FEBRUARY 19, 2021
Study Sees Vast Undertreatment for Hep B
Nearly half of all treatment-eligible patients infected with chronic hepatitis B do not receive treatment for the disease, a new study has found.
The investigators said the research was bolstered by the large, ethnically diverse multicenter cohort that formed the foundation of the analysis.
“We know that hepatitis B is predominantly a disease affecting ethnic minorities, as well as underserved and vulnerable populations,” said Robert Wong, MD, MS, of the Veterans Affairs Palo Alto Health Care System and Stanford University School of Medicine, in Stanford, Calif. “Many data show that hepatitis B remains underdiagnosed due to suboptimal awareness, screening, diagnosis and linkage [to care].”
Wong’s study focused on patients who had already been diagnosed with hepatitis B. “This is sort of considered the low-hanging fruit, because these are patients who have already been diagnosed, yet continue to experience delays in progressing through the cascade of care to receive antiviral treatment,” he said.
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The researchers evaluated 5,157 adults with chronic hepatitis B who presented to four urban safety-net heath systems between Jan. 1, 2010, and Dec. 31, 2015, and who had at least two years of follow-up. The disease was confirmed with laboratory data. Criteria from the American Association for the Study of Liver Diseases were used to determine treatment eligibility.
“The diversity of the group was definitely a strong point, because many previous hepatitis B studies were predominantly Asian,” Wong told Gastroenterology & Endoscopy News. “But we actually captured a very diverse hepatitis B population: 34.6% were African American, 35.7% non-Hispanic white and 7.7% Hispanic.”
Of the patients, 46.8% were eligible for treatment, with significantly higher rates of treatment eligibility among men than women (58.2% vs. 32.9%; P<0.001). Similar rates of eligibility were found across race and ethnicity.
In a study presented at the 2020 International Liver Congress (abstract FRI404), the investigators reported that only 55.7% of treatment-eligible patients received treatment for chronic hepatitis B. Of that group, only 17.5% received treatment within six months of becoming eligible.
Women with treatment-eligible disease were significantly less likely than men to receive therapy (41.2% vs. 62.5%; P<0.01), according to the researchers. Asians were significantly more likely to be treated than whites (49.5% vs. 39.1%; P<0.01).
“This highlights a missed opportunity and a gap in our delivery of care for hepatitis B patients,” Wong said. “We believe this identifies areas where we can develop targeted quality improvement programs to try to address these shortcomings.”
Such efforts include improved linkage to care in at-risk populations, increased patient and provider awareness regarding treatment guidelines, and general hepatitis B educational efforts targeted at patients, he said.
Poor adherence to treatment can be another barrier to comprehensive care. “That’s where taking a comprehensive approach can help—one that targets providers, disease and health systems, and also invests in patient-centered education and engagement,” Wong said. “We used this approach in previous work and found it actually led to better follow-up and improved treatment rates.”
Future efforts, according to Wong, likely will include prospective quality improvement studies. “Now that we’ve identified the problem, we want to evaluate how we can improve this going forward,” he said. “So, we and others are planning prospective studies to see how we can better identify, engage and improve treatment rates for these hepatitis B patients. I think these low numbers really scream that we need to invest more resources in addressing the low rates of hepatitis B treatment in safety-net and vulnerable populations.”
Sammy Saab, MD, MPH, a professor of medicine and surgery at the David Geffen School of Medicine at the University of California, Los Angeles, said the results are a call to action to identify barriers to therapy and develop protocols that extend treatment to a broader range of patients with chronic hepatitis B.
“We need to improve education. People need to understand that hepatitis B is a carcinogen, and a major reason for cirrhosis and liver cancer,” Saab said. “We also need to educate them that we have great therapies that are safe, effective and tolerable. We need more studies to find out where these barriers exist, whether it be at the patient level, office level, pharmacy level, insurance level or physician level.”