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Physicians May Use Risk-Based Screening Strategy to Identify Hepatitis C Virus Infection

Laurie Barclay, MD

June 2, 2010 — In a high-risk, urban ambulatory care setting, physicians may use a risk-based screening strategy to test for hepatitis C (HCV) infection, according to the results of a study published online May 20 in the Journal of Viral Hepatitis. This was the first of several studies from the US Centers for Disease Control (CDC) testing the effectiveness of current and alternative HCV screening strategies.

"Approximately 3.2 million persons are chronically infected with [HCV] in the U.S.; most are not aware of their infection," write William N. Southern, MD, from Albert Einstein College of Medicine of Yeshiva University, Bronx, New York, and colleagues. "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."

Participants consisted of all patients enrolled in the baseline phase of the Hepatitis C Assessment and Testing Project, which is a serial, cross-sectional study examining screening strategies for HCV. All participants were examined from January 1, 2008, to February 29, 2008, during a clinic visit to Montefiore Medical Center. The investigators determined demographic factors, results of laboratory testing, and International Classification of Diseases, 9th Edition, diagnostic codes from March 1, 1997, to February 29, 2008, using electronic medical records.

Birth date; International Classification of Diseases, 9th Edition, codes; and laboratory results data were used to define risk factors for HCV. To estimate the prevalence of HCV infection, the investigators assumed that untested subjects would test positive at the same rate as tested subjects, based on risk factors.

HCV testing was performed in 3803 (39.7%) of 9579 participants evaluated. Of these, 438 (11.5%) were positive, yielding an estimated overall prevalence of HCV infection of 7.7%, which is nearly 5 times higher than the estimated national prevalence of 1.6%. The study authors also estimated that more than 40% of HCV-positive persons were unaware of their status.

Risk factors identified as being associated with being tested and having a positive HCV testing result were:
  • birth date from 1945 to 1964 (the high-prevalence birth cohort),
  • substance abuse,
  • HIV infection,
  • alcohol abuse,
  • diagnosis of cirrhosis,
  • end-stage renal disease, and
  • high alanine transaminase levels.

"In a high-risk urban population, a significant proportion of patients were tested for HCV and the prevalence of HCV infection was high," the study authors write. "Physicians appear to use a risk-based screening strategy to identify HCV infection."

Limitations of this study include that not all patients were tested for anti-HCV and, therefore, an estimated prevalence was used; the use of an electronic medical record for data collection, preventing capture of all risks for HCV infection for each patient; and failure to consider the temporal relationship between risk factors and HCV tests, which means that certain risk factors (eg, substance abuse) may have been identified after the HCV diagnosis was made. Nonetheless, "a strong relationship between high risk co-morbidities and physician testing behaviour" was uncovered.

"We found strong evidence that physicians are using a risk-based screening strategy to identify patients with HCV infection, using known risk factors and other conditions associated with HCV to guide testing," the study authors conclude. "We also found evidence that screening recommendations should be expanded to include the high prevalence birth cohort."

This project was supported by a US Centers for Disease Control and Prevention contract via the Agency Health Care Research and Quality ACTION initiative to Boston University, the Clinical Investigation Core of the Center for AIDS Research at the Albert Einstein College of Medicine and Montefiore Medical Center, the National Institutes of Health and the CTSA from the National Center for Research Resources, a component of the National Institutes of Health. Two of the study authors are Centers for the Disease Control and Prevention employees, and one is an employee of Emerging Health Information Technologies. Some of the study authors report various financial relationships with Roche Pharmaceuticals, Vertex Pharmaceuticals, Sanofi Aventis, and/or DiMagi, Inc.
J Viral Hepatitis. Published online May 20, 2010