Original Research

Diagnosis and 10-Year Follow-Up Of a Community-Based Hepatitis C Cohort

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ABSTRACT

OBJECTIVE: To determine the health care follow-up and treatment associated with physician-diagnosed hepatitis C (HCV) in a community-based population.

STUDY DESIGN: We conducted a retrospective medical record review using records from all providers in Olmsted County, Minnesota.

POPULATION: The study incorporated all Olmsted County residents with physician-diagnosed hepatitis C from 1990 through 1999.

OUTCOMES MEASURED: We assessed demographic and health status information as well as health services use in subjects with physician-diagnosed HCV.

RESULTS: Physicians diagnosed hepatitis C in 355 subjects (219 men [62%], 136 women [38%]), mean age 43 years, in the 10-year period studied. About half of diagnoses (45%, n = 159) were confirmed with polymerase chain reaction or liver biopsies. Identified risk factors included IV drug use (50%), multiple sex partners (36%), and blood transfusion (30%). Follow-up assessment with aspartate aminotransferase/amino alanine transferase (AST/ALT) tests occurred in about half (49%) of subjects, while 202 subjects (60%) were referred for gastrointestinal (GI) specialist evaluation and 49 patients (14% of all, 25% of those referred to a GI specialist) had specific treatment for hepatitis C. Although well over half of patients (60%) had possible contraindications to HCV treatment, including heavy alcohol use, few were referred for chemical dependency therapy.

CONCLUSIONS: In this community, follow-up and treatment related to HCV were limited. Attention to prevention of disease-accelerating coinfections was only modest. Referral or documented recommendations for treatment of alcoholism or heavy chronic alcohol ingestion were minimal.

KEY POINTS FOR CLINICIANS
  • Risk factors associated with acquiring hepatitis C in this small city are similar to those in urban areas: intravenous drug use, frequent sexual exposure, and blood transfusion before 1992.
  • No follow-up of liver testing in people with known hepatitis C occurred in half of cases.
  • Less than 15% of prevalent cases received hepatitis C–specific treatment; many people appeared to have contraindications for hepatitis C therapy.
  • Preventive care measures appropriate for people with hepatitis C (eg, hepatitis B immunization, referral for treatment of known chemical dependency, and screening for HIV) were not universal in this population.

Hepatitis C is reportedly the most common chronic bloodborne infectious disease in the United States.1-3 Prevalence data based on modeling studies and extrapolation from studies such as the National Health and Nutrition Examination Survey (NHANES) and county surveillance projects3,4 report that 3.9 million Americans (1.8%) have been infected with the hepatitis C virus (HCV) and 2.7 million (1.2%) have chronic HCV infection.5 While the natural history of HCV infections is poorly understood,6-9 researchers and clinicians agree that most people with chronic HCV infection remain asymptomatic for many years while seeking medical care, often primary care, for problems other than their silent hepatitis C infections.8,9

Much of the hepatitis C literature is derived from studies of subspecialty clinic patient populations or other special populations such as those with blood transfusion or RhoGAM-acquired hepatitis C.9-12 The former data tend to concentrate on the more severe, symptomatic patients referred to specialty care, whereas the latter special-exposure groups provide little information about a large segment of the population with other risk factors and comorbidity. Neither of these sources provides data on the community population or community practice.1,9,11 Our study describes the people that have been diagnosed with HCV in a geographically defined community, including their physician-directed hepatitis C follow-up evaluations and HCV treatment. In addition, we report on testing and vaccination efforts for hepatitis A and B and on the recognition and treatment of alcoholism and chronic heavy alcohol ingestion (accelerating comorbidities). The ability to follow the patient across all types of care from ambulatory to inpatient and from primary to tertiary care provides a very broad overview of these population-based cases.

Methods

Study setting and instrument

This is a descriptive study of a geographically defined, population-based cohort of all persons living in Olmsted County, Minnesota, who received a physician or laboratory diagnosis of hepatitis C from January 1, 1990, through December 31, 1999. All physician diagnoses were captured using a communitywide diagnostic database, the Rochester Epidemiology Project.13,14 Olmsted County is a metropolitan statistical area that includes the city of Rochester and is served primarily by more than 200 primary care physicians employed by 2 medical facilities, the Olmsted Medical Center and the Mayo Clinic.

All patients with a physician diagnosis of hepatitis C were included, whether the diagnosis had been confirmed by liver biopsy or polymerase chain reaction (PCR) testing or by either positive recombinant immunoblast assay (RIBA) testing or indeterminate RIBA testing and the presence of 1 or more risk factors. Risk factors included blood transfusion before July 1,1992, a diagnosis of hemophilia before 1990, a history of intravenous drug use (IDU), selling sex or trading sex for drugs, having more than 10 sex partners, sexual exposure to a person infected with HCV, intranasal cocaine use, and work in a health care facility with exposure to blood products (eg, phlebotomists) or health care workers with a history of needlesticks. The immigration status of people from Africa or Southeast Asia, where hepatitis C is endemic, is reported when the medical record listed immigration as an HCV risk factor. Patients with acute hepatitis C, defined as those with acute symptoms at the time of diagnosis (N = 4), were included.

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