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.
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.
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.
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.
KeywordsHepatitis B virus Antiviral therapy Treatment guidelines US Panel algorithm AASLD guideline
American Association for the Study of Liver Diseases
Chronic hepatitis B
Hepatitis B e antigen
Hepatitis B virus
Primary care physician
Lily H. Kim was supported in part by the Human Biology Program and Undergraduate Academic Life at Stanford University.
Conflict of interest
- 3.Bosch FX, Ribes J, Cleries R, Diaz M. Epidemiology of hepatocellular carcinoma. Clin Liver Dis. 2005;9:191–211, v.Google Scholar
- 5.EASL clinical practice guidelines. Management of chronic hepatitis B virus infection. J Hepatol. 2012;57:167–185.Google Scholar
- 9.Colvin HM, Mitchell AE, Institute of Medicine (U.S.). Committee on the Prevention and Control of Viral Hepatitis Infections., Institute of Medicine (U.S.). Board on Population Health and Public Health Practice. National Academies Press (U.S.). Hepatitis and liver cancer: a national strategy for prevention and control of hepatitis B and C. Washington, DC: National Academies Press; 2010:xix.Google Scholar
- 18.Keeffe EB, Dieterich DT, Han SH, et al. A treatment algorithm for the management of chronic hepatitis B virus infection in the United States: 2008 update. Clin Gastroenterol Hepatol. 2008;6:1315–1341; quiz 1286.Google Scholar
- 22.Nguyen VG, Wan K, Trinh HN, et al. Chronic hepatitis B (CHB) treatment eligibility and actual treatment rates at community gastroenterology clinics and primary care clinics. Gastroenterology. 2012;142:S993.Google Scholar
- 32.Nguyen LH, Chao DT, Lim JK, Ayoub WS, Nguyen MN. Meta-analysis and systematic review of chronic hepatitis B with minimally elevated alanine aminotransferase (ALT): nearly half of those with ALT 1–2× upper limit of normal have significant fibrosis. Gastroenterology. 2013;144:S972–S973.Google Scholar