D0506 - High Burden of Concurrent Mental Health and Substance Use Disorders Contribute to Gaps in the Hepatitis B Care Cascade Among Underserved U.S. Veterans

Introduction: Gaps in the chronic hepatitis B (CHB) care cascade contribute to delayed diagnosis, disparities in linkage to care, and missed opportunities for hepatocellular carcinoma (HCC) surveillance. High prevalence of mental health (MH) and substance use disorders (SUD) among US Veterans may exacerbate existing disparities in CHB care among this underserved cohort. We aim to evaluate the impact of concurrent MH and SUD on receipt of CHB care among Veterans with CHB.

Methods: We identified 108 CHB patients (>2 positive hepatitis B surface antigen tests >6 months apart) via EHR query of health system laboratory data from 2017 to 2020. Liver care engagement (>1 visit/year with liver clinic), CHB treatment (among eligible patients), and appropriate HCC surveillance were compared between groups using chi-square testing, and further evaluated with adjusted multivariable regression models. Qualitative assessments were performed to understand patient reported barriers in receiving CHB care.

Results: Among 108 CHB patients (89% men; mean age 60y; 51% Asian, 27% non-Hispanic White, 9% African American, 8% Hispanic; 15% cirrhosis), 47% had MH conditions and 66% had SUD. Overall, 62% were engaged into liver care, 79% received guideline-concordant HCC surveillance, and 63% of treatment-eligible patients were on CHB therapy. CHB patients with SUD had lower engagement with liver care (58% vs. 74% in those without SUD) and lower rates of CHB treatment (52% vs. 80%), but no difference in HCC surveillance. CHB patients with MH conditions had lower rates of CHB treatment (46% vs. 76% in those without MH), but similar rates of liver care engagement and HCC surveillance. On multivariable regression, race/ethnicity was strongly associated with receiving comprehensive CHB care (i.e., liver care engagement, HCC surveillance, and CHB therapy), with Asians more likely to meet all CHB care parameters compared to non-Hispanic whites (OR 4.45, 95% CI 1.49-13.31). On qualitative assessment, most common barriers to CHB care reported by patients involved unstable housing, transportation challenges, and lack of awareness about CHB diagnosis.

Discussion: Among an underserved cohort of US Veterans with CHB, high prevalence of MH and SUD were observed, which contributed to gaps in CHB care, particularly appropriate antiviral therapy. Efforts to improve the CHB care cascade must comprehensively address the complex psychosocial factors that further exacerbate existing disparities in CHB care.