Demographic and Lab Differences between                 US-Born and Foreign-Born              Asia Pacific Islanders among...
Background     Globally two billion people are infected with hepatitis B virus      (HBV) and about 350 million live with...
Background (continued)     HBV related liver cancer incidence is highest among APIs and is      a leading cause of cancer...
Objective     Investigate the demographic and lab differences between the      foreign-born and US-born APIs infected wit...
CHeCS     CHeCS is a dynamic multicenter cohort study designed to      assess the impact of chronic infection with HBV an...
CHeCS Hepatitis B Inception Cohort Year 1 Selection                                        1) Patients with any utilizatio...
Data sources           Demography table:                            Encounter        Date of birth, Race, Gender,         ...
Country of origin (COO)     VDW (n=349) supplemented with           – Survey (n=55)           – Chart abstractions (n=109...
Hawaii Sample                                          CHeCS HBV Cohort                                                   ...
Statistical analysis     Analysis performed using SAS, version 9.2 (SAS Institute Inc, Cary, NC)     T-test for continuo...
Hawaii VDW race                       15.80%                             19.17%           0.77%                           ...
Variables of interest                                                            Chronic hepatitis B tests                ...
Age group                      30                      25                                                                 ...
Gender                   60                                                                   Foreign-born                ...
Income level                   60                                    Foreign-born                   50                    ...
Insurance                      100                                      Foreign-born                       80             ...
Enrollment length              120                           Foreign-born              100                           US-bo...
Alanine Aminotransferase (ALT)                     80                     70                                              ...
HBV Viral load (QUANT)                 80                         US-born have significantly higher                       ...
HBeAg ever tested & Liver biopsy                        80                        70                                      ...
Summary & Discussion     Foreign-born APIs are much younger compared to US-born.     US-born APIs have higher income lev...
Summary & Discussion     US-born have significantly higher undetectable viral load (most      recent) compared to foreign...
Next steps     Test the treatment difference between the foreign-born and US-      born APIs     Compare the foreign-bor...
Acknowledgments     Philip Spradling, MD     Anne Moorman, BSN MPH     Scott D Holmberg, MD MPH     Nancy Oja-Tebbe, B...
References    1.     Hepatitis B Fact sheet No. 204. 2008. [Accessed August 31, 2012]. http://www.who.int/mediacentre/fact...
MahaloQuestions© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH   26
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Demographic Differences Between US Borna and Foreign Born Asia Pacific Islanders Among Hep B Patients VIJAYADEVA

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  • Approximate prevalence in US for HBV is 0.3-0.5%
  • Traditionally, the low economic and educational achievement profile of immigrant families would indicate that their children are at increased risk of health disparities.
  • Inclusion criteria were designed using a combination of ICD-9 and laboratory criteria to maximize capture of diagnosed chronic HBV while excluding unconfirmed or rule-out diagnoses.
  • Survey recorded the COO as the following:Asia: East Asia, Asia: Japan, Asia: South Asia, Asia: South-East Asia, Oceania or Pacific Islands, United States or CanadaOther.
  • Median Family Income based on census neighborhood data
  • Upper Limit of NormalThe median ULN was 63 U/L in men (with a range of 32-72) and 52 U/L in women (with a range of 31-72).
  • Most recent viral data: limitation-Spontaneously resolved vs treatment
  • Limitations: Majority of the patients are members of HMO. Cohort participants are not randomly selected and not fully representative of chronic hepatitis B patients, many or most undiagnosed in the US general population.
  • Prevalence general US population 0.3-0.5% Our population 0.003%Limitations: Majority of the patients are members of HMO. Cohort participants are not randomly selected and not fully representative of chronic hepatitis B patients, many or most undiagnosed in the US general population.
  • Demographic Differences Between US Borna and Foreign Born Asia Pacific Islanders Among Hep B Patients VIJAYADEVA

    1. 1. Demographic and Lab Differences between US-Born and Foreign-Born Asia Pacific Islanders among the Hepatitis B Patients of Kaiser Permanente, Hawaii Vinutha Vijayadeva1, Cynthia Nakasato1, Stuart C Gordon2, Loralee B Rupp2, Mei Lu2, Emily Henkle3, Joseph A Boscarino4 Kaiser Permanente Center for Health Research Hawai′i1, Henry Ford Health System 2, The Center for Health Research Northwest3, Geisinger Health System 4 HMO Research Network Conference Seattle 2012© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 1
    2. 2. Background  Globally two billion people are infected with hepatitis B virus (HBV) and about 350 million live with chronic infection.1  Approximately 550,000–2 million people in U.S. live with chronic HBV2-5 with 2,000-4,000 deaths attributed to HBV annually.3,4  40% to 70% of U.S. residents chronically infected with HBV are foreign-born immigrants, mainly Asian and the Pacific Islanders.2© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 2
    3. 3. Background (continued)  HBV related liver cancer incidence is highest among APIs and is a leading cause of cancer deaths in this population.  Due to continuous improvements in mortality and increased life expectancy, it is important to investigate the relationships between different sociodemographic factors and health.© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 3
    4. 4. Objective  Investigate the demographic and lab differences between the foreign-born and US-born APIs infected with HBV at Kaiser Permanente, Hawaii (KPHI). – This study is a part of a larger ongoing study called Chronic Hepatitis Cohort Study (CHeCS). – The study protocol was reviewed by an Institutional Review Board and the federal Office for Human Research Protections.© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 4
    5. 5. CHeCS  CHeCS is a dynamic multicenter cohort study designed to assess the impact of chronic infection with HBV and HCV.  Four HMO Research Network (HMORN) sites: – Henry Ford Health System, Detroit MI (coordinating center) – Geisinger Health System, Danville, PA – Kaiser Permanente- Northwest, Portland, OR – Kaiser Permanente- Honolulu, Hawaii  Funded by CDC Foundation.© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 5
    6. 6. CHeCS Hepatitis B Inception Cohort Year 1 Selection 1) Patients with any utilization between 1/1/06 and 12/31/08, AND 2) At least 18yo as of last date of utilization in period 1/1/06-12/31/08 1Qualifying Hep B diagnoses: • Hep B chronic dx list – 070.22, 070.23, 070.32, 070.33 • Hep B acute/unspec dx list – 070.2, 070.20, 070.21, 070.3, 070.30, 070.31 Retain patients with at least 1 encounter between Retain patients with at least 1 qualifying Hep B lab 1/1/06-12/31/08 with qualifying Hep B diagnosis1 test3 between 1/1/06-12/31/08 with positive/ 2Qualifying CLD* diagnoses: (primary or secondary) detectable result (*CLD = Chronic Liver Disease) 571.5, 456.0, 456.1, 789.59, 155.0, V42.7, V49.83 3Qualifying Hep B lab tests: Distinct MRNs - Candidate patients • HBsAG Pull full history of all encounters with qualifying Hep diagnoses & • HBeAG • HBVQL all Hep lab results for all NC candidate patients • HBVQT Inclusion Category 1 Inclusion Category 2 Inclusion Category 6 Inclusion Category 3 Inclusion Category 4 Inclusion Category 5Throughout full patient hx: Throughout full patient hx: Throughout full patient hx: Throughout full patient hx: Throughout full patient hx: Throughout full patientTwo or more encounters Qualifying Hep B dx1 or HBsAG + AND an elevated Any two of the following tests HBcABM neg prior to or hx:with qualifying Hep B CLD dx2 at any time AND ALT/SGPT (above normal positive/detectable at least 6 at the same time as any HBcABT pos at anydiagnoses1 (primary or HBsAG + or HBVQL upper limit) -- at least 6 mos apart (any two tests or of the following results : time AND HBsAG possecondary) -- occurring at +/detectable or HBVQT mos apart (either first) same test): HBsAG, HBeAG, HBsAG + or HBVQL at any timeleast 6 mos. apart +/detectable at any time NI6 = 156 HBVQL, or HBVQT +/detectable or HBVQT +/detectable EXCLUDE Distinct MRNs INCLUDE in cohort YES Patient qualifies NO (but eligible to be reviewed for inclusion next year) TIME ZERO=Earliest date of qualifying Hep under any inclusion category above? Distinct MRNs B dx or pos. test result in full patient hx © 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 6
    7. 7. Data sources Demography table: Encounter Date of birth, Race, Gender, table: Country of Origin (COO) Diagnoses, date Lab Virtual Data Warehouse Medications (VDW) Source Procedures Census table: Enrollment Household income & Education Survey Non VDW Source Chart abstractions© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 7
    8. 8. Country of origin (COO)  VDW (n=349) supplemented with – Survey (n=55) – Chart abstractions (n=109)  Computed variable based on COO – Foreign-born – US-born© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 8
    9. 9. Hawaii Sample CHeCS HBV Cohort N = 739 Excluded Non-Cases & insufficient evidence n = 86 HBV / HBV+HCV n = 653 Excluded Non APIs n = 132 HBV / HBV+HCV and APIs n = 521 Excluded subjects with no country of origin (COO) n=8 HBV / HBV+HCV, APIs and COO n = 513 Foreign-born US-born n = 388 n = 125© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 9
    10. 10. Statistical analysis  Analysis performed using SAS, version 9.2 (SAS Institute Inc, Cary, NC)  T-test for continuous variables  Chi-square or Fischers Exact for the categorical variables  Wilcoxan Rank Sum test for the categorical values that were clearly ordinal except for viral loads because of the varying upper & lower levels of quantitation for these tests© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 10
    11. 11. Hawaii VDW race 15.80% 19.17% 0.77% Hawaiian, Pacific Islanders 3.53% Asians White Black & AI/AN Unknown 60.74% Before non API exclusion n = 653, 1 missing for race© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 11
    12. 12. Variables of interest Chronic hepatitis B tests Socio-demographic (between 2001-2008) – Age (yr): most recent visit prior – Alanine Aminotransferase to 2008 (ALT, IU/L): maximum – Gender (F/M) – HBV viral load (QUANT, IU/ml): – Income (estimated by census most recent tract geocode) – HBeAg – Insurance type – Liver biopsy – Enrollment length (months): from 01/01/1998© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 12
    13. 13. Age group 30 25 Foreign-born US-born 20 % 15 10 5 0 <20 20-<30 30-<40 40-<50 50-<60 60-<70 70-<80 >=80 Age groups Mean SD - Foreign-born: 49.0 13.8 & US-born: 53.8 17.4© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 13
    14. 14. Gender 60 Foreign-born US-born 55 % 50 45 40 Female Male Fisher’s Exact test 0.41© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 14
    15. 15. Income level 60 Foreign-born 50 US-born 40 % 30 20 10 0 <15,000 15,000 - 29,000 30,000 - 49,000 50,000 - 75,000 >75,000 Income levels (estimated by census tract geocode) Status known: Foreign-born 382 & US-born 124 Wilcoxon Rank Sum test 0.06© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 15
    16. 16. Insurance 100 Foreign-born 80 US-born 60 % 40 20 0 Medicaid Medicare Plus HMO Status known: Foreign-born 366 & US-born 127 Fisher’s Exact test <0.01© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 16
    17. 17. Enrollment length 120 Foreign-born 100 US-born SD 38 80 SD 45 Months 60 40 20 T-test <0.01 0 Enrollment length© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 17
    18. 18. Alanine Aminotransferase (ALT) 80 70 Foreign-born 60 US-born 50 % 40 30 20 10 0 <LLN &/or Normal >ULN to ≤ 2xULN >2xULN to ≤4xULN >4xULN to ≤8xULN > 8xULN Status known: Foreign-born 385 & US-born 124 Wilcoxon Rank Sums test 0.79© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 18
    19. 19. HBV Viral load (QUANT) 80 US-born have significantly higher Foreign-born 70 proportion of undetectable US-born 60 viral load compared to foreign-born. 50 % 40 30 20 10 0 Undetectable >300 to ≤2,000 >2,000 to ≤20,000 >20,000 to >200,000 (detectable) ≤200,000 (ULD=200,000) Status known: Foreign-born 278 & US-born 76 Wilcoxon Rank Sums test 0.13© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 19
    20. 20. HBeAg ever tested & Liver biopsy 80 70 Foreign-born 60 US-born 50 % 40 30 20 10 0 HBeAg Liver biopsy Fisher’s Exact test: HBeAG 0.01 & biopsy >0.99© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 20
    21. 21. Summary & Discussion  Foreign-born APIs are much younger compared to US-born.  US-born APIs have higher income level compared to foreign- born but the difference was not significant.  While most of the patients had HMO insurance, US-born APIs are more likely to have Medicare Plus.  US-born APIs have significantly higher duration of enrollment compared to foreign-born© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 21
    22. 22. Summary & Discussion  US-born have significantly higher undetectable viral load (most recent) compared to foreign-born – Increased number of HBV infected US-born APIs are in inactive state, probably due to:  Spontaneous resolution or treatment  Access to the health care – Higher enrollment length – Higher income level – Older age group with additional insurance like Medicare Plus – Language  Foreign-born have significantly higher HBeAg testing compared to US-born likely because of higher viral load.© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 22
    23. 23. Next steps  Test the treatment difference between the foreign-born and US- born APIs  Compare the foreign-born APIs from high to low HBV prevalent countries  To incorporate the survey data for information on transmission of HBV© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 23
    24. 24. Acknowledgments  Philip Spradling, MD  Anne Moorman, BSN MPH  Scott D Holmberg, MD MPH  Nancy Oja-Tebbe, BS© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 24
    25. 25. References 1. Hepatitis B Fact sheet No. 204. 2008. [Accessed August 31, 2012]. http://www.who.int/mediacentre/factsheets/fs204/en/. 2. Weinbaum CM, Williams I, Mast EE, Wang SA, Finelli L, Wasley A, et al. Centers for Disease Control and Prevention. Recommendations for identification and public health management of persons with chronic hepatitis B virus infection. MMWR Recommend Rep 2008;57(RR-8):1-20. 3. Wasley A, Kruszon-Moran D, Kuhnert W, Simard EP, Finelli L, McQuillen G, Bell B. The prevalence of hepatitis B infection in the United States in the era of vaccination. J Infect Dis 2010;202:192-201.7. 4. Cohen C, Evans AA, London WT, Block J, Conti M, Block T. Underestimation of chronic hepatitis B infection in the United States of America. J Viral Hepat 2008;15:12-13. 5. Ioannou GN. Hepatitis B virus in the United States: infection, exposure, and immunity rates in a nationally representative study. Ann Int Med 2011;154:391-398. 6. Paisano EL. We the Americans: Asians. Washington,DC: US Dept of Commerce, Bureau of the Census;September, 1993. 7. Vogt T, Wise ME, Shih H, Williams IT. Hepatitis B mortality in the United States, 1990--2004 [Abstract]. 45th Annual Meeting of Infectious Diseases Society of America, San Diego, California; October 4--7, 2007.© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 25
    26. 26. MahaloQuestions© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 26
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