VA Fails to Follow Guidelines on Hepatitis B Follow-Up Testing Rates, Treatment

By Brenda L. Mooney

BOSTON – Rates of serologic testing for hepatitis B (HBV) at the VA fail to meet levels recommended by the American Association for the Study of Liver Diseases (AASLD) practice guideline, according to new research.

Researchers from the Philadelphia VAMC and the University of Pennsylvania presented the findings at the annual AASLD meeting in Boston recently.1

“While other chronic viral infections, such as hepatitis C and HIV, have received tremendous educational efforts,” said principal investigator David E. Kaplan, MD, MSc. “Hepatitis B has received far less attention, particularly outside communities with high numbers of immigrants from endemic regions.”

For the study, Kaplan and his co-authors used the VA’s Corporate Data Warehouse to determine that, although only 1% of veterans (26,727) tested positive for hepatitis B between 2002 and 2014, HBV infection is as much as four times as common among VA-treated veterans as in the general population of the United States.

While the Hepatitis B Surface Antigen (HBsAg) is the first test for detecting hepatitis B, a positive result requires additional testing, according to the AASLD practice guidelines. Yet, for the more than 2.5 million veterans who had the HBsAg test, follow-up screening was not performed as frequently as recommended, including the alanine aminotransferase (ALT) and HBV DNA tests.

In those who were further tested, meanwhile, antiviral therapy was used only 25% of the time.

“Chronic HBV infection is approximately 4 times more common in the veteran population than in the general U.S. population,” the authors concluded. “Among HBsAg+ veterans, the rates of serologic testing as recommended by the AASLD for treatment stratification were suboptimal. Among those tested, adherence to treatment guidelines was low, particularly for HBeAg-negative individuals. These data suggest that significant provider education and improvement in clinical processes are needed to improve provider adherence to testing and treatment guidelines.”

“Of those individuals that we can determine ought to be treated based on HBeAg, ALT and HBV DNA criteria,” Kaplan added, “only about 60% of individuals for whom treatment would likely be appropriate actually receive treatment. Individuals referred to a specialist were significantly more likely to receive treatment. Given low referral rates, these data are not surprising.”

Of the 2,643,089 veterans who underwent HBsAg screening, 50,109 (1.9%) tested positive, with more than 95% of them new diagnoses, according to study results.

The median age of new HbsAg positive veterans was 53, and 88.6% were male. In terms of ethnicity and race, 46.6% were white, 31.4% black, 2.4% Asian, 0.2% Hispanic, and 16% had unreported ethnicity.

Among the patients who tested positive with the initial screening, 17.2% received testing for HBcIgM, 23.7% for HBeAg, 20.7% for HBeAb, 78.2% for HCV Ab, 33.2% for HIV Ab, 4.1% for HDVAb or HDV RNA, and 14.2% had HBV DNA PCR testing.

Overall, 6,605 of 47,622 patients (13.8%) received antiviral therapy. Results also showed that, of the 13,144 patients with ALT >2x ULN (62 IU/ml), only 21.3% received antiviral therapy; of the HBeAg+ patients with HBV DNA >20,000 IU/ ml, 72.2% received antiviral therapy. In patients with HBeAg-hepatitis and HBV DNA > 2000IU/ml, only 34.7% received antiviral therapy.

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