Laboratory monitoring and antiviral treatment for chronic hepatitis B among routine care patients in the United States

We investigated factors associated with rates of recommended monitoring of chronic hepatitis B (HBV) patients for viral DNA and alanine aminotransferase (ALT), and initiation of antiviral treatment among eligible patients, in a US cohort of patients under routine care. Patients were categorised by treatment indication: definite, equivocal or ineligible. Baseline covariates included demographics, clinical characteristics and specialist care status. \u27Recommended monitoring\u27 was defined ≥1 ALT or HBV DNA test per year. Logit models, univariate then multivariable, were used to evaluate factors associated with monitoring and treatment. Among 3,830 patients, treatment was received by 67.5% (788/1168 patients) in the \u27definite\u27 category, and 34.1% (208/610 patients) in the \u27equivocal\u27 category, of whom 109 moved up to \u27definite\u27 status at some point during follow-up. Sex, age and specialist care were independently associated with receipt of treatment in \u27definite\u27 patients. Routine monitoring rates were high prior to treatment in \u27definite/ treated\u27 patients (ALT: 77%; DNA: 85%) but declined afterwards (ALT 63%; DNA 36%). Rates of monitoring were lower in \u27definite/ untreated\u27 patients (ALT: 48%; DNA: 32%). Among \u27equivocal/ treated\u27 patients, lower age and comorbidity scores were associated with receipt of treatment; ALT monitoring rates were similar before and after treatment initiation (41% and 46%, respectively), while rates of DNA monitoring declined (55% and 29%). Monitoring among \u27treatment ineligible\u27 patients was similar to those in the \u27equivocal\u27 and untreated \u27definite\u27 groups. A large proportion of US HBV patients under routine care did not receive recommended annual laboratory monitoring, especially after initiation of antiviral treatment, and nearly one-third of patients with \u27definite\u27 indications for antiviral therapy remained untreated

Trends in Cirrhosis and Mortality by Age, Sex, Race, and Antiviral Treatment Status Among US Chronic Hepatitis B Patients (2006-2016)

BACKGROUND: Changing US demographics and evolving chronic hepatitis B (CHB) treatments may affect longitudinal trends in CHB-related complications. We studied trends in the prevalence of cirrhosis (past or present) and incidence of all-cause mortality, stratified by patient age, sex, race, and antiviral treatment status, in a sample from US health care systems. METHODS: Joinpoint and Poisson regression (univariate and multivariable) were used to estimate the annual percent change in each outcome from 2006 to 2016. RESULTS: Among 5528 CHB patients, cirrhosis prevalence (including decompensated cirrhosis) rose from 6.7% in 2006 to 13.7% in 2016; overall mortality was unchanged. Overall rates of cirrhosis and mortality were higher among treated patients, but adjusted annual percent changes (aAPC) were significantly lower among treated than untreated patients (cirrhosis: aAPC +2.4% vs. +6.2%, mortality: aAPC -3.9% vs. +4.0%). Likewise, among treated patients, the aAPC for mortality declined -3.9% per year whereas among untreated patients, mortality increased +4.0% per year. CONCLUSIONS: From 2006 to 2016, the prevalence of cirrhosis among CHB patients doubled. Notably, all-cause mortality increased among untreated patients but decreased among treated patients. These results suggest that antiviral treatment attenuates the progression of cirrhosis and the risk of death among patients with CHB

Cancer and psychiatric diagnoses in the year preceding suicide

BACKGROUND: Patients with cancer are known to be at increased risk for suicide but little is known about the interaction between cancer and psychiatric diagnoses, another well-documented risk factor. METHODS: Electronic medical records from nine healthcare systems participating in the Mental Health Research Network were aggregated to form a retrospective case-control study, with ICD-9 codes used to identify diagnoses in the 1 year prior to death by suicide for cases (N = 3330) or matching index date for controls (N = 297,034). Conditional logistic regression was used to assess differences in cancer and psychiatric diagnoses between cases and controls, controlling for sex and age. RESULTS: Among patients without concurrent psychiatric diagnoses, cancer at disease sites with lower average 5-year survival rates were associated with significantly greater relative risk, while cancer disease sites with survival rates of \u3e70% conferred no increased risk. Patients with most psychiatric diagnoses were at higher risk, however, there was no additional risk conferred to these patients by a concurrent cancer diagnosis. CONCLUSION: We found no evidence of a synergistic effect between cancer and psychiatric diagnoses. However, cancer patients with a concurrent psychiatric illness remain at the highest relative risk for suicide, regardless of cancer disease site, due to strong independent associations between psychiatric diagnoses and suicide. For patients without a concurrent psychiatric illness, cancer disease sites associated with worse prognoses appeared to confer greater suicide risk

Epidemiology of Nontuberculous Mycobacterial Lung Disease and Tuberculosis, Hawaii, USA

Previous studies found Hawaiians and Asian-Americans/Pacific Islanders to be independently at increased risk for nontuberculous mycobacterial pulmonary disease (NTMPD) and tuberculosis (TB). To better understand NTM infection and TB risk patterns in Hawaii, USA, we evaluated data on a cohort of patients in Hawaii for 2005–2013. Period prevalence of NTMPD was highest among Japanese, Chinese, and Vietnamese patients (>300/100,000 persons) and lowest among Native Hawaiians and Other Pacific Islanders (50/100,000). Japanese patients were twice as likely as all other racial/ethnic groups to have Mycobacterium abscessus isolated (adjusted odds ratio 2.0, 95% CI 1.2–3.2) but were not at increased risk for infection with other mycobacteria species. In contrast, incidence of TB was stable and was lowest among Japanese patients (no cases) and highest among Filipino, Korean, and Vietnamese patients (>50/100,000). Substantial differences exist in the epidemiology of NTMPD by race/ethnicity, suggesting behavioral and biologic factors that affect disease susceptibility

Dynamic risk assessment for hepatocellular carcinoma in patients with chronic hepatitis C

Chronic hepatitis C (HCV) is a primary cause of hepatocellular carcinoma (HCC). Although antiviral treatment reduces risk of HCC, few studies quantify the impact of treatment on long-term risk in the era of direct-acting antivirals (DAA). Using data from the Chronic Hepatitis Cohort Study, we evaluated the impact of treatment type (DAA, interferon-based [IFN], or none) and outcome (sustained virological response [SVR] or treatment failure [TF]) on risk of HCC. We then developed and validated a predictive risk model. 17186 HCV patients were followed until HCC, death or last follow-up. We used extended landmark modelling, with time-varying covariates and propensity score justification and generalized estimating equations with a link function for discrete time-to-event data. Death was considered a competing risk. We observed 586 HCC cases across 104,000 interval-years of follow-up. SVR from DAA or IFN-based treatment reduced risk of HCC (aHR 0.13, 95% CI 0.08-0.20; and aHR 0.45, 95% CI 0.31-0.65); DAA SVR reduced risk more than IFN SVR (aHR 0.29, 95% CI 0.17-0.48). Independent of treatment, cirrhosis was the strongest risk factor for HCC (aHR 3.94, 95% CI 3.17-4.89 vs. no cirrhosis). Other risk factors included male sex, White race and genotype 3. Our six-variable predictive model had \u27excellent\u27 accuracy (AUROC 0.94) in independent validation. Our novel landmark interval-based model identified HCC risk factors across antiviral treatment status and interactions with cirrhosis. This model demonstrated excellent predictive accuracy in a large, racially diverse cohort of patients and could be adapted for \u27real world\u27 HCC monitoring

Suicide attempts after bariatric surgery: comparison to a nonsurgical cohort of individuals with severe obesity

BACKGROUND: The rate of suicide is higher among individuals following bariatric surgery compared with the general population; however, it is not clear whether risk is associated with bariatric surgery beyond having severe obesity. OBJECTIVE: To compare the risk of a suicide attempt among those who had bariatric surgery versus a nonsurgical cohort with severe obesity. SETTING: Aggregate count data were collected from 5 healthcare systems. METHODS: Individuals were identified in the surgical cohort if they underwent bariatric surgery between 2009 and 2017 (n = 35,522) and then were compared with a cohort of individuals with severe obesity who never had bariatric surgery (n = 691,752). Suicide attempts were identified after study enrollment date using International Classification of Diseases, Ninth and Tenth Editions (ICD-9 and ICD-10) diagnosis codes from 2009 to 2021. RESULTS: The relative risk of a suicide attempt was 64% higher in the cohort with bariatric surgery than that of the nonsurgical cohort (2.2% versus 1.3%; relative risk = 1.64; 95% CI, 1.53-1.76). Within the cohort with bariatric surgery, suicide attempts were more common among the 18- to 39-year age group (P \u3c .001), women (P = .002), Hawaiian-Pacific Islanders (P \u3c .001), those with Medicaid insurance (P \u3c .001), and those with a documented mental health condition at baseline (in the previous 2 years; P \u3c .001). CONCLUSIONS: The relative risk of suicide attempts was higher among those who underwent bariatric surgery compared with a nonsurgical cohort, though absolute risk remained low. Providers should be aware of this increased risk. Screening for suicide risk after bariatric surgery may be useful to identify high-risk individuals

Prevalence of Hepatitis B Virus (HBV) and Latent Tuberculosis Co-Infection and Risk of Drug-Induced Liver Injury Across Two Large HBV Cohorts in the United States

The epidemiology of latent tuberculosis and hepatitis B virus (HBV-LTBI) co-infection among U.S. populations is not well studied. We aim to evaluate LTBI testing patterns and LTBI prevalence among two large U.S. cohorts of adults with chronic HBV (CHB). Adults with CHB in the Chronic Hepatitis Cohort Study (CHeCS) and Veterans Affairs national cohort were included in the analyses. Prevalence of HBV-LTBI co-infection was defined as the number of HBV patients with LTBI divided by the number of HBV patients in a cohort. Multivariable logistic regression evaluated odds of HBV-LTBI co-infection among CHB patients who underwent TB testing. Among 6,019 CHB patients in the CHeCS cohort (44% female, 47% Asian), 9.1% were tested for TB, among whom 7.7% had HBV-LTBI co-infection. Among HBV-LTBI co-infected patient, only 16.7% (n=7) received LTBI treatment, among whom 28.6% (n=2) developed DILI. Among 12,928 CHB patients in the VA cohort (94% male, 42% African American, 39% non-Hispanic white), 14.7% were tested for TB, among whom 14.5% had HBV-LTBI. Among HBV-LTBI co-infected patient, 18.6% (n=51) received LTBI treatment, among whom 3.9% (n=3) developed DILI. Presence of cirrhosis, race/ethnicity, and country of birth were observed to be associated with odds of HBV-LTBI co-infection among CHB patients who received TB testing. In summary, among two large distinct U.S. cohorts of adults with CHB, testing for LTBI was infrequent despite relatively high prevalence of HBV-LTBI co-infection. Moreover, low rates of LTBI treatment were observed among those with HBV-LTBI co-infection

Laboratory monitoring and antiviral treatment for chronic hepatitis B among routine care patients in the United States

We investigated factors associated with rates of recommended monitoring of chronic hepatitis B (HBV) patients for viral DNA and alanine aminotransferase (ALT), and initiation of antiviral treatment among eligible patients, in a US cohort of patients under routine care. Patients were categorised by treatment indication: definite, equivocal or ineligible. Baseline covariates included demographics, clinical characteristics and specialist care status. \u27Recommended monitoring\u27 was defined ≥1 ALT or HBV DNA test per year. Logit models, univariate then multivariable, were used to evaluate factors associated with monitoring and treatment. Among 3,830 patients, treatment was received by 67.5% (788/1168 patients) in the \u27definite\u27 category, and 34.1% (208/610 patients) in the \u27equivocal\u27 category, of whom 109 moved up to \u27definite\u27 status at some point during follow-up. Sex, age and specialist care were independently associated with receipt of treatment in \u27definite\u27 patients. Routine monitoring rates were high prior to treatment in \u27definite/ treated\u27 patients (ALT: 77%; DNA: 85%) but declined afterwards (ALT 63%; DNA 36%). Rates of monitoring were lower in \u27definite/ untreated\u27 patients (ALT: 48%; DNA: 32%). Among \u27equivocal/ treated\u27 patients, lower age and comorbidity scores were associated with receipt of treatment; ALT monitoring rates were similar before and after treatment initiation (41% and 46%, respectively), while rates of DNA monitoring declined (55% and 29%). Monitoring among \u27treatment ineligible\u27 patients was similar to those in the \u27equivocal\u27 and untreated \u27definite\u27 groups. A large proportion of US HBV patients under routine care did not receive recommended annual laboratory monitoring, especially after initiation of antiviral treatment, and nearly one-third of patients with \u27definite\u27 indications for antiviral therapy remained untreated

Treatment initiation for new episodes of depression in primary care settings

BACKGROUND: Depression is prevalent and costly, but despite effective treatments, is often untreated. Recent efforts to improve depression care have focused on primary care settings. Disparities in treatment initiation for depression have been reported, with fewer minority and older individuals starting treatment. OBJECTIVE: To describe patient characteristics associated with depression treatment initiation and treatment choice (antidepressant medications or psychotherapy) among patients newly diagnosed with depression in primary care settings. DESIGN: A retrospective observational design was used to analyze electronic health record data. PATIENTS: A total of 241,251 adults newly diagnosed with depression in primary care settings among five health care systems from 2010 to 2013. MAIN MEASURES: ICD-9 codes for depression, following a 365-day period with no depression diagnosis or treatment, were used to identify new depression episodes. Treatment initiation was defined as a completed psychotherapy visit or a filled prescription for antidepressant medication within 90 days of diagnosis. Depression severity was measured with Patient Health Questionnaire (PHQ-9) scores on the day of diagnosis. KEY RESULTS: Overall, 35.7% of patients with newly diagnosed depression initiated treatment. The odds of treatment initiation among Asians, non-Hispanic blacks, and Hispanics were at least 30% lower than among non-Hispanic whites, controlling for all other variables. The odds of patients aged  ≥ 60 years starting treatment were half those of patients age 44 years and under. Treatment initiation increased with depression severity, but was only 53% among patients with a PHQ-9 score of ≥ 10. Among minority patients, psychotherapy was initiated significantly more often than medication. CONCLUSIONS: Screening for depression in primary care is a positive step towards improving detection, treatment, and outcomes for depression. However, study results indicate that treatment initiation remains suboptimal, and disparities persist. A better understanding of patient factors, and particularly system-level factors, that influence treatment initiation is needed to inform efforts by heath care systems to improve depression treatment engagement and to reduce disparities