Care quality and outcomes among US veterans with chronic hepatitis B in the hepatitis C direct-acting antiviral era

Adherence to guideline-recommended hepatitis B virus (HBV) care is suboptimal. We hypothesized that national hepatitis C eradication efforts during the era from 2015 to 2017 would improve the quality of care for cHBV given increased recognition and specialty referrals for liver disease. The study described herein is a retrospective cohort study of veterans with at least one positive HBsAg (HBsAg+) result from 1 January 2003 to 31 December 2017 using the VA Corporate Data Warehouse (CDW) analysed by era (2003-2004, 2005-2009, 2010-2014, 2015-2017). Relevant covariates such as HCV co-infection, demographics, cirrhosis and baseline laboratory testing were obtained through previously validated approaches. We evaluated completion of process measures within 2 years of the index HBsAg + result: specialty care referral; testing of ALT, HBV-DNA, HBeAg and anti-HBe; testing for co-infection and/or vaccination for HAV, HCV, HDV and HIV; and hepatocellular carcinoma (HCC) surveillance among those meeting criteria. We also measured use of antiviral therapy in appropriate candidates (ALT ≥ 2 × ULN, HBV-DNA ≥ 2000 IU/mL). Of the 16 673 individuals with HBsAg + test results, 9,521 were confirmed as chronic HBV. Era-related (Era 3:2010-2014 vs Era 4:2015-2017) increases in guideline-recommended process measures included the following: outpatient visits with GI/ID specialists (78%-89%), HBV-DNA testing (73%-79%), HDV testing (27%-35%), appropriate HBV antiviral utilization (55%-70%) and HCC surveillance (40%-43%); all P < .0001. In the subset of HBV/HCV-co-infected patients, HCV DAA therapy was associated with a trend towards improved overall survival. In conclusion, the overall quality of care for HBV has significantly improved in the era of widespread HCV DAA therapy in an integrated health system possibly due to increased recognition and referral for liver disease.