Ying Wu1, Kara B Johnson1, Giorgio Roccaro2, Joanna Lopez2, Hui Zheng3, Anthony Muiru2, Nneka Ufere2, Ruma Rajbhandari1, Omar Kattan2, Raymond T Chung1. 1. 1] Liver Center and Gastroenterology Division, Massachusetts General Hospital, Boston, Massachusetts, USA [2] Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA [3] Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA. 2. 1] Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA [2] Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA. 3. 1] Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA [2] Biostatistics Center, Massachusetts General Hospital, Boston, Massachusetts, USA.
Abstract
OBJECTIVES: Adherence to the American Association for the Study of Liver Disease (AASLD) guidelines for the management of chronic hepatitis B (CHB) has not been systematically assessed. We sought to comprehensively evaluate adherence to five key areas of these guidelines. We also evaluated physician and patient factors underlying nonadherence, and predictors of nonadherence such as physician type, patient demographic factors, and phase of CHB infection. METHODS: Nine hundred and sixty-two adult patients were retrospectively identified. Each patient chart was reviewed in detail. The primary outcome was adherence to five areas of the AASLD guidelines: (i) timely alanine aminotransferase (ALT)/hepatitis B virus DNA level checks needed to monitor inactive carrier and immune-tolerant phases; (ii) liver biopsy to guide decisions on initiating treatment; (iii) treatment initiation when indicated; (iv) hepatocellular carcinoma (HCC) screening; (v) testing for hepatitis A virus (HAV) immunity, HIV, and hepatitis C virus (HCV) co-infections. RESULTS: Sixty percent did not undergo clinically indicated liver biopsies, largely owing to physician nonadherence. Eighty-nine percent of these missed biopsies were needed to further assess possible e-antigen-negative CHB. A high treatment initiation rate was found for the treatment eligible, but 121 patients had unclear treatment eligibility as they warranted, but did not undergo, liver biopsy. Forty-five percent did not have timely HCC screening, although gastroenterology physicians had the highest odds of adherence, and 29% did not have timely CHB lab assessment; patients seen by gastroenterologists had twice the odds compared with primary care physicians of undergoing timely lab monitoring. Thirty-five, 24, and 54% were not tested for HAV, HCV, and HIV co-infections. CONCLUSIONS: Our findings show remarkably poor adherence to AASLD guidelines, particularly in the areas of liver biopsy, timely HCC and ALT monitoring, and testing for co-infection. These findings call for greater efforts to meet physician knowledge gaps, incorporation of decision support tools, and improved communication among providers.
OBJECTIVES: Adherence to the American Association for the Study of Liver Disease (AASLD) guidelines for the management of chronic hepatitis B (CHB) has not been systematically assessed. We sought to comprehensively evaluate adherence to five key areas of these guidelines. We also evaluated physician and patient factors underlying nonadherence, and predictors of nonadherence such as physician type, patient demographic factors, and phase of CHB infection. METHODS: Nine hundred and sixty-two adult patients were retrospectively identified. Each patient chart was reviewed in detail. The primary outcome was adherence to five areas of the AASLD guidelines: (i) timely alanine aminotransferase (ALT)/hepatitis B virus DNA level checks needed to monitor inactive carrier and immune-tolerant phases; (ii) liver biopsy to guide decisions on initiating treatment; (iii) treatment initiation when indicated; (iv) hepatocellular carcinoma (HCC) screening; (v) testing for hepatitis A virus (HAV) immunity, HIV, and hepatitis C virus (HCV) co-infections. RESULTS: Sixty percent did not undergo clinically indicated liver biopsies, largely owing to physician nonadherence. Eighty-nine percent of these missed biopsies were needed to further assess possible e-antigen-negative CHB. A high treatment initiation rate was found for the treatment eligible, but 121 patients had unclear treatment eligibility as they warranted, but did not undergo, liver biopsy. Forty-five percent did not have timely HCC screening, although gastroenterology physicians had the highest odds of adherence, and 29% did not have timely CHB lab assessment; patients seen by gastroenterologists had twice the odds compared with primary care physicians of undergoing timely lab monitoring. Thirty-five, 24, and 54% were not tested for HAV, HCV, and HIV co-infections. CONCLUSIONS: Our findings show remarkably poor adherence to AASLD guidelines, particularly in the areas of liver biopsy, timely HCC and ALT monitoring, and testing for co-infection. These findings call for greater efforts to meet physician knowledge gaps, incorporation of decision support tools, and improved communication among providers.
Authors: Miguel Malespin; Shirley Wong; Fabiolla Siqueira; Brian Luc; Benjamin Ravaee; Charles Vainder; Scott J Cotler Journal: J Clin Gastroenterol Date: 2012-09 Impact factor: 3.062
Authors: Sue Zhang; Jessica T Ristau; Huy N Trinh; Ruel T Garcia; Huy A Nguyen; Mindie H Nguyen Journal: Dig Dis Sci Date: 2012-03-31 Impact factor: 3.199
Authors: C Cohen; S D Holmberg; B J McMahon; J M Block; C L Brosgart; R G Gish; W T London; T M Block Journal: J Viral Hepat Date: 2010-12-08 Impact factor: 3.728
Authors: F M Sanai; A Helmy; K I Bzeizi; M A Babatin; A Al-Qahtani; H A Al-Ashgar; A S Al-Mdani; A Al-Akwaa; S Almutharea; M Q Khan; A S Alghamdi; T Farah; W Al-Hamoudi; M Saadeh; A A Abdo Journal: J Viral Hepat Date: 2011-03-01 Impact factor: 3.728
Authors: Jessica P Hwang; Aimee K Roundtree; Joan C Engebretson; Maria E Suarez-Almazor Journal: J Gen Intern Med Date: 2010-01-05 Impact factor: 5.128
Authors: Jia Li; Stuart C Gordon; Loralee B Rupp; Talan Zhang; Sheri Trudeau; Scott D Holmberg; Anne C Moorman; Philip R Spradling; Eyasu H Teshale; Joseph A Boscarino; Yihe G Daida; Mark A Schmidt; Mei Lu Journal: J Gastroenterol Hepatol Date: 2017-06 Impact factor: 4.029
Authors: Keith C K Lau; Abdel Aziz Shaheen; Alexander A Aspinall; Tazuko Ricento Ba; Kamran Qureshi Mba; Stephen E Congly; Meredith A Borman; Saumya Jayakumar; Bertus Eksteen; Samuel S Lee; Laura Stinton; Mark G Swain; Kelly W Burak; Carla S Coffin Journal: CMAJ Open Date: 2017-06-06
Authors: Linda C Harlan; Helen M Parsons; Charles L Wiggins; Jennifer L Stevens; Yehuda Z Patt Journal: Liver Cancer Date: 2015-03 Impact factor: 11.740
Authors: Matthew S Chang; J Frank Wharam; Fang Zhang; Robert F LeCates; Emma Morton-Eggleston; Ruth E Tuomala; Anna E Rutherford; Muthoka L Mutinga; Karin L Andersson; Robert S Brown; Chinweike Ukomadu; Emily Oken Journal: J Clin Gastroenterol Date: 2019 Nov/Dec Impact factor: 3.062
Authors: Matthew S Chang; Ruth Tuomala; Anna E Rutherford; Muthoka L Mutinga; Karin L Andersson; Blaire E Burman; Robert S Brown; Emily Oken; Chinweike Ukomadu Journal: Am J Obstet Gynecol Date: 2014-09-30 Impact factor: 8.661