In the current study, the monitoring rate of chronic HBV infection was low, and patients had poor adherence to long-term monitoring and HCC surveillance. A series of retrospective studies demonstrated that the monitored rate every year was 50–70% for ALT and 15–40% for HBV-DNA [12–15]; One meta-analysis reported that the overall adherence rate to HCC surveillance was suboptimal at 52% [16]. It could be attributed to the lack of disease knowledge, no follow-up management rules, fragmented services, health care costs, social discrimination, transportation, and scheduling process difficulties [16–18]. Moreover, many patients might underestimate the seriousness of the disease and the importance of disease monitoring. CHB infection takes a long time to develop into severe liver disease, and patients’ awareness of the seriousness of HBV infection decreases over time. Therefore, significant disease educational efforts are needed. Interventional studies conducted programs, such as mailed outreach, clinical reminder, and education to improve adherence to disease monitoring [19–22]. In the present internet age, the medical institution can develop clinical tools, such as electronic medical reminders, order sets, and progress note templates to improve patient adherence; nonetheless, additional studies are needed. The department of infectious disease,3rd affiliated hospital, SUN Yat-sen University from Guangzhou of China has set up a special follow-up clinic for chronic HBV infection and adopted various methods (including SMS, WeChat, website, and phone to book a return visit in advance) to remind and urge patients to regular monitoring [23]. Beste et al. implemented a clinical reminder program to increase the HCC surveillance rate from 18.2–51% [20]. In recent years, clinical management of hepatitis B advocates transition from specialist to primary care. The Third National Hepatitis B Strategy 2018–2022 identifies general practice as a ‘priority setting’ for delivering education, prevention, treatment and care services [24]. However, general practitioners have some challenges to overcome in the management of hepatitis B.
This study suggested that many patients did not undergo all the examinations recommended by the guidelines at each follow-up visit. ALT assessment is carried out frequently, followed by HBV-DNA, HCC surveillance for the least, consistent with the previous studies [13, 16]. This survey showed that only about 26% of patients underwent HCC surveillance annually, which is crucial for managing CHB infection but easy to overlook in practice. Some surveys demonstrated that HCC surveillance for patients with CHB infection is not satisfactory in many countries [10, 12, 16, 23, 25]. A cohort study of 2338 patients with CHB in the United States showed that 46% of patients with cirrhosis never underwent liver imaging [15]. Thus, HCC surveillance should gain increasing attention in clinical follow-up.
This survey also showed that younger, male patient, more outpatient visit times and antiviral treatment with better adherence to the monitoring of ALT and HBV-DNA. Previous studies demonstrated significant differences in age, gender, and outpatient visit times among patients monitored for ALT and HBV-DNA [12, 15, 23]. Juday et al. demonstrated that the male gender was a risk factor of monitoring HBV DNA and ALT [13]. Previous studies indicated that age is related to adherence. Two studies of clinical follow-up in hepatitis B treatment found a high adherence rate among older patients [26, 27]. However, a retrospective study of the medical records of 1727 patients with HBV infection demonstrated that older age was negatively associated with recommended HBV monitoring [28]. These differences need to be explored further. The current result suggested that patients receiving antiviral treatment and initial liver imaging had better adherence to the monitoring of HCC surveillance and all examinations. Supposedly, most patients who need antiviral treatment have a long course of the disease and a high risk of liver-related morbidity. They may also have a deeper understanding of the disease and adverse consequences of HBV infection, requiring additional attention to their health status for high follow-up compliance [23]. On the other hand, patients with antiviral treatment need frequent patient-specialist visits for prescription, and Goldberg et al. demonstrated that the patients who have more specialist visits have better adherence to HCC surveillance [29]. Wong et al. found that regular routine clinic visits might improve adherence to HCC surveillance [30]. This might be because frequent clinic visits indicate that patients are likely to be reminded by physicians to undergo regular HCC surveillance. Patients who detected initial liver imaging had improved compliance. Typically, when the patient is first diagnosed with HBV infection, the initial disease education plays a significant role in the compliance of subsequent disease monitoring. Therefore, patients should be made aware of the importance of disease monitoring, especially at the first diagnosis, to comply with the recommendation.
Nevertheless, the present study has several limitations. First, this was a retrospective study, and only one hospital was included. HBV-related examination performed outside other medical settings could have been missed, and selection bias could not be excluded. To counteract these disadvantages, we utilized the long-term and consecutive outpatient population in January–December 2018 as participants. Thus, a prospective study with a larger sample size and scope is required. Second, the disease-related and socioeconomic background data, such as education, income, and occupation, were not included in the medical records, and the associating factors were not analyzed. These findings suggested that additional supplementary qualitative studies are required to explore the associating factors.