Birth Cohort Screening for Chronic Hepatitis During Colonoscopy Appointments

Dawn M Sears MD; Dan C Cohen MD; Kimberly Ackerman DO; Jessica E Ma; Juhee Song PhD

Disclosures

Am J Gastroenterol. 2013;108(6):981-989. 

In This Article

Methods

Design

During a 3-month period, from October 2010 to January 2011, all insured patients aged 50 to 65 years old (falling into a narrower birth cohort 1945–1960) scheduled for outpatient colonoscopy at Scott & White Healthcare and without prior diagnosis of viral hepatitis were offered participation in the study. Study information was mailed to all eligible patients with their bowel preparation instructions. Packets included information about viral hepatitis and details of the study, including need for blood testing, explanation of results, and possible need for follow-up testing or vaccination. On the day of procedure, a research nurse met with each individual patient in a private examination room before entry to the endoscopy suite. During the meeting, the patient completed the Institutional Review Board (IRB)-mandated consent form stressing the fact that the study did not pay for viral hepatitis screening or vaccination (they were also made aware that their insurance would be billed separately for these services if they wished to participate). Patients filled out a questionnaire regarding (1) exposure and vaccination of hepatitis A and B viruses, (2) existing diagnosis of chronic hepatitis B and/or C viruses, and (3) positive risk factors for chronic hepatitis B and C viruses. Questions regarding risk factors included IV drug use, sexual habits, tattoo placement, receiving of blood transfusions, and imprisonment among other things (see Appendix for questionnaire). Even if a patient had no stated risk factors, they were able to choose to undergo further testing for chronic hepatitis or immunity if desired. No prior knowledge of any of the patient's liver function testing was reviewed. Patients could select any or all viral hepatitis tests including hepatitis A antibody, hepatitis B surface antibody and/or antigen, and hepatitis C antibody. Patient-selected screening was offered as some patients already knew the status of some of their markers. In the endoscopy suite blood was drawn from pre-procedural IV site. Two to four weeks after screening completion, results were mailed with follow-up instructions. Six and twelve months later, data were collected on follow-up rates utilizing review of electronic medical records and telephone interviews.

Study Setting

Study took place within the Gastroenterology Department of Scott & White Healthcare. Scott & White is a non-profit health-care institute and level 1 trauma center located in Temple, Texas. It encompasses a 29,000 square mile service area and treats over a half million patients per year. Our patients typically take advantage of preventative services available through both the Scott & White Healthcare system, as well as the Central Texas Veterans Administration demonstrated by the fact that 65% of 50–65 year olds have received screening colonoscopies.

Study Population

Patients aged 50 to 65 years (born between 1945–1960) without known diagnosis of chronic hepatitis B and/or C scheduled for colonoscopy from the months of October 2010 to January 2011 were invited to enroll into the study. Those excluded from study participation were the uninsured and those unable to consent.

Laboratory Testing

Peripheral blood draw samples from the consented 376 patients were sent for anti-HCV, hepatitis B surface antigen (HbsAg), hepatitis B surface antibody, and/or hepatitis A total antibody testing. Testing was performed on the Abbott Axsym System (Abbott Laboratories, Chicago, IL) according to the manufacturer's recommendations. Patient results were entered into the Scott & White electronic medical record, and then delivered to study personnel.

Definitions

(1) If a patient was discovered to be hepatitis B surface antigen positive, this was defined as possible exposure to viral hepatitis B and in need of further testing to determine whether chronic infection was present. (2) If a patient was discovered to be hepatitis C antibody positive, this was defined as potential exposure to viral hepatitis C, and follow-up PCR was reflexively ordered. (3) If a patient was discovered to be hepatitis A antibody positive, this was defined as being immune to the virus, therefore not needing further assessment. (4) If a patient was found to be hepatitis B surface antibody positive, this was defined as immune to hepatitis B and no further assessment was needed. (5) If a patient was discovered to be hepatitis A and/or B antibody negative, this was defined as vulnerability to the viruses. Patients were therefore offered vaccination series.

Follow-up

Two to four weeks after screening completion, results were mailed with follow-up instructions. Those not immune to hepatitis A and/or B were offered vaccination. Those infected with hepatitis B and/or C were scheduled for a liver clinic appointment to discuss treatment and options. Those with "inadequate blood draw" were informed of such and advised to seek further screening through their primary care physicians, if they desired to do so. Six and twelve months later, data were collected on follow-up rates utilizing electronic medical record including vaccination dates and follow-up appointment notes.

Statistical Analysis

All variables including demographic and risk factors were summarized by frequency (percentage) for entire group, for those who required vaccination among study participants, and according to vaccination status. Among those who required vaccination, χ 2 test or Fisher's exact test was performed to compare those who were vaccinated with those who were not vaccinated in each variable. Univariate and multivariable logistic regression analyses were utilized to identify factors associated with increased odds of getting vaccination. P value of less than 0.05 indicated a statistical significance. SAS 9.2 (SAS Institute INC, Cary, NC) was used for data analysis.

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