Friday, August 9, 2013

Physicians infrequently adhere to hepatitis vaccination guidelines for chronic liver disease

PLoS One. 2013 Jul 26;8(7):e71124. doi: 10.1371/journal.pone.0071124. Print 2013.

Physicians infrequently adhere to hepatitis vaccination guidelines for chronic liver disease

Thudi K, Yadav D, Sweeney K, Behari J.

Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America.

Hepatitis A (HAV) and hepatitis B (HBV) vaccination in patients with chronic liver disease is an accepted standard of care. We determined HAV and HBV vaccination rates in a tertiary care referral hepatology clinic and the impact of electronic health record (EHR)-based reminders on adherence to vaccination guidelines.

We reviewed the records of 705 patients with chronic liver disease referred to our liver clinic in 2008 with at least two follow-up visits during the subsequent year. Demographics, referral source, etiology, and hepatitis serology were recorded. We determined whether eligible patients were offered vaccination and whether patients received vaccination. Barriers to vaccination were determined by a follow-up telephone interview.

HAV and HBV serologic testing prior to referral and at the liver clinic were performed in 14.5% and 17.7%; and 76.7% and 74% patients, respectively. Hepatologists recommended vaccination for HAV in 63% and for HBV in 59.7% of eligible patients. Patient demographics or disease etiology did not influence recommendation rates. Significant variability was observed in vaccination recommendation amongst individual providers (30-98.6%), which did not correlate with the number of patients seen by each physician. Vaccination recommendation rates were not different for Medicare patients with hepatitis C infection for whom a vaccination reminder was automatically generated by the EHR. Most patients who failed to get vaccination after recommendation offered no specific reason for noncompliance; insurance was a barrier in a minority.

Hepatitis vaccination rates were suboptimal even in an academic, sub-speciality setting, with wide-variability in provider adherence to vaccination guidelines.

Hepatitis A and hepatitis B are amongst the most common infectious diseases worldwide [1], [2]. Superinfection with hepatitis A virus (HAV) or hepatitis B virus (HBV) in patients with underlying chronic liver disease is associated with a higher risk of morbidity and mortality [3], [4], [5]. Both HAV and HBV infections are preventable by highly effective and safe vaccines [6], [7], [8], [9]. Experts have recommended screening for susceptibility to HAV and HBV infection and vaccination against them for all patients with chronic liver disease [10], [11]. The CDC and several professional societies have also recommended vaccination against HAV and HBV for susceptible patients with chronic liver disease. In 2008, Centers for Medicare and Medicaid Services (CMS) proposed HAV and HBV vaccination for eligible patients with chronic hepatitis C infection (HCV) as a quality measure [12], [13], [14], [15].

Prior studies have demonstrated shortcomings in adherence to vaccination guidelines in specific subgroups of patients with chronic liver disease in the United States and around the world. In a study of patients with chronic hepatitis C infection in a Veterans Administration Healthy System in California, an adherence rate of 71% for HAV and 70% for HBV and 62% for both vaccination was found [16]. Similarly, in a large cohort of HCV patients from the Department of Veterans Affairs quality measure of HAV and HBV vaccination or documentation of immunity were met in just 57% and 45.5% patients, respectively [17]. A study of patients with autoimmune hepatitis from Germany found vaccination rates of just 11% for HBV and 13% for HAV [18].

Given the increased focus on preventive care and advent of pay for performance models of health care delivery, it likely that adherence to vaccination guideline will be emphasized as a quality measure. Low adherence to vaccination guidelines in primary care settings has been documented [19]. However, limited data are available on whether specialists that care for chronic liver disease patients perform better on these quality measures than community physicians [19]. Furthermore, it is also unknown whether adoption of electronic health records (EHR) and introduction of CMS-mandated quality measures reporting has affected physician practice patterns in terms of adhering to hepatitis vaccination guidelines.

Therefore, the objectives of this study were: (1) To evaluate adherence to hepatitis vaccination guidelines in patients with chronic liver disease at a tertiary care hepatology clinic, (2) to identify barriers to vaccinations in patients with chronic liver disease, and (3) to determine physician variability in adherence to vaccination guidelines......

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