Hospitals Partner in Hep B Care
October 31, 2008
At a press conference held on Sept. 18, the Centers for Disease Control and Prevention (CDC) announced aggressive new guidelines for hepatitis B. Those guidelines are intended to prevent new infections and greatly reduce hepatitis-B-related liver damage and death, particularly within the Asian and Pacific Islander American (API) community, which is disproportionately impacted by the disease. An estimated one out of every 10 APIs is infected with chronic hepatitis B.
The location of the press conference, San Francisco’s Chinatown, was no coincidence.
While the measures prescribed by the CDC will be new for many physicians and hospitals in other parts of the country, they are already quite common at hospitals and doctors’ offices throughout San Francisco.
San Franciscans owe a great deal of thanks for that to San Francisco Hep B Free, a citywide effort undertaken by local government, private healthcare and local non-profit organizations to increase general awareness of the disease, as well as promote proven preventive measures and treatment options, and to screen and vaccinate all API residents. The campaign, which was launched in April 2007, has already screened over 4,000 people.
The national challenge
The new CDC guidelines include an increased emphasis on screening and vaccinating adults. For the first time, they also promote increasing awareness of the disease among communities deemed at risk and address the need for long-term treatment of chronically infected patients.
While that’s music to the ears of those who advocated for federal health officials to take a more proactive and aggressive approach to battling hepatitis B, many believe that across-the-board implementation of the new guidelines will be difficult. And that is what is necessary, they say, if a truly consistent national standard of care for hepatitis B is to be established.
“A lot of doctors didn’t pay attention to the previous guidelines,” says Dr. Samuel So, founder of the Asian Liver Center at Stanford University and a key organizer of the San Francisco Hep B Free campaign. “With so many recommendations being issued all the time [by the CDC], how are doctors supposed to remember?”
A free “flow” of information
The San Francisco Community Clinic Consortium, a partnership of non-profit community clinics providing primary care to uninsured, low-income and homeless patients, devised a clever way to ensure that a consistent standard of care is provided by its member clinics.
In collaboration with the Department of Public Health and doctors from San Francisco General Hospital, the Consortium created an easy-to-use diagnostic flowchart that allows doctors to determine, at a glance, which patients should be screened for hepatitis B and which tests to order. That flowchart was then distributed to all primary care providers within the Consortium network, as well as city-run clinics.
A similar flowchart was distributed by San Francisco Hep B Free to participating hospitals for distribution to their physicians. That flowchart was also mailed to private physicians by the Department of Public Health and inserted into a newsletter distributed to members of the Brown and Toland Medical Group. Seventy-five percent of the physicians in San Francisco are members of Brown and Toland, which is an active partner in the San Francisco Hep B Free effort.
Several other campaign partners, including California Pacific Medical Center and Kaiser, are tweaking the flowchart for distribution and use within their provider networks.
“So you screen a patient and you find out that they have chronic hepatitis B. Now what do you do?” says Dr. Peter Berman, medical director for the South of Market Health Center, a Consortium partner. “Hepatitis B is a really confusing disease. And what primary care doctor has the time or the inclination to read through thirty-pages of guidelines? Some of us see thirty or forty patients in a day. We need information that’s really simple and easy-to-use.”
With that in mind, Berman and his colleagues at the Consortium, San Francisco General Hospital and the Department of Public Health are now working on a treatment flowchart to help primary care doctors determine an appropriate course of action for chronically infected patients.
The idea, according to Berman, is to avoid referring patients to gastroenterologists whose disease isn’t advanced enough to require that degree of specialized care.
“It just doesn’t make sense to dump everybody on the liver doctors,” he explains. “There’s so much that can be done at the primary care level. We just need to take some of the guess work out of it.”
“Letting doctors know who needs to be screened is definitely the first step,” says Dr. Stuart Fong of San Francisco’s Chinese Hospital, which began screening all API patients ten years ago. The hospital now offers free screening clinics at its Chinatown facility six afternoons a week and low-cost vaccination once a month.
Several other hospitals are hosting similar clinics at sites throughout The City. California Pacific Medical Center, for instance, regularly organizes events where attendees can familiarize themselves with hepatitis B, be treated to a free lunch and offered free screening. CPMC follows up with those screened to offer free vaccination, when appropriate, and chronically infected individuals are linked to care.
The University of California’s San Francisco Hepatitis B Collaborative provides free screening and vaccination at monthly clinics at the Mt. Zion UCSF Medical Center and the Chinatown Public Health Center. Those clinics are organized by in-training doctors, nurses and pharmacists at UCSF.
“Every doctor should understand the screening process,” Fong adds. “But if you want it to become second nature to them, you have to simplify and streamline things.”
Re-learning about Hepatitis B
Ensuring a consistent standard of care by continually bringing doctors and other staff up to date on hepatitis B is the goal of continuing education programs being organized by health care organizations throughout San Francisco.
Kaiser Permanente, for instance, has offered four consecutive medical education programs about hepatitis B so far this year.
“Some doctors already have a richer understanding of the disease than others because of their clinical practice,” explains Helen Archer-Duste, chief operating officer for Kaiser Foundation Hospital/Health Plan, San Francisco. “The others, I think, have learned a lot this year. But I think the level of understanding still varies.”
Pharmaceutical companies are also doing what they can to keep everyone, including the medical community, in the know about hepatitis B.
GlaxoSmithKline representatives distribute copies of the San Francisco Hep B Free diagnostic flowchart when they visit doctors’ offices. Bristol-Myers Squibb hosts its own hepatitis B education series that is open to the public.
“All treatment decisions should be made by a patient with his or her health care provider,” says Cristi Barnett, associate director of business communications at Bristol-Myers Squibb. “We believe that an informed patient increases the quality of these decisions.”
Gilead Sciences, Inc.’s Hepatitis Team regularly visits with doctors to bring them up to date on changing prevention guidelines, as well as advances in treatment. Gilead has a second group that focuses on community outreach, educating the public and advocacy groups about hepatitis B.
“For my team, we want to help the doctors better understand the disease,” says the Hepatitis Team’s medical director, Dr. Christopher Ng. “In terms of treatment, it’s not about trying to push our drugs. We just present the latest information available. It’s up to the physicians to decide which is best for their patient.”
“We give a hepatitis B talk at least once a year,” says Dr. Thomas Haddad, a gastroenterologist at Saint Francis Memorial Hospital. “And there are noon conferences and other programs throughout the year. We do whatever we can to get that information out to everyone.”
Saint Mary’s Medical Center (SMMC) provides continuing provider education for physicians working at its main facility. Residents and attendants at its affiliated Sister Mary Philippa Health Center are also being kept in the loop about hepatitis B. APIs comprise a sizable share of the caseload at the hospital-adjacent clinic, which provides free and low-cost outpatient services to uninsured and low-income San Franciscans.
“We’re seeing a lot of chronic hepatitis B cases at the clinic,” says Dr. Kevin Man, a gastroenterologist at SMMC. “So we want to make sure the staff there knows how to monitor patients, and when and how to start people on treatment.”
Some of the continuing education efforts at SMMC and the clinic have been organized by the hospital’s Asian Physicians Advisory Committee.
“We meet regularly to discuss various topics [relating to API patients and doctors], and hepatitis B has been big on our radar for the last year,” says Man, a member of the advisory committee.
Logically, those doctors who see more patients with chronic hepatitis B would have figured out better how to handle it. But, according to Dr. Stewart Cooper, director of California Pacific Medical Center’s Liver Disease Management & Transplant Program, familiarity with hepatitis B doesn’t necessarily guarantee a working knowledge of the disease.
“When I talk to [doctors], I am astonished by some of their practices,” Cooper says. “Hepatitis B is a nuance disease, which makes it very difficult to understand. So I think this is always going to be a work in progress.”
“[And] doctors need to know so much about so many diseases, thus our need for repeated and ongoing educational programs,” says Dr. Robert Gish, medical director of CPMC’s Liver Transplant Program and an expert on hepatitis B.
“The last year has been amazing, though. The knowledge base has improved substantially in San Francisco and throughout the Bay Area.”
“[And] you’ll find a high level of congruence in the level of care in San Francisco,” Cooper adds. “Don’t get me wrong, we’re still figuring out how to do this. But I don’t think we should ever stop looking for ways to do what we do even better.”
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