研究發現乙肝的治療嚴重不足

StephenW

Hepatology in Focus

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.”

StephenW

重點肝病

2021年2月19日
研究發現乙肝的治療嚴重不足

一項新的研究發現，在所有符合治療條件的慢性乙型肝炎患者中，幾乎有一半沒有得到該疾病的治療。

研究人員說，這項研究得到了構成該分析基礎的大型，多族裔多中心研究的支持。

“我們知道，乙型肝炎主要是一種影響少數族裔以及服務不足和脆弱人群的疾病，”位於斯坦福的斯坦福大學醫學院退伍軍人事務部帕洛阿爾托醫療體系的醫學博士，醫學博士Robert Wong說。加利福尼亞州。“許多數據表明，由於對乙肝的認識不足，篩查，診斷和[護理]相關性欠佳，因此對乙肝的診斷仍不足。”

Wong的研究集中於已經被診斷出患有乙型肝炎的患者。“這被認為是垂手可得的結果，因為這些患者已經被診斷出，但是在接受一連串的護理過程中繼續經歷延誤抗病毒治療，”他說。
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研究人員評估了5157例慢性乙型肝炎成年人，他們在2010年1月1日至2015年12月31日期間參加了四個城市安全網衛生系統的隨訪，至少隨訪了兩年。該疾病已通過實驗室數據證實。使用美國肝病研究協會的標準來確定治療資格。

Wong對《胃腸病學和內窺鏡新聞》說：“該組的多樣性絕對是一個優勢，因為以前的許多乙型肝炎研究主要是亞洲人。” “但是我們實際上捕獲了非常多樣化的乙肝人群：非裔美國人佔34.6％，非西班牙裔白人佔35.7％，西班牙裔佔7.7％。”

在這些患者中，有46.8％的患者有資格接受治療，其中男性的治療資格顯著高於女性（58.2％對32.9％； P <0.001）。在種族和族裔中發現了相似的合格率。

在2020年國際肝病大會（摘要FRI404）上進行的一項研究中，研究人員報告說，只有55.7％的符合治療條件的患者接受了慢性乙型肝炎的治療。在這一組中，只有17.5％的患者在符合資格的六個月內接受了治療。

研究人員稱，患有可治療疾病的女性接受治療的可能性明顯低於男性（41.2％比62.5％； P <0.01）。與白人相比，亞洲人接受治療的可能性明顯更高（49.5％比39.1％； P <0.01）。

Wong說：“這凸顯了我們錯過的機會，以及我們為乙肝患者提供醫療服務的差距。” “我們相信，這可以確定我們可以製定針對性的質量改進計劃以嘗試解決這些缺點的領域。”

他說，這些努力包括改善與高危人群的護理聯繫，提高患者和醫護人員對治療指南的認識，以及針對患者的一般乙肝教育努力。

對治療的依從性差可能是全面護理的另一個障礙。 Wong表示：“在這種情況下，採取全面的方法可以有所幫助-以提供者，疾病和衛生系統為目標，並投資於以患者為中心的教育和參與。” “我們在以前的工作中使用了這種方法，發現它實際上導致了更好的隨訪並提高了治療率。”

黃說，未來的努力可能包括前瞻性質量改進研究。他說：“現在，我們已經確定了問題所在，我們想評估如何改善這一問題。” “因此，我們和其他人正在計劃進行前瞻性研究，以了解我們如何更好地確定，參與和改善這些乙型肝炎患者的治療率。我認為，這麼低的人數真的使我們感到尖叫，我們需要投入更多的資源來解決安全網和弱勢人群中乙肝治療率低的問題。”

美國加州大學洛杉磯分校戴維·格芬醫學院的醫學和外科教授薩米·薩伯（Sammy Saab）博士說，研究結果呼籲採取行動，確定治療的障礙，並製定將治療方案擴展到治療的方法。慢性乙型肝炎患者的範圍更廣。

“我們需要改善教育。人們需要了解乙型肝炎是一種致癌物，也是肝硬化和肝癌的主要原因。”薩博說。 “我們還需要教育他們，我們擁有安全，有效和可耐受的出色療法。我們需要進行更多研究，以找出這些障礙存在於何處，無論是在患者級別，辦公室級別，藥房級別，保險級別還是醫生級別。”