Kushner Tatyana, Lam Robert, Gray Daniel L, Kaplan David E, Serper Marina
*Division of Gastroenterology/Liver Transplant, University of California San Francisco, San Francisco, CA †Sidney Kimmel Medical College, Thomas Jefferson University ‡Gastroenterology Section, Corporal Michael J. Crescenz VA Medical Center §Division of Gastroenterology and Hepatology, Hospital of the University of Pennsylvania, Philadelphia, PA.
J Clin Gastroenterol. 2017 Nov/Dec;51(10):900-906. doi: 10.1097/MCG.0000000000000806.
To examine patient, provider, and health system barriers to clinical follow-up among US veterans with chronic hepatitis B virus (HBV).
Studies have demonstrated deficiencies in clinical care and follow-up in HBV; however, patient, provider, and health-system barriers in non-Asian populations are understudied.
A retrospective cohort of 517 US veterans with chronic HBV at 3 diverse Veterans Affairs sites from 1999 to 2015. Laboratory testing and completion of clinical appointments were collected for 2 years following initial presentation.
Among HBV patients, 36% had drug abuse, 41% alcohol misuse, and 45% had psychiatric disorders. Patients had an average of 4.4 primary care visits within 2 years of the index hepatitis B surface antigen positive result, 38% had psychiatry visits, 21% had a psychiatric hospitalization; 26% saw gastroenterology/hepatology specialists. Within 1 year of the index hepatitis B surface antigen positive result, 75% had alanine aminotransferase testing, 14% had HBV entered into the problem list, and 8% had serologic confirmation. In multivariable analyses, cirrhosis [odds ratio (OR)=3.42; 95% confidence interval (CI), 1.84-6.36] was associated with higher odds of appropriate laboratory testing, alcohol misuse (OR=0.45; 95% CI, 0.29-0.80) was associated lower odds. Cirrhosis (OR=2.03; 95% CI, 1.11-3.72) and ≥2 primary care visits per year (OR=1.06; 95% CI, 1.01-1.11) were associated with higher odds of completing gastroenterology/hepatology consultation, whereas ≥1 psychiatric hospitalization in 2 years was associated with lower odds (OR=0.53; 95% CI, 0.34-0.82).
In a diverse cohort of veterans with high psychiatric comorbidity and substance abuse, important patient and provider factors influence appropriate follow-up care. Future studies should evaluate the impact of provider education and care coordination strategies in HBV.
研究美国慢性乙型肝炎病毒（HBV）退伍军人患者、医疗服务提供者和卫生系统在临床随访方面的障碍。
研究表明，HBV的临床护理和随访存在不足；然而，非亚洲人群中的患者、医疗服务提供者和卫生系统障碍尚未得到充分研究。
对1999年至2015年期间来自3个不同退伍军人事务医疗点的517名美国慢性HBV退伍军人进行回顾性队列研究。在首次就诊后的2年内收集实验室检测结果和临床预约完成情况。
在HBV患者中，36%有药物滥用，41%有酒精滥用，45%有精神障碍。在乙肝表面抗原阳性结果的索引日期后的2年内，患者平均进行了4.4次初级保健就诊，38%进行了精神科就诊，21%有过精神科住院治疗；26%看过胃肠病学/肝病学专家。在乙肝表面抗原阳性结果的索引日期后的1年内，75%进行了丙氨酸转氨酶检测，14%将HBV列入问题清单，8%进行了血清学确认。在多变量分析中，肝硬化[比值比（OR）=3.42；95%置信区间（CI），1.84 - 6.36]与适当实验室检测的较高几率相关，酒精滥用（OR = 0.45；95% CI，0.29 - 0.80）与较低几率相关。肝硬化（OR = 2.03；95% CI，1.11 - 3.72）和每年≥2次初级保健就诊（OR = 1.06；95% CI，1.01 - 1.11）与完成胃肠病学/肝病学咨询的较高几率相关，而2年内≥1次精神科住院治疗与较低几率相关（OR = 0.53；95% CI，0.34 - 0.82）。
在一个精神疾病合并症和药物滥用率较高的退伍军人队列中，重要的患者和医疗服务提供者因素会影响适当的后续护理。未来的研究应评估医疗服务提供者教育和护理协调策略对HBV的影响。
