Toward optimal end-of-life care for patients with advanced chronic obstructive pulmonary disease: Insights from a multicentre study

BACKGROUND:

Understanding patients’ needs and perspectives is fundamental to improving end-of-life (EOL) care. However, little is known of what quality care means to patients who have advanced lung disease.

OBJECTIVES:

To describe ratings of importance and satisfaction with elements of EOL care, informational needs, decision-making preferences, obstacles to a preferred location of death, clinical outcomes, and health care use before and during an index hospital admission for patients who have advanced chronic obstructive pulmonary disease (COPD).

METHODS:

A questionnaire with regard to quality EOL care was administered to patients older than 55 years of age who had advanced medical disease in five Canadian teaching hospitals.

RESULTS:

For 118 hospitalized patients who had advanced COPD, the following items were rated as extremely important for EOL care: not being kept alive on life support when there is little hope for meaningful recovery (54.9% of respondents), symptom relief (46.6%), provision of care and health services after discharge (40.0%), trust and confidence in physicians (39.7%), and not being a burden on caregivers (39.6%). Compared with patients who had metastatic cancer, patients with COPD had lower (P<0.05) satisfaction with care, interest in information about prognosis, cardiopulmonary resuscitation or mechanical ventilation, and referral rates to palliative care, whereas use of acute care services was higher (P<0.05) for patients who had advanced COPD.

CONCLUSION:

Canadian patients who have advanced COPD identify several priorities for improving care. Avoidance of prolonged or unwanted life support requires more effective communication, decision making and goal setting. Patients also deserve better symptom control and postdischarge strategies to minimize perceived burdens on caregivers, emergency room visits and hospital admissions.     

The effect of rapid response teams on end-of-life care: A retrospective chart review

BACKGROUND:

A subset of critically ill patients have end-of-life (EOL) goals that are unclear. Rapid response teams (RRTs) may aid in the identification of these patients and the delivery of their EOL care.

OBJECTIVES:

To characterize the impact of RRT discussion on EOL care, and to examine how a preprinted order (PPO) set for EOL care influenced EOL discussions and outcomes.

METHODS:

A single-centre retrospective chart review of all RRT calls (January 2009 to December 2010) was performed. The effect of RRT EOL discussions and the effect of a hospital-wide PPO set on EOL care was examined. Charts were from the Ontario Ministry of Health and Long-Term Care Critical Care Information Systemic database, and were interrogated by two reviewers.

RESULTS:

In patients whose EOL status changed following RRT EOL discussion, there were fewer intensive care unit (ICU) transfers (8.4% versus 17%; P<0.001), decreased ICU length of stay (5.8 days versus 20 days; P=0.08), increased palliative care consultations (34% versus 5.3%; P<0.001) and an increased proportion who died within 24 h of consultation (25% versus 8.3%; P<0.001). More patients experienced a change in EOL status following the introduction of an EOL PPO, from 20% (before) to 31% (after) (P<0.05).

CONCLUSIONS:

A change in EOL status following RRT-led EOL discussion was associated with reduced ICU transfers and enhanced access to palliative care services. Further study is required to identify and deconstruct barriers impairing timely and appropriate EOL discussions.     

Assessing the educational needs of Canadian gastroenterologists and gastroenterology nurses: Challenges to optimal care in Crohn’s disease

OBJECTIVE:

A national needs assessment of Canadian gastroenterologists and gastroenterology nurses was undertaken to determine the perceived and unperceived educational and performance barriers to caring for patients with Crohn’s disease (CD).

METHODS:

A triangulated, mixed-method approach (qualitative and quantitative) was used to determine the nature and extent of knowledge gaps and barriers in the care of patients with CD.

RESULTS:

Qualitative interviews were conducted with nine gastroenterologists, four gastroenterology nurses and nine patients with CD. Based on this exploratory research, a survey was designed and launched nationally (37 gastroenterologists, 36 gastroenterology nurses). Findings indicated that Canadian gastroenterologists and gastroenterology nurses lacked clarity regarding their roles and responsibilities across the continuum of CD care, and face communication gaps within the health care team, undermining their effectiveness. Gastroenterologists identified challenges in optimal diagnosis due to unclear testing and diagnostic criteria. They recognized knowledge gaps when treating patient subgroups and in prescribing biological therapies. Furthermore, gastroenterologists self-identified gaps in skill, knowledge, and confidence in monitoring disease progression and effectively assessing response to therapy. When managing patients with CD, gastroenterologists expressed challenges with patient issues outside their domain of medical expertise, particularly with the skills needed to facilitate effective patient communication and education that would enhance adherence to recommended treatments.

CONCLUSIONS:

Educational initiatives should address diagnostic and treatment guidelines, as well as enhancement of clinical performance gaps in health care team processes and the patient-professional therapeutic relationship. To impact care and patient outcomes, these initiatives must be relevant to clinical practice settings and applicable to the practice context.     

Administrative data have high variation in validity for recording heart failure

BACKGROUND:

Many studies have relied on administrative data to identify patients with heart failure (HF).

OBJECTIVE:

To systematically review studies that assessed the validity of administrative data for recording HF.

METHODS:

English peer-reviewed articles (1990 to 2008) validating International Classification of Diseases (ICD)-8, -9 and -10 codes from administrative data were included. An expert panel determined which ICD codes should be included to define HF. Frequencies of ICD codes for HF were calculated using up to the 16 diagnostic coding fields available in the Canadian hospital discharge abstract during fiscal years 2000/2001 and 2005/2006.

RESULTS:

Between 1992 and 2008, more than 70 different ICD codes for defining HF were used in 25 published studies. Twenty-one studies validated hospital discharge abstract data; three studies validated physician claims and two studies validated ambulatory care data. Eighteen studies reported sensitivity (range 29% to 89%). Specificity and negative predictive value were greater than 70% across 17 studies. Nineteen studies reported positive predictive values (range 12% to 100%). Ten studies reported kappa values (range 0.39 to 0.84).For Canadian hospital discharge data, ICD-9 and -10 codes 428 and I50 identified HF in 5.50% and 4.80% of discharge records, respectively. Additional HF-related ICD-9 and -10 codes did not impact HF prevalence.

CONCLUSION:

The ICD-9 and -10 codes 428 and I50 were the most commonly used to define HF in hospital discharge data. Validity of administrative data in recording HF varied across the studies and data sources that were assessed.     

Integrated interdisciplinary care for patients with chronic obstructive pulmonary disease reduces emergency department visits and admissions: A quality assurance study

BACKGROUND:

Dedicated programs for the management of chronic obstructive pulmonary disease (COPD) can reduce hospitalizations and improve quality of life.

OBJECTIVE:

To investigate whether health care utilization could be reduced by a newly developed integrated, interdisciplinary initiative that included a COPD nurse navigator who educates patients and families, transitions patients through various points of care and integrates services.

METHODS:

The present quality assurance, pre-post study included patients followed by a COPD nurse navigator from January 25, 2010 to November 5, 2011. Information regarding emergency department visits and hospitalizations, including lengths of stay, were obtained from hospital databases. Diagnoses were classified as respiratory or nonrespiratory, and used primary and secondary hospitalization diagnoses to identify acute exacerbations of COPD (AECOPD). Paired sign tests were performed.

RESULTS:

The sample consisted of 202 patients. Following nurse navigator intervention, significantly more patients experienced a decrease in the number of respiratory-cause emergency department visits (P<0.05), number of respiratory hospitalizations (P<0.001), total hospital days for respiratory admissions (P<0.001), number of hospitalizations with AECOPD (P<0.001) and total hospital days for admissions with AECOPD (P<0.001). Financial modelling estimated annual savings in excess of $260,000.

CONCLUSION:

The present quality assurance study indicated that the implementation of an integrated interdisciplinary program for the care of patients with COPD can improve patient outcomes despite the tendency of COPD to worsen over time.     

Assessment of quality of life in patients with advanced non-small cell lung carcinoma treated with a combination of carboplatin and paclitaxel

OBJECTIVE:

Non-small cell lung carcinoma (NSCLC) is the most common type of lung cancer. Most patients are diagnosed at an advanced stage, palliative chemotherapy therefore being the only treatment option. This study was aimed at evaluating the health-related quality of life (HRQoL) of advanced-stage NSCLC patients receiving palliative chemotherapy with carboplatin and paclitaxel.

METHODS:

This was a multiple case study of advanced-stage NSCLC outpatients receiving chemotherapy at a public hospital in Rio de Janeiro, Brazil. The European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire was used in conjunction with its supplemental lung cancer-specific module in order to assess HRQoL.

RESULTS:

Physical and cognitive functioning scale scores differed significantly among chemotherapy cycles, indicating improved and worsened HRQoL, respectively. The differences regarding the scores for pain, loss of appetite, chest pain, and arm/shoulder pain indicated improved HRQoL.

CONCLUSIONS:

Chemotherapy was found to improve certain aspects of HRQoL in patients with advanced-stage NSCLC.     

Incidence and susceptibility of aerobic Gram-negative bacilli from 20 Canadian intensive care units: 1989�C1993

OBJECTIVE:

To assess the prevalence of antibiotic resistance in Canadian intensive care units.

DESIGN:

The antimicrobial profiles of 1939 Gram-negative bacilli isolated in 20 Canadian intensive care units were analyzed using a custom designed MicroScan panel.

SETTING:

The majority of the hospitals were tertiary care institutions, but some community hospitals were included.

PATIENTS:

Adult intensive care unit patients were the sources of isolates.

MAIN RESULTS:

Pseudomonas aeruginosa was the most frequently isolated microorganism overall, with Escherichia coli the most common initial isolate. Comparison of initial and repeat isolates showed that P aeruginosa readily acquired resistance to all antibiotic classes except the aminoglycosides. Enterobacter aerogenes developed resistance to ciprofloxacin and Enterobacter cloacae demonstrated resistance to all beta-lactam antibiotics except for imipenem on repeat isolation. Other Enterobacteriaceae remained susceptible. Historical comparison with data derived four years previously from 15 of the centres showed increased resistance of P aeruginosa and Acinetobacter species to ciprofloxacin while other susceptibility patterns remained stable.

CONCLUSIONS:

The prevalence of Gram-negative resistance in Canadian hospitals is less than that reported in surveys done in some other countries, and was relatively stable over four years.     

Technology for Diabetes Care and Evaluation in the Veterans Health Administration: Veterans Affairs Research on Health Information Technologies for Diabetes Self-Management Support

Background

Like many patients with diabetes, Department of Veterans Affairs (VA) patients frequently fall short of self-management goals and experience multiple barriers to self-care. Health information technologies (HITs) may provide the tools that patients need to manage their illness under the direction of their primary care team.

Methods

We describe several ongoing projects focused on HIT resources for self-management in VA. VA researchers are developing HITs that seek to bolster a variety of potential avenues for self-management support, including patients′ relationships with other patients, connections with their informal care networks, and communication with their health care teams.

Results

Veterans Affairs HIT research projects are developing services that can address the needs of patients with multiple challenges to disease self-care, including multimorbidity, health literacy deficits, and limited treatment access. These services include patient-to-patient interactive voice response (IVR) calling systems, IVR assessments with feedback to informal caregivers, novel information supports for clinical pharmacists based on medication refill data, and enhanced pedometers.

Conclusion

Large health care systems such as the VA can play a critical role in developing HITs for diabetes self-care. To be truly effective, these efforts should include a continuum of studies: observational research to identify barriers to self-management, developmental studies (e.g., usability testing), efficacy trials, and implementation studies to evaluate utility in real-world settings. VA HIT researchers partner with operations to promote the dissemination of efficacious services, and such relationships will be critical to move HIT innovations into practice.     

Similarities and differences between asthma health care professional and patient views regarding medication adherence

BACKGROUND:

The recent literature has reported disparate views between patients and health care professionals regarding the roles of various factors affecting medication adherence.

OBJECTIVE:

To examine the perspectives of asthma patients, physicians and allied health professionals regarding adherence to asthma medication.

METHODOLOGY:

A qualitative, multiple, collective case study design with six focus-group interviews including 38 participants (13 asthma patients, 13 pulmonologist physicians and 12 allied health professionals involved in treating asthma patients) was conducted.

RESULTS:

Patients, physicians and allied health professionals understood adherence to be an active process. In addition, all participants believed they had a role in treatment adherence, and agreed that the cost of medication was high and that access to the health care system was restricted. Major disagreements regarding patient-related barriers to medication adherence were identified among the groups. For example, all groups referred to side effects; however, while patients expressed their legitimate concerns, health care professionals believed that patients’ opinions of medication side effects were based on inadequate perceptions.

CONCLUSION:

Differences regarding medication adherence and barriers to adherence among the groups examined in the present study will provide insight into how disagreements may be translated to overcome barriers to optimal asthma adherence. Furthermore, when designing an intervention to enhance medication adherence, it is important to acknowledge that perceptual gaps exist and must be addressed.     

Attention to Inpatients�� Religious and Spiritual Concerns: Predictors and Association with Patient Satisfaction

Background

Little is known about how often patients desire and experience discussions with hospital personnel regarding R/S (religion and spirituality) or what effects such discussions have on patient satisfaction.

Objective, Design and Participants

We examined data from the University of Chicago Hospitalist Study, which gathers sociodemographic and clinical information from all consenting general internal medicine patients at the University of Chicago Medical Center.

Main Measures

Primary outcomes were whether or not patients desired to have their religious or spiritual concerns addressed while hospitalized, whether or not anyone talked to them about religious and spiritual issues, and which member of the health care team spoke with them about these issues. Primary predictors were patients’ ratings of their religious attendance, their efforts to carry their religious beliefs over into other dealings in life, and their spirituality.

Key Results

Forty-one percent of inpatients desired a discussion of R/S concerns while hospitalized, but only half of those reported having such a discussion. Overall, 32% of inpatients reported having a discussion of their R/S concerns. Religious patients and those experiencing more severe pain were more likely both to desire and to have discussions of spiritual concerns. Patients who had discussions of R/S concerns were more likely to rate their care at the highest level on four different measures of patient satisfaction, regardless of whether or not they said they had desired such a discussion (odds ratios 1.4–2.2, 95% confidence intervals 1.1–3.0).

Conclusions

These data suggest that many more inpatients desire conversations about R/S than have them. Health care professionals might improve patients’ overall experience with being hospitalized and patient satisfaction by addressing this unmet patient need.KEY WORDS: patient satisfaction, physician/patient communication, quality of care, religion, spirituality     

Quality of Internet-based information on gastrointestinal diseases

BACKGROUND:

The Internet is becoming an increasingly common source of health information for patients.

OBJECTIVE:

To examine the quality of gastrointestinal disease- and symptom-related Internet sites that might be searched by patients.

METHODS:

A total of 120 websites were evaluated from July to November 2009 using the DISCERN instrument to determine the quality of content of health and treatment information.

RESULTS:

There was substantial variability in the quality of Internet resources regarding gastrointestinal diseases and their symptoms. Information-based and institutional websites were rated highest. Resources related to celiac disease, colon cancer and abdominal pain scored the highest.

CONCLUSIONS:

Overall, the quality of web-based resources was variable. Because patient education is important in the management of gastroenterological diseases, the increasing use of the Internet poses new opportunities and challenges for physicians.     

Transition to adult health care for adolescents and young adults with congenital heart disease: Perspectives of the patient, parent and health care provider

BACKGROUND:

Pediatric institutions play a large role in preparing young adults with congenital heart disease to transition to adult care.

OBJECTIVE:

To determine the perspectives of patients, parents and providers on transition preparation.

METHODS:

Patients aged nine to 18 years with congenital heart defects and their respective parent(s) participated in semistructured interviews. Health care providers completed a self-administered survey.

RESULTS:

A total of 23 patients, 22 parents and 45 health care providers were enrolled in the study. Only 36% of patients demonstrated a clear understanding of transition and its implications for their cardiac care. Parents were extensively involved in care activities, with 95% accompanying their child to visits at the clinic, 68% staying with their child for the entire visit and 45% administering their medication. Children more knowledgeable about their diagnosis demonstrated a better understanding about their transition to adult care (100% versus 7%, respectively; P<0.01) and were more likely to communicate directly with their providers than those who were less or not knowledgeable (88% versus 33%, respectively; P=0.03). Nurses were more likely than physicians to view increased parental involvement in care activities as a barrier to transition preparation (37% versus 5%, respectively; P=0.02).

CONCLUSIONS:

A lack of clear role expectations indicates a need for the pediatric health care setting to adapt appropriately to address the shifting needs of adolescent and young adult patients and their families. A formalized approach to transition preparation for adolescents with congenital heart disease needs to emphasize comprehensive education. A delegation of explicit responsibilities and the clear definition of roles for parents, providers and patients are necessary to provide young adults with the resources and support necessary to achieve a successful transition to adult care.     

Playing cards on asthma management: A new interactive method for knowledge transfer to primary care physicians

OBJECTIVES:

To describe an interactive playing card workshop in the communication of asthma guidelines recommendations, and to assess the initial evaluation of this educational tool by family physicians.

DESIGN:

Family physicians were invited to participate in the workshop by advertisements or personal contacts. Each physician completed a standardized questionnaire on his or her perception of the rules, content and properties of the card game.

SETTING:

A university-based continuing medical education initiative.

PARTICIPANTS:

Primary care physicians.

MAIN OUTCOME MEASURES:

Physicians’ evaluation of the rules, content and usefulness of the program.

RESULTS:

The game allowed the communication of relevant asthma-related content, as well as experimentation with a different learning format. It also stimulated interaction in a climate of friendly competition. Participating physicians considered the method to be an innovative tool that facilitated reflection, interaction and learning. It generated relevant discussions on how to apply guideline recommendations to current asthma care.

CONCLUSIONS:

This new, interactive, educational intervention, integrating play and scientific components, was well received by participants. This method may be of value to help integrate current guidelines into current practice, thus facilitating knowledge transfer to caregivers.     

A Review of Health Literacy and Diabetes: Opportunities for Technology

Background

The objective of this study was to assess the published literature on health literacy and diabetes, as well as identify opportunities for technology to strengthen information skills and modify behavior to improve diabetes health outcomes.

Methods

Medline (1990–2008), the Cumulative Index to Nursing and Allied Health Literature (1990-2008), and the Education Resources Information Center (1990–2008) were searched, and reference lists from included articles were reviewed to identify additional studies. Articles were included that presented measures of literacy or numeracy specific to diabetes, examined associations between health literacy and diabetes outcomes, or tested a health literacy intervention among persons with diabetes.

Results

Twenty-four articles were included in this review. Five articles reported on measures of literacy or numeracy specific to diabetes. Thirteen of the fifteen cross-sectional studies (87%) associated limited health literacy with poorer diabetes outcomes. Two of the four (50%) health literacy intervention studies lead to improved health outcomes.

Conclusions

The cross-sectional studies provide evidence of an association between health literacy and diabetes outcomes; however, there is a need to design and test strategies to improve diabetes health outcomes that consider health literacy. Information and communication technology opportunities could help to mediate the effect that limited health literacy has on diabetes-related health outcomes.     

Deferred consent in a minimal-risk study involving critically ill subarachnoid hemorrhage patients

INTRODUCTION:

Alterations from first-party and surrogate decision-maker consent can enhance the feasibility of research involving critically ill patients.

OBJECTIVE:

To describe the use of a deferred-consent model to enable participation of critically ill patients in a minimal-risk biomarker study.

METHODS:

A prospective observational study was conducted in which serum biomarker samples were collected three times daily over the first 14 days following aneurysmal subarachnoid hemorrhage. Sample collection was initiated on intensive care unit admission and consent was obtained when research personnel could approach the patient or the patient’s surrogate decision maker.

RESULTS:

Twenty-seven patients were eligible for the study, of whom only five were capable of providing informed consent. Full consent was obtained for 21 (78%) patients through self- (n=4) and surrogate (n=17) consent. Partial consent or refusal (only permitting the collection of blood samples as a part of routine care or use of data) occurred in three patients. Among the 22 consents sought from surrogates, three (11%) refused participation. The refusals included the sickest patients in the cohort. Once consent was provided, no patient or surrogate withdrew consent before study completion.

DISCUSSION:

Use of a deferred consent model enabled participation of critically ill patients in a minimal-risk biomarker study with no withdrawals.

CONCLUSIONS:

Further research and enhanced awareness of the potential utility of hybrid models, including deferred consent in addition to patient or surrogate consent, in the conduct of low-risk and minimally interventional time-sensitive studies of critically ill patients are required.     

A comparison of hospital and nonhospital colonoscopy: wait times, fees and guideline adherence to follow-up interval

BACKGROUND:

Although colonoscopy is increasingly performed in nonhospital facilities, studies to date examining differences between colonoscopy services in hospital and nonhospital settings have been limited, in large part, to administrative databases.

OBJECTIVES:

To describe the experiences of patients receiving colonoscopy in hospital and nonhospital settings, and to compare these settings with respect to wait times and recommended follow-up interval to the next colonoscopy.

METHODS:

A postal survey of 2000 patients, 50 to 70 years of age, from an urban academic family practice was conducted. Most recent colonoscopy was classified as either occurring in a hospital or nonhospital setting. Multivariable logistic regression analysis was used to examine the association among wait times, follow-up intervals and patient factors with respect to colonoscopy setting.

RESULTS:

Patients who underwent their most recent colonoscopy outside of a hospital were more likely to be men (P=0.01) and to have undergone more than one previous colonoscopy (P=0.02). For patients with a normal screening colonoscopy and no family history of colorectal cancer or polyps, nonhospital clinics less often recommended a 10-year follow-up interval (OR 0.13 [95% CI 0.04 to 0.47]). Reported wait times at nonhospital clinics were shorter for patients receiving screening colonoscopy (OR 2.11 [95% CI 1.28 to 3.47]), but not for symptomatic patients (OR 1.74 [95% CI 0.88 to 3.43]). For individuals attending nonhospital clinics, 10% were referred from a hospital by the same specialist performing the procedure; 31.7% reported paying a fee.

CONCLUSION:

Nonhospital clinics were far less likely to adhere to guidelines regarding follow-up intervals for low-risk patients. Given the implications for both health care costs and patient safety, further study is needed to determine the cause of this disparity.     

Abnormal myocardial perfusion and risk of heart failure in patients with type 2 diabetes mellitus

BACKGROUND:

Diabetes is a major risk factor for heart failure (HF), although the pathophysiological processes have not been clarified.

OBJECTIVE:

To determine the prevalence of HF and of abnormal myocardial perfusion in diabetic patients evaluated using technetium (99m) sestamibi single-photon emission computed tomography.

METHODS:

An observational cross-sectional study was conducted that included patients with type 2 diabetes mellitus who underwent echocardiography to diagnose HF and a pharmacological stress test with intravenous dipyridamole to examine cardiac scintigraphic perfusion abnormalities. Clinical and biochemical data were also collected.

RESULTS:

Of the 160 diabetic patients included, 92 (57.6%) were in HF and 68 (42.5%) were not. When patients were stratified according to the presence of abnormal myocardial perfusion, those with abnormal perfusion had a higher prevalence of HF (93%) than those with normal perfusion (44.4%) (P<0.0001). Patients with HF weighed more (P=0.03), used insulin less frequently (P=0.01), had lower total cholesterol (P=0.05) and high-density lipoprotein cholesterol concentrations (P=0.002), and a greater number of their myocardial segments showed abnormal perfusion (P≤0.001). More HF patients had a history of myocardial infarction (P<0.001) compared with those without HF. In a logistic regression analysis, the number of segments exhibiting abnormal myocardial perfusion was an independent risk factor for HF.

CONCLUSIONS:

The prevalence of HF in diabetic patients was high and HF predominantly occured in association with myocardial ischemia.     

Sociocultural factors that potentially affect the institution of prevention and treatment strategies for hepatitis B in Chinese Canadians

BACKGROUND:

Despite the availability of screening for chronic hepatitis B (CHB) infection and effective treatments now available, many at-risk individuals fail to seek appropriate medical attention.

OBJECTIVE:

To identify the barriers to care for CHB infection in a Chinese Canadian community.

METHODS:

A survey conducted in English or Chinese collected information from individuals with CHB infection that evaluated the level of understanding and identified the barriers that may prevent Chinese patients from undergoing monitoring, screening and/or treatment for CHB infection.

RESULTS:

Among the 204 patients enrolled, common misconceptions were that sharing food transmits hepatitis B and that patients with severe disease are always symptomatic. Patients with a better understanding of hepatitis B were better educated, younger and were being followed at a tertiary care centre (P<0.01 for all). Prominent barriers to health care were time, inconvenience and language difficulties. Patients under the care of family physicians who had extended office hours were less likely to cite time (P=0.06) and distance (P=0.05) as barriers.

CONCLUSION:

Patient misconceptions that severe liver disease due to hepatitis B infection is symptomatic may factor into the unwillingness to spare the time and undergo the inconvenience associated with regular medical follow-up. Implementation of programs that increase awareness of the silent progression of CHB infection and provide culturally responsive clinics, better able to work within patients’ time constraints may improve Chinese patients’ access to health care.