Viral Hepatitis in Hawai‘i – Differing Perspectives
III. Perspectives of Physicians
A. General Hepatitis Management:
Robert Jao MD and Alan D. Tice MD
pp. 7-8
From a physician’s perspective, there are several major challenges for general hepatitis management in Hawai‘i, such as patient access to care, obtaining authorization for affordable treatment, and managing clinical treatment complications.
Access to Care and Treatment
In Hawai‘i, the majority of chronic HBV cases are minorities, with ethnicities including: Chinese, Korean, Vietnamese, Filipino, Thai, Laotian, Cambodian, Burmese, Indonesian, Malaysian, Pacific Islander, and Polynesian origins. Many of these people have limited knowledge of medicines and medical care and often do not know the difference between viral hepatitis, HIV, tuberculosis, or leprosy. Hansen’s disease (leprosy) may serve as the model of infectious diseases they are most familiar with. As a result, they might be afraid to tell even their families about any type of chronic infection lest they be isolated and rejected. This is a serious problem particularly when there are household members who could benefit from immunizations for HBV. Minorities, who often see physicians as authority figures, may refrain from seeking health care due to lack of confidence in their communication skills, or because of fear or lack of medical knowledge about diseases. Because individuals with HBV or HCV are usually asymptomatic, it is a challenge to convince an otherwise ‘healthy’ person who may already be apprehensive to expend financial and other resources to seek out testing and eventual treatment.
In Hawai‘i there are estimated to be 10,000 to 20,000 people infected with HBV and 30,000 people with HCV who may be considered for therapy. With interferon and ribavirin therapies costing about $50,000 or more per person for a 48-week course of HCV therapy, and $5,000 per person per year for HBV treatment, the total healthcare costs to treat all those who might benefit from treatment is astronomical. The alternative to consider is the cost of end stage liver disease with its complications, and the costs of liver transplants, which are estimated to be approximately $300,000 per transplant, with about 20 performed per year in Hawai‘i. Affording proper long term therapy is difficult as patients may not be citizens or have insurance. Patients who are insured or who have subsidized insurance such as Medicaid or QUEST still encounter difficulties in being properly treated for viral hepatitis. Insurance companies often have old, inflexible guidelines and administrative problems and co-payments for medications that can be prohibitive. Administrative and paperwork barriers often compromise access, particularly for those who are not proficient in English and are not familiar with the US healthcare system and policies. From a more global perspective, while minority patients may be living in Hawai‘i, many of their family members who should also be screened often reside in another country where experience indicates that it is unlikely for them to be able to be tested.
Educational materials and internet content that is translated into native languages for distribution and the use of interpreters are vital for outreach to the minority populations.Encouraging grassroots efforts in the form of advocacy groups and physicians who are willing to go out in the community and seek out individuals who are infected, a “reverse access” concept, are key components to improving access to care within these at-risk populations.
Eligibility for Treatment
Establishing a working physician-patient relationship is important when evaluating treatment options for individuals with hepatitis. The duration of hepatitis treatment ranges from 24 to 48 weeks, and there are often adverse side effects. It is essential to evaluate the patient’s individual situation prior to deciding on the appropriate course of treatment. General criteria for initiating therapy include patients’ interest and commitment to following through on treatment programs, ability to eliminate drug and alcohol abuse, family and other support groups, a safe living environment, access to insurance, and ability to pay for treatment. Safe treatment programs should begin with a thorough history and physical, basic laboratory tests with screening for co-infections, as well as ensuring emotional and financial support from family or friends, and physician availability and involvement.
Treatment Complications
The duration of therapy for HBV is generally at least six months after suppression of the viral load to undetectable. Indefinite treatment may be recommended depending on the HBV e-antigen and e-antibody. Duration of treatment decisions may be difficult for general practitioners to determine, and expert opinions continue to change depending on the new drugs and information available. Although some of the newest agents are very well tolerated, they are expensive. Resistance to monotherapy over time is an increasing problem. This is especially true with lamivudine (Epivir or 3TC), which is now generic. Resistance has also been detected with telbivudine (Tyzeka) although less with entecavir (Baraclude) and tenofovir (Viread), which has replaced adefovir (Hepsera). There is concern that combination therapy will soon be needed to prevent resistance, as has been the case with HIV. However, combination therapy for naïve patients is not widely covered by insurance companies unless there is proof of prior confirmed resistance to monotherapy.
Managing adverse effects of interferon and ribavirin for HCV is an even greater challenge with complications varying from thrombocytopenia, anemia, or leucopenia and debilitating fatigue and serious depression, sometimes to the point of suicide, if the patient is not followed closely. Psychiatric problems pose additional challenges for practitioners monitoring hepatitis patients. Continued alcohol use and compliance with medication remain significant problems as well. Pharmaceutical companies are often able to help with compassionate use or voucher systems to help with payments and often provide informational brochures. These companies also support education programs in the form of conferences, meetings, and internet programs. Their representatives are generally available to work with primary care providers and specialists to keep them informed of new medications and evolving improvements in the use of therapies.
Initiating a treatment program requires the input of the physician and the patient as well as the payer. The prolonged course of therapy and secondary complications that arise create additional expenses. The side effects of treatment often require frequent support and physician involvement. Differing approaches include the
The Liver Center at Hawai‘i Medical Center East in Honolulu, Kaiser Permanente, the Veterans Administration Medical Center, Infections Limited Hawai‘i, and multiple private gastroenterology and infectious disease specialists are important sources of specialty care for patients with hepatitis in Hawai‘i. These centers serve as sources of information and many have developed programs for analysis of patient databases which can assist in assessing the impact and extent of the disease.
Many people with hepatitis in Hawai‘i live outside a geographic area with ready access to specialty care, particularly in the outer islands in Hawai‘i where there may not be gastroenterologists or infectious disease specialists within practical access. With the help of the Hawai‘i Medical Service Association (HMSA) Foundation and Native Hawaiian Health Department at the University of Hawai‘i John A. Burns School of Medicine, sophisticated telemedicine programs are being developed so that experts can be involved with local care of patients in communities with limited medical resources. The specialty centers may also be able to provide advice and consultation to primary care practitioners to help manage the problems encountered and the decisions that need to be made.
