Ethnicity Influences Effective Transition from Primary Care
to Tertiary Liver Clinic for Chronic Hepatitis B (CHB).
Background/Aims: Hepatitis B virus (HBV) is a global health concern with 450 million
chronically infected worldwide. Due to migration from endemic countries, CHB significantly
contributes to chronic liver disease in Australia. Transition from primary to tertiary care for
the management of CHB is poorly characterised. The aim of this study is to evaluate risk
factors impacting access to tertiary care for CHB patients.
Methods: 204 new CHB patients were referred to Liver Clinics at Monash Health between
January 2010 and 2012. Our retrospective study systematically reviewed the General
Practitioner (GP) referral regarding the patient's ethnicity and stage of CHB. Patient histories
were interrogated extracting clinical characteristics and virological data. Engagement with
the Liver Clinics was quantified according to time from referral to first clinic appointment,
non-attendance , loss to follow-up and this was correlated with ethnicity, gender, age, CHB
phase, presence of advanced disease and geographical distance between patient’s residence
and clinics.
Results: Of the 204 patients referred, 62% attended the clinics. The mean waiting time from
the date of the referral to first attendance was 403 ± 289 days. Of those who had one or
more clinic engagements, 47% were lost to follow up through non-attendance as of the 1st
January 2013. Ten patients were classified as cirrhotic in the GP referral, 9 attended clinic,
the waiting time to the first attendance was 349 ± 364 days vs.408 ± 289 in the non-cirrhotic
population (p-value: 0.6). The immunological phase of CHB was characterised in 60% of the
patients in the referral with 9.3% in immune clearance phase and 1% in immune escape
phase. Top 5 ethnicities were Cambodian 24%, Vietnamese 24%, Mainland Chinese 18%,
Afghani 7% and Sudanese 5%. Multivariate logistic regression analysis found no association
between age, gender and geographical distance from clinic with rates of attendance, loss to
follow up and clinic waiting time. Cambodian ethnicity accounted for 42% of all nonattendance, which was significant on multivariate analysis (Table 1. p-value: 0.002).
Table 1
Risk Factor for Non-Attendance
Age
Gender (Male)
Immune Clearance Phase
Geographical Distance
Ethnicity Cambodian
Beta-Coefficient
-0.023
-0.127
-1.414
1.018
1.435
P-value
0.151
0.745
0.011
0.084
0.002
Conclusions: This preliminary analysis identifies an association between Cambodian
ethnicity and liver clinic non-attendance. The next phase of this study will attempt to
further characterise the barriers relevant to each ethnicity.