Adherence to Chronic Hepatitis B Treatment Guideline Recommendations for Laboratory Monitoring of Patients Who Are Not Receiving Antiviral Treatment

Juday, Timothy; Tang, Hong; Harris, Melissa; Powers, Annette; Kim, Edward; Hanna, George J.

doi:10.1007/s11606-010-1549-9

Cited by 36 publications

(37 citation statements)

References 25 publications

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“…Almost one-third of inactive carriers in our study did not have monitoring of ALT at least every 12 months, although gastroenterologists were more likely to perform timely monitoring than PCPs. This finding is consistent with a large retrospective study assessing adherence to AASLD CHB laboratory monitoring guidelines, which found that ∼ 50% of patients failed to undergo timely ALT assessment (5). …”

Section: Discussionsupporting

confidence: 90%

“…The American Association for the Study of Liver Diseases (AASLD) has published guidelines to assist health-care providers in the management and treatment of CHB, including setting standards for timely alanine aminotransferase (ALT) and viral load monitoring for inactive carriers and immune-tolerant patients (i.e., phases that do not require treatment), liver biopsy to guide treatment decisions, criteria for treatment initiation, screening for HCC, and testing for hepatitis A, hepatitis C, and HIV co-infections (2). A previous study has shown that less than one-third of CHB patients receive appropriate laboratory screening (5). Another study of gastroenterologists' HCC screening practices for CHB patients showed that only 60% performed at least annual HCC screening (6).…”

Section: Introductionmentioning

confidence: 99%

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

Johnson

Roccaro

et al. 2014

American Journal of Gastroenterology

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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.

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Section: Discussionsupporting

confidence: 90%

Section: Introductionmentioning

confidence: 99%

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

Johnson

Roccaro

et al. 2014

American Journal of Gastroenterology

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“…(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. (12) However, no published US studies to date have examined HBV care quality among a national sample.…”

supporting

confidence: 52%

“…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.…”

Section: Discussionmentioning

confidence: 99%

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

et al. 2016

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Previous studies have identified gaps in hepatitis B care. The objectives of this study were to evaluate the delivery of care among a national cohort of US veterans with chronic hepatitis B infection and examine risk factors for adverse clinical outcomes. We conducted a retrospective cohort study using the Veterans Health Administration Corporate Data Warehouse from 1999 to 2013 to evaluate (1) care delivery and (2) clinical outcomes such as hepatocellular carcinoma, hepatic decompensation, and mortality among US veterans with hepatitis B. Incidence rates with 95% confidence intervals were calculated and Cox regression models were used to evaluate clinical outcomes. We identified 21,419 veterans with a positive hepatitis B surface antigen, and 97% of patients had alanine aminotransferase and 44% had hepatitis B virus DNA testing; hepatitis B e antigen and hepatitis B e antibody were tested <50% of the time. Patients receiving specialty care had a higher prevalence of recommended laboratory testing. Patients with elevated alanine aminotransferase in specialty care were more likely to receive antiviral therapy (50% versus 24% for specialty care versus no specialty care, P < 0.001). Among patients with cirrhosis, 69% received one-time liver imaging. The proportion of follow-up time adherent to annual imaging was 0.39 (standard deviation 5 0.42), and the proportion was 0.28 (standard deviation 5 0.33) for biannual imaging; both proportions were higher in the specialty care group (all P < 0.05). Antiviral therapy (hazard ratio 5 0.85, 95% confidence interval 0.76-0.95, P 5 0.005) and liver imaging (hazard ratio 5 0.84, 95% confidence interval 0.76-0.91, P < 0.001) were independently associated with decreased mortality in adjusted analyses. Conclusion: We observed a low prevalence of recommended laboratory testing, antiviral therapy initiation, and liver imaging among a national cohort of veterans with hepatitis B infection; antiviral therapy and liver imaging were independently associated with decreased mortality. (HEPATOLOGY 2016;63:1774-1782 SEE EDITORIAL ON PAGE 1755A pproximately 350 million people worldwide are chronically infected with hepatitis B virus (HBV). In the United States, the prevalence of chronic hepatitis B remains incompletely quantified, with estimates ranging from approximately 800,000 individuals to as high as 2.2 million when including foreign-born Americans. (1,2) Chronic HBV infection is a significant cause of morbidity and mortality, leading to liver failure, cirrhosis, and hepatocellular carcinoma (HCC) in 25%-40% of infected persons. (3) Specifically, in the United States, hepatitis B is the underlying cause of an estimated 1800-4000 deaths each year. (2,4) Despite the significant burden of disease and existence of management guidelines for the evaluation and treatment of chronic HBV, (5) studies have shown variable adherence to recommended HBV care, including low rates of alanine aminotransferase (ALT) and HBV DNA level monitoring and infrequent HCC surveillance. (6,7) Significant gaps i...

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“…Over the past 10 years, screening and treatment of HCV in the VA health care system have received a great deal of attention, while little, if any, focus has been directed to the diagnosis and management of chronic HBV despite the high hepatitis B surface antigen seroprevalence among veterans. Other studies have evaluated care delivery and outcomes for civilian segments of the US population with chronic HBV using large administrative claims data sets or manual review of individual patient records (Table ) . Regardless of the research methodology employed, these retrospective studies have consistently found that rates of antiviral therapy and HCC surveillance are suboptimal and that specialty care is associated with a greater likelihood of receiving recommended care.…”

Section: Studies Of Care Quality Metrics In Americans With Chronic Hbvmentioning

confidence: 99%

Quality of care metrics in chronic hepatitis B

Mellinger

Fontana

2016

Hepatology

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A n increasing emphasis in the US health care system is being placed on improving the quality of care for patients with various common chronic diseases for which there are interventions to improve outcomes and reduce resource use. In hepatology, quality measures are best established for chronic hepatitis C virus (HCV) care such as viral load and genotype testing prior to treatment, screening for hepatocellular carcinoma (HCC) in patients with cirrhosis, and shared decision-making for treatment options.(1) However, quality metrics for chronic hepatitis B (HBV)-related medical care are substantially lagging behind. The reasons for this may be inadequate recognition of the significant morbidity and mortality related to HBV, a lack of patient/physician advocacy, and controversy regarding meaningful quality metrics.An estimated 1.4 million to 1.8 million Americans have chronic HBV, and 15%-40% of these individuals are projected to develop complications such as cirrhosis, HCC, or liver failure during their lifetime. (2,3) However, a diagnosis of chronic HBV requires a high index of suspicion based upon risk factors such as country of birth, and many providers are uncertain on how to interpret HBV serologies. Furthermore, optimal management of chronic HBV requires accurate identification of the phase of infection, reliable assessment of disease severity, and knowledge of who and when to treat. Fortunately, there are several safe and well-tolerated oral antiviral therapies that can reduce the rate of disease progression and even potentially improve survival. However, endpoints for treatment discontinuation and means to enhance hepatitis B surface antigen clearance leading to a virologic "cure" remain elusive.In this issue of HEPATOLOGY, Serper et al. analyzed the Veterans Administration (VA) claims database to determine the quality of care delivery and clinical outcomes in over 12,000 veterans with chronic HBV seen between 1999 and 2013.(4) Although there were missing data in many of the process measures analyzed, the large size of this national data set along with the established validity of the diagnostic codes employed improve the internal validity of their findings. The authors found that >90% of veterans received appropriate initial serum alanine aminotransferase (ALT) testing but that there was low overall use of serum HBV DNA (44%) and hepatitis B e antigen (HBeAg) testing (49%) initially and during a mean follow-up of 2 years. In addition, adherence to the recommended screening for HCC was low (39%), particularly in high-risk patients without cirrhosis. Although receipt of specialty care improved the adherence rate, only one-third of patients seen by a specialist received the recommended biannual imaging. Moreover, the authors found no significant improvement in adherence to recommended care processes over the 14-year study period.(2) The reason(s) for the low rates of adherence to HBV quality care metrics in the VA is not clear. Over the past 10 years, screening and treatment of HCV in the VA health care system...

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Adherence to Chronic Hepatitis B Treatment Guideline Recommendations for Laboratory Monitoring of Patients Who Are Not Receiving Antiviral Treatment

Cited by 36 publications

References 25 publications

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

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

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

Quality of care metrics in chronic hepatitis B

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