Hepatopancreatobiliary Fellowship Graduates: Where Do They Stand today?

BACKGROUND: The Americas Hepato-Pancreato-Biliary Association (AHPBA) Education and Training Committee standardized a Hepatopancreatobiliary (HPB) Surgery Fellowship certification process in 2010. Several classes of fellows have since graduated from HPB, combined Society of Surgical Oncology/AHPBA, and combined American Society of Transplant Surgeons/AHPBA fellowships, but there is little information on their career outcomes. We seek to offer long-term data on the careers of HPB fellowship graduates. METHODS: A 26-question anonymous survey was distributed among graduates of accredited programs for the last 10 years. We generated descriptive statistics from the responses. RESULTS: The respondents were evenly distributed in terms of graduation years between 2010 and 2019. Fifty-eight percent of fellows had completed a prior fellowship, 82% received 1 to 3 job offers during the fellowship, and 75% of respondents were still at their first job. The majority of graduates (>60%) were able to secure a job with a >50% HPB practice and >40 HPB cases per year within 3 years of graduation. Overall, >90% candidates rated their satisfaction with fellowship training greater than 8 out of 10. DISCUSSION: This survey helps shed light on the early formative years in the practices of HPB fellowship graduates. These data show that HPB fellowship training is essential and effective in providing job security and helps fellowship graduates develop a gratifying practice.

Investigating Factors at Play in Hepatopancreatobiliary Fellowship Selection: Beliefs versus Reality.

BACKGROUND: Selection biases affecting candidate matches to fellowship programs directly influence diversity within the surgical community. The review of selection bias has never been distinctively investigated in the Hepatopancreatobiliary (HPB) surgery community. This study seeks to (i) evaluate factors affecting selection of candidates to HPB fellowships, (ii) examine explicit biases among program directors and faculty of HPB programs in North America, and (iii) compare the demography of the HPB faculty and recently graduated fellows to general surgery residents. STUDY DESIGN: An anonymous, self-reported survey consisting of 10 sets of fictional applications was distributed to 52 faculty members, including program directors, of AHPBA-affiliated HPB fellowships in North America. The respondents had to pick a preferred candidate between two abridged, fictional HPB fellow applications and give an open-ended response as to why they picked that candidate. The applications were nearly identical with one notable characteristic of interest. Demographic information of both faculty and their recent fellows was also collected. This survey was administered and collected between February and April, 2020. RESULTS: A total of 29 fully completed responses were received, comprising a 55.7% response rate. Respondents were 72.4% male, 69.0% Caucasian, and 79.3% held US medical degrees (MD). 50.0% of respondents preferred an MD candidate to a DO candidate, and 37% preferred US graduates to foreign-trained candidates. The respondents were unanimous in stating that gender, race, and family status were not a factor in their selection process. 5.0% said they would support an LGBTQ candidate when faced with otherwise similar applicants. Seventy-six HPB fellows from the past 5 years were 76.3% male, 56.6% Caucasian, and 51.3% US graduated Doctor of Medicine (US MD). CONCLUSION: This is the first study explicitly exploring the impact of demographic factors in the HPB fellowship selection process. The respondents unanimously and explicitly stated that race and gender do not play any role in their selection process. Yet, there is stark discordance between general surgery resident demographics and HPB fellow demographics. A greater effort to promote a more diverse HPB surgery community may be needed.

Current Developments in Digital Quantitative Volume Estimation for the Optimisation of Dietary Assessment.

Obesity is a global health problem with wide-reaching economic and social implications. Nutrition surveillance systems are essential to understanding and addressing poor dietary practices. However, diets are incredibly diverse across populations and an accurate diagnosis of individualized nutritional issues is challenging. Current tools used in dietary assessment are cumbersome for users, and are only able to provide approximations of dietary information. Given the need for technological innovation, this paper reviews various novel digital methods for food volume estimation and explores the potential for adopting such technology in the Southeast Asian context. We discuss the current approaches to dietary assessment, as well as the potential opportunities that digital health can offer to the field. Recent advances in optics, computer vision and deep learning show promise in advancing the field of quantitative dietary assessment. The ease of access to the internet and the availability of smartphones with integrated cameras have expanded the toolsets available, and there is potential for automated food volume estimation to be developed and integrated as part of a digital dietary assessment tool. Such a tool may enable public health institutions to be able to gather an effective nutritional insight and combat the rising rates of obesity in the region.

The impact of socioeconomic status on outcomes in hepatocellular carcinoma: Inferences from primary insurance.

BACKGROUND: To investigate the impact of insurance status on outcomes in patients with hepatocellular carcinoma (HCC). METHODS: Patients diagnosed with HCC in the cancer registry from 2005 to 2016 were retrospectively stratified by insurance group. Overall survival was assessed via Kaplan-Meier curves and Cox proportional hazard models including potential confounders in multivariable analyses. RESULTS: Seven hundred and sixty-nine patients met inclusion criteria (median age 63 years, 78.8% male, 65.9% Caucasian). 44.5% had private insurance (n = 342), 29.1% had Medicare (n = 224), and 26.4% had Medicaid (n = 203). At diagnosis, Medicaid patients had higher rates of Child-Pugh B (32.0%) and C disease (23.6%) vs Medicare (28.6% and 9.8%) and private insurance (26.9% and 6.7%, P < 0.0001) and higher MELD scores (median 11.0) vs Medicare (9.0) and private insurance (9.0, P = 0.0266). Across insurance groups, patients had similar distribution of American Joint Committee on Cancer stage, tumor size, and multifocal tumor burden. Patients with private insurance had the highest survival (median OS 21.9 months) vs Medicare (17.7 months) and Medicaid (13.0 months, overall P = 0.0061). On univariate analysis, Medicaid patients demonstrated decreased survival vs private insurance (HR 1.40, 95% CI: 1.146-1.715, P = 0.0011). After adjustment for liver disease factors, this survival difference lost statistical significance (Medicaid vs private insurance, HR 1.02, 95% CI: 0.819-1.266, P = 0.8596). CONCLUSION: Medicaid was associated with advanced liver disease at HCC diagnosis; however, insurance status is not an independent predictor of HCC survival.

Healthcare resource utilization and costs by disease severity in an insured national sample of US patients with chronic hepatitis B.

BACKGROUND & AIMS: Chronic hepatitis B (CHB) affects over 2 million people in the US, with little reported on healthcare utilization and cost. We aimed to quantify annual CHB utilization and costs by disease severity and payer type. METHODS: Using Commercial, Medicare, and Medicaid databases from 2004 to 2015 and ICD9 codes, we retrospectively identified adults with CHB, analyzing all-cause inpatient, outpatient, and pharmaceutical utilization and costs by disease severity. We compared healthcare utilization and costs between patients with CHB, without advanced liver disease, and matched non-CHB controls. All-cause inpatient, outpatient, and pharmaceutical utilization and costs were reported for each year and adjusted to 2015 dollars. RESULTS: Our sample consisted of 33,904 CHB cases and 86,072 non-CHB controls. All-cause inpatient admissions (average stay 6-10 days) were more frequent in advanced liver disease states. Across all payers, patients with decompensated cirrhosis had the highest emergency department utilization (1.6-2.8 annual visits) and highest mean annual costs. The largest all-cause cost components for Commercial and Medicaid were inpatient costs for all advanced liver disease groups (Commercial: 62%, 47%, 68%; Medicaid: 81%, 72%, 74%, respectively), and decompensated cirrhosis and hepatocellular carcinoma groups for Medicare (Medicare 49% and 48%). In addition, patients with compensated liver disease incurred costs 3 times higher than non-CHB controls. CONCLUSION: Patients with CHB, regardless of payer, who experienced decompensated cirrhosis, hepatocellular carcinoma, or a liver transplant incurred the highest annual costs and utilization of healthcare resources, but even patients with CHB and compensated liver disease incurred higher costs than those without CHB. All stakeholders in disease management need to combine efforts to prevent infection and advanced liver disease through improved vaccination rates, earlier diagnosis, and treatment. LAY SUMMARY: Hepatitis B virus can be a progressive disease leading to cirrhosis, hepatocellular carcinoma, liver transplant, and death. These progressive disease states are associated with a higher rate of hospitalizations, emergency room visits, outpatient visits, and costs compared to similar patients without hepatitis B. The most ill patients have the highest costs, but even patients who are less sick experience higher costs than patients without hepatitis B.

Advancing Age and Comorbidity in a US Insured Population-Based Cohort of Patients With Chronic Hepatitis B.

Chronic hepatitis B (CHB) comorbidity data are limited. Using insurance claims databases, our aims were to determine the prevalence and incidence of nonliver comorbidities in CHB patients over time and the predictors of select comorbidities in CHB patients. Patients were adults with continuous coverage (commercial/Medicare or Medicaid) 6 months prior to and after the first CHB diagnosis and matched non-CHB patients. Deyo-Charlson Comorbidity Index (DCCI) and comorbidities were analyzed (cardiovascular disease [CVD], carcinoma, diabetes mellitus [DM], obesity, hypertension [HTN], hyperlipidemia, alcohol use, renal impairment, chronic kidney disease [CKD], and osteoporosis/fracture [OF]). The study population included 44,026 CHB cases and 121,568 matched controls. CHB patient mean age increased from 48.1 ± 11.9 years in 2006 to 51.8 ± 12.4 years in 2015 for commercial/Medicare and from 44.1 ± 11.1 years to 50.2 ± 10.2 years for Medicaid (P < 0.001 for both). The Medicaid CHB cohort was the sickest (DCCI, 2.6, P < 0.001). The commercial/Medicare 2006 CKD prevalence rate was 36.1/1,000 in CHB patients and 10.2/1,000 in controls, increasing to 97.6 and 38.8 in 2015, respectively. The 2006 CKD incidence (per 1,000 person-years) was 10.3 and 4.8 and 15.2 and 11.3 by 2015, respectively (P < 0.05 for all). The strongest predictors for CKD were DM (hazard ratio [HR], 2.48), HTN (HR, 3.29), and CVD (HR, 2.61) (all P < 0.0001). Similar prevalence and incidence changes were observed for OF. The strongest predictors for OF were female gender (HR, 2.22), alcohol use (HR, 2.02), and viral coinfection (HR, 1.37) (all P < 0.0001). Conclusion: Insured CHB patients were older, had more comorbidities, and experienced higher incidence and prevalence of CKD and OF than controls.

A comprehensive assessment of patient reported symptom burden, medical comorbidities, and functional well being in patients initiating direct acting antiviral therapy for chronic hepatitis C: Results from a large US multi-center observational study.

BACKGROUND: Symptom burden, medical comorbidities, and functional well-being of patients with chronic hepatitis C virus (HCV) initiating direct acting antiviral (DAA) therapy in real-world clinical settings are not known. We characterized these patient-reported outcomes (PROs) among HCV-infected patients and explored associations with sociodemographic, liver disease, and psychiatric/substance abuse variables. METHODS AND FINDINGS: PROP UP is a large US multicenter observational study that enrolled 1,600 patients with chronic HCV in 2016-2017. Data collected prior to initiating DAA therapy assessed the following PROs: number of medical comorbidities; neuropsychiatric, somatic, gastrointestinal symptoms (PROMIS surveys); overall symptom burden (Memorial Symptom Assessment Scale); and functional well-being (HCV-PRO). Candidate predictors included liver disease markers and patient-reported sociodemographic, psychiatric, and alcohol/drug use features. Predictive models were explored using a random selection of 700 participants; models were then validated with data from the remaining 900 participants. The cohort was 55% male, 39% non-white, 48% had cirrhosis (12% with advanced cirrhosis); 52% were disabled or unemployed; 63% were on public health insurance or uninsured; and over 40% had markers of psychiatric illness. The median number of medical comorbidities was 4 (range: 0-15), with sleep disorders, chronic pain, diabetes, joint pain and muscle aches being present in 20-50%. Fatigue, sleep disturbance, pain and neuropsychiatric symptoms were present in over 60% and gastrointestinal symptoms in 40-50%. In multivariable validation models, the strongest and most frequent predictors of worse PROs were disability, unemployment, and use of psychiatric medications, while liver markers generally were not. CONCLUSIONS: This large multi-center cohort study provides a comprehensive and contemporary assessment of the symptom burden and comorbid medical conditions in patients with HCV treated in real world settings. Pain, fatigue, and sleep disturbance were common and often severe. Sociodemographic and psychiatric markers were the most robust predictors of PROs. Future research that includes a rapidly changing population of HCV-infected individuals needs to evaluate how DAA therapy affects PROs and elucidate which symptoms resolve with viral eradication. TRIAL REGISTRATION: (Clinicaltrial.gov: NCT02601820).

New Hepatitis C Drugs Are Very Costly And Unavailable To Many State Prisoners.

Prisoners bear much of the burden of the hepatitis C epidemic in the United States. Yet little is known about the scope and cost of treating hepatitis C in state prisons-particularly since the release of direct-acting antiviral medications. In the forty-one states whose departments of corrections reported data, 106,266 inmates (10 percent of their prisoners) were known to have hepatitis C on or about January 1, 2015. Only 949 (0.89 percent) of those inmates were being treated. Prices for a twelve-week course of direct-acting antivirals such as sofosbuvir and the combination drug ledipasvir/sofosbuvir varied widely as of September 30, 2015 ($43,418-$84,000 and $44,421-$94,500, respectively). Numerous corrections departments received smaller discounts than other government agencies did. To reduce the hepatitis C epidemic, state governments should increase funding for treating infected inmates. State departments of corrections should consider collaborating with other government agencies to negotiate discounts with pharmaceutical companies and with qualified health care facilities to provide medications through the federal 340B Drug Discount Program. Helping inmates transition to providers in the community upon release can enhance the gains achieved by treating hepatitis C in prison.

Drug Authorization for Sofosbuvir/Ledipasvir (Harvoni) for Chronic HCV Infection in a Real-World Cohort: A New Barrier in the HCV Care Cascade.

BACKGROUND: New treatments for hepatitis C (HCV) infection hold great promise for cure, but numerous challenges to diagnosing, establishing care, and receiving therapy exist. There are limited data on insurance authorization for these medications. MATERIALS AND METHODS: We performed a retrospective chart review of patients receiving sofosbuvir/ledipasvir (SOF/LED) from October 11-December 31, 2014 to determine rates and timing of drug authorization. We also determined predictors of approval, and those factors associated with faster decision and approval times. RESULTS: Of 174 patients prescribed HCV therapy during this period, 129 requests were made for SOF/LED, of whom 100 (77.5%) received initial approval, and an additional 17 patients (13.9%) ultimately received approval through the appeals process. Faster approval times were seen in patients with Child-Pugh Class B disease (14.4 vs. 24.7 days, p = 0.048). A higher proportion of patients were initially approved in those with Medicare/Medicaid coverage (92.2% vs. 71.4%, p = 0.002) and those with baseline viral load ≥ 6 million IU/mL (84.1% vs. 62.5%, p = 0.040). Linear regression modeling identified advanced fibrosis, high Model of End Stage Liver Disease (MELD) score, and female gender as significant predictors of shorter decision and approval times. On logistic regression, Medicare/Medicaid coverage (OR 5.96, 95% CI 1.66-21.48) and high viral load (OR 4.52, 95% CI 1.08-19.08) were significant predictors for initial approval. CONCLUSIONS: Early analysis of real-world drug authorization outcomes between October-December 2014 reveals that nearly one in four patients are initially denied access to SOF/LED upon initial prescription, although most patients are eventually approved through appeal, which delays treatment initiation. Having Medicare/Medicaid and advanced liver disease resulted in a higher likelihood of approval as well as earlier decision and approval times. More studies are needed to determine factors resulting in higher likelihood of denial and to evaluate approval rates and times after implementation of restrictive prior authorization guidelines.

Evidence-based interventions to enhance assessment, treatment, and adherence in the chronic Hepatitis C care continuum.

BACKGROUND: With the explosion of newly available direct acting antiviral (DAA) Hepatitis C virus (HCV) treatments that demonstrate 95% sustained virologic response (SVR) rates, evidence-based strategies are urgently needed to achieve real-world effectiveness in challenging patient populations. While HIV is incurable, lessons from over 30 years of experience overcoming obstacles to the HIV treatment cascade could be applied to the HCV context. METHODS: Using Institute of Medicine guidelines, we conducted a systematic review of published interventions from PubMed, Medline, GoogleScholar, EmBASE, and PsychInfo bibliographic databases and citation indices. Abstracts were first screened by three independent reviewers and studies were included if they involved original research, described a specific intervention, were published in English in a peer-reviewed journal between 2001 and 2014, and had full text available. RESULTS: Evidence-based interventions to enhance HCV assessment, treatment, and adherence generally fell into one of 4 categories, including those involving: (1) diagnosis or case-finding; (2) linkage to HCV care; (3) pre-therapeutic evaluation or treatment initiation; or (4) treatment adherence. While most available eligible studies described interventions using non-contemporary interferon-based HCV treatments, future research will need to address how these interventions apply to the context of well-tolerated, simple, oral treatment regimens. In some cases, we explored how HIV-specific interventions might be modified to fit the HCV spectrum of care engagement. CONCLUSIONS: Evidence-based interventions should be strategically incorporated into HCV treatment implementation efforts to most effectively deliver treatment and maximize treatment outcomes.

Management of chronic hepatitis C infection in children.

PURPOSE OF REVIEW: Chronic hepatitis C infection remains a global public health burden and has important clinical implications due to progressive liver fibrosis and development of cirrhosis and its complications. The role of antiviral therapy in infected children is an area of controversy due to an indolent clinical course in the majority of children, and a low likelihood of viral eradication in response to an intensive interferon-based treatment course that is associated with a wide spectrum of adverse effects. This review summarizes new concepts in the epidemiology, natural history, and management of chronic hepatitis C infection in children. RECENT FINDINGS: In the past 18 months, two large prospective studies demonstrated high rates of sustained virologic response in children with chronic hepatitis C infection, estimated at 53% in genotype 1 with peginterferon α-2b-ribavirin, and 47% in genotype 1 with peginterferon α-2a-ribavirin. On this basis, both combination regimens have been recently approved by the Food and Drug Administration (FDA) for use in children. SUMMARY: Children with hepatitis C infection may benefit from early treatment, and the decision to pursue antiviral therapy should be based on individual assessment of host and viral characteristics, and stage of liver fibrosis.