Evaluation of a Program to Improve Linkage to and Retention in Care Among Refugees With Hepatitis B Virus Infection

Three U.S. Cities, 2006-2018

Janine Young; Colleen Payton; Patricia Walker; Daniel White; Megan Brandeland; Gayathri S. Kumar; Emily S. Jentes; Ann Settgast; Malini DeSilva

Disclosures

Morbidity and Mortality Weekly Report. 2020;69(21):647-650. 

In This Article

Abstract and Introduction

Abstract

An estimated 257 million persons worldwide have chronic hepatitis B virus (HBV) infection.[1] CDC recommends HBV testing for persons from countries with intermediate to high HBV prevalence (≥2%), including newly arriving refugees.[2] Complications of chronic HBV infection include liver cirrhosis and hepatocellular carcinoma, which develop in 15%–25% of untreated adults infected in infancy or childhood.[3] HBV-infected patients require regular monitoring for both infection and sequelae. Several studies have evaluated initial linkage to HBV care for both refugee and nonrefugee immigrant populations,[4–9] but none contained standardized definitions for either linkage to or long-term retention in care for chronic HBV–infected refugees. To assess chronic HBV care, three urban sites that perform refugee domestic medical examinations and provide primary care collaborated in a quality improvement evaluation. Sites performed chart reviews and prospective outreach to refugees with positive test results for presumed HBV infection during domestic medical examinations. Linkage to care (29%–53%), retention in care (11%–21%), and outreach efforts (22%–71% could not be located) demonstrated poor access to initial and ongoing HBV care. Retrospective outreach was low-yield. Interventions that focus on prospective outreach and addressing issues related to access to care might improve linkage to and retention in care.

Patients with a positive HBV surface antigen (HBsAg) test result during domestic medical examinations were included in the quality improvement evaluation; this result was used as a proxy for presumed chronic HBV infection. For patients not receiving optimal HBV care as defined by each clinic, trained personnel performed phone outreach using standardized phone scripts and certified medical interpreters. The script queried patients about HBV care, included HBV education, and emphasized the need for follow-up. Patients were advised to reestablish care with a primary care provider if they were living outside clinic catchment areas and not in care. Sites sent scripted messages on HBV best practices to primary care providers within their health systems if their patients were lost to follow-up or not receiving optimal HBV care.

From 2006 through 2012, a state-based public health refugee medical screening clinic in Denver, Colorado, (clinic A) performed domestic medical examinations and provided follow-up care for a proportion of persons screened. All clinic A patients with positive test results for HBsAg were referred to a gastrointestinal (GI) specialist for ongoing management. Chart reviews and telephone outreach for patients with positive test results for HBsAg were conducted during 2016–2018 to determine whether patients were up to date with laboratory testing. Persons who were not up to date were offered follow-up appointments; an online search database was used to find current telephone numbers for those who could not be contacted. A nurse updated problem lists in patient charts with chronic hepatitis B diagnoses.

Clinic B, in St. Paul, Minnesota, performed domestic medical examinations and provided follow-up primary and ongoing HBV care for some patients, although patients might also have received ongoing hepatitis B care through GI specialists. Patients with domestic medical examinations performed during 2008–2017 who were aged ≥18 years at the start of the quality improvement project and had received medical care within the health system during the previous 3 years were included. During 2017, chart reviews were performed to determine whether patients were up to date with laboratory testing and liver ultrasound and had at least one appointment with a GI specialist. Initial linkage to HBV care was not evaluated at clinic B because the standard of care was to obtain alanine aminotransferase (ALT) levels and HBsAg testing for all patients and reflex laboratories (i.e., HBeAg, hepatitis B e-antibody [HBeAb], hepatitis B core antibody [HBcAb], and HBV DNA) for patients with positive test results for HBsAg; hepatitis B education was provided to patients with positive test results for HBsAg at the second visit.

Clinic C, in Philadelphia, Pennsylvania, conducted domestic medical examinations and provided follow-up care. Patients with domestic medical examinations performed during 2007–2018 were included in the analysis. Refugees with positive test results for HBsAg were followed by a primary care provider, a GI specialist, or an infectious disease specialist for ongoing hepatitis B care. Chart reviews were performed to determine whether patients were up to date with laboratory tests and appointments. Telephone outreach to patients not receiving optimal hepatitis B care was conducted from 2017 through 2018.

All sites received an Institutional Review Board waiver based on quality improvement designation. A CDC human subjects advisor determined that this project did not meet the definition of research under 45 CFR 46.102(d).*

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