Sub-Optimal Linkage of Care Among Newly Diagnosed Chronic Hepatitis B Virus (HBV) Patients Despite an Integrated HBV Screening Model in the Outpatient Gastroenterology Endoscopy Unit

Abstract

Introduction: Screening high risk patients for chronic hepatitis B virus (HBV) infection is important for early diagnosis, treatment, hepatocellular carcinoma screening. Linkage of care among newly diagnosed HBV patients is not well reported, especially among underserved safety-net populations. We aim to evaluate the outcomes of a pilot model of integrated HBV testing and linkage of care among the outpatient endoscopy unit of a large ethnically diverse safety-net hospital. Methods: From July 2015-March 2016, all consecutive adults presenting for outpatient endoscopy were evaluated for risk-based HBV screening using U.S. Preventative Services Task Force guidelines. Primary outcomes included HBsAg prevalence among high risk patients offered screening, HBV DNA testing among HBsAg positive patients, and linkage of care to HBV clinic. Completion of testing was stratified by sex, ethnicity, language (English vs. non-English), and place of birth (U.S. vs foreign born) and evaluated with multivariate logistic regression. Results: Among 446 high risk patients who accepted HBV testing, 69.7% (n=311) completed testing, with higher rates of completion among women (76.0% vs. 63.1% in men, p < 0.01), foreign born patients (73.1% vs. 44.2% in US born, p < 0.001), and non-English speakers (72.9% vs. 63.9% in English speakers, p < 0.05). Hispanics (72.0%) and Asians (77.6%) also had higher rates of test completion compared to whites (33.3%), p < 0.001. On multivariate regression, men were significantly less likely to complete testing (OR 0.55, 95% CI 0.34-0.87, p < 0.001), and compared to whites, Hispanics were more likely to complete testing (OR 5.21, 95% CI 0.96-28.2, p=0.055). Among those completing testing, 82.3% completed testing on the same day, 95.8% completed testing within 1 week. Overall prevalence of HBsAg positive among those tested was 2.25%. Among newly diagnosed HBsAg positive patients, 71.4% completed HBV DNA testing (3 with detectable DNA and 2 with undetectable DNA). Among HBsAg patients that needed HBV clinic evaluation, only 60% were successfully linked to HBV care.Table 1: HBV Screening OutcomesConclusion: Among a pilot model of integrated HBV testing at an outpatient endoscopy unit of underserved safety-net populations, the prevalence of HBsAg positivity among high risk patients was 2.25%. However, sub-optimal linkage of care was observed despite this integrated approach: 30% of patients did not complete HBV DNA testing and 40% of HBsAg positive patients were not linked to HBV clinic.