According to the CDC, 3 million people in the United States are living with chronic hepatitis C infection and of this group, 75 percent were born from 1945 to 1965. National prevalence data show that people born during this period -- best known as baby boomers -- have a prevalence of hepatitis C infection that is five times higher than that among other adults.
That's why in August 2012, the CDC recommended(www.cdc.gov) that adults born between 1945 and 1965 be offered a one-time test for hepatitis C virus (HCV) regardless of their specific risk for the disease. The CDC estimated one-time testing of this population would identify 800,000 infections and could help avert more than 120,000 HCV-related deaths, saving the nation $1.5-$7.1 billion in disease-related costs.
Around the time of the recommendation, the CDC also released a draft version of A Guide to Comprehensive Hepatitis C Counseling and Testing to field-test with primary care health professionals, soliciting their feedback and, subsequently, crafting a final iteration.
To facilitate the field-testing process, the CDC contracted with Battelle Health & Analytics who, in turn, partnered with the AAFP National Research Network (AAFP NRN) to connect with Academy members' practices that would use and review the guide.
- The AAFP's National Research Network recently worked with the CDC to develop A Guide to Comprehensive Hepatitis C Counseling and Testing.
- To field-test the manual, 10 primary care practices in seven states participated, providing feedback from 19 health care professionals, including 16 family physicians.
- The CDC recommends offering adults born between 1945 and 1965 a one-time test for hepatitis C virus regardless of their specific risk for the disease.
Kim Kimminau, Ph.D., AAFP NRN's research director and lead on the project, told AAFP News that the field assessment of the CDC's HCV manual had the objective of putting the manual in the hands of primary care teams so the resource could be improved.
Kimminau said some participating family physicians told the research team that asking their baby boomer patients about behaviors that might lead to HCV infection was something that probably should have been done previously but hadn't, and the manual offered them a conversation starter to do so.
"That was exactly the purpose of the manual; it provides a way to frame the conversation with a patient who you maybe know well but the topic has never come up," she said. "Providers told us it was easier to talk about liver health instead of starting from the point of view of illicit drug use and unprotected sex."
Field Assessment Basics
Gary Chovnick, M.P.H., principal research scientist and lead for Battelle on the project, told AFFP News that in total, 10 primary care practices in seven states participated, providing feedback from 19 health care professionals: 16 family physicians, two physician assistants and one nurse practitioner. The project was conducted from July 2012 through October 2013.
Participants were asked to use the draft manual to test any patients born from 1945 to 1965 for HCV during a four-week period and to check in weekly with any questions or feedback. All participants provided an in-depth wrap-up interview at the conclusion of the field test.
It turned out that the majority of participating health care professionals -- about 75 percent -- were not doing routine HCV testing prior to their involvement in the manual field test. Previously, most reported HCV testing was conducted only in high-risk patients.
Findings From Research
Chovnick said the majority of participants found their discussions with patients about HCV to be very straightforward.
"In most cases, once the provider said, 'This is a new recommendation provided by the CDC, and it recommends people born in the year that you were born have a one-time hepatitis C test,' most patients were very receptive to the message and didn't ask for a whole lot more information," he said.
It also was much easier to incorporate this discussion and testing into their daily work than most physicians expected, Chovnick said, and in most cases it didn't take much extra time either. One of the biggest challenges participants noted was simply remembering to offer the test to patients in this age group.
Participants said the most important topics included in the manual were those in the section on what to do if a patient has positive HCV results. These topics include offering a positive and hopeful message about the diagnosis, information on treatment and prognosis, an overview of how hepatitis C is transmitted, and what the diagnosis means for the patient's future use of alcohol.
Most physicians found the draft manual helpful but thought it needed to be much more abbreviated than the original four-section version to speed the process. "Also, some areas of the manual were repeated in sections for emphasis, but the physicians said once was enough to get the message across," Chovnick said.
So the final manual was a shorter version and reflected physicians' feedback on what they thought were the most important topics to include.
In addition, Chovnick noted that when the field test began, the CDC's recommendation for HCV testing was different from that of the U.S. Preventive Services Task Force (USPSTF) guideline; whereas the CDC recommended the universal one-time HCV test for the baby boomer age group, the USPSTF recommended testing only for higher-risk populations. But in 2013, the USPSTF updated its guidelines(www.uspreventiveservicestaskforce.org) to include a recommendation for one-time screening of those born from 1945 to 1965, as well. The AAFP's HCV screening recommendations have consistently mirrored those of the USPSTF.
As for the bottom line results, even though some physicians were skeptical that HCV testing would find any of their patients to be positive for the disease, a number of participants did, in fact, identify patients as HCV-positive, and they used the manual to guide their approach to providing positive results, next steps and answering patient questions.
"Over the course of the four-week period, an average of 11 patients were tested for hepatitis C by each participant," Chovnick said.
Kimminau said she thought it was great that research the AAFP NRN was involved in opened up a dialogue and provided the framework for what clinicians needed to have in their hands to work with their patient population.
"This means more people are going to be screened, and we are going to find more hep C and be able to treat it before it's a really serious disease," she said. "Left untreated, it has serious health implications. The fact that this might identify someone who is at risk or actually has hepatitis C that a physician didn't know about prior is pretty remarkable."
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