Demographic Differences Between US Borna and Foreign Born Asia Pacific Islanders Among Hep B...

© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 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 ConferenceSeattle 2012


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


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.


Objective

Investigate the demographic and lab differences between the foreign-born and US-born APIs infected with HBV at Kaiser Permanente, Hawai'i (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.


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.


1) Patients with any utilization between 1/1/06 and 12/31/08, AND2) At least 18yo as of last date of utilization in period 1/1/06-12/31/08

CHeCS Hepatitis B Inception Cohort Year 1 Selection

Retain patients with at least 1 encounter between 1/1/06-12/31/08 with qualifying Hep B diagnosis1 (primary or secondary)

Retain patients with at least 1 qualifying Hep B lab test3 between 1/1/06-12/31/08 with positive/ detectable result

Distinct MRNs - Candidate patientsPull full history of all encounters with qualifying Hep diagnoses &

all Hep lab results for all NC candidate patients

Inclusion Category 1Throughout full patient hx: Two or more encounters with qualifying Hep B diagnoses1 (primary or secondary) -- occurring at least 6 mos. apart

Inclusion Category 3Throughout full patient hx:Any two of the following tests positive/detectable at least 6 mos apart (any two tests or same test): HBsAG, HBeAG, HBVQL, or HBVQT

Inclusion Category 2Throughout full patient hx:Qualifying Hep B dx1 or CLD dx2 at any time AND HBsAG + or HBVQL +/detectable or HBVQT +/detectable at any time

Inclusion Category 6Throughout full patient hx:HBsAG + AND an elevated ALT/SGPT (above normal upper limit) -- at least 6 mos apart (either first)

NI6 = 156

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

2Qualifying CLD* diagnoses: (*CLD = Chronic Liver Disease) 571.5, 456.0, 456.1, 789.59, 155.0, V42.7,

V49.83

3Qualifying Hep B lab tests:• HBsAG• HBeAG• HBVQL• HBVQT

Inclusion Category 4Throughout full patient hx:HBcABM neg prior to or at the same time as any of the following results : HBsAG + or HBVQL +/detectable or HBVQT +/detectable

Inclusion Category 5Throughout full patient hx:HBcABT pos at any time AND HBsAG pos at any time

Distinct MRNs INCLUDE in cohortTIME ZERO=Earliest date of qualifying Hep

B dx or pos. test result in full patient hx

EXCLUDE(but eligible to be reviewed for inclusion next year)

Distinct MRNs

Patient qualifies under any inclusion category above?

YES NO


Data sources

Virtual Data Warehouse (VDW) Source

Demography table:Date of birth, Race, Gender,

Country of Origin (COO)

Census table: Household income &

Education

Encounter table:

Diagnoses, date

Lab Medications

Non VDW Source

Chart abstractions

Survey

ProceduresEnrollment


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


Hawaii Sample CHeCS HBV CohortN = 739

HBV / HBV+HCV n = 653

HBV / HBV+HCV and APIsn = 521

Foreign-bornn = 388

US-bornn = 125

Excluded Non-Cases & insufficient evidence

n = 86

Excluded Non APIsn = 132

Excluded subjects with no country of origin (COO)

n = 8HBV / HBV+HCV,

APIs and COOn = 513


Statistical analysis

Analysis performed using SAS, version 9.2 (SAS Institute Inc, Cary, NC)

T-test for continuous variables

Chi-square or Fischer's 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


Hawaii VDW race

19.17%

60.74%

3.53%

0.77%15.80%

Hawaiian, Pacific IslandersAsiansWhiteBlack & AI/ANUnknown

Before non API exclusion n = 653, 1 missing for race


Variables of interestSocio-demographic

– Age (yr): most recent visit prior to 2008

– Gender (F/M)– Income (estimated by census

tract geocode)– Insurance type– Enrollment length (months):

from 01/01/1998

Chronic hepatitis B tests (between 2001-2008)

– Alanine Aminotransferase (ALT, IU/L): maximum

– HBV viral load (QUANT, IU/ml): most recent

– HBeAg– Liver biopsy


Age group

<20 20-<30 30-<40 40-<50 50-<60 60-<70 70-<80 >=800

5

10

15

20

25

30

Foreign-bornUS-born

Age groups

%

Mean ± SD - Foreign-born: 49.0 ± 13.8 & US-born: 53.8 ± 17.4


Gender

Female Male40

45

50

55

60Foreign-bornUS-born

%

Fisher’s Exact test 0.41


Income level

<15,000 15,000 - 29,000 30,000 - 49,000 50,000 - 75,000 >75,0000

10

20

30

40

50

60

Foreign-bornUS-born

Income levels (estimated by census tract geocode)

%

Status known: Foreign-born 382 & US-born 124Wilcoxon Rank Sum test 0.06


Insurance

Medicaid Medicare Plus HMO0

20

40

60

80


%

Status known: Foreign-born 366 & US-born 127Fisher’s Exact test <0.01


Enrollment length

Enrollment length 0

20

40

60

80

100


Mont

hs

T-test <0.01

SD 45

SD 38


Alanine Aminotransferase (ALT)

<LLN &/or Normal >ULN to ≤ 2xULN >2xULN to ≤4xULN >4xULN to ≤8xULN > 8xULN0

1020304050607080

Foreign-bornUS-born

%

Status known: Foreign-born 385 & US-born 124Wilcoxon Rank Sums test 0.79


HBV Viral load (QUANT)

Undetectable >300 to ≤2,000 (detectable)

>2,000 to ≤20,000

>20,000 to ≤200,000

>200,000 (ULD=200,000)

0

10

20

30

40

50

60

70


%

Status known: Foreign-born 278 & US-born 76Wilcoxon Rank Sums test 0.13

US-born have significantly higher proportion of undetectable viral load compared to foreign-born.


HBeAg ever tested & Liver biopsy

HBeAg Liver biopsy0

1020304050607080

Foreign-bornUS-born

%

Fisher’s Exact test: HBeAG 0.01 & biopsy >0.99


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


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.


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


Acknowledgments

Philip Spradling, MD Anne Moorman, BSN MPH Scott D Holmberg, MD MPH Nancy Oja-Tebbe, BS


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.

http://www.who.int/mediacentre/factsheets/fs204/en/


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Demographic Differences Between US Borna and Foreign Born Asia Pacific Islanders Among Hep B...

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