Context of Clinical Care: The Case of Hepatitis C in Underserved Communities—A Report from the Primary Care Multiethnic Network (PRIME Net) Consortium

Robert R. Leverence; Robert L. Williams; Wilson Pace; Bennett Parnes; Yvonne Fry-Johnson; Dorothy R. Pathak; Betty Skipper; Elvan Daniels; Philip Kroth

doi:10.3122/jabfm.2009.06.090020

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Table 1.

National Guidelines for Screening Those at High Risk for Hepatitis C

Organization	Recommendation	Year of Latest Publication	References
National Institutes of Health Consensus Conference	Promote the establishment of screening tests for all groups at high risk of HCV infection	2002	7
US Preventive Services Task Force	Insufficient evidence to recommend for or against routine screening for HCV infection in adults at high risk for infection (“I” recommendation)	2004	9–11
Centers for Disease Control and Prevention	Testing should be offered routinely to persons most likely to be infected with HCV who might require medical management, and testing should be accompanied by appropriate counseling and medical follow-up	1996, 2004	5, 6
American College of Preventive Medicine	Individuals at high risk for hepatitis C infection should be screened for anti-HCV	2005	8

HCV, hepatitis C.

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Table 2.

Clinician Demographics and Practice Characteristics

Variable	n (%)
Network affiliation (N = 494)
CaReNet	217 (43.9)
RIOS Net	150 (30.4)
SERCN	31 (6.3)
UNM Preceptor	93 (18.8)
Other	3 (0.6)
Practice type (N = 484)
Community health center	184 (38.0)
Indian Health Service	53 (11.0)
University faculty	122 (25.2)
Veterans Administration	4 (0.8)
Solo practitioner	16 (3.3)
Other group practice	105 (21.7)
Specialty (N = 485)
Family medicine	216 (44.5)
Pediatrics	71 (14.6)
Internal medicine	81 (16.7)
Nurse practitioners/physician assistants	43 (8.9)
Family medicine resident	64 (13.2)
Other resident	10 (2.1)
Years since completing primary care residency^* (N = 368)
<10	139 (37.8)
10–20	115 (31.2)
>20	101 (27.4)
Not applicable	13 (3.5)
Community Size (N = 491)
Town ≤25,000 people	109 (22.2)
Town >25,000 but <100,000 people	60 (12.2)
City of 100,000 to 500,000 people	88 (17.9)
Urban or suburban area in city of >500,000 people (not inner city)	138 (28.1)
Inner city, >500,000 people	96 (19.6)
HCV patients currently in practice (N = 491)
0	94 (19.1)
1–5	180 (36.7)
6–20	139 (28.3)
>20	78 (15.9)
New diagnoses of HCV during the past year^† (N = 395)
0	103 (26.1)
1–5	246 (62.3)
6–15	34 (8.6)
>15	12 (3.0)
Prescribed antiviral therapy for HCV patients^† (N = 393)
Yes	72 (18.3)

* Among physicians not currently in residency.
† Among clinicians with HCV patients in their practice.
HCV, hepatitis C; CaReNet, Colorado Research Network; RIOS Net, Research Involving Outpatient Settings Network; SERCN, Southeast Regional Clinicians’ Network; UNM, University of New Mexico.

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Table 3.

Clinician Perspectives Regarding the Detection and Management of Hepatitis C

Survey Question	% (n)
Compared with the common problems you face in practice, how important would you consider hepatitis C to be? (percent responding more important/important; N = 491)	67.8 (333)
Compared with the common medical problems you screen for in practice, how important would you consider screening for HCV to be? (percent responding more important/important; N = 490)	58.8 (288)
The extent to which you agree or disagree about whether primary care providers should be doing the following with respect to hepatitis C (percent responding strongly agree/agree; N = 494^*)
Screening	87.5 (428)
Diagnosis	93.0 (456)
Treatment with antiviral therapy	29.6 (144)
Monitoring and follow-up	66.9 (327)
Referral for consultation and comanagement of hepatitis C	94.9 (463)
Referral for all hepatitis C management	50.6 (247)
How do you assess patients for these concerns (N = 490–494):
Intravenous drug use
Routinely ask new patients	53.8 (266)
Ask patients who give a history of other illicit drug use	54.0 (267)
Blood transfusion or solid organ transplant before July 1992
Routinely ask new patients	28.4 (139)
Ask patients who have abnormal liver function tests	42.7 (209)
Under what circumstances do you order serum ALT levels? (N = 487)
Routine screen for new patients	25.3 (123)
Patients with other risk factors for hepatitis C	60.6 (295)
Patients with a history of hepatitis C	56.3 (274)
How often do you order a hepatitis C antibody test? (percent responding always/frequently; N = 494^*)
Patient history of intravenous drug use	75.9 (375)
Patient history of blood transfusion/organ transplant before 1992	52.8 (261)
Patient with an abnormal serum ALT	79.6 (393)
What percent of patients in your practice with hepatitis C have you referred for treatment? (N = 394)^†
<25	23.6 (93)
25–75	30.2 (119)
>75	46.2 (182)
Do you routinely offer to patients with hepatitis C (N = 397)^†
Counseling about alcohol avoidance	93.7 (371)
Counseling about acetaminophen avoidance	78.6 (312)
Hepatitis A vaccination/testing	84.4 (335)
Hepatitis B vaccination/testing	89.7 (356)
HIV testing	82.4 (327)

* Minor differences in item responses (range, 487–490).
† Clinicians with hepatitis C patients in their practices.
ALT, alanine aminotransferase; HIV, human immunodeficiency virus.

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Table 4.

Factors That Influence the Approach to Screening for Hepatitis C Risk Factors (N = 494*)

	Yes (% [n])	No (% [n])	Not Applicable (% [n])
Consequences of untreated hepatitis C can be serious for most people	89.5 (437)	7.0 (34)	3.5 (17)
Guideline recommendations	75.0 (366)	25.0 (122)	—
Presence of comorbidities in patient	73.5 (358)	26.5 (129)	—
Treatment availability	54.8 (268)	45.2 (221)	—
Treatment effectiveness (ability to improve outcome)	50.0 (243)	38.1 (185)	11.9 (58)
Other competing issues	44.5 (216)	55.5 (269)	—
High prevalence of hepatitis C among my patients	44.5 (217)	25.0 (122)	30.5 (149)
Treatment intolerance	44.4 (216)	55.6 (270)	—
Financial barriers	39.3 (190)	60.7 (294)

* Minor differences in item responses (range, 484–9).

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Table 5.

Primary Reason(s) Patients Have Not Undergone Treatment for Hepatitis C* (N = 354)

	n
Alcohol use, psychiatric morbidity, or other contraindication	267
Lack of patient interest in treatment	227
Lack of insurance	209
Poor tolerance of treatment (recent or in past)	197
Poor access to treatment services or staff	187
Insurance companies will not cover treatment	136
My personal views of treatment	78