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

by U.S. Medicine

January 5, 2015

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.

“Appropriate serological testing is critical for determining whether or not an individual patient meets AASLD treatment criteria for HBV,” Kaplan said. “Our and other data definitively demonstrate that antiviral therapy in appropriate individuals has a significant impact on mortality, hepatic decompensation and HCC development. Improving adherence with guidelines is likely therefore to reduce death and healthcare costs.”

He suggested that nonfederal medical systems might not be doing much better.

“We suspect that in the baby boomer population, there is a significant population of injection drug use-related chronic HBV that is undiagnosed and will not be captured by current [U.S. Preventive Services Task Force] screening guidelines. Not only is there underdiagnosis, the majority — up to 70% — of screening HBsAg tests are not followed by referral from primary care to GI or ID providers with expertise in treatment decisions.”

  1. Serper M, Forde KA, Kaplan DE. (2014, November). Serologic testing rates among US veterans with hepatitis B.Paper presented at the meeting of the American Association for the Study of Liver Diseases (AASLD), Boston, MA.

VA Patient Information on Testing for Hepatitis B

You can be tested for hepatitis B at your VA medical center. This test is done by taking a sample of your blood.

Your doctor may ask you to do the following tests:

  • Hepatitis B surface antibody(Anti-HBs)
    If this test is positive, it means that
    • you have antibodies against hepatitis B and are safe from getting the disease
    • you were either vaccinated against hepatitis B or exposed to it at some point in your lifetime
  • Hepatitis B core antibody (Anti-HBc)
    If the test is positive, it means that
    • you have been exposed to hepatitis B and have developed an antibody to only part of the virus
    • they will do more tests to find out if you have the disease
  • Hepatitis B surface antigen (HBsAg)
    If this test is positive, it means that
    • you do currently have hepatitis B infection
    • you can spread the virus to others
  • Hepatitis B e antigen (HBeAg)
    If this test is positive, it means that
    • you may have very active hepatitis B and should be followed closely by your doctor and possibly take hepatitis B medications
    • you may be very contagious to others

Source: VA viral hepatitis website

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