Hepatitis B learning needs assessment of family medicine trainees in Canada : Results of a nationwide survey

1Department of Medicine; 2Department of Surgery, University of Toronto, Toronto, Ontario Correspondence: Dr Hemant Shah, Division of Gastroenterology, Toronto Western Hospital, 6B Fell, Room 153, 399 Bathurst Street, Toronto, Ontario M5T 2S8. Telephone 416-603-5914, fax 416-603-6281, e-mail hemant.shah@utoronto.ca Received for publication February 2, 2010. Accepted September 15, 2010 More than one-third of the world’s population is infected with the hepatitis B virus (HBV), and an estimated 350 million people worldwide have chronic hepatitis B (CHB) infection (1), which is a leading cause of cirrhosis and hepatocellular carcinoma (HCC) (2). In developed countries, the burden of disease is greatest among immigrants from highor intermediate-prevalence countries, and in individuals who exhibit high-risk behaviours (1,3,4). Individuals with CHB from endemic countries have a 100-fold relative risk of developing HCC (5) and, accordingly, are at a disproportionately high risk of death from HCC. Therefore, CHB represents an important, yet clinically silent public health issue. Studies indicate inadequate screening of these high-risk populations by primary care physicians (PCPs) in the United States (6,7). Because most chronically infected individuals are asymptomatic – even when advanced disease is present – they are usually diagnosed by their treating physician as a result of biochemical or serological testing triggered by clinical suspicion. There are limited data assessing knowledge levels and practice patterns of PCPs concerning screening and management of CHB (7-9). We sought to determine the knowledge base and practice patterns of family medicine trainees across Canada regarding the management of CHB. oRiginal aRtiCle


Study population
The study population consisted of family medicine residents at all levels of training at all accredited family medicine residency programs across Canada.

Survey design and content
A questionnaire (Appendix 1A) was developed to assess the knowledge of family medicine trainees regarding screening and management of patients with CHB and cirrhosis.The questionnaire focused on vaccination, screening at-risk patients, diagnostic testing, recognizing and managing cirrhosis, indications for specialist referrals, and trainees' self-assessment of their current and desired knowledge of CHB.All collaborating authors reviewed the questionnaire for validity.The questionnaire was reviewed by four family physicians at the University of Toronto (Toronto, Ontario), who provided feedback on the clarity of the survey, and the comprehensiveness and appropriateness of the items and response categories.Correct responses were determined by current published guidelines (4,10) and by consensus of the participating hepatologists.The questionnaire was pilot tested among PCPs during the Hepatitis Symposium at The Conference on Health Care of the Chinese in North America, held September 27, 2008, in Toronto, Ontario, and was revised and translated into French by a professional translation service (Appendix 1B).

Survey administration and data collection
The family medicine program directors at the accredited Canadian family medicine training programs were contacted in writing with a description of the present study and a request to distribute the electronic link to the survey, a cover letter and a consent form to their residents.Program directors who did not respond within two weeks received a second e-mail inviting them to participate in the study.The questionnaire was made available online through QuestionPro (a survey engine) and was administered between November 2008 and March 2009.All responses remained anonymous and were coded with a unique identification number.

Outcome measures
The main outcome measures included knowledge of risk factors and screening for CHB, and recognition and management of cirrhosis.The secondary outcome measures included self-reported current and desired levels of knowledge regarding CHB, and the respondents' preferred learning format.

Statistical analysis
Data were collected in an Excel 2007 spreadsheet (Microsoft Corporation, USA) using the QuestionPro software.Descriptive statistics were used to describe the responses to each question.

Ethical considerations
The research protocol was approved by the Research Ethics Boards of the University Health Network (University of Toronto) and The University of Western Ontario (London, Ontario).

RESULtS
Table 1 summarizes the demographics and characteristics of the respondents.Three programs chose not to participate (Table 2).A total of 158 family medicine residents completed the questionnaire.The estimated response rate among the programs that participated in the present study was 15%, based on the Canadian Residents Matching Service statistics reflecting the total number of first-and second-year family medicine residents in the country at the time of the study (11).Respondents had a mean (± SD) age of 30±5.0 years, the majority of whom (76%) were women.Ninety-seven per cent knowingly saw less than five patients with CHB per month.

vaccination
Routine vaccination against HBV in those known to have no immunity was recommended by 54% of the respondents, while vaccination against hepatitis A virus (HAV) in CHB patients without immunity to HAV was offered by 56%.Eighty-four per cent of respondents were familiar with how to protect an infant born of an HBV surface antigen (HBsAg)-positive mother (ie, by administering the HBV vaccine series and the HBV immune globulin to the newborn at birth [3,12]).

Screening
Forty-two per cent of respondents regularly asked their patients whether they had risk factors for HBV.Thirty-four per cent incorrectly believed that men who have sex with men do not require routine screening for HBV, while 27% and 26%, respectively, would not routinely screen patients from an HBV-endemic country or a patient with a history of intravenous drug use (Table 3).Appropriate use of the three recommended screening tests (ie, HBsAg, anti-HBV surface antibody, anti-HBV core antibody) to determine HBV status was practised by 49% of respondents.Thirty-nine per cent of respondents used HBeAg as an  initial screening test for HBV.Between 86% and 91% correctly interpreted a variety of serological test results, which included immunity due to vaccination, previous infection with HBV and active ongoing infection.

Recognition and management of patients with cirrhosis
Ninety-one per cent of respondents knew that normal levels of alanine aminotransferase (ALT) did not necessarily exclude liver disease.While 81% acknowledeged that cirrhosis is often asymptomatic, 73% recognized that a normal abdominal ultrasound examination did not exclude cirrhosis.In our case scenario of an individual with CHB and thrombocytopenia but preserved hepatic synthetic function, 3% of respondents accurately recognized the patient's high likelihood of having cirrhosis.A total of 47% of respondents incorrectly selected a narcotic as the safest option for pain management in a cirrhotic patient, and 31% chose a nonsteroidal anti-inflammatory drug.Acetaminophen was chosen by 4% of respondents to be the safest for use in patients with liver disease.

Referral to specialists
Ninety per cent of respondents would refer a patient in the immunetolerant phase for treatment (ie, a 24-year-old woman, HBeAg positive, HBV DNA 9log IU/mL, ALT 24 IU/L and platelets 285×10 9 /L), while 59% recognized HBeAg-negative CHB status as an indication to consider treatment (ie, a 45-year-old man, HBeAg negative, HBV DNA 5log IU/mL, ALT 43 IU/L and platelets 145×10 9 /L).

Current and desired levels of knowledge
Sixty-one per cent of respondents believed that they had moderate to high levels of knowledge concerning the recognition of cirrhosis, but 68% were not confident in managing a patient with cirrhosis.Eighty-four per cent and 77%, respectively, believed that they possessed moderate to high levels of knowledge with regard to identifying risk factors for HBV and who should be screened for HBV.Overall, 65% believed that they had moderate to high levels of knowledge in interpreting screening tests for HBV.The majority (more than 90%) wanted to learn more about CHB including identifying risk factors, screening, recognizing and managing cirrhosis, and screening for HCC.

Sources of knowledge
Sixty-four per cent of respondents believed that online resources were the best way to update their knowledge, 13% believed that conferences would be the preferred mode of learning and 8% would consult books or journals.

DiSCUSSiON
HBV has important medical, economic and social consequences, particularly among immigrants to North America.Early diagnosis of HBV is crucial because it provides the patient with the opportunity to be counselled about preventive measures to decrease the risk of transmission to others, receive preventive services, and be monitored and evaluated for therapy.We identified knowledge gaps regarding CHB among family medicine trainees in several domains.The most striking areas were primary prevention (ie, vaccination in those without immunity, identification of those at risk for CHB and initiation of appropriate screening tests) and recognition of cirrhosis.The American Association for the Study of Liver Diseases practice guidelines (4) advise that all seronegative individuals should be vaccinated against HBV, while patients with CHB who are not immune to HAV should be vaccinated against HAV.The low number of patients with CHB reportedly seen each month by the respondents was likely an underestimate, particularly for those practicing in major Canadian cities.In our study, 36% and 13% of respondents were from Toronto and Montreal (Quebec), respectively, both of which are high-density areas for immigrants.Under recognition of this chronic infection may be due to failure to screen at-risk individuals.This is consistent with another study (7) in which 91% of family physicians reportedly diagnosed five or fewer cases of HBV in the previous year.Our data showed that a significant proportion of trainees did not recognize the major risk groups for CHB as outlined in the current guidelines (4,13).By comparison, Ferrante et al (7) showed that although more than 90% of family physicians in north central New Jersey (USA) recommended screening for HBV in injection drug users and men who have sex with men, less than 70% would screen immigrants from endemic countries (7).
It is concerning that only 3% of trainees correctly recognized cirrhosis in a patient with CHB and thrombocytopenia.The common misconception that it is unsafe to prescribe acetaminophen to control pain in cirrhosis was demonstrated by the fact that only 4% of respondents believed that it was safe for use, whereas almost 80% would have prescribed either a narcotic or a nonsteroidal anti-inflammatory drug, even though these medications may precipitate hepatic encephalopathy and/or the hepatorenal syndrome in an individual with cirrhosis (14,15).
Although the majority of respondents would refer a patient in the immune-tolerant phase to a specialist for treatment even though therapy is currently not considered appropriate at this stage of infection (12), 43% did not recognize the need to refer a patient with CHB who tested negative for HBeAg.Whereas the immune-tolerant phase in a young patient is associated with minimal liver injury, active HBeAgnegative CHB is associated with progression to cirrhosis and HCC, and these patients should be assessed for treatment.
The discrepancy between trainees' self-assessment and the objective measurements of their levels of knowledge, particularly with respect to screening for CHB and recognizing cirrhosis, is concerning.Sixty-two per cent of respondents believed that they possessed moderate to high levels of knowledge with regard to recognizing cirrhosis, but only 3% recognized the patient with probable cirrhosis in our case scenario.While less than 50% chose the appropriate screening tests for HBV, almost 80% of trainees were confident that their knowledge in this area was adequate.
Our study has several limitations.The overall response rate of 15% was lower than that obtained in other surveys of PCPs or residents (7,(16)(17)(18)(19)(20).Moreover, the response rate from each school was variable.Selection bias was a possibility, and residents who completed the survey may have had reason to be more interested in HBV than those who did not participate.If that was the case, then it is possible that their knowledge levels may represent the 'best-case' scenario.In retrospect, we realize that the option of answering 'I don't know' should have been offered because results from this category may have provided us with a more comprehensive assessment of trainees' knowledge levels and, possibly, would have encouraged higher participation.Our data were based on self-reports; therefore, it is not clear whether our figures reflect actual practice.However, this is the first study to evaluate knowledge levels and screening practices for HBV among family medicine trainees across Canada.Because our study was limited to residents, the results cannot necessarily be generalized to practicing family physicians, but they do suggest that HBV may be inadequately represented in the medical curricula.Specific educational initiatives and guidelines designed for PCPs are needed to overcome these knowledge gaps to assist them in identifying patients at risk, conducting initial diagnostic tests and initiating appropriate referrals.The majority of the trainees supported online resources as the most effective way to update their knowledge.While there are several current national and international guidelines that address the management of patients with CHB, these guidelines can be difficult to integrate into a family physician's busy practice.Even more confusing are the differences between the treatment guidelines for CHB and a frequently cited expert treatment algorithm in the United States (21).To our knowledge, there are no specific guidelines on screening, monitoring, or the initial management or referral of CHB patients in the adult population that are targeted toward family physicians.The Public Health Agency of Canada and The College of Family Physicians of Canada published Primary Care Management of Chronic Hepatitis C: Professional Desk Reference 2009 (22), a concise clinical tool that delineates an assessment sequence for family physicians.A similar electronic resource for HBV would be equally as valuable.Moreover, in collaboration with gastroenterology and hepatology faculties, a standardized curriculum that includes an emphasis on liver diseases should be developed for family medicine trainees.

CONCLUSiONS
We identified knowledge gaps pertaining to CHB among family medicine trainees.The knowledge deficits demonstrated in our survey of this group may reflect suboptimal access to care for patients and suggest that opportunities to prevent potentially life-threatening complications of CHB are being missed.Further research assessing knowledge gaps and learning goals regarding CHB is necessary among family medicine trainees.In addition, a study to assess physicians in practice is warranted to determine which types of educational initiatives are most effective in creating sustainable, long-term practice changes in managing CHB.Results from further needs assessment studies may subsequently be used to increase public awareness of HBV as an important issue, particularly as it relates to immigrant health.This needs to be addressed countrywide by the Public Health Agency of Canada.This is also an excellent opportunity for organizations such as the Canadian Association for the Study of the Liver and the Canadian Association of Gastroenterology to develop resources related to HBV that are targeted toward family physicians.

ACKNOWLEDGEMENtS:
The authors thank the primary care physicians, and the family medicine program directors and trainees who participated in this study.

9. Do you routinely offer hepatitis A vaccination to patients with chronic hepatitis B who are seronegative for HAv Ab?
11. Who would you NOt routinely screen for hepatitis B?(choose all who apply) 1) Any individual with a history of IV drug abuse 2) Hepatitis C infected individual 3) Any individual who received a blood transfusion before 1992 4) Any individual from a country with an HBV carrier rate of ≥2%