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