Barriers to Disease Monitoring and Liver Cancer Surveillance Among Patients with Chronic Hepatitis B in the United States

Psychometric Tests for Hepatitis B - A Systematic Review

Hepatitis B is a condition that directly affects hundreds of millions of people, who may require testing for certain psychological constructs. This systematic review presents the current state with regard to the instruments that are used for the measurement of psychological variables in relation to hepatitis B. We conducted a comprehensive search in bibliographic databases (PubMed, Embase, Scopus, Web of Science, PsycINFO, CINAHL, and the Cochrane Library), and grey literature search. We identified commonly used measures, their psychometric properties and gaps in the research. Our findings from the 38 papers included in the review indicate that while several tests have been developed to cater to hepatitis B patients, most are focused on quality of life, with few targeting other needed directions, such as stigma or attitudes to vaccination. We also show the limits in current measures and discuss potential improvements.

Barriers to accessing hepatitis B medication: a qualitative study from the USA and Canada

OBJECTIVES

To collect and document the numerous barriers that people living with hepatitis B (PLHB) encounter when trying to access their hepatitis B virus (HBV) medications.

DESIGN

Researchers collected qualitative data through 24 online interviews. The semistructured interview questions focused on the impact that HBV has on different aspects of daily life (physical, emotional and social), personal experiences managing their infection, HBV treatment experiences and interactions with healthcare providers.

SETTING

All interviews occurred over Zoom.

PARTICIPANTS

The participant cohort consisted of 12 males and 12 females. 63% of all participants represented communities of colour (37% white, 17% black/African/African American and 46% Asian/Asian American). Most of the participants were on antiviral treatment at the time of the study (62%). Participants were PLHB (self-reported), ≥18 years old, living in the USA or Canada and spoke English.

RESULTS

Participants reported several barriers to accessing medicine among PLHB including financial barriers, health insurance and pharmacy preauthorisation process and other intangible barriers like lack of access to reliable patient-friendly information and stigma. The identified barriers to accessing HBV medication impacted patients' continuity of care.

CONCLUSIONS

Access to medicine is essential to improving health outcomes. PLHB experience significant barriers to accessing HBV antivirals at different levels. Patient-related, physician-related and healthcare system barriers were identified as themes contributing to antiviral access challenges. More research is needed to identify strategies to improve access to HBV medications.

Hepatitis B Care Continuum Models-Data to Inform Public Health Action

The application of a care continuum model (CCM) can identify gaps in diagnosis, care, and treatment of populations with a common condition, but challenges are inherent in developing a CCM for chronic hepatitis B. In contrast with treatment for HIV or hepatitis C, treatment is not indicated for all people with chronic hepatitis B, clinical endpoints are not clear for those receiving treatment, and those for whom treatment is not indicated remain at risk for complications. This topical review examines the data elements necessary to develop and apply chronic hepatitis B CCMs at the jurisdictional health department level. We conducted a nonsystematic review of US-based publications in Ovid MEDLINE (1946-present), Ovid Embase (1974-present), and Scopus (not date limited) databases, which yielded 724 publications for review. Jurisdictional health departments, if properly supported, could develop locale-specific focused CCMs using person-level chronic hepatitis B registries, updated longitudinally using electronic laboratory reporting data and case reporting data. These CCMs could be applied to identify disparities and improve rates in testing and access to care and treatment, which are necessary to reduce liver disease and chronic hepatitis B mortality. Investments in public health surveillance infrastructure, including substantial enhancements in electronic laboratory reporting and case reporting and the use of supplementary data sources, could enable jurisdictional health departments to develop modified CCMs for chronic hepatitis B that focus, at least initially, on "early" CCM steps, which emphasize optimization of hepatitis B diagnosis, linkage to care, and ongoing clinical follow-up of diagnosed people, all of which can lead to improved outcomes.

Addressing Barriers to Care in Hepatocellular Carcinoma: Promoting Equity and Access

Chronic hepatitis B virus (HBV) infection is the leading cause of hepatocellular carcinoma (HCC). Chronic viral hepatitis is projected to surpass the composite mortality rates of the human immunodeficiency virus (HIV), tuberculosis, and malaria by 2040. It can be attributed to several barriers to chronic HBV infection (CHBVI) surveillance that warrant urgent attention. Here, we report a case of a 40-year-old male with CHBVI who developed HCC and underwent partial hepatic resection. However, due to an interruption in insurance and medication regimen, the patient became the victim of healthcare disparity, which led to the progression of HCC and succumbed to widespread metastasis. This case highlights and discusses the healthcare disparity and critical value of continuity of care for patients with HBV infection to promote optimal patient outcomes.

Individual and population screening of varices needing treatment by a simple, safe and accurate test

BACKGROUND

Several tests have been developed to screen varices needing treatment (VNT) in different screening settings. We aimed to develop simple estimators to quantify VNT risk and spare endoscopy while missing <5% of VNT, adapted to different screenings in the main etiologies.

METHODS

2,368 patients with chronic liver disease were included. The main VNT predictors were platelets, prothrombin index (PI) and LSM. Their interactions led to score construction, LIP: (LSM*45)/(PI*platelets), and BLIP: BMI-adjusted LIP in NAFLD. Scores were categorized either for population (VNT sensitivity ≥95%) or individual (negative predictive value ≥95%) VNT screening.

RESULTS

1) Scores diagnosing VNT. AUROCs were, PLER: 0.767 Anticipate: 0.773 (p=0.059 vs previous), LIP: 0.779 (p=0.136), PLEASE: 0.789 (p=0.196). 2) Population screening performance was in increasing order (with missed VNT rate), Baveno6 criteria: 23.9% (2.5%), Anticipate: 24.5%, p=0.367 vs previous (3.3%), PLER: 27.3%, p<0.001 (3.6%), LIP: 33.4%, p<0.001 (4.2%), PLEASE: 35.2%, p=0.006 (3.6%). In NAFLD, LIP: 38.6%, BLIP: 40.8%, p=0.038. 3) Individual screening performance was, expanded Baveno6 criteria: 42.7%, LIP: 54.1%, p<0.001. In NAFLD, performance was, NAFLD-cirrhosis criteria: 66.7%, BLIP: 74.6%, p<0.001.

CONCLUSION

LIP combined simplicity, performance and safety in each etiology. In NAFLD, BMI-adjusted LIP outperformed other tests.

Gaps and Disparities in Chronic Hepatitis B Monitoring and Treatment in the United States, 2016-2019

BACKGROUND

Chronic hepatitis B (CHB) carries an increased risk of death from cirrhosis and hepatocellular carcinoma (HCC). The American Association for the Study of Liver Diseases recommends patients with CHB receive monitoring of disease activity, including ALT, hepatitis B virus (HBV) DNA, hepatitis B e-antigen (HBeAg), and liver imaging for patients who experience an increased risk for HCC. HBV antiviral therapy is recommended for patients with active hepatitis and cirrhosis.

METHODS

Monitoring and treatment of adults with new CHB diagnoses were analyzed using Optum Clinformatics Data Mart Database claims data from January 1, 2016, to December 31, 2019.

RESULTS

Among 5978 patients with new CHB diagnosis, only 56% with cirrhosis and 50% without cirrhosis had claims for≥1 ALT and either HBV DNA or HBeAg test, and among patients recommended for HCC surveillance, 82% with cirrhosis and 57% without cirrhosis had claims for≥1 liver imaging within 12 months of diagnosis. Although antiviral treatment is recommended for patients with cirrhosis, only 29% of patients with cirrhosis had≥1 claim for HBV antiviral therapy within 12 months of CHB diagnosis. Multivariable analysis showed patients who were male, Asian, privately insured, or had cirrhosis were more likely (P<0.05) to receive ALT and either HBV DNA or HBeAg tests and HBV antiviral therapy within 12 months of diagnosis.

CONCLUSION

Many patients diagnosed with CHB are not receiving the clinical assessment and treatment recommended. A comprehensive initiative is needed to address the patient, provider, and system-related barriers to improve the clinical management of CHB.

Improving Long-Term Adherence to Monitoring/Treatment in Underserved Asian Americans with Chronic Hepatitis B (CHB) through a Multicomponent Culturally Tailored Intervention: A Randomized Controlled Trial

BACKGROUND

Although Asian Americans make up 6% of the U.S. population, they account for 58% of Americans with chronic hepatitis B (CHB). Yet, adherence to monitoring and antiviral treatment guidelines among Asian American CHB patients remains suboptimal.

METHODS

The purpose of this study was to evaluate the efficacy of a multicomponent intervention on adherence to CHB monitoring among Asian Americans with CHB. The intervention components included virtual patient education, patient navigation, and mobile health reminders delivered by bilingual community health educators. Chi-square test and t-test were used to compare demographic characteristics and two CHB measures: CHB clinical follow-up and CHB laboratory monitoring by the time of the 12-month follow-up assessment. A generalized linear mixed-effects model (GLMM) was fitted to assess the effectiveness of the intervention.

RESULTS

The study sample consisted of 358 Chinese and Vietnamese Americans living with CHB, including 181 in the intervention group and 177 in the control group. The intervention group had a significantly higher rate of CHB clinical follow-up (86.2%) and CHB laboratory monitoring (79.0%) than did the control group (54.2% and 45.2%, respectively). Results of the GLMM showed significant intervention effects on CHB clinical follow-up (odds ratio = 7.35, 95% confidence interval = 4.06-13.33) and CHB laboratory monitoring (odds ratio = 6.60, 95% confidence interval = 3.77-11.56) at the 12-month follow-up assessment.

CONCLUSION

The multicomponent intervention was effective in improving adherence to CHB monitoring among Asian Americans. Additional implementation research is needed to better understand and apply effective interventions to other underserved populations.

Comparison of screening strategies with two new tests to score and diagnose varices needing treatment

BACKGROUND AND AIMS

We aimed to improve non-invasive screening of varices needing treatment (VNT) and compare different screening strategies.

METHODS

2,290 patients with chronic liver disease were included in a retrospective study. Etiologies were: virus: 50.0%, NAFLD: 29.5%, alcohol: 20.5%, VNT: 14.9%. Test descriptors were performance (spared endoscopy) and safety (missed VNT). VNT tests were evaluated according to their safety levels either for individual screening (95% negative predictive value (NPV)), population screening (95% sensitivity) or undifferentiated screening (100% sensitivity/NPV) without missed VNT. The tests provided three categories: missed VNT <5%, VNT 100% specificity (new category), both sparing endoscopies, and intermediate (endoscopy required).

RESULTS

Independent VNT predictors (etiology, sex, age, platelets, prothrombin index, albumin, ALT, liver stiffness) were included in two tests: VNT virus alcohol NAFLD test (VANT) and varice risk score (VARS). We report results of the whole population. Considering population screening, performances were, Baveno VI criteria: 24.1%, Anticipate: 24.7%, VariScreen: 35.3%, VANT: 40.2% (p<0.001 vs other tests). VANT spared 58.0% more endoscopies in the whole population than Baveno criteria in compensated advanced chronic liver diseases. Considering individual screening, VARS performance was, in all patients: 62.0% vs 42.9% for the expanded Baveno VI criteria (p<0.001), and, in NAFLD: 72.8% vs 65.1% for the NAFLD cirrhosis criteria (p<0.001). Considering undifferentiated screening, VARS performance was 12%. The VARS score estimated VNT probability from 0 to 100% (AUROC: 0.826).

CONCLUSION

VANT and VARS spared from 12% (undifferentiated screening) to 40% (population screening) or 62% (individual screening) of endoscopies in main-etiology patients without ascites.

Examining the Influencing Factors of Chronic Hepatitis B Monitoring Behaviors among Asian Americans: Application of the Information-Motivation-Behavioral Model

Background: Compared to non-Hispanic whites, Asian Americans are 60% more likely to die from the disease. Doctor visitation for chronic hepatitis B (CHB) infection every six months is an effective approach to preventing liver cancer. Methods: This study utilized baseline data from an ongoing randomized controlled clinical trial aimed at improving long-term adherence to CHB monitoring/treatment. Guided by the information-motivation-behavioral skills (IMB) model, we examined factors associated with CHB monitoring adherence among Asian Americans with CHB. Multivariable logistic regression was conducted to test the associations. Results: The analysis sample consisted of 382 participants. Multivariable logistic regression showed that HBV knowledge (OR = 1.24, p < 0.01) and CHB-management motivation (OR = 1.06, p < 0.05) are significant predictors of having a doctor’s visit in the past six months. Both factors were positively associated with the likelihood of having had blood tests for HBV in the past six months. Conclusion: We found that greater HBV-related knowledge and CHB-management motivation are significantly associated with performing CHB-monitoring behaviors in the past six months. The findings have critical implications for the development and implementation of evidence-based interventions for CHB monitoring and liver cancer prevention in the Asian American community.

Low eligibility for hepatitis B treatment in the Brazilian public health system

BACKGROUND

Chronic hepatitis B (CHB) affects 257 million people worldwide. However, the proportion of patients eligible for treatment in the public health system has not been established. This study describes the clinical and laboratory profiles of untreated CHB patients and estimates the eligibility rate for antiviral therapy in accordance with the Brazilian Clinical Protocol and Therapeutic Guidelines.

METHODS

Records of 670 CHB patients were collected from May 2012 to September 2013 in Minas Gerais. Data from each patient were analyzed by hepatitis B virus (HBV) management.

RESULTS

461 CHB patients were treatment-naive. Of these, 23 were HBeAg-positive, 352 were HBeAg-negative, and 14 were clinically diagnosed with cirrhosis. Periodic monitoring was performed in only three patients. However, 9.3% of untreated patients met the eligibility criteria for HBV treatment.

CONCLUSIONS

Few CHB patients were active carriers and eligible candidates for antiviral therapy. This study revealed inadequate pre-treatment conduct in the Brazilian public health system, emphasizing the need for regular laboratory follow-up for patients initially not eligible for treatment. Such information may indirectly subsidize the planning and improvement of actions and services related to optimal HBV management in the public sphere.