Improving Healthcare Systems to Reduce Healthcare Disparities in Viral Hepatitis

Improving Care for Patients with Chronic Hepatitis B via Establishment of a Disease Registry

In the United States, there is poor clinician adherence to the American Association for the Study of Liver Disease and other guidelines for chronic hepatitis B virus (CHB) management. This prospective cohort study evaluated whether a CHB registry improves CHB management. We included patients with CHB aged ≥ 18 years and who had a clinical encounter during September 1, 2016–August 31, 2019. We divided patients into three groups based on care received before September 1, 2019: 1) CIH: primary care clinician at HealthPartners Center for International Health, 2) GI: not CIH and seen by gastroenterology within previous 18 months, and 3) primary care (PC): not CIH and not seen by gastroenterology within previous 18 months. We created and implemented a CHB registry at CIH that allowed staff to identify and perform outreach to patients overdue for CHB management. Patients with laboratory testing (i.e., alanine transaminase and hepatitis B virus DNA) and hepatocellular carcinoma screening in the previous 12 months were considered up to date (UTD). We compared UTD rates between groups at baseline (September 1, 2019) and pilot CHB registry end (February 28, 2020). We evaluated 4,872 patients, 52% of whom were female: 213 CIH, 656 GI, and 4,003 PC. At baseline, GI patients were most UTD (69%) followed by CIH (51%) and PC (11%). At pilot end the percent of UTD patients at CIH increased by 11%, GI decreased by 10%, and PC was unchanged. CHB registry use standardized care and increased the percent of CHB patients with recent laboratory testing and HCC screening.

Exploring factors associated with hepatitis B screening in a multilingual and diverse population

BACKGROUND

Racial/ethnic minorities bear a disproportionate burden of hepatitis B virus (HBV) infection and disease. Disparities in HBV screening contribute to worse outcomes for communities of color. We examined the impact of race/ethnicity, language preference, and having a usual place of care on HBV screening in a multilingual, urban cohort.

METHODS

We used questions from the Health Information National Trends Survey and added validated questions about healthcare access and health literacy. We administered this survey in English, Spanish, and Chinese to a selected convenience sample of San Francisco city/county residents in 2017, with pre-specified targets for populations with known cancer disparities: 25% Spanish-speaking, 25% Chinese-speaking, and 25% Black Americans. Using weighted multivariable logistic regression analyses, we assessed how race/ethnicity, language preference, and having a usual place of care impacts self-report of HBV screening.

RESULTS

Overall, 1027 participants completed the survey (50% of surveys administered in English, 25% in Spanish, and 25% in Chinese). Only 50% of participants reported HBV screening. In multivariable analysis, Black (OR = 0.20, 95% CI 0.08-0.49), Latinx (OR = 0.33, 95% CI 0.13-0.85), Asian (OR = 0.31, 95% CI 0.10, 0.94), and 'Other' race/ethnicity (OR = 0.17, 95% CI 0.05-0.53) respondents had lower odds of HBV screening compared to non-Hispanic White respondents. Participants who had insurance had increased odds of HBV screening (OR = 2.70, 95% CI 1.48-4.93).

CONCLUSIONS

HBV screening disparities persist for Black Americans, Asian Americans, Latinx, and the uninsured. Future studies should explore reasons why current strategies have not been implemented or are not successful, particularly in addressing racial/ethnic and insurance disparities.

Improving HCV Risk Assessment and Testing in a Federally Qualified Health Center Setting in Baltimore, Maryland

Approximately 4.1 million adults in the United States have past or current hepatitis C virus (HCV) infection. Despite efforts to test at least once for the 1945-1965 birth cohort population and others identified at risk, the completion of the annual risk assessment tool and testing of these patients has been suboptimal. The aim of this project was to reduce HCV risk assessment and testing barriers and improve both these rates by 30% within a federally qualified health center setting in Baltimore, Maryland. As part of ongoing efforts to promote HCV risk screening and testing, targeted interventions of staff education, streamlined risk screening assessment, automated electronic health record alerts, push reports, and standing orders were integrated into current screening and testing practices. This study examined the risk assessment tool use and testing rates for 1 month before and after project implementation. All patients who were seen for a primary care visit during the month preceding (n = 8911) and following (n = 8228) the intervention were evaluated. A total of 2973 risk assessments and 1831 HCV tests were completed pre-intervention compared to 3708 risk assessments and 3790 tests post-intervention, demonstrating a 35% and 125% improvement respectively. Seropositivity prevalence of 2.1% pre-intervention increased to 2.9% post-intervention. Efficiencies in workflow processes and staff education successfully impacted the HCV risk screening tool completions and testing rates for the birth cohort and non-birth cohort patients. Integrating such strategies in the primary care workflow can increase HCV detection and timely follow up for vulnerable populations.

Healthcare Disparities Identified Between Hmong and Other Asian Origin Groups Living with Chronic Hepatitis B Infection in Sacramento County 2014-2017

Chronic hepatitis B (CHB) disproportionately affects non-US born Asians. The Hmong have been shown to have the highest rates of CHB and mortality from liver cancer compared to other Asian groups. From September 2014 to September 2017, testing for CHB within Sacramento County was conducted through community-based testing events and an electronic health record alert that identified Asian patients by surname. Demographic and laboratory data were collected for analysis and patients were followed through the study period to assess linkage to care and treatment to compare differences between Asian origin groups. Of 4350 patients tested for CHB, 318 (7.3%) were HBsAg positive, including 90 Chinese, 47 Hmong, and 101 Vietnamese. Hmong were more likely to have Medicaid insurance compared to other Asian origin groups (15%, p < 0.001). Hmong had significantly lower rates of hepatitis B DNA testing (p < 0.001), referral to hepatology (p < 0.001), attendance of first (p < 0.001) and second medical visit (p = 0.0003), and lower rates of antiviral treatment compared to other Asian origin groups. Hmong also had the highest proportion of non-English speakers (p < 0.001). Hmong patients in the Sacramento CHB testing and linkage to care program experience socioeconomic disadvantages compared to Vietnamese and Chinese patients. These factors may contribute to decreased linkage of care and decreased anti-viral treatment rates for CHB.

Assessment of risk factors, and racial and ethnic differences in hepatocellular carcinoma

Despite improved screening and surveillance guidelines, significant race/ethnicity‐specific disparities in hepatocellular carcinoma (HCC) continue to exist and disproportionately affect minority and disadvantaged populations. This trend indicates that social determinants, genetic, and environmental factors are driving the epidemic at the population level. Race and geography had independent associations with risk of mortality among patients with HCC. The present review discusses the risk factors and issues related to disparities in HCC. The underlying etiologies for these disparities are complex and multifactorial. Some of the risk factors for developing HCC include hepatitis B (HBV) and hepatitis C (HCV) viral infection, nonalcoholic fatty liver disease, nonalcoholic steatohepatitis, smoking and alcohol consumption. In addition, population genetics; socioeconomic and health care access; treatment and prevention differences; and genetic, behavioral, and biological influences can contribute to HCC. Acculturation of ethnic minorities, insurance status, and access to health care may further contribute to the observed disparities in HCC. By increasing awareness, better modalities for screening and surveillance, improving access to health care, and adapting targeted preventive and therapeutic interventions, disparities in HCC outcomes can be reduced or eliminated.

Individual and neighborhood socioeconomic status in the prediction of liver transplantation among patients with liver disease: A population-based cohort study in Taiwan

Given the fact that >80% of liver transplantations (LTs) were living donor liver transplantation (LDLT) in Taiwan, we conducted this study to assess whether patients with lower socioeconomic status are subject to a lower chance of receiving hepatic transplantation.This was a cohort study including 197,082 liver disease patients admitted in 1997 to 2013, who were at higher risk of LT. Personal monthly income and median family income of living areas were used to indicate individual and neighborhood socioeconomic status, respectively. Cox proportional hazard model that considered death as a competing risk event was used to estimate subdistribution hazard ratio (sHR) of LT in association with socioeconomic status.Totally 2204 patients received LT during follow-up, representing a cumulative incidence of 1.12% and an incidence rate of 20.54 per 10 person-years. After adjusting for potential confounders, including age, sex, co-morbidity, location/urbanization level of residential areas, we found that patients with < median monthly income experienced significantly lower incidence of LT (aHR = 0.802, 95% confidence interval (CI) = 0.717-0.898), but those with >- median monthly income had significantly elevated incidence of LT (aHR = 1.679, 95% CI = 1.482-1.903), as compared to those who were not actively employed. Additionally, compared to areas with the lowest quartile of median family income, the highest quartile of median family income was also associated with significantly higher incidence rate of LT (aHR = 1.248, 95% CI = 1.055-1.478).Higher individual and neighborhood socioeconomic status were significantly associated with higher incidence of LT among patients with higher risk of LT.

Hepatitis C Virus: A Review of Treatment Guidelines, Cost-effectiveness, and Access to Therapy

Hepatitis C virus (HCV) infection remains a significant medical concern in the United States and around the world. It is still one of the leading causes of chronic liver disease, and, for more than 20 years, there has been little progress in the treatment of HCV infection. The advent of direct-acting antivirals (DAAs) initiated the era of high efficacy and well-tolerated medications with high cure rates. The efficacy of these medications has prompted many professional societies around the world to update their treatment guidelines to include DAAs as first-line treatment. Guidelines by the American Association for the Study of Liver Disease/Infectious Disease Society of America, World Health Organization, Asian-Pacific Association for the Study of Liver and the European Association for the Study of Liver have all incorporated DAAs into their treatment guidelines. Despite the promising data supporting these medications, however, their cost represents a limiting factor to their use, even though studies have shown DAAs to be cost-effective. In addition to the expense of these medications and limited resources, there are many barriers preventing patients from receiving this potentially life-saving treatment. In order to overcome these barriers, these issues need to be recognized and addressed.