, Sherman M. Practice Guidelines Committee AAftSoLD. Management of hepatocellular carcinoma. Hepatology. 2005;42:1208–1236.PubMedCrossRefGoogle Scholar
  32. 32.
    Foster T, Hon H, Kanwal F, et al. Screening high risk individuals for hepatitis B: physician knowledge, attitudes, and beliefs. Dig Dis Sci. 2011;56:3471–3487.PubMedCrossRefGoogle Scholar
  33. 33.
    Kim WR. Epidemiology of hepatitis B in the United States. Hepatology. 2009;49:S28–S34.PubMedCentralPubMedCrossRefGoogle Scholar
  34. 34.
    Centers for Disease C, Prevention. Screening for chronic hepatitis B among Asian/Pacific Islander populations–New York City, 2005. MMWR Morb Mortal Wkly Rep. 2006;55:505–509.Google Scholar
  35. 35.
    Nguyen TT, Gildengorin G, Truong A, et al. Factors influencing physicians’ screening behavior for liver cancer among high-risk patients. J Gen Intern Med. 2007;22:523–526.PubMedCentralPubMedCrossRefGoogle Scholar
  36. 36.
    Wong ST, Gildengorin G, Nguyen T, et al. Disparities in colorectal cancer screening rates among Asian Americans and non-Latino whites. Cancer. 2005;104:2940–2947.PubMedCentralPubMedCrossRefGoogle Scholar
  37. 37.
    Wen XJ, Balluz L. Racial disparities in access to health care and preventive services between Asian Americans/Pacific Islanders and Non-Hispanic Whites. Ethn Dis. 2010;20:290–295.PubMedGoogle Scholar
  38. 38.
    Ye J, Mack D, Fry-Johnson Y, et al. Health care access and utilization among US-born and foreign-born Asian Americans. J Immigr Minor Health. 2012;14:731–737.PubMedCrossRefGoogle Scholar
  39. 39.
    Taylor VM, Yasui Y, Burke N, et al. Hepatitis B knowledge and testing among Vietnamese-American women. Ethn Dis. 2005;15:761–767.PubMedGoogle Scholar
  40. 40.
    Shiau R, Bove F, Henne J, et al. Using survey results regarding hepatitis B knowledge, community awareness and testing behavior among Asians to improve the San Francisco Hep B Free campaign. J Community Health. 2012;37:350–364.PubMedCrossRefGoogle Scholar
  41. 41.
    Rauscher GH, Johnson TP, Cho YI, et al. Accuracy of self-reported cancer-screening histories: a meta-analysis. Cancer Epidemiol Biomarkers Prev. 2008;17:748–757.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Blaire E. Burman
    • 1
  • Nizar A. Mukhtar
    • 1
  • Brian C. Toy
    • 1
  • Tung T. Nguyen
    • 1
  • Alice Hm Chen
    • 1
  • Albert Yu
    • 2
  • Peter Berman
    • 2
  • Hali Hammer
    • 2
  • Daniel Chan
    • 3
  • Charles E. McCulloch
    • 4
  • Mandana Khalili
    • 5
    • 6
  1. 1.Department of MedicineUniversity of California, San FranciscoSan FranciscoUSA
  2. 2.Department of Family and Community MedicineUniversity of California, San FranciscoSan FranciscoUSA
  3. 3.North East Medical ServicesSan FranciscoUSA
  4. 4.Department of Epidemiology and BiostatisticsUniversity of California, San FranciscoSan FranciscoUSA
  5. 5.Department of MedicineUniversity of California, San FranciscoSan FranciscoUSA
  6. 6.Liver CenterUniversity of California, San FranciscoSan FranciscoUSA

Personalised recommendations