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

Discussion

To our knowledge this study is the first to assess the possibility of combining colonoscopy with screening for viral hepatitis in patients born between 1945 and 1965, the baby boomers. To date, the majority of viral hepatitis screening programs have focused on high-risk patient populations including STD clinics, immigration centers, drug treatment centers, homeless shelters, and prisons.[6,7,8,9,10,11] However, the US preventative task force concluded that there is no evidence that screening high-risk individuals leads to improved long-term health outcome.[23] The CDC has announced the recommendation of one time screening of all baby boomers for chronic hepatitis C. Discovery of the most appropriate venue to feasibly accomplish this daunting task is now in the forefront.

The few studies that followed high-risk patients from screening to treatment showed limited implementation of treatment and vaccination recommendations. In fact, only 21% of patients found to have chronic hepatitis through these high-yield screening programs ultimately received antiviral therapy.[24] The reasons for the lack of follow-up throughout therapy are numerous and include poor access to healthcare, unreliable behavior, language barriers, transportation issues, and contraindications to therapy.[7,11] By screening patients who are insured, have taken a bowel preparation, and requires a driver in order to appear for an appointment, many of these barriers are factored out.

Acceptance of Viral Hepatitis Screening

The aim of our study was twofold. First we sought assessment of the feasibility and patient acceptance of screening for chronic HCV and HBV infection, and HAV and HBV immunity during colonoscopy. We hypothesized that patients who present for outpatient colonoscopies have access to healthcare and are more likely to accept screening for viral hepatitis. As predicted, we were able to demonstrate that acceptance of screening for viral hepatitis in baby boomers presenting for colonoscopy was high, 376/483 (78%). Moreover, all participants who agreed to be screened also agreed to take a risk factor questionnaire before having their blood drawn.

Studies assessing the acceptance of general viral hepatitis screening in the primary care setting have been shown to be low, largely due to patient reluctance to discuss risk factors coupled with the lack of primary care physician awareness of patients with chronic hepatitis in their practice.[8,25,26,27] Additionally, further referral to specialists (gastroenterologists and infectious disease physicians) for treatment and management has been shown to pose a barrier to screening acceptance. In a large screening study, only 39% of patients found to have HCV antibodies kept the referral to a hepatologist.[28] However, our high percentage of screening acceptance was not entirely surprising. A 2008 study on veteran's affairs patients, which found that 73% of patients screened positive for hepatitis C antibodies, complied with follow-up in a dedicated hepatitis C clinic.[28]

We believe that the setting in which viral hepatitis screening took place had an integral role in attaining a high patient acceptance. First, information mailed to patients before their visit allowed time for patients to learn about viral hepatitis. Second, patients appeared relieved by the fact that no additional needle sticks would be necessary and that the IV site placed for their colonoscopy would suffice for blood collection for hepatitis screening. Third, patients were reassured that the same doctors who would be performing their colonoscopies are the experts on viral hepatitis and would therefore be the ones checking their viral hepatitis screening results and making further recommendations regarding treatment, vaccination, and follow-up. Further studies to evaluate what impact the outpatient colonoscopy setting has on viral hepatitis screening acceptance are necessary to verify this information.

Follow-up

Our second aim was to assess the effectiveness of this screening method in achieving substantial patient follow-up for treatment of chronic viral hepatitis and vaccinations to prevent acute viral hepatitis. We hypothesized that patients who present for outpatient colonoscopy are innately invested in their health and therefore would be more likely to adhere to follow-up recommendations, specifically HCV RNA testing and vaccination for HAV and HBV.

Chronic Viral Hepatitis

Chronic Hepatitis C. Out of 346 participants with adequate blood draws, we found only four patients with anti-HCV antibodies. All four patients with anti-HCV positivity were followed up with HCV PCR testing. With the estimated prevalence of chronic HCV infection among baby boomers being 1 in 30, we expected ~17 patients to be HCV antibody positive. We found 17 patients who already knew that they were infected with hepatitis C. This resulted in the additional capture of only one new case of chronic hepatitis C. The usual prevalence of chronic hepatitis C is despite the fact that our patient population at Scott & White Healthcare (a non-urban hospital catering to small communities in central Texas) would have a perceived low risk for chronic hepatitis. This notion is reinforced by the low prevalence of high-risk behaviors on our questionnaire, as only 7% reported a history of injection drug use, the most common risk factor for chronic HCV infection ( Table 3). As a group, baby boomers have a prevalence of prior drug use (including one time experiment) of 40–60%. In some recent studies, ~10% of baby boomers state that they have used illegal drugs within the last year.[29] Demographically, one might expect our population to have a lower prevalence for chronic hepatitis C, however, our actual prevalence was exactly the predicted norm for all baby boomers. Therefore, we believe that no community is immune to undiagnosed chronic hepatitis C.

Chronic Hepatitis B. No patients tested positive for HBsAg. Scott & White Healthcare in Temple has a low prevalence of chronic hepatitis B. Our study population also has a very low racial diversity: 80% Caucasian, 12.1% African-American, 7% Hispanic, and 0.8% Asian and Pacific Islanders. Less than 10% of our patients were born outside the United States (mostly Mexico). With a very low pre-test probability, we only screened with hepatitis B surface antigen. In low-risk populations, screening with hepatitis B core antibody usually results in false-positive findings and ultimately more expensive follow-up laboratory work. Hepatitis B core antibody should be combined with hepatitis B surface antibody for accurate screening for current or past hepatitis B infections in most screening situations. However, in our population, we felt that the false-positive risks outweighed the small potential benefit of discovering a patient with hepatitis B core positivity and surface antigen negativity.

Hepatitis A and B Immunity. With regard to immunity to HAV and HBV, we found that 315 (84%) of our participants might benefit from least one vaccination. Of those 315 patients, only 51 (16%) had documented complete vaccination series follow-up in our electronic medical records at 1-year follow-up. This low number of follow-up was contrary to what we expected. We believe some of this can be explained by our open access screening colonoscopy system. Many of our patients travel several hours to Scott & White Healthcare for their outpatient colonoscopies. These patients may have found it more convenient to obtain these multi-appointment vaccinations from their primary care physicians rather than in our gastroenterology clinic in Temple, Texas. Also, the timing of our study was during the height of an economic downturn during which many patients are known to have avoided preventative care appointments and procedures. Repeating this study in a narrowed geographic focus with more than a single letter recommending vaccination might lead to better vaccination completion rates.

Economics

Acute and chronic viral hepatitis are costly diseases, and cirrhosis caused by chronic HCV infection represents the most common need for liver transplant in the United States.[30] The economic burden of chronic hepatitis for an individual is great: chronic hepatitis ($8,000), cirrhosis ($10,000), liver cancer ($40,000), and liver transplant ($200,000).[31–34] The annual cost of chronic HCV in the United States includes $24 million for outpatient physician services and $530 million for antiviral treatments.[31] In addition, an annual economic burden for acute hepatitis A is $500 million.[35] Efforts to increase vaccinations, screening, and early treatment for hepatitis are cost effective for patients with or without risk factors for viral hepatitis.[21,22,30,36–38] With the advent of the new protease inhibitors, treatment can achieve cure in 65–90% of treatment-naive patients who complete therapy, and new therapy is even more promising in the near future. Additionally, treatment of chronic HCV infection reduces lifetime risk of hepatocellular carcinoma by 10% and improves all cause mortality.[39] Thus, there is potential significant cost savings from screening with a $43 hepatitis A antibody, $35 hepatitis B surface antigen, or $25 hepatitis C antibody, followed by a $100 hepatitis A and $60 hepatitis B vaccine series.

Limitations of Our Study

There are several limitations to our study. The low-risk factor prevalence, exclusion of the uninsured and limited demographics within our population likely muted the potential disease capture rate for this technique of screening for chronic viral hepatitis. If this study were to be reproduced in an urban center with higher prevalence of risk factors and ethnic diversity, higher capture rates of previously undiagnosed hepatitis infections would be expected. Our high patient pre-test knowledge of viral hepatitis status speaks of the ongoing community screening at both Scott & White Healthcare and our Central Texas Veterans Administration. However, it probably blunted the capture rate for this technique in our community. It can be argued that combining screening for hepatitis with outpatient colonoscopy may not capture an adequate number of patients requiring screening. However, now that it has been proven that colonoscopy is reduces mortality by 53%, it is possible that more patients will be referred for screening colonoscopy.[40] Additionally, our study was conducted in a non-urban setting and the acceptance of our patients to be screened for viral hepatitis during outpatient colonoscopy may not generalize to a more urban setting with a more diverse ethnic population.

Finally, although our screening acceptance rate was 78%, we are uncertain as to the full reason for 22% to decline participation. We did not collect formal data on these patients until the final month of enrollment. We know that all were aged 50–65 and had medical funding sources. Most patients expressed uncertainty regarding medical insurance coverage (the time period of the study crossed that calendar year and many patients had not met their annual out of pocket deductibles). A smaller group of patients were uncomfortable filling out potentially embarrassing risk factor assessments. The remaining decliners either did not participate in research or did not believe that they had any risk factors or need testing. Quantitatively describing why all eligible patients declined would be interesting and may further aid in program development for screening for viral hepatitis in this venue.

Practical Implementation

If this technique of combining viral hepatitis screening with colonoscopy were to be instituted, plans for a nurse to explain viral hepatitis during bowel preparation instruction could be easily incorporated into practice. From our experience (almost 10% of samples being inadequate), we would recommend two vials of blood to be drawn from the IV site placed in the pre-endoscopy unit. Blood results from hepatitis screening could be delivered at the same time and with same mechanism, as polypectomy results are currently conveyed (often letters for expected results and telephone calls for unexpected or serious results). Therefore, extra appointments and new delivery systems would not be needed, however, broader nursing education and a slightly extended time spent with each patient would be necessary. The service of hepatitis screening is completely separate and should be billed to insurance as a unique issue. We did not follow-up with reimbursement rates for hepatitis screenings and vaccinations in our study population. However, we did have an agreement with our self-funded Scott & White Health Plan to pay for the screenings and vaccinations for those patients on Scott & White Health Plan (42% of our screened population- data not shown). If this mechanism were instituted on a larger scale willingness-to-pay would need to be explored further to assure feasibility.

With the recommendation for one time hepatitis screening of over 80 million baby boomers in the United States, utilizing an existing health-care screening system to deliver this service is highly desirable. As gastroenterologists, we see most baby boomers at least once and we also understand viral hepatitis. Incorporating viral hepatitis screening into colorectal cancer screening has the potential to be an easily instituted mass-screening mechanism. We hypothesize that this strategy will focus our limited national healthcare resources on those patients who are most likely to appear for follow-up testing and ultimately curative therapy. This will have to be explored at other diverse centers to determine the validity of this claim. We offer the colonoscopy suite as a potential venue to achieve baby boomer screening for chronic hepatitis.

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