Loo NM, Kim WR, Larson JJ, Wieland ML, Chaudhry R. Hepatitis B Screening in a US Academic Primary Care Practice. Arch Intern Med. 2012;172(19):1517-1519. doi:10.1001/archinternmed.2012.3647
Author Affiliations: Divisions of Internal Medicine (Drs Loo, Wieland, and Chaudhry), Gastroenterology and Hepatology (Dr Kim), and Biomedical Statistics and Informatics (Mr Larson), Mayo Clinic, Rochester, Minnesota.
Chronic hepatitis B virus (HBV) infection is a major cause of cirrhosis, liver failure, and hepatocellular carcinoma globally, with its highest burden in Asia.1,2 In the United States, up to 2 million persons have chronic HBV infection, of whom more than 50% are of Asian ancestry.1,3 In Asian Americans, HBV testing has been shown to be cost-effective.4 The Centers for Disease Control and Prevention recommends HBV screening in persons born in Asia in addition to their US-born children who were not vaccinated as infants.5
To date, data on HBV screening practices in the United States have been sparse and based primarily on patient and provider surveys.2,3,6,7 This study describes HBV testing in Asian Americans at an academic primary care practice and explores the reasons for lack of adherence to screening recommendations.
Mayo Clinic Rochester is a large multidisciplinary group practice that is located in Minnesota's Olmsted County. Although known for specialty care in patients referred from elsewhere, Mayo Clinic also provides a large share of primary care to local residents. Out of approximately 140 000 residents of Olmsted County, 110 000 are seen at 6 practice locations by more than 200 physicians. The latest census indicated that Asian Americans account for 5% of the population of Olmsted County,8 similar to the percentage nationally.9
Our practice incorporates a process called impanelment, whereby a designated primary care provider is assigned to an individual patient who meets certain criteria in order to maintain accountability and continuity of care. This study included patients who were impaneled from January 2005 to December 2009 and who gave research authorization and self-identified as Asian at registration.
In eligible patients, demographic and insurance information was obtained from the registration and billing data, respectively. The laboratory database was queried for any HBV serologic test and serum activities of aminotransferases between January 1994 and January 2010. This time frame was chosen based on the availability of electronic data. A chart review was performed on a 5% sample of randomly selected patients who were tested for HBV. Further details about the clinical circumstance in which the HBV testing was performed were determined.
A total of 4055 Asian Americans were impaneled for primary care from 2005 through 2009. As shown in the Table, 1377 patients underwent at least 1 serologic test for HBV, including 1242 (31%) who underwent tests for hepatitis B surface antigen and 135 who underwent other HBV tests. The remaining 2678 underwent no testing for HBV. Among those who were tested, 105 (8.5%) were positive for hepatitis B surface antigen. Compared with untested patients, older and female patients were more frequently tested. Having insurance was not associated with increased HBV testing; in fact, insured patients were tested less frequently than those without insurance (31.9% vs 58.5%, respectively; P < .01).
In the 5% random sample (n = 75) of patients, the most common reason for HBV testing was pregnancy (25%) followed by preemployment examination (12%) and other medical indications such as abnormal laboratory data, occupational exposure, or adoption. In only 1 patient, the medical record specifically indicated that the provider performed HBV testing for a screening purpose following the guideline of the Centers for Disease Control and Prevention. There were 8 other patients in whom HBV testing was performed without a specified reason. Therefore, at most, a total of 9 patients (12%) underwent HBV testing for a screening purpose. Consistent with the most common reason for testing being pregnancy, obstetrics-gynecology was the most common specialty to order HBV testing.
This study shows that (1) HBV testing in Asian Americans has been inadequate, with only 31% of primary care recipients having evidence for testing for HBV; and (2) even when appropriate HBV testing was performed, it was rarely for the purpose of screening. It is also relevant to point out that the study participants were under consistent, continuous care (impaneled) at an academic practice. Screening for HBV may be even less frequent in other settings. Although limited, previously published data report screening rates for HBV in Asian Americans to be 35% to 70%.2,3,6,7
While there may be a number of reasons for the low adherence to screening recommendations, the lack of provider awareness constitutes one of the most significant barriers. Prior studies have shown that when recommended by a physician, the patient was 2.3 times more likely to undergo HBV screening.6 Other factors such as concordant ethnicity between the provider and patient may promote HBV screening.7 We did not find insurance status to be correlated with HBV screening. A possible explanation could be the mandatory HBV screening in pregnant women that occurs independent of insurance status.
In summary, in this academic primary care practice, HBV testing has been inadequate, with an extremely low frequency of provider-initiated screening. Multifaceted approaches, including provider education and automatic reminders in electronic medical records, need to be studied to improve HBV screening in target individuals.
Correspondence: Dr Kim, Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (firstname.lastname@example.org).
Published Online: September 10, 2012. doi:10.1001/archinternmed.2012.3647
Author Contributions:Study concept and design: Loo, Kim, Wieland, and Chaudhry. Acquisition of data: Loo, Kim, Larson, and Wieland. Analysis and interpretation of data: Loo, Kim, and Larson. Drafting of the manuscript: Loo and Kim. Critical revision of the manuscript for important intellectual content: Loo, Kim, Larson, Wieland, and Chaudhry. Statistical analysis: Kim and Larson. Obtained funding: Kim. Administrative, technical, and material support: Loo, Kim, Larson, Wieland, and Chaudhry. Study supervision: Kim.
Financial Disclosure: Dr Kim is a consultant for Bristol-Myers Squibb and Gilead Sciences.
Funding/Support: This work was supported in part by a grant from the National Institute of Diabetes, Digestive, and Kidney Disease (DK-82843).