Current Practice Patterns of Primary Care Physicians in the Management of Patients With Hepatitis C

Hepatology, September 1999, p. 794-800, Vol. 30, No. 3

http://hepatitis-central.com/Hepatitis C Virus/hepatitis/current/practices.html

Thomas M. Shehab¹, Seema S. Sonnad², Mark Jeffries¹, Naresh Gunaratnum¹, and Anna S. F. Lok¹

From the ¹Division of Gastroenterology and ²CHOICES (Consortium for Health Outcomes Innovations and Cost-effectiveness Studies), Department of Internal Medicine, University of Michigan and V.A. Medical Centers, Ann Arbor, MI.

ABSTRACT

Approximately 4 million Americans are infected with the hepatitis C virus (Hepatitis C Virus). Most patients with hepatitis C have no symptoms until cirrhosis is established. Thus, initial diagnosis and management of hepatitis C rely on primary care physicians identifying and screening high-risk individuals. We administered a survey to 1,233 primary care physicians in a health maintenance organization (HMO) in April 1997 to assess their knowledge of the risk factors for Hepatitis C Virus infection and approach to the management of 2 hypothetical Hepatitis C Virus antibody-positive patients, 1 with elevated and the other with normal alanine transaminase (ALT). Four hundred four (33%) physicians returned the survey. Ninety percent of respondents correctly identified the risk factors for Hepatitis C Virus infection, but 20% still considered blood transfusion in 1994 as a significant risk factor for Hepatitis C Virus infection. Sixty-two percent of respondents would refer Hepatitis C Virus antibody-positive patients with abnormal transaminase levels, but 33% would follow these patients themselves, even though none of the respondents had treated any hepatitis C patient on their own. Forty-three percent of respondents overestimated, while 29% did not know the efficacy of interferon treatment. Sixty-five percent of respondents would retest patients for Hepatitis C Virus antibody, regardless of risk factors and transaminase levels. We found that most primary care physicians correctly identified the significant risk factors for Hepatitis C Virus infection and appropriately managed the 2 hypothetical patients, but there was considerable confusion about the use of Hepatitis C Virus tests and the effectiveness of treatment. Educational programs for primary care physicians are needed to implement hepatitis C screening and to initiate further evaluation and management of those who test positive. (HEPATOLOGY 1999;30:794-800.)

INTRODUCTION

It has been estimated that approximately 4 million Americans are infected with the hepatitis C virus (Hepatitis C Virus).¹ Hepatitis C accounts for 8,000 to 10,000 deaths annually and is the leading indication for liver transplantation in the United States. Significant advances in the diagnosis and treatment of hepatitis C have been made in the years since the first diagnostic tests became available in 1990. This rapid growth of knowledge has taken place without formal standardization of crucial diagnostic tests or official recommendations for treatment. The lack of consensus on the best evidence-based approach to care for patients with hepatitis C led to the National Institutes of Health (NIH) consensus development conference in March 1997 and the release of the NIH consensus statement on hepatitis C.² The objective of this conference was to provide health care providers, patients, and the general public with a responsible assessment of currently available methods to diagnose and manage hepatitis C.

Many patients with hepatitis C are not aware that they are at risk for Hepatitis C Virus infection. In addition, the vast majority of patients with hepatitis C have no or nonspecific symptoms until cirrhosis is established. The occult nature of the disease in its early stage means that initial diagnosis and management rely on primary care physicians recognizing and testing high-risk individuals. It is therefore imperative that primary care physicians can identify patients at risk for hepatitis C, institute proper diagnostic testing, and begin initial management or referral of these patients. However, the knowledge of primary care physicians concerning hepatitis C has not been assessed.

We designed this study to determine:

1) The knowledge base of primary care physicians on risk factors and management of hepatitis C;

2) The factors that influence primary care physicians' knowledge and approach to patients   with hepatitis C; and

3) The effect of the NIH consensus statement on hepatitis C as an educational intervention in primary care physicians.

MATERIALS AND METHODS

We developed a survey to assess primary care physicians' knowledge of the risk factors for Hepatitis C Virus infection and their approach to the management of patients with hepatitis C. The survey contained 9 questions on risk factors and 9 questions on the management of patients with hepatitis C. A copy of the survey is available from the authors (T.M.S.). The questions on risk factors listed various exposures, and the respondents were asked to rate each of the exposures as "significant" or "minimal" risk factors for Hepatitis C Virus infection. Patient management questions were based on 2 clinical vignettes of patients who tested positive for Hepatitis C Virus antibody by enzyme-linked immunoabsorbent assay (EIA). The first patient had normal and the second had elevated alanine transaminase (ALT) levels (Table 1). The survey also elicited basic demographic information on the respondents, including specialty, years in practice, number of hepatitis C patients seen in the previous year, and experience

The study comprised 3 phases. First, we used the survey to assess the baseline knowledge of 1,233 primary care physicians in a large health maintenance organization (HMO) in Michigan in April 1997. The list of physicians' names and addresses was obtained from the HMO administrative office. The survey was mailed with a cover letter signed by one of the authors (A.S.-F.L.). The cover letter stated that the purpose of the survey was to assess the knowledge and practice of primary care physicians regarding hepatitis C and assured confidentiality of the results. The baseline knowledge of the respondents was compared with evidence-supported information in the NIH consensus statement. In July 1997, we mailed a summary of the NIH consensus statement to all the physicians who returned the initial survey. The summary contained 13 pages of text without illustrations. One month after the mailing of the consensus statement, we sent a new copy of the same survey to all the respondents and asked them to complete and return the second survey. To improve the response rate, a reminder was sent 2 weeks after the mailing of both the initial and the second surveys.

To identify factors that influence the physicians' responses, the responses to each question were further analyzed according to the physicians' specialty, number of years in practice, and the number of hepatitis C patients seen in the previous year. To determine if the responses were influenced by the NIH consensus statement, the responses between the initial and second surveys were compared. Statistical comparisons between groups were made using t tests.

RESULTS

Of the 1,233 primary care physicians, 404 (33%) returned the initial survey. One hundred twenty-six (31%) of those who responded to the initial survey returned the second survey.

Respondent Demographics.

The majority of the respondents were family practitioners (48%) or internists (31%) (Table 2). The remaining respondents were comprised of pediatricians (17%), general practitioners (3%), and medicine subspecialists (1%). Approximately half (54%) of the respondents had been in practice for more than 10 years. Most respondents (84%) had seen less than 5 patients with hepatitis C in the previous year. At the time of the initial survey, 75% had not seen the NIH consensus statement, 23% had read excerpts of it, and only 2% had read the entire statement. The majority (71%) of the respondents had no experience with interferon therapy, and none had treated any patient with interferon without the assistance of a gastroenterologist.

There was no difference between the subgroup of respondents who completed both surveys and the total responder cohort with regard to specialty, number of years in practice, or number of hepatitis C patients seen in the previous year (Table 2). A higher proportion of the subgroup that responded to both surveys had experience in following patients treated with interferon. However, fewer members of this subgroup had seen the NIH consensus statement on hepatitis C at the time of the initial survey.

Risk Factors for Hepatitis C Virus Infection.

The respondents were asked to rate various exposures as "significant" or "minimal" risk factors for Hepatitis C Virus infection (Fig. 1). There was strong agreement between the respondents and the published data that intravenous drug use (98%), blood transfusion in 1982 (88%), and sexual contact with multiple partners (87%) were significant risk factors for Hepatitis C Virus infection. The vast majority of the respondents also correctly identified casual household contact (92%) and sexual contact in a monogamous relationship (93%) as exposures associated with a minimal risk for Hepatitis C Virus infection. Most (80%) respondents considered the risk of acquiring Hepatitis C Virus infection by an infant born to a hepatitis C-infected mother as significant. A surprisingly high proportion (20%) of the respondents identified blood transfusion in 1994 as a significant risk factor for Hepatitis C Virus infection.

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Fig. 1.   Percent of all respondents (n = 404) identifying various exposures as significant risk factors for Hepatitis C Virus infection.

When the responses to questions on risk factors were further analyzed based on the respondents' specialty, years in practice, and the number of hepatitis C patients seen during the previous year, there were significant differences based on specialty (Fig. 2). A higher proportion of internists correctly ranked blood transfusion in 1982 as a significant risk factor for Hepatitis C Virus infection, and a lower proportion of internists ranked blood transfusion in 1994 as a significant risk factor for Hepatitis C Virus infection. Internists were less likely than family practitioners to identify casual household contact (an exposure with negligible risk) as a significant risk factor for Hepatitis C Virus infection. No significant difference in responses to questions on risk factors was found based on years in practice or the number of hepatitis C patients seen in the previous year (Fig. 3).

Fig. 2.   Percent of all respondents (n = 404) identifying various exposures as significant risk factors for Hepatitis C Virus infection based on respondents' specialty. a vs. b: P = .007; a vs. c: P = .001; d vs. e: P = .02; f vs. g: P = .02.

Fig. 3.   Percent of all respondents (n = 404) identifying various exposures as significant risk factors for Hepatitis C Virus infection based on respondents' experience with hepatitis C patients in the past y ear.

In the subgroup of physicians who completed both surveys, the only significant difference between the responses in the initial and second surveys was a decrease in the proportion of physicians who ranked birth to a hepatitis C-infected mother as a significant risk factor for Hepatitis C Virus infection: 83% vs. 65% (P < .001) (Fig. 4).

Fig. 4.   Percent of respondents (n = 126) within the subgroup who responded to both surveys identifying various exposures as significant risk factors for Hepatitis C Virus infection in the initial and second surveys. *P < .05.

Clinical Vignettes. The physicians were asked how they would manage 2 hypothetical patients who tested positive for Hepatitis C Virus antibody using EIA (Table 1). As expected, the respondents were more likely to refer patient 1 to a gastroenterologist and to support further intervention, but they were less certain about the need for and the choice of further Hepatitis C Virus testing in the 2 patients.

Patient 1 had risk factor for Hepatitis C Virus infection and abnormal ALT levels. Nevertheless, when asked what additional Hepatitis C Virus tests should be performed, more than half of the respondents would recheck for Hepatitis C Virus antibody including retesting with EIA (59%) (Table 3). The majority (82%) of the respondents would test for Hepatitis C Virus RNA. Very few (15%) respondents would perform Hepatitis C Virus genotyping. Most (62%) respondents would refer patient 1 to a gastroenterologist, but 33% would follow the patient themselves, even though none of the respondents had any experience in treating patients with hepatitis C on their own. An alarming response, albeit from a small minority (1%) of respondents, was to reassure the patient that he/she is immune to Hepatitis C Virus infection. The vast majority of respondents would support gastroenterologists' recommendations to perform liver biopsy (89%) and to initiate interferon alfa therapy (84%). However, when asked to estimate the likelihood of a sustained response after one course of interferon therapy, 43% of the respondents overestimated the response rate, while 29% did not know the answer.

Patient 2 had normal ALT levels and no identifiable risk factor for Hepatitis C Virus infection, yet the responses to further Hepatitis C Virus testing were remarkably similar to patient 1. Most respondents agreed that confirmatory testing is necessary for this patient, but they were uncertain which should be the next test. A similar proportion would retest the patient for Hepatitis C Virus antibody using EIA (68%) or recombinant immunoblot assay (RIBA) (63%) or for Hepatitis C Virus RNA (70%) (Table 3). As expected, only a minority (18%) of the respondents would refer patient 2 to a gastroenterologist; most (75%) would follow the patient in their clinics. Contrary to patient 1, only one third of the respondents would support further intervention such as liver biopsy (39%) or interferon treatment (36%), even if recommended by a gastroenterologist.

To identify the factors that may influence the management of patients with hepatitis C, physician responses were further analyzed according to their specialty, years in practice, and number of hepatitis C patients seen in the previous year (Table 4). Internists were more likely to refer patient 1 to a gastroenterologist compared with other physicians. Internists and physicians who had seen more patients with hepatitis C were less likely to answer that they "did not know" when asked to estimate the likelihood of response to interferon therapy. The management of patient 2 was considerably more uniform irrespective of the physicians' specialty (Table 4), years in practice (Table 5), or number of hepatitis C patients seen in the previous year.