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

That HCV treatment was uncommon in this population may reflect the limited efficacy of single-agent therapy before 1998, as well as the large proportion of subjects with contraindications to therapy, primary care physician confusion regarding who should be treated, and current limited knowledge of the long-term outcomes of treatment.²⁹ Cure rates are unknown and measures of cure are unclear, since clearing the virus from the bloodstream (negative PCR) may not confirm clearing of the virus from the liver.²⁹ All these data together provide little experimental evidence for a standard set of recommendations for follow-up, nor do they support a clear rationale for the use of those follow-up data in determining HCV progression. The existing data have been used to develop consensus (expert opinion–based) guidelines published by NIH (1997)²⁸ and CDC (1998,³⁰ with an update in the summer of 2001). The substance of those consensus statements has changed over time^5,28 as experts’ experience has increased and newer observations have become available. Recent changes in available treatments^31-33 and FDA approval of a pegylated inferferon^34,35 are likely to keep recommendations in flux for the near future.

The limited attention given to the identification, prevention, or treatment of comorbid accelerating conditions (HIV, HBV, HAV, and heavy alcohol intake)^{5,19,27,36-38} in this cohort is less understandable, since the literature is more consistent on these issues. Documented HIV testing was not universal even in those with a history of IDU or promiscuous sexual exposure. While testing for HBV was almost universal, HBV prevention in the form of vaccination was documented in only about one fourth (23%) of eligible subjects. Immunization for hepatitis A was documented in less than one tenth of subjects. Treatment or documented physician recommendations for treatment of ongoing alcohol abuse or heavy alccohol ingestion occurred in the minority of patients. Studies of combined chemical dependency and HCV therapy might be appropriate in this population.

The Olmsted County population from which the subjects were identified is more than 90% white. Therefore, community-based prevalence rates of physician diagnoses may not be representative of other racial or ethnic groups. The high frequency of drug use and sexual exposure suggests that our community’s problems associated with HCV are similar to those identified in other communities with greater economic, ethnic, and racial diversity. We did not perform PCR, liver biopsy, or yearly liver function tests on all subjects. One aim of our study, however, was to understand community practice and the resulting variations in information and testing completed for each subject. The existence of a large medical education program and the local availability of hepatologists may affect the care provided. Yet even in this setting, additional attention to follow-up of liver disease and comorbid conditions appeared indicated.

Conclusions

Primary care physicians make most diagnoses and perform most initial management of hepatitis C. However, primary care directed long term follow-up care is inconsistent and management of accelerating comorbidities is incomplete. Family physicians can offer important additional services to their patients who have hepatitis C.