Infectious Diseases in Obstetrics and Gynecology
Volume 2018 (2018), Article ID 4107329, 9 pages
https://doi.org/10.1155/2018/4107329

Research Article

Hepatitis B Virus Testing and Care among Pregnant Women Using Commercial Claims Data, United States, 2011–2014

Aaron M. Harris, Cheryl Isenhour, Sarah Schillie, and Claudia Vellozzi

Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, GA, USA

Correspondence should be addressed to Aaron M. Harris; ieo9@cdc.gov

Received 18 January 2018; Accepted 13 February 2018; Published 1 April 2018

Academic Editor: Lu-Yu Hwang

Copyright © 2018 Aaron M. Harris et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract.

Introduction. Pregnant women should receive hepatitis B virus (HBV) testing with hepatitis B surface antigen (HBsAg), but it is unclear whether HBV-infected pregnant women are linked to care. Methods. We analyzed MarketScan™ commercial insurance claims. We included pregnant women, aged 10–50 years, with 42 weeks of continuous enrollment before (predelivery) and 6 months after (postdelivery) the first delivery claim for each unique pregnancy between 1/1/2011 and 6/30/2014. We identified claims for HBsAg testing by CPT code and described the care continuum among pregnancies with an associated ICD-9 HBV diagnosis code by demographic and clinical characteristics, including HBV-directed care ([HBV DNA or hepatitis B e antigen] and ALT test codes) and antiviral treatment (claims for tenofovir, entecavir, lamivudine, adefovir, or telbivudine) pre- and postdelivery. Results. There were 870,888 unique pregnancies (819,752 women) included. Before delivery, 714,830 (82%) pregnancies had HBsAg test claims, but this proportion decreased with subsequent pregnancies : second (80%), third (71%), and fourth (61%). We identified 1,190 (0.14%) pregnancies with an associated HBV diagnosis code: most were among women aged ≥ 30 years (76%) residing in the Pacific (34%) or Middle Atlantic (18%) regions. Forty-two percent of pregnancies with an HBV diagnosis received HBV-directed care (42% predelivery and 39% postdelivery). Antiviral treatment was initiated before delivery in 128 (13%) of 975 pregnancies and postdelivery in 16 (1.6%) pregnancies. Conclusions. While most of these commercially insured pregnant women received predelivery HBV screening, we identified gaps in HBV testing and the HBV care continuum which highlight potential targets for public health interventions.

1. Introduction

Hepatitis B virus (HBV) infection remains a major public health issue [1]. In the United States, an estimated 847,000 persons are living with chronic hepatitis B virus (HBV) infection [2], with about 14,000 attributable deaths annually [3]. Approximately one in four persons living with chronic HBV infection will die prematurely from liver cirrhosis, hepatocellular carcinoma, or liver failure [4].

Serologic testing for hepatitis B surface antigen (HBsAg) is the primary way to identify persons with HBV infection. The Advisory Committee on Immunization Practices (ACIP) recommends that all pregnant women receive HBsAg testing during each pregnancy to identify infants needing postexposure prophylaxis [5]. There are approximately 25,000 infants born to HBsAg-positive pregnant women annually [6], and, without intervention, transmission can occur in up to 85% of exposed infants; among infected infants approximately 90% will become chronically HBV-infected [5, 7]. Infants born to HBsAg-positive women should receive hepatitis B vaccine and hepatitis B immunoglobulin (HBIG) within 12 hours of birth, followed by completion of the hepatitis B vaccine series and postvaccination serologic testing [5]. Postexposure prophylaxis is up to 95% effective in preventing HBV transmission among infants born to HBsAg-positive mothers [8, 9]. While prophylaxis has been successful in reducing maternal-to-child HBV transmission, there has been little support to address healthcare needs of mothers with HBV infection [10].

Prior studies have used claims data to study hepatitis B using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes to identify persons with HBV who have liver cirrhosis [11] and antiviral treatment rates during pregnancy among women with HBV [12]. Claims data have also been used to assess the proportion of pregnant women receiving HBsAg testing [13]. We are not aware of previous studies that evaluated the complete HBV care continuum, from testing to linkage to care and treatment, among pregnant and postpartum women using claims data.

As a first step to address gaps in the HBV care continuum for pregnant women with HBV infection, we used commercial claims data to describe HBsAg testing during pregnancy and assess whether pregnant women with hepatitis B are linked to recommended care and antiviral treatment pre- and postdelivery.

2. Methods

2.1. Data Source and Study Population

We obtained demographic, enrollment, and insurance claims data from Truven Health’s MarketScan Commercial Claims and Encounters insurance claims database, for women aged 10 to 50 years, from January 1, 2011, through June 30, 2014. This database includes claims for millions of persons with private insurance under the age of 65 years. A unique enrollee identification number allows linkage of medical claims with outpatient pharmacy claims data. This secondary analysis of deidentified insurance claims data did not require ethics approval.

To identify unique pregnancies during the study period, we searched medical claims for delivery-related diagnosis and procedure codes [12]. We defined the delivery index date for each pregnancy as the first service date on which a delivery-related code was documented. During the study period, women could have multiple unique pregnancies and associated delivery index dates, if all other study inclusion criteria were met. Specifically, for pregnancies to be included in the study, women were required to be continuously enrolled both 42 weeks before and 6 months following the delivery index date.

2.2. HBV Testing and Care Continuum Description and Statistical Analysis

To evaluate HBV testing, care, and treatment during pregnancy, we searched both inpatient and outpatient insurance claims for Current Procedural Terminology (CPT) codes, International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedure codes, and ICD-9-CM diagnosis codes associated with each cascade step (Table 1). We first calculated the proportion of all unique pregnancies with a claim for at least one HBsAg test during the 42-week period prior to the delivery index date and also used the Cochran–Armitage test for trend to examine differences in HBsAg testing rates with each subsequent pregnancy.

Table 1: Procedure and diagnosis codes used to identify hepatitis B diagnosis, testing, care, and treatment.

Test or condition
Code number
Code description

HBsAg tes
87340
Hepatitis B surface antigen

80055
Obstetric panel

80074
Acute hepatitis panel

HB
070.22
Chronic viral hepatitis B with hepatic coma without hepatitis delta

070.23
Chronic viral hepatitis B with hepatic coma with hepatitis delta

070.32
Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta

070.33
Chronic viral hepatitis B without mention of hepatic coma with hepatitis delta

V02.61
Hepatitis B carrier

ALT tes
80076
Hepatic Function Panel

84460
Alanine Aminotransferase (ALT)

HBV DNA tes
87515
Hepatitis B virus detection by nucleic acid using direct probe technique

87516
Hepatitis B Virus DNA, Qualitative, Real-Time PCR

87517
Hepatitis B Virus DNA, Quantitative, Real-Time PCR

HBeAg tes
87350
Hepatitis Be Antigen

Newborn live birt
V30–V39
Live born infants according to type of birth

HBIG administere
J1573
Injection, hepatitis b immune globulin

90371
Hepatitis B immune globulin

Hep B vaccin
90739
Hepatitis B vaccine (HepB), adult dosage, 2 dose schedule, for intramuscular use

90740
Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (3 dose schedule), for intramuscular use

90743
Hepatitis B vaccine, adolescent (2 dose schedule), for intramuscular use

90744
Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), for intramuscular use

90746
Hepatitis B vaccine, adult dosage (3 dose schedule), for intramuscular use

90747
Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (4 dose schedule), for intramuscular use

urrent Procedural Terminology or Healthcare Common Procedure Coding System. nternational Classification of Diseases, Ninth Edition, Clinical Modification.

We then described the HBV care continuum among all pregnancies in which the mother was diagnosed with chronic HBV, defined as at least one chronic HBV ICD-9-CM diagnosis code (070.22, 070.23, 070.32, 070.33, or V02.61) documented on a claim prior to the delivery index date. Pregnancies with at least one HIV diagnosis code (795.71, V08, 042, or 079.53) documented on a claim prior to delivery were excluded because we sought to evaluate the HBV care continuum for HBV monoinfected women. We defined engagement in HBV-directed care as an alanine aminotransferase (ALT) test in conjunction with either an HBV DNA or hepatitis B e antigen (HBeAg) test, either before (up to 42 weeks before) or after (up to 6 months after) the delivery index date, and calculated the proportion of HBV-infected pregnancies in which the mother was engaged in care. Among a subset of pregnancies with pharmacy claims available for review, we calculated the proportion of HBV-infected pregnancies in which the mother initiated HBV treatment, defined as at least one claim for antiviral treatment (tenofovir, entecavir, lamivudine, adefovir, or telbivudine) either before or after the delivery index date.

We fit simple logistic regression models, with general estimating equations to account for women with multiple pregnancies, to evaluate the differences in characteristics between pregnancies in which women did or did not receive recommended HBV care. Analyses were completed using SAS, version 9.3 (Cary, North Carolina). Statistical tests were considered significant at .

3. Results

There were 870,888 unique pregnancies (819,752 women) included (Figure 1). Of these, 714,830 (82%) had at least one HBsAg test claim prior to delivery. This proportion decreased with subsequent pregnancies (, Table 2). HBsAg testing was more often performed in pregnancies occurring among women aged 20 to 39 years, residing in the North and South Central US, located in urban areas, and with a preferred provider organization (PPO) plan (Table 2). Lower HBsAg testing proportions were observed in pregnancies among women older than 40 years and those located in the Pacific census division.

Table 2: Hepatitis B screening among 870,888 pregnancies in commercial insurance claims data, 2011–2014.

HBsA tested

Total

Row%
valu

Total
870,88
714,830
82.08

Pregnancy

<0.001

    1st pregnancies
795,870
655,218
82.33

    2nd pregnancies
73,247
58,359
79.67

    3rd pregnancies
1,743
1,236
70.91

    4th pregnancies
28
17
60.71

Age group

<0.001

    19 or younger
39,067
28612
73.24

    20 to 29
356,474
300727
84.36

    30 to 39
438,844
363708
82.88

    40 or older
36,503
21783
59.67

Census divisio

<0.001

    New England
40,403
32,767
81.10

    Middle Atlantic
102,312
80,774
78.95

    East North Central
161,920
130,865
80.82

    West North Central
45,137
38,475
85.24

    South Atlantic
153,566
128,662
83.78

    East South Central
52,726
45,441
86.18

    West South Central
100,916
89,101
88.29

    Mountain
56,611
47,470
83.85

    Pacific
134,756
103,260
76.63

    Other/unknown
22,541
18,015
79.92

Urbanicit

<0.001

    Nonurban
106,490
85,273
80.08

    Urban
745,585
613,825
82.33

Insurance plan

<0.001

    Managed car
207,179
159,265
76.87

    PPO or othe
637,739
533,989
83.73

Boldface indicates statistical significance ; BsAg = hepatitis B surface antigen. mong 819,752 women continuously enrolled 42 weeks before and 6 months after first delivery CPT or ICD-9-CM diagnosis code (Table 1).   ogistic regression models with general estimating equations to account for women with multiple pregnancies during the study period. ew England = CT, MN, MA, NH, RI, VA; Middle Atlantic = NJ, NY, PA; East North Central = IN, IL, MI, OH, WI; West North Central = IA, KS, MN, MO, NB, ND, SD; South Atlantic = DC, DE, FL, GA, MD, NC, SC, VA, WV; East South Central = AL, KY, MS, TN; West South Central = AR, LA, OK, TX; Mountain: AZ, CO, ID, NM, MT, UT, NV, WY; Pacific = AK, CA, HI, OR, WA; and other/unknown = Puerto Rico and unknown state of residence. rbanicity was determined by metropolitan statistical area (MSA); 15,732 HBsAg tested of 18,813 (83.6%) were missing urbanicity; 1,576 HBsAg tested of 25,970 (83.1%) were missing insurance plan type. ealth maintenance organizations (HMO), exclusive provider organizations (EPO), and point of Service (POS) plans. referred provider organizations (PPO), high deductible, and comprehensive plans.

Figure 1: Flow chart of study criteria and cascade of hepatitis B testing, care, and treatment among pregnancies in MarketScan, 2011–2014.

We identified 1,190 of 870,888 (0.14%) pregnancies (1146 women) with an associated HBV diagnosis code, and six pregnancies that had an associated HIV diagnosis code were excluded. The proportion of pregnancies during which the mother was diagnosed with HBV increased with increasing age and was higher during pregnancies occurring in urban areas (Table 3). In addition, there were a higher proportion of pregnancies during which the mother was diagnosed with HBV in the Pacific and Middle Atlantic census divisions (Table 3).

Table 3: Characteristics of pregnancies by hepatitis B diagnosis and care engagement before and after delivery.

Pregnancies with HBV diagnosi engage before deliver
Pregnancies with HBV diagnosis engaged after deliver
Pregnancies with HBV diagnosis engaged EITHER before or after

Total pregnancies
Pregnancies with HBV diagnosis
row%
valu

row%
valu

row%
valu

row%
valu

Total
870888
1190
0.14

501
42.10

463
38.91

505
42.44

Age group

<0.001

0.064

0.246

0.074

    19 or younger
39067
6
0.02

0
0.00

0
0.00

0
0.00

    20 to 29
356473
282
0.08

126
44.68

109
38.65

126
44.68

    30 to 39
438839
797
0.18

346
43.41

329
41.28

350
43.91

    40 or older
36503
105
0.29

29
27.62

25
23.81

29
27.62

Census divisio

<0.001

0.003

0.004

0.004

    New England
40403
48
0.12

28
58.33

27
56.25

28
58.33

    Middle Atlantic
102310
210
0.21

71
33.81

65
30.95

71
33.81

    East North Central
161920
153
0.09

34
22.22

33
21.57

37
24.18

    West North Central
45137
50
0.11

35
70.00

34
68.00

35
70.00

    South Atlantic
153565
127
0.08

56
44.09

52
40.94

56
44.09

    East South Central
52726
29
0.06

12
41.38

9
31.03

12
41.38

    West South Central
100914
120
0.12

52
43.33

44
36.67

52
43.33

    Mountain
56610
32
0.06

15
46.88

12
37.50

15
46.88

    Pacific
134756
401
0.30

190
47.38

181
45.14

191
47.63

    Other/unknown
22541
20
0.09

8
40.00

6
30.00

8
40.00

Urbanicit

<0.001

0.098

0.098

0.091

    Nonurban
106490
33
0.03

9
27.27

8
24.24

9
27.27

    Urban
745579
1137
0.15

482
42.39

447
39.31

486
42.74

    Missing
18813
20
0.11

10
50.00

8
40.00

10
50.00

Insurance plan type

<0.001

0.193

0.117

0.166

    Managed car
207178
384
0.19

171
44.53

161
41.93

173
45.05

    PPO or othe
637734
786
0.12

321
40.84

295
37.53

323
41.09

    Missing
25970
20
0.08

9
45.00

7
35.00

9
45.00

Boldface indicates statistical significance . t least 1 chronic HBV diagnosis code prior to delivery index date among pregnancies without HIV diagnosis. efined as HBV DNA and ALT or HBeAG and ALT. efore (up to 42 weeks before) or after (up to 6 months after) the deliver index date. ogistic regression models with general estimating equations to account for women with multiple pregnancies during the study period. ew England = CT, MN, MA, NH, RI, VA; Middle Atlantic = NJ, NY, PA; East North Central = IN, IL, MI, OH, WI; West North Central = IA, KS, MN, MO, NB, ND, SD; South Atlantic = DC, DE, FL, GA, MD, NC, SC, VA, WV; East South Central = AL, KY, MS, TN; West South Central = AR, LA, OK, TX; Mountain: AZ, CO, ID, NM, MT, UT, NV, WY; Pacific = AK, CA, HI, OR, WA; and other/unknown = Puerto Rico and unknown state of residence. rbanicity was determined by metropolitan statistical area (MSA). ealth maintenance organizations (HMO), exclusive provider organizations (EPO), and point of Service (POS) plans. referred provider organizations (PPO), high deductible, and comprehensive plans.

Among the 1,190 pregnancies with an HBV diagnosis code, 505 received HBV-directed care. The proportion of pregnancies with HBV-directed care was similar predelivery and postdelivery (501 and 463 , resp.). While there were geographic differences noted among pregnancies with HBV-directed care (with the greatest engagement in care among those in the West North Central and New England regions and the least engagement in care among those in the East North Central and Middle Atlantic regions), there were no significant differences by age groups, urbanicity, or insurance plan type of the women at the time of the pregnancy (Table 3).

Of the 1,190 pregnancies with an HBV diagnosis code, 975 (81.9%) had pharmacy claims available for review. Antiviral treatment was prescribed during 144 (15%) of these 975 pregnancies: predelivery in 128 (13%) and postdelivery in 16 (1.6%) (Table 4). There were no significant differences in maternal demographic characteristics for antiviral prescription status. Tenofovir (76%) was the most commonly prescribed antiviral medication followed by lamivudine (10%) and entecavir (9%); adefovir and telbivudine make up the remaining 5%.

Table 4: Characteristics of 975 hepatitis B diagnosed pregnancies with pharmacy claims by antiviral treatment.

Pregnancies with HBV diagnosis treated before deliver
Pregnancies with HBV diagnosis treated after deliver
Pregnancies with HBV diagnosis treated EITHER before or after deliver

Total

%
valu

%
valu

%
valu

Total
975
128
13.13

16
1.64

144
14.77

Age group

0.631

0.062

0.916

    19 or younger
5
0
0.00

0
0.00

0
0.00

    20 to 29
232
33
14.22

1
0.43

34
14.66

    30 to 39
654
85
13.00

14
2.14

99
15.14

    40 or older
84
10
11.90

1
1.19

11
13.10

Census divisio

0.284

0.347

0.439

    New England
36
7
19.44

1
2.78

8
22.22

    Middle Atlantic
143
27
18.88

1
0.70

28
19.58

    East North Central
127
10
7.87

1
0.79

11
8.66

    West North Central
44
5
11.36

1
2.27

6
13.64

    South Atlantic
105
13
12.38

3
2.86

17
15.18

    East South Central
27
4
14.81

0
0.00

3
11.11

    West South Central
112
16
14.29

1
0.89

13
11.61

    Mountain
27
3
11.11

0
0.00

2
7.41

    Pacific
346
42
12.14

8
2.31

50
14.45

    Other/unknown
8
1
12.50

0
0.00

1
12.50

Urbanicit

0.422

---

0.333

    Non-urban
26
2
7.69

0
0.00

2
7.69

    Urban
939
125
13.31

16
1.70

141
15.02

    Missing
10
1
10.00

0
0.00

1
10.00

Insurance Plan Type

0.405

0.162

0.566

    Managed car
329
49
14.89

8
2.43

57
17.33

    PPO or othe
629
78
12.40

8
1.27

86
13.67

    Missing
17
1
5.88

0
0.00

1
5.88

Boldface indicates statistical significance . mong 975 of 1190 HBV+ pregnancies where prescription drug claims were available for review. efore (up to 42 weeks before) or after (up to 6 months after) the deliver index date. ogistic regression models with general estimating equations to account for women with multiple pregnancies during the study period. ew England = CT, MN, MA, NH, RI, VA; Middle Atlantic = NJ, NY, PA; East North Central = IN, IL, MI, OH, WI; West North Central = IA, KS, MN, MO, NB, ND, SD; South Atlantic = DC, DE, FL, GA, MD, NC, SC, VA, WV; East South Central = AL, KY, MS, TN; West South Central = AR, LA, OK, TX; Mountain: AZ, CO, ID, NM, MT, UT, NV, WY; Pacific = AK, CA, HI, OR, WA; and other/unknown = Puerto Rico and unknown state of residence. rbanicity was determined by metropolitan statistical area (MSA). ealth maintenance organizations (HMO), exclusive provider organizations (EPO), and point of service (POS) plans. referred provider organizations (PPO), high deductible, and comprehensive plans.

4. Discussion

Using commercial claims data, we evaluated HBsAg testing practices and the HBV care continuum among commercially insured pregnant women. Most pregnancies (82%) had HBsAg test claim and 1,190 (0.14%) had an HBV diagnosis code. Our data demonstrated a gap in linkage to care among commercially insured pregnant women with HBV, as only 42% of pregnancies had claims suggesting HBV-directed care engagement. Furthermore, while an estimated 25% of persons with chronic HBV infection are treatment eligible, our study showed only 13% of pregnancies with an HBV diagnosis code were prescribed an antiviral prior to delivery, and 1.6% had an antiviral prescription postdelivery; however, we did not assess treatment eligibility (e.g., HBV DNA > 200,000 IU/mL) among these pregnancies.

Of a population of pregnant women with private health insurance, we showed many pregnancies (18%) without evidence of HBsAg test claim. CDC recommends that all pregnant women should be tested for HBsAg during an early prenatal visit (e.g., first trimester) in each pregnancy, even if they have been previously vaccinated or tested [5]. Testing provides documentation of the positive HBsAg test result and helps to ensure that infants will be identified for timely prophylaxis [5]. Previous data using MarketScan showed that 12% of insured pregnant women did not receive HBsAg testing [13], which differed from our data, possibly due to methodologic differences in amount of time in continuous enrollment (15 months in our study versus 12 months) and age groups included (10–50 years in our study versus 15–44 years). We also included more years of data (2011–2014 versus 2013-2014). Our analysis showed that women aged 20–39 years had higher testing proportions than women aged 40 years or older. This is consistent with the decreased proportion of women receiving HBsAg testing in subsequent pregnancies. While it is reassuring that a large proportion of pregnant women receive HBsAg testing, strategies are needed to get closer to 100% HBsAg testing.

Nationally and regardless of pregnancy status, few persons with HBV are linked to care and many public health efforts are underway to fill this gap [14, 15]. Even though a large number of pregnant women received HBsAg testing, many HBsAg-positive women were not linked to care [10]. Our data indicated that 58% of pregnancies with an associated HBV diagnosis code were not linked to appropriate HBV care either during pregnancy or postpartum. There were geographic differences for linkage to care; however, there were not significant differences for HBV linkage to care identified during pregnancy in urban versus nonurban areas. In addition to reducing maternal-to-child transmission, HBsAg testing during pregnancy provides an opportunity to link women to care. Linking HBsAg-positive pregnant women to HBV-directed care is the critical second step in the care continuum to identify those who may benefit from antiviral therapy which can delay HBV-associated liver complications and prevent maternal-to-child transmission.

In addition to prophylaxis for infants born to HBsAg-positive women, pregnant women with HBV may require antiviral treatment. The American Association for the Study of Liver Diseases (AASLD) guidelines suggest maternal antiviral therapy when the maternal HBV DNA is > 200,000 IU/mL [16]. Regarding antiviral treatment prescriptions, a prior analysis using commercial claims data showed a 13% antiviral prescription rate overall among pregnant women, which was significantly lower than that among nonpregnant women (20%) with HBV [12]. About 25% of persons with HBV are eligible for antiviral therapy [14]. Our data showed that 15% of pregnant women with an HBV diagnosis code were prescribed an antiviral overall and only 1.6% were prescribed an antiviral postdelivery. Tenofovir is first-line antiviral medication for treatment eligible pregnant women, although lamivudine or telbivudine has also been used as there is no evidence of adverse outcomes in infants born to mothers treated with these agents [16]. Although 11 pregnant women were treated with entecavir predelivery, entecavir is not recommended because the safety during pregnancy is not known. Our analysis showed that tenofovir was most commonly used, followed by lamivudine and entecavir. We did not include interferon in our analysis because it is contraindicated during pregnancy. Even though our analysis included claims data between 2011 and 2014, which is prior to the publication of updated AASLD clinical guidelines in 2016 [16], our analysis demonstrated significant linkage to care and treatment gaps among pregnant women with HBV.

Our analysis was subject to at least five limitations. First, we used a commercially insured claims database that does not include women without insurance and therefore does not represent the general US population. The HBV care continuum among under- or uninsured women and children still needs to be characterized to better target public health interventions. Second, there may have been misclassification related to claim codes used to identify pregnant women. For instance, if a claim was not submitted or reimbursed, it may not have been captured in the dataset, thereby leading to an underestimated sample. Third, there was potential for misclassification of HBsAg testing. We included a broad set of codes to include all potential HBV diagnoses; however, codes may have not equated to actual HBV infection as we were unable to confirm infection status with laboratory results or medical record review. Fourth, not all women had prescription claims data available for analysis, which may have led to an underestimated proportion of women receiving antiviral prescriptions. Fifth, we were not able to ascertain the proportion of pregnancies that would have been eligible for treatment, such as those with HBV DNA > 200,000 IU/mL, because we did not have laboratory data. In addition, since we defined care engagement as having one ALT, HBV DNA, or HBeAg, we were unable to assess continued follow-up care beyond initial care engagement. However, our results are consistent with other published data [12].

There have been several strategies identified that lead to increased testing and linkage to care for persons with HBV that may be applied to address gaps for pregnant women with HBV infection identified in this study. Patient education has shown success by facilitating increased HBV testing in hard to reach populations [15, 17, 18] and can be applied to pregnant women. In addition, provider education is important to ensure HBV testing is performed and correctly interpreted, and persons with positive results receive appropriate management [19], which can be applied to prenatal care clinics. Coordination of care through care managers or peer navigators has been shown to increase linkage to care [15, 20] and can be applied postdelivery to mothers identified with HBV. Utilization of health information technology may increase hepatitis B testing for pregnant women and prompt the provider to order appropriate HBV tests both pre- and postdelivery [21]. Further study is warranted to identify best practice strategies to increase linkage to care for pregnant women with HBV infection.

5. Conclusion

Commercial claims data can be used to evaluate the hepatitis B care continuum among commercially insured pregnant women. Our data showed that many pregnant women received predelivery hepatitis B testing; however testing should approach 100% among a commercially insured population. Furthermore we identified gaps in the hepatitis B care continuum among HBV-infected women which highlight potential targets for public health interventions to decrease HBV-associated morbidity and mortality among pregnant women and their infants.

Data Availability

MarketScan data is publically available.

Disclosure

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. This work was presented at the American Public Health Association 2017 Annual Meeting in Atlanta, GA, on November 7, 2017 (abstract number 4049.0).

Conflicts of Interest

The authors have no financial conflicts of interest.

Authors’ Contributions

Dr. Aaron M. Harris helped design the study, supervised the analytic plan, interpreted the data, drafted the initial manuscript, revised the manuscript, and approved the final manuscript; Dr. Cheryl Isenhour managed the database, helped design the study, led the data analysis and interpretation, critically reviewed the manuscript, and approved the final manuscript; Dr. Sarah Schillie contributed to study design, critically reviewed the manuscript as a subject matter expert, helped interpret the data, and approved the final manuscript as submitted; Dr. Claudia Vellozzi obtained funding to conduct the study, supervised Drs. Cheryl Isenhour and Aaron M. Harris in the analysis and scientific writing, critically reviewed and revised the manuscript, and approved the final manuscript as submitted.

Acknowledgments

This study was funded by the Centers for Disease Control and Prevention.

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