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Transcript of 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
© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 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 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 4
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.
© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 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 6
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
© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 7
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
© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 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 9
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
© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 10
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
© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 11
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
© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 12
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
© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 13
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
© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 14
Gender
Female Male40
45
50
55
60Foreign-bornUS-born
%
Fisher’s Exact test 0.41
© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 15
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
© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 16
Insurance
Medicaid Medicare Plus HMO0
20
40
60
80
100Foreign-bornUS-born
%
Status known: Foreign-born 366 & US-born 127Fisher’s Exact test <0.01
© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 17
Enrollment length
Enrollment length 0
20
40
60
80
100
120Foreign-bornUS-born
Mont
hs
T-test <0.01
SD 45
SD 38
© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 18
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
© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 19
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
80Foreign-bornUS-born
%
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.
© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 20
HBeAg ever tested & Liver biopsy
HBeAg Liver biopsy0
1020304050607080
Foreign-bornUS-born
%
Fisher’s Exact test: HBeAG 0.01 & biopsy >0.99
© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH 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 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 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 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 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 26
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