The patient, the doctor, and the system: underdiagnosis and undertreatment of hepatitis B

Diagnostic Overshadowing of Chronic Hepatitis C in People With Mental Health Conditions Who Inject Drugs: A Scoping Review

Diagnostic overshadowing refers to a phenomenon whereby people with mental health conditions encounter inadequate or delayed medical attention and misdiagnosis. This occurs when physical symptoms are mistakenly attributed to their mental health condition. This paper presents a scoping review focusing on direct causes and background factors of diagnostic overshadowing in the context of hepatitis C infection in people who inject drugs and have concurrent mental health conditions. Despite significant strides in hepatitis C treatment with direct-acting antiviral drugs, the complex interplay of mental health conditions and physical symptoms necessitates a nuanced approach for accurate diagnosis and effective screening. This review was conducted using Joanna Briggs Institute's methodology for scoping reviews. The databases searched included Medline, Embase, PsycInfo, Global Health, CINAHL and Scopus. This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). The search strategies identified 1995 records. Overall, 166 studies were excluded. Forty-two (42) studies met the inclusion criteria. Three (n = 3) studies represented direct causes, and 39 (n = 39) with background factors related to diagnostic overshadowing. Studies highlighted six key themes encompassing diagnostic overshadowing, with communication barriers, stigma and knowledge deficiencies being the most prominent. Recognising and addressing diagnostic overshadowing in chronic hepatitis C will lead to increased screening, diagnosis and timely administration of life-saving antiviral therapy, resulting in profound enhancements in well-being and health outcomes. Moreover, this proactive approach will play a pivotal role in advancing the global effort towards eliminating hepatitis C by 2030.

Patients with suboptimal hepatitis B virus diagnostic characterization are at risk of liver fibrosis progression

BACKGROUND

Many patients with chronic hepatitis B virus infection remain infradiagnosed and untreated. In a national health system with unrestricted access to treatment, our aims were to assess the level of compliance with clinical guidelines and the characteristics and risk of fibrosis progression in patients with suboptimal diagnosis.

METHODS

In a cohort of patients with positive hepatitis B surface antigen from January 2011 to December 2013, data were registered to assess characteristics and compliance with guidelines. For assessing the risk of liver fibrosis, positive hepatitis B surface antigen patients from January 2008 to December 2013 were grouped depending on DNA request. Liver fibrosis was estimated by serological scores.

RESULTS

Of 41 158 subjects with hepatitis B surface antigen request, 351 (0.9%) tested positive, and DNA was not available from 110 patients (66.4% male, mean 42.4 ± 14.5 years) after a median of 25.6 months (range 12.0-43.5). Most of these patients (76%) were assessed by primary care. Half of the patients (47.2%) showed hypertransaminasemia, at least significant fibrosis, or both conditions. After long follow-up (mean 90.1 ± 45.2 months), these patients had a higher risk of achieving at least significant fibrosis during follow-up (log-rank 8.73; P = 0.003).

CONCLUSION

In more than one-third of patients with positive hepatitis B surface antigen, DNA was not requested despite showing hypertransaminasemia and significant fibrosis. Patients without DNA request are at high risk of liver fibrosis progression. Thus, educational measures and other strategies are necessary, especially targeting primary care, to improve access to treatment.

Identifying Patient and Provider-specific Gaps in Care Among Patients With Hepatitis B

GOALS

To examine patient, provider, and health system barriers to clinical follow-up among US veterans with chronic hepatitis B virus (HBV).

BACKGROUND

Studies have demonstrated deficiencies in clinical care and follow-up in HBV; however, patient, provider, and health-system barriers in non-Asian populations are understudied.

STUDY

A retrospective cohort of 517 US veterans with chronic HBV at 3 diverse Veterans Affairs sites from 1999 to 2015. Laboratory testing and completion of clinical appointments were collected for 2 years following initial presentation.

RESULTS

Among HBV patients, 36% had drug abuse, 41% alcohol misuse, and 45% had psychiatric disorders. Patients had an average of 4.4 primary care visits within 2 years of the index hepatitis B surface antigen positive result, 38% had psychiatry visits, 21% had a psychiatric hospitalization; 26% saw gastroenterology/hepatology specialists. Within 1 year of the index hepatitis B surface antigen positive result, 75% had alanine aminotransferase testing, 14% had HBV entered into the problem list, and 8% had serologic confirmation. In multivariable analyses, cirrhosis [odds ratio (OR)=3.42; 95% confidence interval (CI), 1.84-6.36] was associated with higher odds of appropriate laboratory testing, alcohol misuse (OR=0.45; 95% CI, 0.29-0.80) was associated lower odds. Cirrhosis (OR=2.03; 95% CI, 1.11-3.72) and ≥2 primary care visits per year (OR=1.06; 95% CI, 1.01-1.11) were associated with higher odds of completing gastroenterology/hepatology consultation, whereas ≥1 psychiatric hospitalization in 2 years was associated with lower odds (OR=0.53; 95% CI, 0.34-0.82).

CONCLUSIONS

In a diverse cohort of veterans with high psychiatric comorbidity and substance abuse, important patient and provider factors influence appropriate follow-up care. Future studies should evaluate the impact of provider education and care coordination strategies in HBV.

Survey of Asian patients with hepatitis B infection: limited knowledge of transmission and screening of family members

Asian American families are disproportionately affected by Hepatitis B (HBV) infection. We aimed to assess the extent of screening family members of Asian patients with known HBV infection as well as patients' knowledge of HBV disease. A cross-sectional survey of established Asian patients with HBV-infection was performed at a university liver clinic. Outcome measures included the percentage of family members whose HBV serostatus was unknown and the percentage of patients who were able to correctly identify modes of transmission. A total of 803 US-based family members were identified by 58 patients. Patients did not know the HBV serostatus of 50% of their family members and 28% of their immediate family members. Fifty percent of participants did not know how they had acquired HBV or stated unlikely transmission modes. Though nationwide vaccination campaigns target this underrepresented population, screening family members of Asian patients with HBV remains a challenge.

Therapeutic management of chronic hepatitis B in clinical practice: a region-wide survey

GOALS

To characterize the clinical and treatment pattern in a large population of hepatitis B virus (HBV) patients managed at tertiary referral centers in clinical practice.

BACKGROUND

Successful treatment, either with interferon (IFN) or nucleos(t)ide analogs (NUCs), of chronic HBV infection is associated with improved long-term patient outcome. However, in clinical practice, the actual management of these patients is not well characterized, and data regarding treatment pattern in this setting are lacking.

METHODS

In this cross-sectional study, we evaluated 505 patients chronically infected with HBV alone and who had at least 1-year follow-up. We assessed indication to, rate of, and type of treatment as well as the characteristics of treated patients.

RESULTS

Overall prevalence of positivity for HBe antigen was 19.3%, and the majority of patients had chronic hepatitis (47.5%). Non-Italian patients represented approximately one third of the population (27.1%). Among patients with indication to antiviral therapy (n=318), treatment was actually carried out in 264 patients (83.0%), prevalently with NUCs (65.9%). IFN-treated patients were younger (P<0.001), more frequently male (P=0.025) and HBeAg positive (P=0.003), and less frequently cirrhotics (P<0.001) as compared with patients treated with NUCs.

CONCLUSIONS

In a geographical area with a low positivity for HBe antigen, antiviral therapy is actually carried out in the majority of patients who have indication to treatment, prevalently with NUCs, whereas IFN treatment is more frequently carried out in young, HBe antigen-positive patients who do not have advanced liver disease.

Low treatment rates in patients meeting guideline criteria in diverse practice settings

BACKGROUND AND AIMS

Data on usage of antiviral therapy and application of chronic hepatitis B (CHB) management guidelines in different settings are limited. Our goal is to evaluate the proportion of treatment-eligible patients by 6-month follow-up and treatment rate among eligible patients by 12-month follow-up in diverse settings.

METHODS

In this retrospective cohort study, 1,976 treatment-naïve CHB patients were categorized as primary care physician (PCP) group if seen by community PCP (n = 329), gastroenterology (GI) group if seen by community gastroenterologists (n = 1,268), and hepatology group if seen by university hepatologists (n = 379). Treatment eligibility was based on the US Panel 2008 and American Association for the Study of Liver Diseases (AASLD) 2009 guidelines.

RESULTS

All groups had similar age, gender, and ethnic distribution. GI and hepatology groups had similar treatment eligibility rates by US Panel (53-54 %) and AASLD guidelines (24-25 %). However, treatment rate was significantly higher in hepatology compared to GI group by the US Panel guideline (59 vs. 45 %, P = 0.001). PCP group had the lowest eligibility and treatment rates by both guidelines. Common reasons for non-treatment were perceived "normal" alanine aminotransferase, desire for further observation, and patient refusal. Male gender, age >50, and subspecialty care predicted treatment initiation in treatment-eligible patients.

CONCLUSIONS

Less than half of treatment-eligible patients at primary care clinics received treatment. Community gastroenterology and university liver clinics treated about one-half to two-thirds of eligible patients. Patient and provider education should highlight treatment benefits and the new alanine aminotransferase upper limit of normal.