AIM: To investigate physicians’ knowledge including chronic hepatitis B (CHB) diagnosis, screening, and management in various stages of their training.

METHODS: A voluntary 20-question survey was administered in Santa Clara County, CA where Asian and Pacific Islanders (API) account for a third of the population. Among the 219 physician participants, there were 63 interns, 60 second-year residents, 26 chief residents and 70 attending physicians. The survey asked questions regarding respondents’ demographics, general hepatitis B virus knowledge questions (i.e., transmission, prevalence, diagnostic testing, prevention, and treatment options), as well as, self-reported practice behavior and confidence in knowledge.

RESULTS: Knowledge about screening and managing patients with CHB was poor: only 24% identified the correct tests to screen for CHB, 13% knew the next steps for patients testing positive for CHB, 18% knew the high prevalence rate among API, and 31% knew how to screen for liver cancer. Wald chi-square analysis determined the effect of training level on knowledge; in all cases except for knowledge of liver cancer screening (P = 0.0032), knowledge did not significantly increase with length in residency training or completion of residency.

CONCLUSION: Even in a high-risk region, both medical school and residency training have not adequately prepared physicians in the screening and management of CHB.

Chronic hepatitis B infection (CHB) remains a global epidemic resulting in significant morbidity and mortality. An estimated 240-360 million people worldwide are chronically infected with hepatitis B virus (HBV), resulting in nearly 800000 deaths annually from CHB-related liver disease[1-3]. A vaccine that is safe, effective, and cost-saving has been available for over 30 years. However, global disease burden remains high and CHB continues to be the leading cause of liver cancer and chronic liver disease globally. In the United States, the major risk factor for chronic hepatitis B is foreign born in an endemic country where many became chronically infected at an early age. An estimated 1.3 million foreign born persons have CHB, and Asian and Pacific Islander Americans (API) are disproportionately affected[4]. There is a greater than 50-fold difference in CHB prevalence between the API and White non-Hispanic population[5]. The Institute of Medicine report estimates that two-thirds are not aware of their infection[6]. Without receiving care and treatment, 15%-25% will die as a result of disease progression. The Centers for Disease Control and Prevention (CDC) and the United States Preventive Services Task Force (USPSTF) recommended HBV screening of all individuals born in countries with HBV prevalence ≥ 2%[7,8]. Our group has demonstrated that HBV screening of API, treatment of the infected and ring vaccination of household contact is a cost-effective intervention[9].

Although early detection of CHB offers the best opportunity for prevention and treatment[7,8], screening rates among API remain extremely low[10]. It is incumbent on physicians to recognize the importance of routine screening and how to screen this high prevalence population. Yet physicians’ knowledge remains deficient and adherence to screening guidelines is inadequate. Even among API physicians serving predominantly API patient populations, 50% did not routinely screen API patients for HBV infection and most reported less than half of their API patients had been immunized against HBV[10]. While many studies have demonstrated the inadequacy of HBV knowledge among established providers[10-12], no studies have assessed attainment of HBV knowledge as trainees progress through medical school and residency training.

In this study we examine the incremental gains in knowledge regarding CHB screening and management by surveying physicians at all levels of training from recent medical school graduates to attending physicians. We hypothesize that as providers progress through the medical education system: (1) HBV knowledge would improve; and (2) providers would report better adherence to screening, diagnosis, referral and treatment guidelines as delineated by the CDC and the American Association for the Study of Liver Diseases (AASLD)[10].

Chronic infection with hepatitis B and its sequelae continue to be major public health problems that all physicians will likely encounter and need to manage at some point in their practice. Early diagnosis through screening can lead to the prevention of devastating consequences like liver cancer and liver failure. The under-diagnosis, under-referral, and inadequate treatment of chronic hepatitis B are well-documented, especially in the API population[10-24]. Barriers to hepatitis B care in API can be distilled into three meaningful and interacting elements: resource-related, patient-related, and provider-related[25]. Resource-related barriers include lower per capita income, inadequate health care coverage, and underutilization of health services[15,25,26]. Patient-related barriers are associated with poor hepatitis B knowledge, low-English fluency, and the culture, beliefs, and attitudes surrounding hepatitis B and related care[22,27-29]. Provider-related barriers also revolve around physician knowledge, attitudes, and beliefs about hepatitis B and liver cancer in the API population[11].

Our study identifies physician-related barriers, which include gaps in physician knowledge and attitudes which can impede appropriate screening and prevention. Only a minority of physicians we surveyed were able to correctly identify the proper screening tests for CHB infection. Moreover, even fewer physicians were able to identify the appropriate next steps in management once a diagnosis of CHB infection was made. Most physicians expressed a lack of confidence in screening and caring for patients with CHB infection. In our study, although most physicians recognized that the API population carried the highest burden of disease, the majority greatly underestimated the disease prevalence among API. Just 18% recognized that 1 in 10 API are chronically infected with HBV. When presented with clinical case scenarios, our data show that providers were more likely to screen HIV-positive individuals (95% of respondents) and patients with hemophilia (76% of respondents) for CHB than a health 28-year-old man born in China (71% of respondents). Only 32% of providers surveyed reported feeling confident in knowing who to screen for CHB. These data suggest that providers may not be aware of racial, ethnic, or cultural differences in CHB risk, or may not be aware of the CDC screening guidelines[7,30,31]. Upadhyaya et al[31] similarly reported that although providers were aware of the high prevalence of CHB in API, this awareness is not associated with higher rates of screening and detection[30]. In a national survey of racial and ethnic minorities in the US, persons at high risk of CHB (API and foreign-born Americans) reported screening rates similar to persons who are at low risk, and 52% of foreign-born API reported having never been tested for CHB[32].

Studies demonstrate that, in general, PCPs provide counseling and preventive services at alarmingly low rates. In a national survey, less than one-third of PCPs report routine assessment and vaccination of adults at risk of CHB infection[17]. In a survey by Daley et al, one-quarter of PCP respondents rate identification and vaccination of HBV a “low priority”[17]. While most physicians we surveyed recognized CHB as being vaccine-preventable, less than half recognized the importance of immunizing uninfected household contacts of CHB patients.

Studies consistently demonstrate poor follow-up in HBsAg positive patients by providers. Jung et al[16] reports less than 30% of CHB patients received further evaluation of their infection; in fact, this study revealed that API ethnicity was instead significantly associated with not receiving treatment. In another study of 2238 CHB patients, only 32% reported having been referred to a gastroenterologist or hepatologist[14]. Our data corroborates current literature by suggesting that low rates of treatment, liver cancer screening, and referral may be due to poor knowledge about appropriate follow-up procedure following CHB detection; only 16% of respondents were able to accurately describe the appropriate next steps for a patient previously diagnosed as a “healthy hepatitis B carrier”. Only 34% were able to identify the appropriate screening tests for liver cancer according to the AASLD guidelines and just 11% of respondents knew how to report new hepatitis B diagnoses to local infectious disease control agencies. Perhaps this is due to the poor understanding of the devastating consequences of untreated and unmonitored CHB infection. Most providers significantly underestimated the mortality risk associated with CHB.

To date, we are the only group to examine provider knowledge and practice based on training level. Across all training levels, from interns to attending physicians, most providers expressed a lack of confidence regarding which populations should be screened for CHB infection. Only 39% of providers surveyed were confident that they knew when to refer patients with chronic hepatitis B. Alarmingly, 80% of providers did not feel adequately prepared by their medical training to manage patients with CHB infection. This is corroborated by our observation that no differences in CHB knowledge and screening practices were observed between interns, senior residents, and attending physicians. This not only demonstrates a failure in our current model of physician training in chronic hepatitis B management, but suggests similar deficiencies may exist with other public health concerns.

We postulated whether poor CHB screening was indicative of poor preventive practices by providers in general, rather than due to poor HBV knowledge and awareness. Thus we separately analyzed those providers who self-reported good preventive medicine practices. We included internal control questions asking providers to select the most appropriate screening tests for breast and colon cancer, as well as, to report how frequently they counsel patients regarding smoking cessation. Providers who always advised patients to quit smoking and correctly identified breast and colon cancer screening practices were deemed “Good Screeners”. However, Good Screeners were not significantly associated with increased knowledge, proper identification of HBsAg as the most appropriate CHB screening test, or improved screening of asymptomatic individuals for CHB.

We believe this study is representative of overall deficiencies in provider knowledge, training, and practices as it pertains to CHB infection. Limitations of this study may include selection bias as all physicians were recruited from a single geographic region (Northern California) and trainees from a single academic medical center. However, we do not believe this region reflects a training model that is significantly different from national trends. In addition, this region has a larger API population among physicians and patients, which we would expect to result in slightly improved knowledge and sensitivity towards CHB screening. As with all surveys, generalizability is limited and conclusions are based on associations of responses. Respondents were assumed to have answered truthfully (i.e., accurate reporting of level of training, ethnicity, field of practice), to carefully read and interpret the questions, and answers reflect actual practice.

Providers routinely cite inadequate knowledge as a barrier to appropriate management of CHB[18,31,33] which has been demonstrated by our study and others. In addition, we report low levels of provider knowledge that persist across increased levels of provider training. This is suggestive of the inadequate education provided by current medical training practices in regards to chronic hepatitis B infection, a disease which affects over one million Americans with an additional 40000 imported new cases each year[5]. We found that trainee confidence in their HBV-related knowledge remains low throughout graduate medical education, with no significant difference between training cohorts; 79% of respondents indicated that they did not feel their training adequately prepared them to manage patients with CHB infection. Foster et al[11] examined how different information sources influence health behaviors among Asian immigrants. After controlling for age, sex, education, English proficiency, insurance coverage, proportion of life spent in the United States, and family history of CHB, learning about HBV from physicians had the strongest direct effect on positive screening behavior (i.e., perceived benefits, severity, self-efficacy, and knowledge). The Department of Health and Human Service’s Viral Hepatitis Action Plan (VHAP) identifies educating providers as a top priority to reduce the health disparity associated with CHB infection in the API population[34]. Better provider knowledge about CHB is associated with increased rates of screening and vaccination for CHB[10,18,20] and even decreased mortality from liver cancer and liver disease[35,36]. Toy reported that life long monitoring of CHB is cost effective, and adherence to monitoring and treatment could reduce CHB related deaths by 83%[36]. However, our current medical training paradigm is failing our providers and their patients.

In 2010, the Institute of Medicine released a landmark report identifying CHB as an important public health issue requiring national attention. As a result of this report and the ratification of the Patient Protection and Affordable Care Act (ACA) in 2011, the Department of Health and Human Services released the VHAP, which highlights strategies to prevent, care for, and treat CHB and related liver-disease[6,34]. In 2014, the USPSTF also issued recommendation for hepatitis B screening of asymptomatic, non-pregnant adolescents and adults including those born in regions with ≥ 2% CHB prevalence and United States born persons who were unvaccinated at birth whose parents were born in high endemic countries including Asia[8]. This means that hepatitis B screening of the at risk population would be among the preventive services covered in the ACA.

Both the IOM report and the VHAP call for improved physician education. Our study highlights poor provider CHB screening practices and we suggest this is directly related to the lack of CHB education provided during formal medical training. It is imperative that we reform health care education to reduce CHB-related morbidity and mortality among our nation’s rapidly growing immigrant communities.

The authors would like to recognize Chrissy Cheung and Sharon Wong for their generous assistance in participant recruitment.