title: Poor adherence to AASLD guidelines for chronic hepatitis B Management and treatment in a large academic medical center.
abstract: OBJECTIVE
  Adherence to the American Association for the Study of Liver Disease (AASLD) guidelines for the management of chronic hepatitis B (CHB) has not been systematically assessed. We sought to comprehensively evaluate adherence to five key areas of these guidelines. We also evaluated physician and patient factors underlying nonadherence, and predictors of nonadherence such as physician type, patient demographic factors, and phase of CHB infection.
  
  
  METHODS
  Nine hundred and sixty-two adult patients were retrospectively identified. Each patient chart was reviewed in detail. The primary outcome was adherence to five areas of the AASLD guidelines: (i) timely alanine aminotransferase (ALT)/hepatitis B virus DNA level checks needed to monitor inactive carrier and immune-tolerant phases; (ii) liver biopsy to guide decisions on initiating treatment; (iii) treatment initiation when indicated; (iv) hepatocellular carcinoma (HCC) screening; (v) testing for hepatitis A virus (HAV) immunity, HIV, and hepatitis C virus (HCV) co-infections.
  
  
  RESULTS
  Sixty percent did not undergo clinically indicated liver biopsies, largely owing to physician nonadherence. Eighty-nine percent of these missed biopsies were needed to further assess possible e-antigen-negative CHB. A high treatment initiation rate was found for the treatment eligible, but 121 patients had unclear treatment eligibility as they warranted, but did not undergo, liver biopsy. Forty-five percent did not have timely HCC screening, although gastroenterology physicians had the highest odds of adherence, and 29% did not have timely CHB lab assessment; patients seen by gastroenterologists had twice the odds compared with primary care physicians of undergoing timely lab monitoring. Thirty-five, 24, and 54% were not tested for HAV, HCV, and HIV co-infections.
  
  
  CONCLUSIONS
  Our findings show remarkably poor adherence to AASLD guidelines, particularly in the areas of liver biopsy, timely HCC and ALT monitoring, and testing for co-infection. These findings call for greater efforts to meet physician knowledge gaps, incorporation of decision support tools, and improved communication among providers.
authors.affiliation: 1] Liver Center and Gastroenterology Division, Massachusetts General Hospital, Boston, Massachusetts, USA [2] Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA [3] Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.
authors.forename: Ying
authors.initials: Y
authors.lastname: Wu
authors.affiliation: 1] Liver Center and Gastroenterology Division, Massachusetts General Hospital, Boston, Massachusetts, USA [2] Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA [3] Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.
authors.forename: Kara B
authors.initials: KB
authors.lastname: Johnson
authors.affiliation: 1] Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA [2] Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.
authors.forename: Giorgio
authors.initials: G
authors.lastname: Roccaro
authors.affiliation: 1] Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA [2] Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.
authors.forename: Joanna
authors.initials: J
authors.lastname: Lopez
authors.affiliation: 1] Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA [2] Biostatistics Center, Massachusetts General Hospital, Boston, Massachusetts, USA.
authors.forename: Hui
authors.initials: H
authors.lastname: Zheng
authors.affiliation: 1] Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA [2] Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.
authors.forename: Anthony
authors.initials: A
authors.lastname: Muiru
authors.affiliation: 1] Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA [2] Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.
authors.forename: Nneka
authors.initials: N
authors.lastname: Ufere
authors.affiliation: 1] Liver Center and Gastroenterology Division, Massachusetts General Hospital, Boston, Massachusetts, USA [2] Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA [3] Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.
authors.forename: Ruma
authors.initials: R
authors.lastname: Rajbhandari
authors.affiliation: 1] Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA [2] Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.
authors.forename: Omar
authors.initials: O
authors.lastname: Kattan
authors.affiliation: 1] Liver Center and Gastroenterology Division, Massachusetts General Hospital, Boston, Massachusetts, USA [2] Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA [3] Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.
authors.forename: Raymond T
authors.initials: RT
authors.lastname: Chung
mesh_terms: D000046:Academic Medical Centers; D000328:Adult; D000368:Aged; D000410:Alanine Transaminase; D000998:Antiviral Agents / Q000627:therapeutic use*; D001706:Biopsy; D004279:DNA, Viral; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D019694:Hepatitis B, Chronic / Q000175:diagnosis / Q000188:drug therapy*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D012189:Retrospective Studies
chemical_list: D000998:Antiviral Agents; D004279:DNA, Viral; D000410:Alanine Transaminase
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