US doctors failing to diagnose hepatitis C years after first signs of cirrhosis

Doctors are failing to test for hepatitis C in up to one in five people who have advanced liver disease despite many years of medical care, and these people are more likely to have hospital stays after hepatitis C diagnosis, a US study published in The American Journal of Managed Care has found.

Late diagnosis was even more common among people born between 1945 and 1965, all of whom should have been screened for hepatitis C under US Centers for Disease Control and Prevention (CDC) guidelines. One in four were diagnosed late despite often having raised liver enzymes on previous laboratory tests. In some cases, patients had evidence suggesting cirrhosis on laboratory tests five years prior to hepatitis C diagnosis.

If hepatitis C is diagnosed before the development of cirrhosis or end-stage liver disease, treatment with directly-acting antivirals can cure hepatitis C and prevent progression to advanced liver disease. But people who develop cirrhosis will continue to be at higher risk of hepatocellular carcinoma (liver cancer) and if they develop decompensated cirrhosis, conditions such as portal hypertension and oesophageal varices may not be reversible even if hepatitis C infection is cured.

To reduce late diagnosis, the CDC issued guidelines in 2012 recommending one-time screening for hepatitis C in all people born between 1945 and 1965. This birth cohort has the highest prevalence of hepatitis C in the United States and if implemented in full, screening would have detected 800,000 hepatitis C infections and averted 120,000 deaths due to liver disease.

Investigators from the Chronic Hepatitis C Cohort Study in the United States wanted to see what effect the guidance had on hepatitis C diagnosis. The cohort covers four large integrated health systems in Pennsylvania, Michigan, Oregon and Hawaii providing care to 2.7 million people.

They looked at hepatitis C testing, diagnosis and hospitalisation for liver disease between 2014 and 2016. They defined late diagnosis as a diagnosis of severe liver disease within three months prior to hepatitis C diagnosis, or in the year after hepatitis C diagnosis. Severe liver disease was defined as cirrhosis diagnosed by biopsy or FIB-4 score. End-stage liver disease was defined as a diagnosis of hepatocellular carcinoma, liver failure, hepatic encephalopathy, portal hypertension, oesophageal varices, ascites, gastroesophageal haemorrhage, or undergoing a liver transplant.

During the study period, 2695 people were diagnosed with hepatitis C and had 12 months of subsequent follow-up available for analysis. Twenty-one per cent were diagnosed late.

Sixty per cent of those diagnosed with hepatitis C were born between 1945 and 1965. In this group, the rate of late diagnosis was higher; 27% were diagnosed late and people in this age cohort were three times more likely to be diagnosed late (odds ratio 3.3, 95% CI 2.57-4.22, p < 0.001). Late diagnosis was more common in men than women (23% vs 18%, p < 0.001), and in people in receipt of Medicare or Medicaid public health insurance compared to the privately insured (29%, 25% vs 18%, p = 0.004).

Patients with late diagnosis had been under medical observation with their current health providers for an average of nine years. Forty-six percent had visited an emergency room at least once during that period and 22% had elevated liver enzymes.

On average, people diagnosed late had their first elevated liver enzyme measurement seven years before diagnosis of hepatitis C. At the time of late diagnosis, one in four people had liver enzyme measurements and platelet counts on their medical records that would have enabled a physician to check if they had advanced liver disease. In a third of these people, the data suggested possible or likely cirrhosis, and the first measurements that would have indicated cirrhosis were available five years prior to hepatitis C diagnosis.

People who were diagnosed prior to the development of advanced liver disease also had long delays between liver enzyme elevations and diagnosis (an average of six years).

People diagnosed late were more likely to be hospitalised after diagnosis compared to people diagnosed prior to the development of advanced liver disease (32% vs 12%, p < 0.001) and spent much longer in hospital (358 days vs 78 days per 100 person-years of follow-up, p < 0.001).

“Patients with undiagnosed cirrhosis are being followed in health systems for years prior to receiving a diagnosis of HCV, but waiting until it is clear that liver disease is present is a failed strategy for reducing morbidity and health costs,” the study authors conclude.

“These patients are losing the opportunity to access the healthcare appropriate for those with cirrhosis, such as vaccinations, screening for liver cancer and oesophageal varices, and counselling about the risks of common medications or foods in those with cirrhosis.”