Patient Knowledge, Beliefs and Barriers to Hepatitis B Care: Results of a Multicenter, Multiethnic Patient Survey

Expanding treatment indications in chronic hepatitis B: Should we treat all patients?

Nucleos(t)ide analogues (NUCs) are first-line agents for chronic hepatitis B (CHB). Current guidelines provide recommendations for NUC initiation, yet the guidelines are complex and restrictive. Accumulating data on hepatitis B virus (HBV) replication and HBV integration suggests that there are no real quiescent disease phases in CHB, and treatment-ineligible patients in current guidelines still have substantial risks of cirrhosis and hepatocellular carcinoma. Expanding CHB treatment indications can effectively reduce the risks of liver-related complications. Furthermore, treatment indication expansion can be cost-effective, and can simplify care pathways to remove treatment barriers. Potential caveats for treatment expansion include risks of non-compliance, long-term side effects from NUCs, and poor patient acceptability. Nonetheless, these caveats are not insurmountable, and the benefits of treatment expansion outweigh the disadvantages. There is consensus among hepatologists in supporting treatment indication expansion, although expert panels have varying recommendations on treatment strategies. A treat-all approach, which involves treating all CHB patients, has also been proposed. A treat-all strategy is straightforward, and should yield the greatest benefits from a population health perspective. However, the feasibility of new treatment strategies, especially the treat-all approach, is influenced by multiple factors including local epidemiology, healthcare resource availability, and socioeconomic factors. A one-size-fits-all approach is not optimal, and treatment expansion strategies that are tailored based on local data should yield the greatest impact toward hepatitis elimination.

Steatotic Liver Disease Education Enhances Knowledge and Confidence to Adhere to Provider Recommendations in Diverse and Vulnerable Populations

Background and Aims

Patient knowledge of steatotic liver disease (SLD) is suboptimal. We assessed the impact of SLD education on patient knowledge and confidence to follow provider recommendations among a diverse vulnerable population.

Methods

In this prospective study from February 19, 2020, to January 31, 2024, 296 adults with SLD were surveyed before and after receipt of formal SLD education. Linear regression (adjusted for age, sex, race) assessed factors associated with baseline SLD knowledge score and its change after education (delta in prescores and postscores), along with confidence to follow provider recommendations following receipt of education.

Results

Participant characteristics were as follows: median age 53 years, 40.9% male, 55.1% Hispanic (27.0% Asian and 10.5% White), and 23.8% reported heavy alcohol use. SLD knowledge and confidence to follow provider recommendations increased posteducation (all P < .05). On multivariable analyses, greater than high school education (vs high school or less) (coef. 0.62), perceived severity of disease (coef. 0.62), treatment efficacy (coef. 1.38), self-efficacy to discuss SLD (coef. 0.71), and perceived susceptibility to disease risk (coef. 0.93) were associated with greater baseline knowledge (all P < .05). Following education, heavy alcohol use (vs none) was associated with greater change in knowledge (coef. 0.74), while perceived severity (coef. -0.52) and treatment efficacy (coef. -0.72) were associated with lesser change in knowledge (all P < .05). While perceived barriers (coef. -0.14) were associated with less confidence, self-efficacy to discuss SLD, older age, Hispanic, and other race was associated with greater confidence to follow provider recommendations (coef. 0.38, 0.18, 0.64, and 1.26, respectively, all P < .05).

Conclusion

Formal SLD education enhanced knowledge and confidence to follow provider recommendations in Hispanics and heavy alcohol users. SLD education is integral to SLD management in safety net populations.

Characterization of Individuals With Hepatitis B Virus-Related Cirrhosis in a Large Integrated Health Care Organization, 2008-2019

CONTEXT

Chronic hepatitis B (CHB), caused by hepatitis B virus (HBV), is a risk factor for cirrhosis. The management of HBV-related cirrhosis is challenging, with guidelines recommending treatment initiation and regular monitoring for those affected.

OBJECTIVE

Our study characterized Kaiser Permanente Southern California patients with HBV-related cirrhosis and assessed whether they received recommended laboratory testing and imaging monitoring.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

We identified KPSC members aged ≥18 years with CHB (defined by 2, consecutive positive hepatitis B surface antigens ≥6 months apart) from 2008 to 2019. Of these patients, we further identified patients with potential HBV-related cirrhosis through ICD-10 code diagnosis, adjudicated via chart review.

MAIN OUTCOME MEASURES

Age, race/ethnicity, laboratory tests (eg, alanine aminotransferase [ALT]), and hepatocellular carcinoma (HCC) screening (based on standard screening recommendations via imaging) were described in those with HBV-related cirrhosis versus those without.

RESULTS

Among patients with CHB, we identified 65 patients with HBV-related cirrhosis over ~8 years. Diabetes was the most common comorbidity and was approximately 3 times more prevalent among patients with cirrhosis compared to patients without cirrhosis (21.5% vs. 7.1%). Of the 65 patients with cirrhosis, 72.3% (N = 47) received treatment. Generally, we observed that liver function tests (eg, ALT) were completed frequently in this population, with patients completing a median of 10 (6, 16) tests/year. All patients with cirrhosis had ≥1 ALT completed over the study period, and almost all cirrhotic patients (N = 64; 98.5%) had ≥1 HBV DNA test. However, the proportion of yearly imaging visits completed varied across the study years, between 64.0% in 2012 and 87.5% in 2009; overall, 35% (N = 23) completed annual imaging.

CONCLUSIONS

Our findings suggest that among patients with HBV-related cirrhosis, at the patient-level, completed imaging orders for HCC screening were sub-optimal. However, we observed adequate disease management practices through frequent liver function tests, linkage to specialty care, image ordering, and shared EHR between KPSC providers.

Assessing Adherence to US LI-RADS Follow-up Recommendations in Vulnerable Patients Undergoing Hepatocellular Carcinoma Surveillance

Purpose To assess adherence to the US Liver Imaging Reporting and Data System (LI-RADS) recommendations for hepatocellular carcinoma (HCC) surveillance and associated patient-level factors in a vulnerable, diverse patient sample. Materials and Methods The radiology report database was queried retrospectively for patients who underwent US LI-RADS-based surveillance examinations at a single institution between June 1, 2020, and February 28, 2021. Initial US and follow-up liver imaging were included. Sociodemographic and clinical data were captured from electronic medical records. Adherence to radiologist recommendation was defined as imaging (US, CT, or MRI) follow-up in 5-7 months for US-1, imaging follow-up in 3-6 months for US-2, and CT or MRI follow-up in 2 months for US-3. Descriptive analysis and multivariable modeling that adjusted for age, sex, race, and time since COVID-19 pandemic onset were performed. Results Among 936 patients, the mean age was 59.1 years; 531 patients (56.7%) were male and 544 (58.1%) were Asian or Pacific Islander, 91 (9.7%) were Black, 129 (13.8%) were Hispanic, 147 (15.7%) were White, and 25 (2.7%) self-reported as other race. The overall adherence rate was 38.8% (95% CI: 35.7, 41.9). The most common liver disease etiology was hepatitis B (60.6% [657 of 936 patients]); 19.7% of patients (183 of 936) had current or past substance use disorder, and 44.8% (416 of 936) smoked. At adjusted multivariable analysis, older age (odds ratio [OR], 1.20; P = .02), male sex (OR, 1.62; P = .003), hepatology clinic attendance (OR, 3.81; P < .001), and recent prior US examination (OR, 2.44; P < .001) were associated with full adherence, while current smoking (OR, 0.39; P < .001) was negatively associated. Conclusion Adherence to HCC imaging surveillance was suboptimal, despite US LI-RADS implementation. Keywords: Liver, Ultrasound, Screening, Abdomen/GI, Cirrhosis, Metabolic Disorders, Socioeconomic Issues Supplemental material is available for this article. © RSNA, 2024.

Patient acceptability of, and attitudes towards, hepatitis B cure research - A scoping review and identification of knowledge gaps

Functional cure, defined as durable loss of hepatitis B surface antigen (HBsAg) and hepatitis B virus (HBV) DNA suppression off therapy, is an increasingly important goal in the treatment of chronic hepatitis B. Although novel treatments aimed at achieving functional cure are being developed and tested in clinical trials, it is important to assess the perspectives of people living with HBV towards these potential treatments and their participation in HBV functional cure research. We have performed a scoping review that revealed that there is limited knowledge regarding patient perspectives of HBV functional cure research and then identified gaps in knowledge for further investigation. Our work highlights the need for further studies in patient perspectives in HBV functional cure research.

Association of language concordance and restraint use in adults receiving mechanical ventilation

PURPOSE

Clinician-patient language concordance improves patient outcomes in non-intensive care unit (ICU) settings. We sought to assess the association of ICU nurse-patient language concordance with delirium-related outcomes.

METHODS

We conducted a retrospective cohort study of adult English- or Spanish-speaking mechanically ventilated ICU patients admitted to ICUs at the University of Miami Hospital and Clinics (January 2021-September 2022). Our primary exposure was nurse-patient language concordance on each shift. We used mixed-effects multivariable regression to evaluate the association of language concordance with the primary outcome of restraint use, and secondary outcomes of agitation and identification of delirium, during each shift (with patient as a random effect).

RESULTS

Our cohort included 4326 shifts (3380 [78.1%] with language concordance) from 548 patients and 157 nurses. Spanish language was preferred by 269 (49.1%) of patients. English-speaking patients tended to be younger (65 [53, 75] vs 73 [61, 83], p < 0.001) and of non-Hispanic ethnicity (55.5% vs 7.1%, p < 0.001). English-speakers had restraints ordered on fewer of their included shifts (0 [0, 3] vs 1 [0, 3], p = 0.005). After adjustment, the odds of restraint use on shifts with language concordance was significantly lower (odds ratio [OR, 95% confidence interval [CI]]: 0.50 [0.39-0.63], p < 0.001). Agitation (18.6% vs 25.2%; OR [95% CI]: 0.71 [0.55-0.92], p = 0.009) and delirium identification (34.5% vs 41.3%; OR [95% CI]: 0.54 [0.34-0.88], p = 0.014) were also less common.

CONCLUSIONS

We identified a twofold reduction in the odds of restraint use among mechanically ventilated patients for language concordant nurse-patient dyads. Ensuring nurse-patient language concordance may improve ICU delirium, agitation, and restraint use.

Fatty Liver Education Promotes Physical Activity in Vulnerable Groups, Including Those With Unhealthy Alcohol Use

BACKGROUND AND AIMS

Fatty liver disease (FLD), alcohol-associated and metabolically associated, often coexists. Increase in physical activity is associated with metabolic health and decreased FLD. We aimed to identify factors associated with physical activity and its improvement following FLD education in a racially diverse, vulnerable population.

METHODS

From February 19, 2020 to December 30, 2022, 314 adults with FLD at safety-net hepatology clinics in San Francisco were surveyed at baseline, immediately after FLD education, and at 6-month follow-up. After collecting clinical and sociodemographic data, logistic regression (adjusted for age, sex, and race/ethnicity) assessed factors associated with physical activity at baseline and its improvement following education.

RESULTS

Participant characteristics in those without vs with any physical activity were median age 49 vs 55 years, 64% vs 56% female, 66% vs 53% Hispanic race/ethnicity, 75% vs 55% obese, and 30% vs 22% consumed heavy alcohol, respectively. On multivariable analysis, older age was the only significant factor associated with physical activity at baseline (relative risk ratio 1.37 per decade increase, 95% confidence interval [CI] 1.07-1.75). Hispanic (vs non-Hispanic) participants had a significantly higher odds of improvement in physical activity (vs no change) 6 months after education (odds ratio 2.36, 95% CI 1.27-4.39). Among those with suboptimal or no physical activity at baseline, participants who consumed heavy alcohol (vs no drinking) had a significantly higher likelihood of achieving optimal physical activity following education (relative risk ratio 1.98, 95% CI 1.05-3.74).

CONCLUSION

Despite social and structural barriers, FLD education increased uptake of physical activity in vulnerable populations, especially among Hispanic individuals and those consuming heavy alcohol. Implementation of patient-centered education is important for FLD management.

Chronic hepatitis B: a scoping review on the guidelines for stopping nucleos(t)ide analogue therapy

INTRODUCTION

Nucleos(t)ide analogues (NAs) are effective in suppressing the replication of the hepatitis B virus. However, NAs cannot effectively induce hepatitis B surface antigen (HBsAg) seroclearance, which represents the optimal treatment endpoint in chronic hepatitis B (CHB). Hence, most CHB patients are advised for indefinite NA therapy, but recent data has supported the concept of finite NA therapy before HBsAg seroclearance.

AREAS COVERED

This article covered the latest evidence on stopping NAs in CHB, with a focused analysis on international guidelines. Articles were retrieved by a literature search on PubMed with the keywords 'chronic hepatitis B,' 'antiviral therapy,' 'nucleos(t)ide analogue,' 'cessation,' 'stopping', and 'finite.' Studies up till 1 December 2022 were included.

EXPERT OPINION

Finite NA therapy in CHB has the potential in enhancing HBsAg seroclearance, however it also carries rare but potentially severe risks. NA cessation before HBsAg seroclearance is only suitable for a highly selected group of patients, whereas the majority of CHB patients should be treated indefinitely or until HBsAg seroclearance. Current guidelines have provided recommendations on stopping NAs, but further research is required to optimize the monitoring and retreatment protocol after stopping NAs.

Formal Hepatitis C education increases willingness to receive therapy in an onsite shelter-based HCV model of care in persons experiencing homelessness

Background

To evaluate the effectiveness of formal Hepatitis C (HCV) education on engagement in therapy in persons experiencing homelessness in an onsite shelter-based model of care. As policies to eliminate Medicaid access restrictions to HCV treatment are expanded, patient education is paramount to achieving HCV elimination targets in difficult to engage populations including persons experiencing homelessness.

Methods

This prospective study was conducted at four shelters in San Francisco and Minneapolis from August 2018 to January 2021. Of the 162 HCV Ab positive participants, 150 participated in a 30-minute HCV education session. Post-education changes in knowledge, beliefs, barriers to care and willingness to accept therapy scores were assessed.

Results

Following education, knowledge scores (mean change 4.4 ± 4.4, p&lt;0.001) and willingness to accept therapy (70% to 86% p=0.0002) increased. Perceived barriers to HCV care decreased (mean change -0.8 ± 5.2 p=0.001). Higher baseline knowledge was associated with lesser gain in knowledge following education (coef. -0.7, p&lt;0.001). Post-education knowledge (OR 1.2, p=0.008) was associated with willingness to accept therapy.

Conclusions

An HCV educational intervention successfully increased willingness to engage in HCV therapy in persons experiencing homelessness in an onsite shelter-based HCV model of care.

Breaking down barriers for hepatitis B screening in the Bronx West African community through education in collaboration with faith-based organizations: A cohort study

Background

Many residents of the Bronx are from West Africa where chronic hepatitis B is endemic. Hepatitis B screening is low in West African immigrant communities due to multiple possible cultural and socioeconomic factors.

Methods

A culturally sensitive educational program on hepatitis B with a special emphasis on the relevance for the West African community was developed. Arrangements were made with leaders of West African faith-based organizations to conduct educational programs following religious services after which a survey was completed to assess changes in attitudes towards the infection and motivation for testing. Arrangements were then made for serologic testing at which time hypertension screening was also performed.

Findings

Nine events in which a total of 550 people attended were held. Among the 339 (61.6%) participants who completed the questionnaire, 325 of the participants (95.1%) reported improved understanding, and 236 (67.0%) indicated greater comfort in sharing a meal and talking with an infected individual. Two hundred seventy-four participants (82.7%) indicated an intention to undergo testing, and 339 (97.8%) indicated that they would encourage family and friends to undergo screening. Three hundred thirty-two of the 550 participants (60.3%) requested serologic testing. Among those requesting testing, 224 (67.5%) underwent testing.

Interpretation

A culturally sensitive educational program in collaboration with faith-based organizations is effective in motivating people from West Africa to undergo screening for hepatitis B at which time other preventative health care measures such as hypertension screening can be performed.

Funding

Check Hep B Navigation Program funded by the New York Council, Gilead Sciences, Albert Einstein College of Medicine Global Health Center and generous donations by Friends and Family of Jason Marks and the 41-74 Club of NY.

Bayan

XXX.

fage

Yawancin mazauna Bronx sun fito ne daga Yammacin Afirka inda cutar hepatitis B ke ci gaba da yaduwa. Binciken hepatitis B yana da karanci a cikin al'ummomin baƙi na Yammacin Afirka saboda yuwuwar abubuwan al'adu da na tattalin arziƙi.

Hanyoyi

An haɓaka wani shirin ilmantarwa na al'adu kan cutar hepatitis B tare da ba da fifiko na musamman ga dacewa ga al'ummar Yammacin Afirka. An yi shiri tare da shugabannin ƙungiyoyin addinan Afirka ta Yamma don gudanar da shirye-shiryen ilimi bayan ayyukan addini bayan haka aka kammala bincike don tantance halaye game da kamuwa da cutar da himma don gwaji. Sannan an yi shirye -shirye don gwajin serologic wanda a lokacin ne kuma aka yi gwajin hawan jini.

Sakamakon

An gudanar da abubuwa tara wanda jimlar mutane 550 suka halarta. Daga cikin mahalarta 339 (61.6%) da suka kammala tambayoyin, 325 daga cikin mahalarta (95.1%) sun ba da rahoton ingantacciyar fahimta, kuma 236 (67.0%) sun nuna ƙarin ta'aziyya wajen raba abinci da yin magana da mai cutar. Mahalarta ɗari biyu da saba'in da huɗu (82.7%) sun nuna niyyar yin gwaji, kuma 339 (97.8%) sun nuna cewa za su ƙarfafa dangi da abokai don yin gwajin. Dari uku da talatin da biyu daga cikin mahalarta 550 (60.3%) sun buƙaci gwajin serologic. Daga cikin wadanda ke neman gwaji, 224 (67.5%) sun yi gwaji.

Fassara

shirin ilmantarwa mai mahimmanci na al'adu tare da haɗin gwiwar ƙungiyoyi masu imani suna da tasiri wajen motsa mutane daga Yammacin Afirka don yin gwajin cutar hepatitis B a lokacin da za a iya yin wasu matakan kula da lafiya kamar rigakafin hawan jini.

Kuɗi

Shirin Hep B Navigation Programme wanda Majalisar New York, Kimiyya ta Gilead, Cibiyar Kiwon Lafiya ta Duniya ta Albert Einstein da Cibiyar Kyauta ta Abokai da Iyalan Jason Marks da 41-74 Club na NY suka bayar.