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A NEEDS ASSESSMENT AMONG PRIMARY HEALTHCARE PROVIDERS: MANAGEMENT OF CHRONIC HEPATITIS B (CHB)
J Sam, D Wong, D Wooster, J Heathcote
University of Toronto, Toronto, Ontario
Aims: To assess the knowledge base and practice patterns of primary care physicians (PCPs) regarding the management of chronic hepatitis B (CHB).
Methods: A questionnaire was developed to assess the knowledge of PCPs (family doctors and internists) regarding screening and management of patients with CHB, and referral patterns to specialists. The questionnaire was piloted among PCPs in Toronto and administered to Asian PCPs during the annual "Conference on Health Care of the Chinese in North America" to obtain their baseline knowledge. Two lectures delivered by hepatologists emphasized areas of hepatitis B knowledge addressed in the questionnaire. The questions were administered again immediately following these lectures.
Results: 30 PCPs completed the questionnaire. The majority (72%) of physicians had been in practice >15 years, with 78% in urban community practices, and with 56% knowingly seeing <5 CHB patients per month. Only 50-57% of PCPs routinely offered vaccination for hepatitis A or B virus (HAV or HBV) in those known to have no immunity. While only 30% appropriately screened "at risk" individuals for CHB, this increased to 83% (p=0.0002) after this educational event. Between 53-87% of PCPs correctly interpreted a variety of potential HBV screening test patterns. Initially, only 57% recognized that a normal ALT did not exclude significant liver disease, but this subsequently increased to 73% (p=0.0253). Despite the lectures, 30% of PCPs still believed that a normal abdominal ultrasound excluded cirrhosis. 70% recognized that cirrhosis could be asymptomatic, and this increased to 93% (p=0.0196) after the lectures. Only 27% recognized the significance of thrombocytopenia as an indicator of cirrhosis; this increased to 53% (p=0.0209) after the lectures. The majority (87%) knew when to screen for hepatocellular carcinoma in CHB. Over 80% recognized indications for treatment, namely HBeAg-positivity with high HBV DNA and high ALT, and markers for inactive disease, namely HBeAg-negativity with low HBV DNA and low ALT. While only 67% recognized HBeAg-negative chronic hepatitis as an indication for referral and treatment, this increased to 90% (p=0.0196) after the lectures.
Conclusions: Gaps in knowledge related to CHB among PCPs were particularly evident in the area of access to care. The lack of recognition of those at risk for CHB and of silent cirrhosis in our survey of Asian PCPs practicing in North America suggests that opportunities to prevent potentially life-threatening complications are being missed.