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Alan Franciscus
HCV Advocate

Saturday, June 1, 2013

U.S. Doctors Failing to Treat Patients Who Need Treatment

Fewer than 50% of patients infected with the hepatitis B virus (HBV) who need treatment get antivirals or interferon from their primary care doctors and fewer than 70% of patients who go to university liver clinics get appropriate treatment, according to research presented at the Digestive Disease Week medical conference held in Orlando in May.

Stanford University researchers conducted a real-life study to see what percentage of 1,976 hepatitis B patients treated in various clinical settings over four years received treatment. They used current medical guidelines when evaluating whether patients received appropriate treatment.
In their analysis:
  • 329 patients (Group 1) were treated at community primary care clinics
  • 1,268 (Group 2) were treated at community gastroenterology clinics, and
  • 379 (Group 3) were treated at university liver clinics, where one would expect treatment based on medical guidelines.
All three patient groups were similar in age, gender, and nearly all were Asian-American. Group 2 had slightly higher viral loads (HBV DNA) and Group 3 had significantly higher alanine aminotransferase (ALT) levels, which indicate liver damage.

The patients treated at specialized liver clinics had the highest treatment rates—59% of those eligible for treatment actually received it, compared to 45% at community gastroenterology clinics.
Patients treated at community primary care clinics had the lowest treatment rate—only 25% to 50% of patients who needed treatment received it.

The reasons the doctors gave for not treating patients was that patients did not ask for treatment, or because doctors wanted to continue observing the patients, or they incorrectly decided there was not sufficient liver damage to merit treatment.

Source: "Antiviral Treatment Eligibility and Treatment Rates..." by Kim, Nguyen et al. Digestive Disease Week, May 2013.

Doctors Say Poor Training and Limited Resources Contribute to Substandard Care 

Another study finds that obstetricians and nurses are so poorly trained about hepatitis B that they fail to educate even pregnant, HBV-infected women about infection prevention and treatment.

Asian Liver Center researchers at Stanford University interviewed 16 obstetricians and 17 perinatal nurses in Santa Clara County, California, which has one of the highest hepatitis B rates in the U.S., for the study published in the current issue of the Asian Pacific Journal of Cancer Prevention (Vol. 14, 2013, Issue 3).

Treating and educating pregnant women, who are nearly all screened for HBV during prenatal visits, is a high priority because fewer than half of 24,000 infants born to HBV-infected women across the U.S. each year get the proper immunization and prevention treatment to reduce mother-to-child infection. Additionally, if pregnant women with high viral loads are identified during prenatal visits and treated with antivirals, the risk of infecting newborns is dramatically reduced.

But even these doctors and nurses knew little about hepatitis B despite their patients' high risk of infection. Their medical training was inadequate, they reported, and they lacked effective educational materials for patients (especially in multiple languages). As a result, they often failed to teach patients about how the infection occurred, how it could be treated, and how it could be prevented.
If patients knew something about hepatitis B, providers were more willing to talk and educate them about the infection, but they frequently failed to teach those who appeared disinterested or fearful. In one example, a female patient asked the doctor not to mention her infection in front of her husband.

"The obstetricians and nurses perceived a stigma attached to hepatitis B that made patients reluctant to receive information and/or encourage their sexual contacts and family members to be tested for hepatitis B," researchers reported. This sense of stigma made the providers, "wary of openly discussing hepatitis B with their patients, especially if the patients were accompanied by other people."

Nurses also lamented the lack of time they had to share information about hepatitis B with patients—most of their interactions focused on childbirth and how to care and breastfeed the newborn.

This missed opportunity to educate, screen, and treat people with HBV is another example of a healthcare system that fails to address hepatitis B, researchers noted. If the healthcare system could make institutional changes to address HIV infection, it should be able to make the changes and allocate the resources needed to combat hepatitis B, the doctors and nurses noted.

As noted in a recent Institute of Medicine report, "the surveillance system for viral hepatitis in the United States is poorly funded, incomplete, inadequate for follow-up of recently-diagnosed cases, and insufficiently informative for policymakers to best allocate resources for viral hepatitis prevention and control programs."

This study underscores the need for improved provider education and institutional changes to better care for people with hepatitis B, so that "both providers and patients can be empowered with the knowledge, skills and attitudes to prevent perinatal transmission of hepatitis B and promote long-term care of hepatitis B among (infected) women."

Source: "Education and Counseling..." by Yang, Cheung et al. APJPC vol 14.3, 2013


Christine Kukka, HBV Project Manager, HBV Advocate

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