— Christine M. Kukka, Project Manager, HBV Advocate
Harvard Medical School researchers found physicians at the
prestigious Massachusetts General Hospital in Boston repeatedly failed
to monitor hepatitis B patients properly in compliance with medical
guidelines defined by the American Association for the Study of Liver
Diseases - AASLD.
In an indicting report, published in the April issue of the American Journal of Gastroenterology,
researchers wrote that doctors working at Harvard's teaching hospital,
"... show remarkably poor adherence to AASLD guidelines, particularly
in the areas of liver biopsy, timely liver cancer and ALT (liver
damage) monitoring, and testing for co-infection."
Harvard researchers evaluated the charts of 962
adult hepatitis B patients treated at Mass General to see whether
doctors complied with AASLD medical guidelines in:
- Monitoring ALT levels. When liver cells are damaged or die, these liver enzymes rise above normal.
- Measuring patients' viral load to determine how active the HBV infection was
- Performing liver biopsies when needed to guide treatment decisions
- Treating patients when liver damage was evident
- Screening for liver cancer
- And testing HBV-infected patients for hepatitis A (to see if vaccination was needed), HIV and hepatitis C.
They discovered that 60% of patients did not have
liver biopsies, despite clinical signs of liver damage that should
have triggered biopsies. "Eighty-nine percent of these missed biopsies
were needed to further assess possible HBeAg-negative chronic hepatitis
B," they wrote.
Most patients who needed treatment received it,
but 121 patients who had unclear symptoms did not receive liver
biopsies, which would have clarified whether treatment was merited.
Additionally, 45% of patients did not undergo
timely liver cancer screening and 29% did not have timely blood tests
to assess liver health and hepatitis B status.
Patients treated by liver experts –
gastroenterologists – had slightly better rates of proper monitoring
than those treated by primary care physicians, but 35% of the patients
were not tested for hepatitis A, 24% weren't tested for hepatitis C,
and 54% were not tested for HIV.
"These findings call for greater efforts to meet
physician knowledge gaps, incorporation of decision support tools, and
improved communication among providers," they wrote in the April issue
of the American Journal of Gastroenterology. (1)
An unrelated study, published in the April issue of the journal of Digestive Diseases and Sciences,
evaluated the quality of care given to 12,016 hepatitis B patients
treated by the Northern California Kaiser Permanente Medical Care
Program (KPNC) from July 2009 to December 2010 and found it lacking.
About 51% of the patients visited doctors during
the study period, 14% saw gastroenterologist or infectious disease
specialists and 37% saw primary care providers.
Fewer than 40% had both viral load and ALT
testing done, as recommended by medical guidelines, and only 56% of
eligible patients received screening for liver cancer.
Liver doctors tended to comply with current
guidelines better than primary care providers, with 90% of specialists
properly screening patients versus 47% of primary care providers.
"Most patients initiated on HBV treatment met
eligibility, and very few patients with evidence of needing treatment
were left untreated," researchers from Kaiser Permanente noted.
"However, monitoring of ALT and HBV DNA levels, as well as liver cancer
surveillance, were not frequent, underestimating the proportion of
patients that warranted HBV therapy."(2)
1. Source: www.ncbi.nlm.nih.gov/pubmed/24732869
2. Source: www.ncbi.nlm.nih.gov/pubmed/24728968
HBV Journal Review
May 1, 2014, Vol 11, no 5
http://www.hbvadvocate.org/news/HBJ11.5.htmLabels: adequate monitoring, adherence to guidelines, physician awareness
