Service delivery models and care cascade outcomes for people living with chronic hepatitis B: a global systematic review and meta-analysis.

In 2022, only 13% of the 254 million people with chronic hepatitis B were diagnosed and 3% were treated, highlighting a major gap in care provision.

2022年，在2.54亿慢性乙型肝炎患者中，只有13%被诊断出病情，3%接受了治疗，这凸显了护理提供方面的巨大差距。

We aimed to comprehensively review service delivery models and their outcomes across the hepatitis B care cascade.

我们的目标是全面审查乙型肝炎护理流程中服务提供模式及其结果。

Methods

For this systematic reviewand meta-analysis, we searched PubMed, Embase, and Scopus for observational and interventional studies of chronic hepatitis B service delivery models that reported care outcomes, published between May 1, 2013, and July 15, 2024, with no language restrictions.

在这项系统评价和荟萃分析中，我们对PubMed、Embase和Scopus进行了检索，寻找报告了护理结果的慢性乙型肝炎服务提供模式的观察性和干预性研究，这些研究发表于2013年5月1日至2024年7月15日期间，没有语言限制。

Care cascade outcomes were the proportion of people diagnosed with hepatitis B who were assessed for treatment eligibility; the proportion of eligible people who started antiviral therapy; the proportion retained in care; and the proportion on therapy who had HBV DNA viral suppression.

关怀级联结果包括被诊断为乙型肝炎的人群中评估治疗资格的比例；符合条件开始抗病毒治疗的人群比例；保持在关怀中的人群比例；以及接受治疗且HBV DNA病毒抑制的人群比例。

We evaluated pooled outcomes across hospital-based specialist care; co-managed care between primary and specialist care; community screening with linkage to specialist care; community screening with passive linkage to care; community test and treat clinics; primary care; and integrated care with antenatal, non-communicable disease, HIV, prison health, and substance misuse services and clinics, using a generalised linear mixed model with logit link and study random effects.

我们使用广义线性混合模型，以logit链接和研究随机效应，评估了医院专科护理、初级与专科护理共同管理、社区筛查与专科护理链接、社区筛查与被动护理链接、社区检测与治疗诊所、初级护理以及与产前护理、非传染性疾病、HIV、监狱健康和药物滥用服务及诊所整合的护理的综合结果。

For within-study comparisons of different models, we used inverse variance weighting to estimate the pooled risk ratio (RR).

在对不同模型进行研究内比较时，我们使用了逆方差加权来估计汇总风险比（RR）。

Heterogeneity was assessed with I2.

异质性通过I2进行评估。

This study is registered with PROSPERO (CRD42023410009).

本研究已在PROSPERO注册（CRD42023410009）。

Results

Of 4883 studies identified in the search, we included 106 studies comprising 110 cohorts from 50 countries in our meta-analysis. 45 (41%) of 110 cohorts were from low-income and middle-income countries and 65 (59%) were from high-income countries. 76 (72%) of 106 studies were observational, 23 (22%) were non-randomised interventional studies, and seven (7%) were randomised trials.

在检索到的4883项研究中，我们纳入了106项研究，这些研究包括来自50个国家的110个队列，用于我们的荟萃分析。

Treatment eligibility assessment occurred in 73·9% (95% CI 65·8-80·6; I2=98·5%) of patients for hospital-based specialist care (20 cohorts), 63·1% (53·0-72·2; I2=99·9%) for co-managed care (23 cohorts), 50·4% (25·9-74·8; I2=99·7%) for primary care (four cohorts), 82·3% (58·7-93·8; I2=96·1%) for community screening with linkage to specialist care (ten cohorts), 33·2% (23·1-45·1; I2=98·6%) for community screening with passive linkage to care (three cohorts), 56·9% (40·2-72·1; I2=98·8%) for diagnosis in antenatal clinics and post-delivery linkage to specialist care (five cohorts), 75·0% (37·7-93·7; I2=0·0%) for integrated care with harm reduction services (two cohorts), and 85·4% (78·0-90·6; I2=0·0%) for integrated care with prison health services (two cohorts).

在医院专科护理中，73.9%（95%置信区间65.8-80.6；I2=98.5%）的患者接受了治疗资格评估（20个队列），在共同管理护理中为63.1%（53.0-72.2；I2=99.9%）（23个队列），在初级护理中为50.4%（25.9-74.8；I2=99.7%）（四个队列），在社区筛查与专科护理链接中为82.3%（58.7-93.8；I2=96.1%）（十个队列），在社区筛查与被动护理链接中为33.2%（23.1-45.1；I2=98.6%）（三个队列），在产前诊所诊断并产后与专科护理链接中为56.9%（40.2-72.1；I2=98.8%）（五个队列），在整合护理与减害服务中为75.0%（37.7-93.7；I2=0.0%）（两个队列），在整合护理与监狱卫生服务中为85.4%（78.0-90.6；I2=0.0%）（两个队列）。

Initiation of antiviral therapy when eligible was 78·1% (95% CI 68·1-85·7; I2=99·2%) in hospital-based specialist care (25 cohorts), 67·2% (55·5-77·1; I2=95·8%) in co-managed care (11 cohorts), 49·3% (32·4-66·4; I2=87·9%) in primary care (four cohorts), 97·7% (80·6-99·8; I2=39·2%) in community screening with linkage to specialist care (seven cohorts), and 49·4% (22·1-77·0; I2=84·0%) for integrated care with non-communicable disease clinics (two cohorts).

在医院专科护理中，当患者符合资格时，78.1%（95%置信区间68.1-85.7；I2=99.2%）的患者开始了抗病毒治疗（25个队列），在共同管理护理中为67.2%（55.5-77.1；I2=95.8%）（11个队列），在初级护理中为49.3%（32.4-66.4；I2=87.9%）（四个队列），在社区筛查与专科护理链接中为97.7%（80.6-99.8；I2=39.2%）（七个队列），在整合护理与非传染性疾病诊所中为49.4%（22.1-77.0；I2=84.0%）（两个队列）。

Higher rates of treatment eligibility assessment (RR 2·07 [95% CI 1·65-2·59], p<0·0001; I2=97·1%; three cohorts) and initiation of antiviral therapy (1·45 [1·13-1·85], p=0·0031; I2=0·0%; three cohorts) were observed in hospital-based specialist versus primary care models.

在医院专科模式与初级保健模式中，治疗资格评估的比率更高（相对风险 RR 2.07 [95% 置信区间 CI 1.65-2.59]，p<0.0001；I2=97.1%；三个队列），以及抗病毒治疗的开始率也更高（1.45 [1.13-1.85]，p=0.0031；I2=0.0%；三个队列）。

Retention in care, assessed between 12 and 48 months, was 87·7% (95% CI 79·9-92·8, I2 =96·7%) in patients on antiviral therapy in hospital-based specialist care (13 cohorts) and 47·2% (95% CI 22·2-73·6, I2=99·5%) in patients not receiving antiviral therapy (two cohorts).

在12至48个月的随访期间，医院专科护理中接受抗病毒治疗的患者的保持治疗率为87.7%（95% CI 79.9-92.8，I2=96.7%；13个队列），而未接受抗病毒治疗的患者保持治疗率为47.2%（95% CI 22.2-73.6，I2=99.5%；两个队列）。

Overall, retention was higher in patients with versus without antiviral therapy (RR 1·72 [95% CI 1·16-2·54]; p=0·019).

总体而言，接受抗病毒治疗的患者的保留率高于未接受抗病毒治疗的患者（相对风险 RR 1·72 [95% 置信区间 CI 1·16-2·54]；p=0·019）。

HBV DNA viral suppression for patients on antiviral therapy in specialist care (nine cohorts) was 73·1% (95% CI 64·3-80·4; I2=92·0%) after a median of 12 months on antiviral therapy (IQR 12-33).

在专科护理下接受抗病毒治疗的患者中，HBV DNA病毒抑制率为73·1%（95% 置信区间 CI 64·3-80·4；I2=92·0%），中位抗病毒治疗时间为12个月（四分位数间距 IQR 12-33个月）。

interpretation

Considerable attrition was seen across the chronic hepatitis B care cascade, with low rates of retention especially in patients not on antiviral therapy.

在整个慢性乙型肝炎治疗过程中，脱落率较高，特别是在未接受抗病毒治疗的患者中，保留率尤其低。

Assessment for treatment eligibility and initiation of antiviral therapy were lower in primary versus hospital-based specialist care models.

与医院专科护理模式相比，初级保健模式下的治疗资格评估和抗病毒治疗的启动率较低。

Chronic hepatitis B services need to adopt strategies to optimise linkage to care after diagnosis, initiation of antiviral therapy if eligible, adherence to antiviral therapy and retention in care, as promoted in 2024 WHO hepatitis B guidelines.

慢性乙型肝炎服务需要采取策略，在诊断后优化与护理的联系，如果符合条件则开始抗病毒治疗，遵守抗病毒治疗并保持在护理中，正如2024年世界卫生组织乙型肝炎指南所提倡的。

Further research is also needed to explore simplified care models integrated with existing services to promote access.

还需要进一步研究以探索与现有服务集成的简化护理模式，以促进获取服务。

funding

World Health Organization.

世界卫生组织。