Cost-effectiveness of screening patients for hepatitis C

Physician nonadherence with a hepatitis C screening program

BACKGROUND

Testing for patients at risk for hepatitis C virus (HCV) infection is recommended, but it is unclear whether providers adhere to testing guidelines. We aimed to measure adherence to an HCV screening protocol during a multifaceted continuous intervention.

SUBJECTS AND METHODS

Prospective cohort design to examine the associations between patient-level, physician-level, and visit-level characteristics and adherence to an HCV screening protocol. Study participants included all patients with a visit to 1 of the 3 study clinics and the physicians who cared for them. Adherence to the HCV screening protocol and patient-level, physician-level, and visit-level predictors of adherence were measured.

RESULTS

A total of 8981 patients and 154 physicians were examined. Overall protocol adherence rate was 36.1%. In multivariate analysis, patient male sex (odds ratio [OR] = 1.18), new patient (OR = 1.23), morning visit (OR = 1.32), and patients' preferred language being non-English (OR = 0.87) were significantly associated with screening adherence. There was a wide variation in overall adherence among physicians (range, 0%-92.4%). Screening adherence continuously declined from 59.1% in week 1 of the study to 13.7% in week 15 (final week). When implementing complex clinical practice guidelines, planners should address physician attitudinal barriers as well as gaps in knowledge to maximize adherence.

Public health issues of hepatitis C virus infection

Hepatitis C virus (HCV) is a leading cause of liver disease worldwide, as 130-170 million individuals are chronically infected and 350,000 patients die every year from HCV infection. The HCV prevalence varies widely among countries being highest in several African and Eastern Mediterranean countries. The incidence of new HCV infections may be declining in developed countries, but there is still a large reservoir of chronic infections. The most important mode of HCV transmission has been injecting drug use in developed countries with low prevalence and unsafe therapeutic injections in developing countries with moderate-high prevalence. Since there are no systematic screening policies, most patients remain undiagnosed. Even among diagnosed patients, a minority receives treatment due to several barriers to therapy. Given the high efficacy of treatment, public health authorities should recognise the importance of HCV and make resources available for the implementation of effective primary prevention, screening and management policies.

Hepatitis C testing practices and prevalence in a high-risk urban ambulatory care setting

Approximately 3.2 million persons are chronically infected with the hepatitis C virus (HCV) in the U.S.; most are not aware of their infection. Our objectives were to examine HCV testing practices to determine which patient characteristics are associated with HCV testing and positivity, and to estimate the prevalence of HCV infection in a high-risk urban population. The study subjects were all patients included in the baseline phase of the Hepatitis C Assessment and Testing Project (HepCAT), a serial cross-sectional study of HCV screening strategies. We examined all patients with a clinic visit to Montefiore Medical Center from 1/1/08 to 2/29/08. Demographic information, laboratory data and ICD-9 diagnostic codes from 3/1/97-2/29/08 were extracted from the electronic medical record. Risk factors for HCV were defined based on birth date, ICD-9 codes and laboratory data. The prevalence of HCV infection was estimated assuming that untested subjects would test positive at the same rate as tested subjects, based on risk-factors. Of 9579 subjects examined, 3803 (39.7%) had been tested for HCV and 438 (11.5%) were positive. The overall prevalence of HCV infection was estimated to be 7.7%. Risk factors associated with being tested and anti-HCV positivity included: born in the high-prevalence birth-cohort (1945-64), substance abuse, HIV infection, alcohol abuse, diagnosis of cirrhosis, end-stage renal disease, and alanine transaminase elevation. In a high-risk urban population, a significant proportion of patients were tested for HCV and the prevalence of HCV infection was high. Physicians appear to use a risk-based screening strategy to identify HCV infection.

Tattooing and the risk of transmission of hepatitis C: a systematic review and meta-analysis

OBJECTIVES

In this systematic literature review we sought to determine whether tattooing is a risk factor for the transmission of hepatitis C.

METHODS

A comprehensive search was performed to identify all case-control, cohort or cross sectional studies published prior to November 2008 that evaluated risks related to tattooing or risk factors of transmission of hepatitis C infection.

RESULTS

A total of 124 studies were included in this systematic review, of which 83 were included in the meta-analysis. The pooled odds ratio (OR) and 95% confidence interval (CI) of the association of tattooing and hepatitis C from all studies was 2.74 (2.38-3.15). In a subgroup analysis we found the strongest association between tattooing and risk of hepatitis C for samples derived from non-injection drug users (OR 5.74, 95% CI 1.98-16.66).

CONCLUSIONS

Findings from the current meta-analysis indicate that tattooing is associated with a higher risk of hepatitis C infection. Because tattooing is more common among the youth and young adults and hepatitis C is very common in the imprisoned population, prevention programs must focus on youngsters and prisoners to lower the spread of hepatitis infection.

The effects of hepatitis C recurrence on health-related quality of life in liver transplant recipients

Orthotopic liver transplantation (OLT) remains the definitive treatment for hepatitis C (HCV). Although HCV is the number one indication for OLT in the USA, health-related quality of life (HRQOL) scores are consistently lower for HCV patients when compared with all OLT indications. HCV is unique in that 95% of transplanted patients experience virological recurrence of HCV hepatitis. Despite few physical manifestations of disease at the time of HCV recurrence, patients report an impaired quality of life and functional status compared with OLT recipients without recurrence. Studies show that patient knowledge of the diagnosis of recurrent HCV alone can negatively impact HRQOL. This suggests that patients perceive themselves as unwell and have significant changes in their mental and physical health despite the absence of disease-related complications. Multiple studies show that patients with HCV recurrence report significantly higher scores for depression, anxiety and psychological distress. However, only a limited number of studies have investigated the influence of gender, HCV genotype, or HCV antiviral treatment on the HRQOL of OLT recipients with HCV recurrence. This review article describes what is currently known about the impact of recurrent HCV on HRQOL specifically after OLT. Understanding modifiable factors on HRQOL after HCV recurrence in OLT patients can greatly aid in tailoring multidimensional interventions to improve patient HRQOL.

The global burden of hepatitis C

Hepatitis C is of concern both to industrialized and developing countries. Preliminary unpublished estimates of the global burden of disease (GBD) attributable to HCV-related chronic liver disease seem to be substantial. Therefore, the reduction of global mortality and morbidity related to chronic hepatitis C should be a concern to public health authorities, and primary, secondary and tertiary prevention activities should be implemented and monitored in each country, with precise targets set to be reached. In order to decide on national health policies, there is a need to estimate the burden of disease, globally, regionally and nationally. To evaluate the GBD, three components have to be assessed: 1) The global, regional and national burden of morbidity and mortality associated with HCV infection, based on prevalence, incidence, transmission and economics; 2) The natural history of HCV infection, including 'healthy individuals'; and 3) The areas for which more research is needed. A working group was created to assist the World Health organization (WHO) in estimating the GBD associated with HCV infection.

Self-reported hepatitis C virus antibody status and risk behavior in young injectors

OBJECTIVE

This study was conducted to assess the accuracy of self-reported hepatitis C virus (HCV) antibody (anti-HCV) serostatus in injection drug users (IDUs), and examine whether self-reported anti-HCV serostatus was associated with recent injection risk behavior.

METHODS

In five U.S. cities (Baltimore, Chicago, Los Angeles, New York, and Seattle), 3,004 IDUs from 15 to 30 years old were recruited for a baseline interview to determine eligibility for a randomized controlled trial of a behavioral intervention. HIV and HCV antibody testing were performed, and subject data (e.g., demographics, drug and sexual risk behavior, and history of HIV and HCV testing) were collected via audio computer-administered self-interview. Risk behavior during the previous three months was compared to self-reported anti-HCV serostatus.

RESULTS

Anti-HCV prevalence in this sample of young IDUs was 34.1%. Seventy-two percent of anti-HCV-positive and 46% of anti-HCV-negative IDUs in this sample were not aware of their HCV serostatus. Drug treatment or needle exchange use was associated with increased awareness of HCV serostatus. Anti-HCV-negative IDUs who knew their serostatus were less likely than those unaware of their status to inject with a syringe used by another IDU or to share cottons to filter drug solutions. Knowledge of one's positive anti-HCV status was not associated with safer injection practices.

CONCLUSIONS

Few anti-HCV-positive IDUs in this study were aware of their serostatus. Expanded availability of HCV screening with high quality counseling is clearly needed for this population to promote the health of chronically HCV-infected IDUs and to decrease risk among injectors susceptible to acquiring or transmitting HCV.

The economics of hepatitis C virus

Hepatitis C virus is a disease of major public health significance throughout the world in terms of overall morbidity and mortality and in its economic consequences and demands on medical resources. The global economic burden of this disease has yet to be fully realized. In this article the authors discuss the economic burden of hepatitis C, the economics of therapy, and the economics of its prevention and screening.

A Clarified Conceptual Meaning of Hepatitis C-Related Depression

A clarified conceptual meaning of depression in individuals with hepatitis C virus infection is proposed based on a critical review of literature. Moving beyond an exclusively biomedical perspective, depression in hepatitis C is explained by a cluster of factors that incorporate physiological, psychological, and social dimensions. Symptom experience, stigma, and uncertainty are factors that span the complex nature of depression in individuals with hepatitis C. This broadened perspective incorporates individual and societal values and beliefs regarding hepatitis C and encompasses the multidimensional complexity of depression in hepatitis C. Hepatitis C-related depression presents an enormous challenge for nurses because of its interference with treatment adherence and significant negative impact on the individual's quality of life. Nursing theorists, researchers, and clinicians may benefit from a clear conceptual understanding of the unique nature of depression in this growing segment of the U.S. population. This clarified conceptual meaning needs to be validated through qualitative, quantitative, and longitudinal studies with this population. It is hoped that future theorists, researchers, and practitioners will contribute to our conceptual understanding, resulting in improved quality of life for this special population.

Efficiency of hepatitis C virus screening strategies in general practice

Hepatitis C viral infection (HCV) is a frequent and severe disease; screening strategies to-date remain insufficient.

OBJECTIVE

To assess the efficiency of HCV screening of high-risk groups among patients consulting general practitioners.

METHODS

A cost-effectiveness analysis was performed involving general medicine screening practices recorded during a survey of 127 practitioners (10,041 patients) conducted in 1997. A reference strategy, defined as HCV screening for illicit drug users and transfused patients, and five extended strategies, where the screening population was broadened to include other risk groups as well, were considered. Average cost and marginal cost-effectiveness ratios were determined for each extended strategy and compared with those observed for the reference strategy. The sensitivity of HCV screening to funding modalities, HCV seroprevalence and proportion of HCV high-risk groups among patients attending general practitioners was studied.

RESULTS

The reference strategy was the most cost-effective method irrespective of the funding modality considered. Fixed practitioner payment was the least efficient funding modality. The average cost of one positive test was sensitive to variations of HCV seroprevalence in the high-risk group as well as the proportion of high-risk patients among the general practitioners' patients.

CONCLUSION

Extension of hepatitis C screening to risk groups other than transfused patients and illicit drug users implies a substantial increase in healthcare costs as well as social consensus for such expenditures.

A comparison of HCV antibody testing in drug-free and methadone maintenance treatment programs in the United States

Drug treatment programs are uniquely situated to screen patients for antibodies for hepatitis C virus (HCV), an infectious disease that has reached epidemic proportions among drug users. This paper compares the accessibility and patients' use of opportunities for HCV antibody testing in a large sample of methadone and drug-free treatment programs (N=256) in the US, and reports programs' recent changes and future plans concerning it. Results indicate that almost all methadone and about two-thirds of drug-free programs in the sample provided HCV antibody screening to at least some patients in 2001. While about two-thirds of the methadone and close to one-third of the drug-free programs offered this service to all patients, these programs report that only about 3/5 of their patients actually provided specimens for testing for HCV antibodies. Some drug treatment programs were planning to increase the availability and accessibility of HCV antibody screening, but others were planning to cut back on these services, primarily due to limited resources. These results can inform policymakers who advocate for increased HCV antibody screening in drug treatment programs about the current level and future plans for implementing these services, illuminating where resources and motivational efforts need to be targeted.

The association between knowledge of hepatitis C virus status and risk behaviors in injection drug users

AIMS

The three primary objectives of this study were (1) to document the prevalence of the hepatitis C virus (HCV) and awareness of one's status in a sample of street-recruited injection drug users (IDUs); (2) to compare the drug use and HCV risk behaviors of IDUs who reported that they were HCV infected with those who were unaware of their status and subsequently tested positive for HCV antibodies; and (3) to assess associations between risk factors and HCV status by comparing those who tested positive with those who tested negative.

DESIGN

IDUs responded to structured interview questions assessing HCV risk behaviors and were offered a free HCV test.

SETTING

Subjects were recruited through street outreach in Denver, CO, USA.

PARTICIPANTS

Participants were current, out-of-treatment IDUs.

MEASUREMENTS

A modified version of the Risk Behavior Assessment (RBA) and HCV test results were used.

FINDINGS

Of the 197 participants, 20% had been diagnosed previously with HCV. Of those who did not know their status, 61% tested positive for HCV antibodies. Those who knew they were positive had been injecting longer but engaged in fewer HCV risk behaviors than those who did not know their status. Compared to those who tested negative, those who tested positive were more likely to be male, non-white and older. They also had been injecting longer, were more likely to use heroin and/or crack cocaine and consumed more alcohol.

CONCLUSIONS

In this study, a very large proportion of injection drug users who had hepatitis C were unaware of it, and they were engaging in more risk behaviors than those who were aware of their positive status. Risk factors associated with positive HCV status were identified so that those who are most at-risk for HCV might be targeted for testing and subsequent prevention or care.

Analysis of HCV-IG isotype complexes by a novel immuno-capture RT-PCR method

HCV can be present in the circulating blood either as a free virus or as a virion-immunoglobulin (Ig) complex. All isotypes of Igs may form the virus complexes, but it remains unclear what specific role of each Ig plays in the clearance of HCV. In the present study, we have combined immuno-capture and RT-PCR, and developed a quick double-specificity method for detecting and distinguishing different HCV-Ig complexes. We compared our new method, the immuno-capture RT-PCR (iRT-PCR), with the conventional RT-PCR (cRT-PCR) for the sensitivity of detecting HCV in 35 clinically diagnosed patients with HCV infection. The results showed that 31 patients were detected to be positive by using iRT-PCR, whereas 16 patients were positive with the use of cRT-PCR. HCV-IgM, HCV-IgG, HCV-IgA could separately be detected by iRT-PCR and their positive rates were 66.7%, 51.0%, 62.7%, respectively. HCV bound to antibody was a common feature of hepatitis C (HC) and 86.3% of patients were positive at least by one of the HCV-Ig tests. The patterns of HCV RNA constituents varied according to disease categories. In summary, iRT-PCR is a valuable method for analysis of the composition of the immune complexes, which may provide new and valuable insights into HCV pathogenesis.

Factors associated with testing for hepatitis C in an internet-recruited sample of men who have sex with men

BACKGROUND

Nearly 4 million individuals in the United States (1.8%) have been infected with hepatitis C virus, yet few are aware of their infection.

GOAL

To identify correlates associated with hepatitis C virus testing among a sample of men who have sex with men.

STUDY DESIGN

Internet communications were used for solicitation and collection of data, using a 31-question survey.

RESULTS

When the study was restricted to men who have sex with men in the United States (n = 381), 95% of the respondents (n = 361) reported at least one risk factor for hepatitis C virus transmission, 39% of these respondents (n = 140) reported having been tested for hepatitis C virus. Testing was associated with a history of nonsexual risk behavior, increased knowledge of the hepatitis C virus, and healthcare provider communication.

CONCLUSION

A significant proportion of at-risk respondents had not been tested. Interventions are needed to increase hepatitis C virus knowledge in the community of men who have sex with men, and to encourage providers to communicate about hepatitis to the men in this group who screen as high risk on the basis of their risk behaviors.

Chronic hepatitis C. Implications for health-related quality of life

Hepatitis C viral infection with its sequelae is a significant healthcare problem. Hepatitis C infects nearly 4 million Americans with almost half of these unaware of their infection. Many of those individuals infected with hepatitis C develop chronic hepatitis C and in 15% of these patients, the infection will progress to cirrhosis within 20 years. Several cross-sectional and longitudinal studies have demonstrated the negative impact of chronic hepatitis C on health-related quality of life. This review describes what is currently known about the impact of chronic hepatitis C on health-related quality of life during pharmacologic treatment and after liver transplantation. It is important to note that few studies have prospectively followed patients over time with respect to quality of life or examined other factors including symptoms, markers of disease progression, or host immune function. Studies suggest that patients with chronic hepatitis C, even without major disease-related complications, perceive themselves to be unwell and have significant changes in their physical and mental well being. Such results have important implications for nursing care and management. Intervention studies focused on self-care management with an emphasis on symptom reduction are warranted.

Assessment of hepatitis C infection in injecting drug users attending an addiction treatment clinic

BACKGROUND

Injecting drug users represent a high risk group for hepatitis C (HCV) infection. Currently, screening of this group for HCV is inconsistently implemented.

AIM

We designed a HCV assessment algorithm and sought to determine the frequency with which injecting drug users completed the assessment process.

METHODS

Prospective study of a HCV assessment algorithm in the setting of a specialist outpatient addiction treatment clinic. Participants consisted of consecutive new attenders over a six-month period with a history of injecting.

RESULTS

Only 21 (18%) of 119 patients reached a satisfactory endpoint of assessment. Forty-eight injectors were tested for antibody to HCV, of whom 26 (54%) tested positive. Thirteen of those with positive test results were no longer attending when the test result became available. Only four of the 19 patients who were referred, attended the on-site hepatology clinic.

CONCLUSIONS

Thorough screening of injecting drug users for HCV within one treatment service is difficult. There is a need for explicit policies on this issue involving co-operation between primary care providers and addiction services and hepatology services.