| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH |
|
|
|
|||||||
|
|||||||||
TRACK to:
|
|
Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Physician Practice Patterns with Ethnic Minority Patients and the Poor
View from a hepatologist
Management of Hepatitis C in a Very High Risk Population: Corrections
Repairing The Holes in the HCV Safety Net
|
|
|||
|
M. Rosa Solorio, Los Angeles, CA Physician Scientist
Send response to journal:
|
It was a pleasure to read the recent article by Gazzuola et al. which examines the rates of documented discussions regarding hepatitis C treatment and the treatment rates by specialty of diagnosing physician. The overall treatment rates for hepatitis C were low. The article highlights that opportunities exist for treating more patients with hepatitis C infection. The authors report that documented treatment discussions and treatment were more likely to occur for White (non- Hispanic) patients with more than a high school education and for patients who did not have a history of cocaine use. I find this finding particularly relevant for physicians who care for ethnic minority populations and would like to highlight that another recent study found similar physician practice patterns in the care of HIV patients [1]. This recent study found that Hispanics, women, and the poor were more likely to receive later treatment with protease-inhibitors and the authors conclude that given the rising HIV infection rates among minorities, women, and the poor, further investigation of physicians current treatment strategies is warranted. Physician practice patterns have implications for addressing the ethnic health care disparities that currently exist in our country. Rosa Solorio, MD MPH References 1. Wong MD, Cunningham WE, Shapiro MF, Andersen RM, Cleary PD, Duan N, Liu HH, Wilson IB, Landon BE, Wenger NS. Diparities in HIV treatment and physician attitudes about delaying protease inhibitors for nonadherent patients. J Gen Intern Med. 2004;19(4):366-74. Competing interests: None |
|||
|
|
|||
|
Steven K Herrine, Philadelphia, PA Physician, Thomas Jefferson University
Send response to journal:
|
I read with interest the article “Management of Patients With Hepatitis C in a Community Population: Diagnosis, Discussions, and Decisions to Treat” by Dr. Rocca and colleagues. As a hepatologist involved in the tertiary care of patients with advanced liver disease, the viewpoint of this community-based observation was revealing. The very low incidence of HCV in the Olmstead County population may well represent not only underdiagnosis, but underrepresentation of infected individuals in this cohort. In fact, even the 1.8% prevalence reported in the US was based on NHANES III data, which specifically excludes incarcerated individuals. (1) The lack of specific questioning for HCV risk factors by generalists in this study may be in part due to physicians’ perception of therapeutic impotence in the management of this chronic infection. In fact, sustained viral response is seen in more than half of those patients treated with interferon-based antiviral therapies. (2, 3) Long-term observations confirm the near equivalence of sustained virologic response and HCV cure. Numerous outcomes investigations have demonstrated the cost- effectiveness of antiviral therapy. (4) Although depression has been described as a relative contraindication for the use of interferon-based regimens, it is the small minority of patients that cannot be treated due to psychiatric contraindications. (5) Based on these considerations and others, I agree wholeheartedly with the authors’ conclusion that “the generalist is central to community-based hepatitis C management.” 1. Alter MJ, Kruszon-Moran D, Nainan OV, McQuillan GM, Gao F, Moyer LA, Kaslow RA, Margolis HS. The prevalence of hepatitis C virus infection in the United States, 1988 through 1994. N Engl J Med. 1999 Aug 19;341(8):556-62. 2. Fried MW, Shiffman ML, Reddy KR, Smith C, Marinos G, Goncales FL Jr, Haussinger D, Diago M, Carosi G, Dhumeaux D, Craxi A, Lin A, Hoffman J, Yu J. Peginterferon alfa-2a plus ribavirin for chronic hepatitis C virus infection. N Engl J Med. 2002 Sep 26;347(13):975-82. 3. Manns MP, McHutchison JG, Gordon SC, Rustgi VK, Shiffman M, Reindollar R, Goodman ZD, Koury K, Ling M, Albrecht JK. Peginterferon alfa -2b plus ribavirin compared with interferon alfa-2b plus ribavirin for initial treatment of chronic hepatitis C: a randomised trial. 4. Chander G, Sulkowski MS, Jenckes MW, Torbenson MS, Herlong HF, Bass EB, Gebo KA. Treatment of chronic hepatitis C: a systematic review. Hepatology. 2002 Nov;36(5 Suppl 1):S135-44. 5. Koskinas J, Merkouraki P, Manesis E, Hadziyannis S. Assessment of depression in patients with chronic hepatitis: effect of interferon treatment. Dig Dis. 2002;20(3-4):284-8. Competing interests: Grant support from Intermmune, Roche, Schering. |
|||
|
|
|||
|
Kay A. Bauman, MD, MPH, Honolulu, HI professor, JABSOM, U. of HI, Medical Director, Department of Public Safety (Corrections)
Send response to journal:
|
I particularly enjoyed reading the manuscript, "Management of Patients with Hepatitis C in a Community Population", because managing hepatitis C has been a major challenge to me in my new position as Medical Director of the State of Hawaii Department of Public Safety (Corrections). I found some contrasts in my population to the population of Olmsted County studied in the article. The authors correctly contrasted the rate of hepatitis C in the general US population, 2%, to the far lower rate in their own population, 0.2%. The estimate in incarcerated individuals in the state of Hawaii is approximately 30%, based on blinded studies done by our Department of Health for 3 years in succession. This rate is similar in correctional facilities across the nation. I also contrast this with the much lower HIV rates in Hawaii and in the US in incarcerated populations: in Hawaii, our HIV rate is approximately 0.4% while in the US, it is about 2%. (1) This brings to mind first, how we practitioners can better take histories to look for hepatitis risk behaviors. Most inmates have a history of drug use, although in our state a large percent are non injection users. I have learned to ask patients, "Have you ever, even once, injected drugs?" I also ask as a part of this discussion, "Would you like to be tested for hepatitis C?" because I realize from 10-15% of hepatitis C positives in various studies do not have a known risk factor for transmission (injection drug use or high risk sexual behavior), but are drug users. I had always known about the potentially high rate of transmission of hepatitis B from an infected mother to her unborn child, but only in recent years learned about transmission of hepatitis C from mothers to newborns at rate of 4-5%. This is important patient education information to women planning children and merits discussion and testing consideration. Two eye-opening 'holes' in our health care system glared at me from the manuscript: 1) lack of follow up from ER visits where hepatitis C was diagnosed, and 2) lack of referral from drug treatment programs where hepatitis was diagnosed. It challenges us to tackle these problems in our own hospitals and in drug treatment programs we may be involved with. Reference: 1. HIV in Prisons, 2001, Bureau of Justice Statistics Bulletin, US Department of Justice. Competing interests: None declared |
|||
|
|
|||
|
Lorren Sandt, Oregon City, USA Director, Hepatitis C Caring Ambassadors Program, Tina M. St. John, MD
Send response to journal:
|
The article by Dr. Rocca and colleagues clearly brings to the fore an issue HCV advocates have been trying to communicate for many years: HCV- infected persons are falling through the cracks. Several detrimental downstream consequences resulting from the absence of a nationally coordinated HCV prevention and control program are documented in this article. • A significant proportion of people infected with HCV are not informed of the option for potentially curative treatment. • Follow-up counseling after HCV testing is lacking. • Ongoing monitoring and surveillance systems are absent or inadequate, especially among high-risk populations. • Relative contraindications to therapy are incompletely addressed resulting in low overall treatment rates. The long-term consequences of these gaping holes in the current HCV- safety net are potentially devastating to those presently infected and the public at large. Particularly alarming facts presented in this article include: • Over 8% of the study population were apparently unaware of their HCV status. • Nearly 10% of those not treated were excluded from therapy for financial reasons. • Over 40% of those not treated had transient or potentially remediable contraindications. • Both discussions of treatment and actual treatment significantly favored Caucasians and those with higher education. It appears the relatively well educated and medically insured in the population receive adequate care in community-based settings, including full-disclosure of their disease status and treatment options. However, the same level of care is far less certain among the uninsured, underinsured, and those with mental health and/or chemical dependency problems. How do we close the gaps? The Hepatitis C Epidemic Control and Prevention Act has been introduced in both houses of Congress. This groundbreaking legislation calls for funding and implementation of activities intended to bring the HCV epidemic under control, and prevent or reduce future HCV-related disease burden. Tasks addressed include: • education and training: public awareness campaigns, community outreach activities (with a focus on underserved, at-risk populations), curriculum development for health care professionals, and HCV counselor training • expansion of voluntary testing and risk reduction counseling • placement and training of hepatitis C coordinators to work with state, local, and tribal health departments • establishment of a coordinated HCV surveillance and monitoring system The passage of this legislation will go a long way toward establishing the infrastructure and providing the necessary funding to ensure an equitable safety net for all whose lives are affected by HCV. Our thanks to Dr. Rocca and colleagues for their contribution to this important topic. For additional information about HCV-related topics addressed in this commentary, please visit our Internet site at www.hepchallenge.org or the National Hepatitis C Advocacy Council site at www.hepcnetwork.org. Competing interests: None declared |
|||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH |
TRACK: