What barriers do primary care physicians face in the management of patients with chronic hepatitis B infection in primary care?

NC Tan, SL Cheah
Correspondence: Dr Ngiap-Chuan Tan, Tan.Ngiap.Chuan@singhealth.com.sg

ABSTRACT
Introduction Asymptomatic chronic hepatitis B virus (HBV) carriers, followed-up in primary care, present a challenge to primary care physicians as they encounter problems in monitoring this group of patients. The study aims to explore the barriers faced by primary care physicians in the management of patients with chronic hepatitis B infection in primary care.
Methods Qualitative analysis of eight focus group discussions with 43 primary care physicians in Singapore was conducted.
Results Primary care physicians highlighted the HBV carriers' poor compliance to disease monitoring as a major hurdle, attributing to their lack of understanding of the disease, state of denial, fear of stigmatisation in society, failure to perceive benefits, costs and reluctance of investigations due to physical discomfort. The carriers' health-seeking behaviour, such as doctor hopping and the use of traditional medication, were other barriers. The investigators noted that the physicians placed emphasis on passive disease monitoring, focusing on the investigation results when they reviewed the carriers. They were less proactive in explaining the disease's natural history nor discussing the possibility of definitive anti-viral treatment for suitable carriers. These physicians varied in their approaches in disease monitoring of chronic HBV infection. The fees-for-service healthcare system allowed the carrier to seek consultation from different doctors, which could result in disruption of disease surveillance. This was further compounded by the differential cost of investigations in private practices and government-aided polyclinics. The absence of a national HBV registry and recall system and waiting time for referral to specialist clinics in restructured hospitals, were other barriers.
Conclusion The management of HBV carriers in primary care could be enhanced by measures that eliminate the barriers involving the patient, doctor and healthcare system.

Keywords: chronic hepatitis B infection, hepatitis, primary care physicians
Singapore Med J 2005; 46(7): 333-339