Acceptability of opt-out consent in a hospital patient population

Suong Le et al. published in Internal Medicine Journal.

Read article here.

Antenatal maternal Hepatitis B care is a predictor of timely perinatal administration of Hepatitis B immunoglobulin

Suong Le et al. published in the Internal Medicine Journal.

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Be Positive: Monash researchers improving screening rates for hepatitis B

Ms Kate Sievert

Improved screening and vaccination rates for chronic hepatitis B in migrant populations in Melbourne is the aim of a project recently recognised as a winner in the One Monash Health Awards.

Project leaders Ms Kate Sievert and Mr Paul O’Neill from the Department of Gastroenterology and Hepatology, Monash Health received the competitive innovation award for their B_e Positive project, that has challenged both healthcare worker and community preconceived ideas about hepatitis B, and how these populations interact with the Australian healthcare system.

Mr Paul O'Neill

Chronic hepatitis B (CHB) is an emerging challenge for healthcare services in Australia. The estimated prevalence of CHB has increased by 50,000 patients in the last 10 years and affects 1% of all Australians.  The long-term complications of CHB include cirrhosis, liver failure, and liver cancer.

“The burden of CHB is over-represented among migrants from endemic countries, indigenous

Australians, intravenous drug users, and prisoners,” said Ms Sievert.  “Early diagnosis and treatment of CHB can reduce the progression to cirrhosis, liver cancer and the need for liver transplantation.”

Despite recommendations for universal testing for CHB among at-risk migrant populations, it is estimated that 30% of chronically infected adults in Australia may be unaware of their disease.

“The B_e Positive project is the first of its kind at Monash Health and the first in Australia to target the Rohingyan, Afghan, and South Sudanese communities using the same model of peer education and leadership among CHB patients.”

 Public Health strategies aimed at these three communities have been virtually non-existent, despite significantly poor health outcomes in each group relative to the wider Australian-born population.

 “Patients born in countries with high CHB prevalence are 6-12 times more likely to be diagnosed with liver cancer compared to Australian-born individuals,” said Ms Sievert.

“It is imperative that targeted healthcare interventions are developed and carried out within at risk populations to prevent the high morbidity and mortality associated with CHB.”

Opportunistic testing for CHB is considered essential as a prevention strategy for liver cancer but there is a lack of targeted public health projects addressing the poor rates of screening and vaccination among these at-risk populations.

Ms Sievert said that language and cultural barriers, lack of awareness of transmission routes, and poor understanding of severity of disease due to the often-times lack of symptoms are some of the factors contributing to low levels of screening and treatment compliance amongst migrant CHB patients.

“Our B_e Positive project focused on the Sudanese, Rohingyan and Afghani migrant population due to the high prevalence of CHB within these groups (8.6-11%), increased resettlement as asylum seekers within the Monash Health catchment area and the lack of any health promotion within these groups,” said Ms Sievert.

“Monash Health serves a large variety of migrant populations in the south-east of Victoria, and we devised a pilot public health intervention within these difficult to engage new migrant communities aimed at reducing future liver cancer burden.”

Using a trained CHB patient leader to tell their story to their own community, stigma and misinformation about CHB was dispelled while culturally relevant information was exchanged.

“We successfully opened conversations about hepatitis B virus (HBV) through SBS radio and community forums, improving the level of HBV knowledge among patients and their wider communities,” said Ms Sievert.

 “Our goal is to increase the rates of testing for HBV across South-east Melbourne and ensure those who may have been living unknowingly with HBV are monitored by the system and treated if required.”

The B_e Positive project has shown that we must continue to engage sensitively with migrant groups with a high prevalence of CHB and we cannot approach every migrant group using the same general strategy.

The project was supervised by Dr Suong Le and Dr Anouk Dev, Consultant Hepatologists at Monash Health. The B_e Positive project was funded by a Bristol Myers Squibb research grant awarded to Monash Health EMR Benefits Clinician Dr Suong Le, who designed the project.

Engaging new migrant populations—a lesson in humility

Kate Sievert et al. published in The BMJ.

Read article here.

Monash research sheds light on chronic liver disease

Dr Sahhar, Dr Ha, Professor Sievert and Dr Le

Cirrhosis related ascites is a common and complex medical condition associated with increased morbidity, mortality, healthcare utilisation, and reduced quality of life.  It is estimated that up to 0.5% of the general population have cirrhosis and according to the World Health Organisation it is the 6^th leading cause of death worldwide.

While other chronic diseases such as heart failure are well managed by a range of health professionals and a dedicated ambulatory care service, there is no comprehensive model of care for people living with cirrhosis. 

Published recently in the prestigious American Journal of Gastroenterology, a team of researchers at Monash University and Monash Health have shown for the first time that early intervention using diuretic therapy or paracentesis (removing fluid from the abdomen) for patients with cirrhosis and ascites significantly reduces hospital readmission and mortality. 

“Cirrhosis, or scarring of the liver, is commonly caused by alcohol and viral hepatitis. 50% of cirrhosis patients develop ascites, the most common complication of this debilitating disease” said gastroenterologist and lead researcher Dr Suong Le.

Ascites is the build-up of fluid in the abdomen and results from scarred liver tissue unable to filter substances in the body.

“Some of our patients present in the emergency department looking like they’re nine months pregnant; they can’t breathe; they can’t walk and they’re extremely sick,” said Dr Le.  “We often drain 5 to 10 litres of fluid from their abdomen.”

While there is no cure for cirrhosis related ascites other than liver transplantation, it can be managed to improve quality of life.

“Our study found that giving patients diuretics as early as possible lowers 90-day mortality, and early paracentesis lowers 30-day hospital admission rates,” said Dr Le.

Senior author and Monash University Professor of Medicine William Sievert said 70% of patients initially hospitalised for new onset cirrhotic ascites were being readmitted within 90 days because of recurrent ascites.

“People with cirrhotic ascites have a higher mortality rate than those with cirrhosis who have never developed ascites, and 30 day readmission was a very strong predictor of 90 day mortality,” said Professor Sievert, who is also Director, Gastroenterology and Hepatology Unit at Monash Health.

“We found that if patients had a paracentesis within 30 days of the diagnosis of ascites or during their initial hospitalization then those patients were significantly less likely to be readmitted for recurrent ascites and that early initiation of diuretics significantly lowered the risk of mortality at 90 days.”

“Adherence to these two quality of care indicators had the greatest benefit for patients, which was especially important given that 40% of the unplanned 30-day readmissions were to the ICU,” said Professor Sievert. Dr Le said there’s a lack of awareness in the community about cirrhosis and patients and medical staff need to be educated that these simple and early interventions will extend and significantly improve quality of life.

“One of the most shocking findings of our study was that 58% of patients did not even know they had liver disease until they presented to hospital with ascites,” said Dr Le.

“These patients have previously had no formal diagnosis—cirrhosis is a long process, taking 10 to 20 years to develop and progress.”

More than 300 patient records were analysed for the research study, revealing that most patients with the disease were men who lived alone, with a mean age of 57 years. 

The Monash research team included Dr Phil Ha, Dr Lukas Sahhar, Dr Julian Lim and Dr Tony He, all of whom were medical students when the project commenced.

Dr Tony He said he had a particular interest in gastroenterology and was keen to help facilitate better management of patients with chronic liver disease and their complications. 

Of the research project, Dr Lukas Sahhar said he’d learnt about the conduct and application of real-world medical research.

“It was a very satisfying experience working with doctors and researchers at Monash Health and Monash University and we are all grateful to Dr Le and Professor Sievert for the opportunity,” said Dr Sahhar.

Monash Health intern Dr Phil Ha said it was a fascinating project that assessed the degree to which current practices had followed best practice guidelines.

“Investigating whether higher adherence to evidence-based medicine translates into better outcomes for patients with advanced liver disease was a fantastic learning experience,” said Dr Ha.

In 2014, then medical student Phil Ha undertook at Bachelor of Medical Science (Honours) under the supervision of Professor Sievert to investigate the use of a smartphone app to improve outpatient care for patients with cirrhotic ascities.

“In Dr Le’s research project, we found there was a particularly high readmission and mortality rate for patients with advanced liver disease, and strategies to identify outpatients at risk of deteriorating could improve these outcomes,” said Dr Ha. 

“For my BMedSc research project, I developed and implemented a remote monitoring system for outpatients with cirrhotic ascites using a smartphone app, enabling the transmission of real-time information to the treating team.” 

Simple indicators such as weight and symptoms suggestive of decompensation were transmitted via the smartphone app to the liver team, and abnormal values were automatically flagged, and prompted a telephone consultation with the patient.

Dr Ha said they trialled the system with nine patients and found some promising results.

“Future studies will evaluate the potential benefits of using this technology to improve patient outcomes.”