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Integrating hepatitis prevention services into a substance use disorder clinic
Journal of Substance Abuse Treatment 32 (2007) 391 – 398
Regular article
Integrating hepatitis prevention services into a substance use disorder clinic Hildi Hagedorn, (Ph.D.)a,b,4, Eric Dieperink, (M.D.)a,b,c, Debra Dingmann, (R.N.)a, Janet Durfee, (N.P.)a,b,c, Samuel B. Ho, (M.D.)a,b,c, Carl Isenhart, (Psy.D.)a,b, Nancy Rettmann, (M.S.)a, Mark Willenbring, (M.D.)d a
Minneapolis Veterans Affairs Medical Center, Minneapolis, MN 55417, USA b University of Minnesota, Minneapolis, MN 55455, USA c Veterans Affairs Hepatitis C Resource Center, Minneapolis, MN 55417, USA d National Institute on Alcohol Abuse and Alcoholism, Rockville, MD 20892, USA Received 24 May 2006; received in revised form 3 October 2006; accepted 24 October 2006
Abstract The Healthy Liver Program, established at the Minneapolis Veterans Affairs Medical Center Substance Use Disorder Clinic, provides screening for exposure to hepatitis infections, a group education class, and an individual nursing appointment to review screening results, give vaccinations for hepatitis A and hepatitis B, and make referrals to the hepatitis clinic as appropriate. A patient chart audit was completed 11 months after the establishment of the Healthy Liver Program. The attendance rate for the educational group and individual feedback sessions was 66.9%, with 94.1% of attendees accepting recommended hepatitis A and/or hepatitis B vaccinations. All patients with chronic hepatitis C who attended the Healthy Liver Program received a referral for evaluation in the hepatitis clinic, as compared with only 50% of patients with chronic hepatitis C who were identified before the establishment of the program. The importance of providing comprehensive educational sessions and recommendations for how patients with substance use disorders can access hepatitis screening, vaccination, and treatment resources are stressed. D 2007 Elsevier Inc. All rights reserved. Keywords: Substance abuse treatment programs; Hepatitis C infections; Hepatitis services; Implementation; Vaccinations
1. Introduction Nearly 4 million people in the United States are infected with hepatitis C. Although the numbers of new cases are declining, there are still 30,000 new cases of hepatitis C diagnosed each year. Most hepatitis C infections become chronic, and, despite their declining incidence, the burden from these infections is expected to increase markedly as those who were infected 20–30 years ago present with
The opinions expressed in this article are those of the authors and do not represent those of the U.S. Department of Veterans Affairs or the VHA. 4 Corresponding author. Minneapolis Veterans Affairs Medical Center, One Veterans Drive (116A9), Minneapolis, MN 55417, USA. Tel.: +1 612 467 3875; fax: +1 612 467 5265. E-mail address: [email protected] (H. Hagedorn). 0740-5472/06/$ – see front matter D 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.jsat.2006.10.004
advanced liver disease (Centers for Disease Control and Prevention, 2002). Most people infected with chronic hepatitis C may not be aware that they are infected because they are not clinically ill (Heintges & Wands, 1997). This results in delayed identification that increases the risk for transmission to others and delays treatment until serious complications arise (Simonetti, Camma, & Fiorello, 1992; Yu, Tong, & Corsaget, 1990). Injection drug use currently accounts for up to 60% of hepatitis C transmissions in the United States (Centers for Disease Control and Prevention, 1998). Although the rate of infection in the general population in the United States is lower than 2%, individuals who participate in injection drug use are at a particularly high risk, with rates of infection reported to be between 50% and 90% (Abraham, Degli-Esposti, & Marino, 1999; Dhopesh & Taylor, 2000;
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Fingerhood, Jasinski, & Sullivan, 1993; Kelen et al., 1992; Sorensen, Masson, & Perlman, 2002). Although intravenous drug use appears to be the major risk factor associated with substance use disorders (SUDs), rates of infection among drug- and alcohol-dependent individuals reporting no history of intravenous drug use also have been shown to be higher than those among the general population (Abraham et al., 1999; Dhopesh & Taylor, 2000; Rosman et al., 1996; Tortu, Neaigus, McMahon, & Hagen, 2001). Dhopesh and Taylor reported a rate of hepatitis C infection of 24% among individuals presenting for SUD treatment who reported no history of intravenous drug use. Abraham et al. reported a hepatitis C infection rate of 12.5% among a middle class sample of individuals presenting for SUD treatment who reported no history of intravenous drug use. Because of common risk factors, individuals at high risk for hepatitis C are also at higher risk for exposure to hepatitis A and hepatitis B. In addition, several systematic reviews of the literature have demonstrated that patients already compromised by chronic liver disease, as a result of either hepatitis C or alcoholic liver disease, are at a much higher risk for poor outcomes, including fatality if coinfected with acute hepatitis A or hepatitis B (Almasio & Amoroso, 2003; Keeffe, 1995, 1999; Koff, 2001; Reiss & Keeffe, 2004; Vento et al., 1998). Therefore, it is imperative that these patients receive vaccination against these infections. However, Shim, Khaykis, Park, and Bini (2005) reported that, despite published recommendations to vaccinate chronic hepatitis C-positive patients against hepatitis A, hepatitis A testing and vaccination rates were low in clinical practice, representing missed opportunities to provide a potentially life-saving intervention. The Department of Health and Human Services has set goals for the reduction of viral hepatitis in highrisk groups as part of its Healthy People 2010 goals (http://www.healthypeople.gov/document/html/volume1/ 14immunization.htm). Included in these goals are the following recommendations: 1.
2.
3.
To identify hepatitis C-infected individuals so they can be counseled to prevent further transmissions, vaccinated against hepatitis A and hepatitis B to prevent additional liver damage, evaluated for chronic liver disease and possible antiviral therapy, and counseled to avoid potential hepatotoxins, such as alcohol, that may increase the severity of hepatitis C-related liver disease. To immunize adults presenting to settings with high rates of infection, including SUD treatment clinics, against hepatitis B. To immunize high-risk groups, including illicit drug users, against hepatitis A.
Substance use disorder treatment clinics represent an ideal venue to target screening, prevention, and treatment referral services for hepatitis infections. In fact, because
individuals with SUDs are often medically underserved (Chitwood, McBride, French, & Comerford, 1999; Contoreggi, Rexroad, & Lange, 1998), SUD treatment clinics may represent a unique opportunity to provide these individuals with services related to infectious diseases. Currently, SUD treatment clinics are not taking full advantage of this opportunity. According to nationwide surveys of SUD treatment clinics, although most clinics provide education to at least some of their patients, important information and services are commonly missed (Astone, Strauss, Vassilev, & Des Jarlais, 2003; Strauss, Astone, Hagan, & Des Jarlais, 2004; Strauss, Falkin, Vassilev, Des Jarlais, & Astone, 2002). For example, only approximately half of clinics educate patients about the importance of hepatitis A and hepatitis B vaccinations for patients at high risk and, although most units educate patients about the importance of being tested for hepatitis C, offering testing or actively encouraging patients to be tested is less common. Only 7% of units tested all clients, and 22% did not test any client. The Veterans Health Administration (VHA) is an ideal medical system through which to begin to address this gap in services. In Fiscal Year 2004, more than 200,000 VHA outpatients were diagnosed with an SUD. Veterans with SUDs have been shown to be the patient group within the VHA with the highest prevalence of hepatitis C and the highest risk for alcoholic liver disease (El-Serag, Kunik, Richardson, & Rabeneck, 2002; Nguyen et al., 2002). Mendenhall et al. (1993) reported a hepatitis C infection rate of 18.4% among patients with chronic alcoholism within the VHA system. Finally, many VHA SUD clinics exist within medical centers that have access to laboratory, pharmacy, and gastroenterology services. The Liver Health Initiative is a program jointly sponsored by the VHA SUD Quality Enhancement Research Initiative (SUD QUERI) and the Minneapolis VHA Hepatitis C Resource Center (HCRC). The broad goal of the Liver Health Initiative is to improve access to services for the prevention, identification, and treatment of viral hepatitis infections among patients seeking treatment at VHA SUD clinics. The specific goals of the Liver Health Initiative are to (1) implement testing for hepatitis B and hepatitis C infections and for prior exposure to hepatitis A and hepatitis B, (2) provide comprehensive structured patient education on liver health, (3) provide access to hepatitis A and hepatitis B vaccinations, and (4) increase rates of successful referrals of hepatitis B- and hepatitis C-positive patients to hepatitis treatment providers for evaluation, all within the context of SUD treatment clinics. As an initial step toward these goals, a pilot project was conducted at the Minneapolis Veterans Affairs (VA) Medical Center to establish a healthy liver program that would provide the services described above. In July 2004, a stakeholder group that included clinical and administrative staff from both the SUD clinic and the hepatitis clinic as well as consultants from the SUD QUERI and the HCRC
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was convened. The goals of the stakeholder group were to conduct a baseline assessment of services currently offered in the clinic, identify specific service improvement goals, and develop policies, procedures, and tools for meeting those improvement goals. A small research grant provided support for the initial 6-month planning phase of the project. The research funds were used to support a research assistant who was responsible for conducting chart reviews and developing educational materials for patients and providers based on instructions from the stakeholder group. The research funds also provided for the supplies, such as color printing and copying, required to create educational materials. Research funds were not requested to cover clinical expenses because the goal of this project was to create a program that would be sustainable beyond initial research funding. All clinical services for the program (e.g., laboratory testing, vaccinations, and nursing staff) were obtained through standard medical center operating procedures.
Diagnostics, Indianapolis, IN, USA), hepatitis B (hepatitis B surface antigen, VITROS ECI Chemiluminescence Assay, Ortho-Clinical Diagnostics), immunity to hepatitis A (hepatitis A antibody, HAV Total Assay, Bio-Rad laboratories, Hercules, CA, USA), and immunity to hepatitis B (hepatitis B surface antibody, VITROS ECI Chemiluminescence Assay, Ortho-Clinical Diagnostics). The baseline testing information was used to determine the percentage of those tested who were positive for chronic hepatitis B and hepatitis C and prior exposure to hepatitis A and hepatitis B. The percentage of those who tested positive for chronic hepatitis B and hepatitis C who received a referral to the hepatitis clinic for evaluation was also determined. Based on the results of the baseline assessment, which are presented in detail below, the stakeholder group identified five specific practice improvement goals: 1. 2.
2. Methods
3.
2.1. The Minneapolis VA Medical Center SUD Clinic The Minneapolis VA Medical Center SUD Clinic serves approximately 2,300 unique patients per year. It offers several treatment tracks, including the following: (1) the Intensive Outpatient Program, which meets 5 days per week (20 hours per week) for 3–5 weeks; (2) the Life Skills Program, which meets for 3 days per week (12 hours per week) for 8 weeks; and (3) the Recovery Training Program, which includes two 1.5-hour sessions per week and is open-ended. All these tracks also include individual case management and/or addiction psychiatry appointments. After the completion of their intensive treatment program, patients are expected to complete at least 12 weeks of continuing care, including a weekly group session, case management, and addiction psychiatry clinic appointments. Patients who are unable to maintain abstinence despite intensive treatment interventions are not discharged but are followed up in care management and addiction psychiatry clinics using a harm reduction approach. 2.2. The baseline assessment of services The baseline assessment of services included a review of current clinic policies related to the identification, prevention, and treatment of hepatitis infections. The baseline assessment also included a chart audit of 104 consecutive intakes into the SUD treatment clinic. The purpose of conducting the chart review was to determine the percentage of patients being tested for hepatitis C (hepatitis C antibody, VITROS ECI Chemiluminescence Assay, Ortho-Clinical Diagnostics, Raritan, NJ, USA, and hepatitis C confirmatory, Cobas Amplicor Hepatitis C Virus Test, version 2.0, Roche
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4. 5.
Improve the percentage of patients who are tested for hepatitis C; Implement routine testing for hepatitis B infection and prior exposure to hepatitis A and hepatitis B; Develop standardized procedures to ensure feedback of test results to patients and referral to the hepatitis clinic for evaluation of hepatitis B- and hepatitis Cpositive patients; Develop a liver health education program available to patients entering SUD treatment; and Develop procedures for providing hepatitis A and hepatitis B vaccinations within the SUD clinic.
2.3. The Healthy Liver Program From June through December 2004, the stakeholder group discussed and debated different intervention models, identified potential barriers to implementation, enlisted staff from specific areas (e.g., pharmacy, administration, and clerical) to identify solutions to barriers, developed patient and provider educational materials, and provided educational in-services to promote the intervention among the SUD clinic staff. The Healthy Liver Program was officially launched in January 2005. The first component of the Healthy Liver Program is that testing for hepatitis B and hepatitis C infections and prior exposure to hepatitis A and hepatitis B was added to the routine blood work conducted on patients attending an intake appointment in the SUD clinic. The second component is that patients completing an intake into the SUD clinic are scheduled to attend a Healthy Liver Group session approximately 3–4 weeks after their intake appointment. The Healthy Liver Group is a 60-minute intervention staffed by an RN who is a member of the SUD clinic staff. The intervention consists of a 30-minute group educational session followed by individualized meetings with the RN to review laboratory results. Educational sessions and individual RN appointments were all held in the SUD clinic to facilitate patient attendance. During the educational
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Table 1 Medicare reimbursement rates for laboratory tests provided as part of the Healthy Liver Program Laboratory test Hepatitis Hepatitis Hepatitis Hepatitis Hepatitis
C antibodyb C confirmatoryc B surface antigend B surface antibodye A antibodyf
Medicare 2006 national limitation amounta $19.94 $21.64 $14.43 $15.01 $17.31
a
Rates available at the Centers for Medicare and Medicaid Services Web site, accessed October 2, 2006 (http://www.cms.hhs.gov/ClinicalLab FeeSched/). b Tests for the presence of antibodies to hepatitis C virus; a positive result indicates exposure to hepatitis C virus. c A positive result confirms chronic infection with hepatitis C virus. d A positive result confirms chronic infection with hepatitis B virus. e Tests for the presence of antibodies to hepatitis B virus; a positive result indicates prior exposure to and immunity to hepatitis B virus. f Tests for the presence of antibodies to hepatitis A virus; a positive result indicates prior exposure to and immunity to hepatitis A virus.
session, the patients watch a 15-minute video and then have 15 minutes for questions and answers. See Box 1 for a list of topics covered in the educational session. Box 1: Components of the Healthy Liver Group Educational Session ! What are hepatitis A, hepatitis B, and hepatitis C infections? ! How are hepatitis infections transmitted? ! How can I protect myself from hepatitis infections? ! How does alcohol use affect the health of my liver? ! If I have hepatitis C, what can I do to maintain my health and to protect others from infections?
Liver Group session are sent a letter stating that they missed their Healthy Liver Group appointment and providing them with a phone number to call if they would like to reschedule. This is a standard procedure for all missed appointments in the Minneapolis VA Medical Center SUD Clinic. 2.4. Time and costs associated with the Healthy Liver Program For an SUD clinic of this size, the RN responsible for the Healthy Liver Program spends approximately 4 hours per week on tasks related to the program. These include running two 1-hour group sessions per week, preparing for the group sessions, and completing required documentation. The LPN, who occasionally assists with the group sessions, spends no more than 1 hour per week on the program assisting with vaccinations for 30 minutes for each group. All patients receive serological testing, which includes the hepatitis C antibody, hepatitis B surface antigen, hepatitis B surface antibody, and hepatitis A antibody tests. Patients testing positive for hepatitis C antibody undergo the hepatitis C confirmatory test. Table 1 shows the Medicare reimbursement rates for these tests. Table 2 shows the Centers for Disease Control and Prevention purchasing prices and the private sector purchasing prices for the various vaccinations used in the Healthy Liver Program. A follow-up chart audit of the 171 patients scheduled into a Healthy Liver Group session between January 1 and November 30, 2005, was completed to assess the impact of the Healthy Liver Program. 3. Results 3.1. The patient population
During the individualized meeting with the RN, the RN reviews each patient’s laboratory work, including hepatitis B and hepatitis C status, hepatitis A and hepatitis B immunity status, liver function test results, and any abnormal findings from additional routine laboratory tests. The RN also recommends vaccinations for hepatitis A and hepatitis B depending on a patient’s immunity status. Patients who are interested in receiving vaccinations are given their first vaccine and scheduled to return to the Healthy Liver Group at appropriate intervals to receive their booster shots. Patients returning for boosters are given their shots by the RN while the new patients are watching the educational video. Finally, if patients are positive for hepatitis B or hepatitis C, the RN has the authority to directly schedule them into the hepatitis clinic group intake so that the patients can leave the Healthy Liver Group with an appointment card for an intake appointment. By using a group format, one RN (assisted by an LPN for larger groups) can provide education, feedback, vaccinations, and referrals for up to 12 patients during the 1-hour group session. Patients who do not attend their scheduled Healthy
Two hundred seventy-five patient charts (104 at baseline and 171 during follow-up) were reviewed to assess the impact of the Healthy Liver Program. To provide an overview of the demographics of the patient population at the Minneapolis VA Medical Center SUD Clinic, we also reviewed a random sample of 25% of the 275 patient charts (n = 69) for demographic information. Typical of VHA patient populations, this sample was predominantly male (95.7%) and predominantly Caucasian (58.0%) and African American (36.2%). The patients’ mean age was 49.2 years, Table 2 Costs of vaccinations provided as part of the Healthy Liver Program Vaccine (brand name)
CDC cost per dosea
Private sector cost per dosea
Hepatitis A (HavrixR) Hepatitis B (ENGERIX-BR) Hepatitis A–Hepatitis B (TwinrixR)
$19.33 $25.25 $38.57
$54.38 $50.35 $78.16
Note. CDC indicates Centers for Disease Control and Prevention. a Rates available on the CDC Web site, accessed September 7, 2006 (http://www.cdc.gov/nip/vfc/cdc_vac_price_list.htm).
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and their mean number of years in school was 13.2 years. Most patients were not working as a result of unemployment, disability, or retirement (62.3%). Most patients were either divorced or never married (72.4%). The most frequent diagnosis at intake was alcohol dependence (82.6%); the second most frequent diagnosis was cocaine dependence (27.5%). Other diagnoses included marijuana (7.2%), opioid (5.8%), and methamphetamine (4.3%) dependence. These percentages add to more than 100% because 30.4% of the patients received more than one diagnosis. 3.2. The baseline assessment of services At baseline, clinic policies indicated that all new patients were to be tested for hepatitis C infection. However, there was no policy in place to ensure that patients received their testing results or, if they were positive for hepatitis C, that they received a referral to the hepatitis clinic for evaluation. Education regarding hepatitis infections was a standard part of the Intensive Outpatient Program curriculum. However, patients who entered less intensive programming were not targeted for education regarding hepatitis infections. No procedure to routinely test for hepatitis B infection or prior exposure to hepatitis A and hepatitis B was in place. There was also no procedure for providing hepatitis A and hepatitis B vaccinations in the SUD clinic. As seen in Table 3, the baseline chart audit indicated that 72.1% (75/104) of the patients were tested for hepatitis C at intake. Therefore, although clinic policy stated that all patients should be tested, there was significant room for improvement. In addition, the chart audit indicated a high risk for established infection with hepatitis C (22.7% positive for hepatitis C antibody and 13.3% positive for hepatitis C confirmatory). These results confirm that this is a high-risk population with the potential to benefit from targeted screening, prevention, and referral services. Finally, of the six patients who screened positive for hepatitis C and did not have an indication in their chart that they had been previously diagnosed, only three (50%) had documentation in their chart that they received feedback on their test results and a referral to the hepatitis clinic. As expected, baseline testing rates for chronic hepatitis B and prior exposure to Table 3 Baseline and intervention hepatitis testing rates and results Laboratory test
Baseline
Patients tested [n (%)] Hepatitis C antibody 75/104 (72.1) Hepatitis B surface antigen 20/104 (19.2) Hepatitis A antibody 13/104 (12.5) Hepatitis B surface antibody 14/104 (13.5) Patients who tested positive [n (%)] Hepatitis C antibody 17/75 (22.7) Hepatitis C confirmatory 10/75 (13.3) Hepatitis B surface antigen 0 (0) Hepatitis A antibody 7/13 (53.8) Hepatitis B surface antibody 4/14 (28.6)
Intervention 113/115 113/115 113/115 113/115 19/113 14/113 1/113 34/113 17/113
(98.3) (98.3) (98.3) (98.3) (16.8) (12.4) (0.9) (30.1) (15.0)
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Table 4 Acceptance of vaccinations for hepatitis A and hepatitis B Vaccination status
n (%)
Appropriate for vaccination Accepted vaccination as recommended by RN Declined recommended vaccination Returned for 1-month booster Returned for 6-month booster
101/113 (89.4) 95/101 (94.1) 6/101 (5.9) 73/85 (85.9) 57/95 (60.0)
hepatitis A and hepatitis B were much lower. No cases of chronic hepatitis B were identified. The rates of prior exposure to or vaccination for hepatitis A and hepatitis B were 53.8% and 28.6%, respectively. 3.3. Follow-up results One hundred seventy-one patients were scheduled to attend a Healthy Liver Group session between January 1 and November 30, 2005. Of these 171 patients, 115 attended the group session, for an attendance rate of 66.9%. Table 3 shows the results of hepatitis testing for the 115 patients who attended a Healthy Liver Group session. One hundred thirteen of the 115 scheduled patients (98.3%) had their laboratory work completed before attending their scheduled group session. Nineteen (16.8%) of these patients were positive for hepatitis C antibody and 14 (12.4%) were positive for hepatitis C confirmatory, confirming the high rate of hepatitis C infection found in the baseline assessment. One patient (0.9%) was found to have chronic hepatitis B infection. The rates of prior exposure to or vaccination for hepatitis A and hepatitis B were 30.1% and 15.0%, respectively. Table 4 shows the results regarding vaccinations for hepatitis A and hepatitis B received by patients attending a Healthy Liver Group session. One hundred one of the 113 patients attending a Healthy Liver Group session (89.4%) were appropriate for vaccination for hepatitis A, hepatitis B, or both. The additional 12 patients (10.6%) who attended a Healthy Liver Group session tested positive for prior exposure to both hepatitis A and hepatitis B and therefore were not appropriate for vaccination. Of patients who received a recommendation from the RN for vaccination, 94.1% (95/101) started a vaccination series. Of those who started a vaccination series that required a 1-month booster shot, 85.9% (73/85) returned for their 1-month booster. Sixty percent of patients who started a vaccination series (57/95) returned for their 6-month booster. Table 5 Outcomes for hepatitis C-positive patients Hepatitis C status
n (%) a
No prior knowledge of hepatitis C-positive status Referred to hepatitis intake clinicb Attended hepatitis intake appointmentb a b
9 (64.3) 9 (100) 7 (77.8)
Total number of hepatitis C-positive patients identified, 14. Of 9 patients not yet receiving treatment in the hepatitis C clinic.
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Table 5 shows the outcomes for the patients who were identified as positive for hepatitis C. Of the 14 patients who were confirmed as positive for hepatitis C, 9 (64.3%) had no prior knowledge of their hepatitis C-positive status. The remaining 5 patients were already receiving treatment in the hepatitis clinic. All of the 9 patients with no prior knowledge of their hepatitis C-positive status (including the 1 patient also diagnosed with chronic hepatitis B) were referred for a hepatitis clinic group intake appointment. Seven of the 9 patients (77.8%) attended their intake appointment.
4. Discussion The results of this project confirm that patients entering SUD treatment have a high risk for hepatitis C infection and a low rate of immunity to hepatitis A and hepatitis B, highlighting the importance of establishing a mechanism for addressing the issue of hepatitis infections among patients who present for SUD treatment. The project was successful in meeting its goal of improving testing rates for hepatitis C infection from 72.1% to 98.3% and in implementing routine testing for hepatitis B infection and prior exposure to hepatitis A and hepatitis B. Rates of testing for hepatitis A and hepatitis B improved from less than 20% to 98.3%. The project was also highly successful in establishing a standardized mechanism for communicating these test results to patients and referring patients with hepatitis B and hepatitis C to the hepatitis clinic. Referrals of newly diagnosed chronic hepatitis C patients to the hepatitis clinic improved from 50% to 100%. Finally, the project was successful in establishing an educational program and a clinic for administration of hepatitis A and hepatitis B immunizations within the SUD clinic. The rate of patient attendance at the Healthy Liver Group session and the vaccination rate (94.1% of those eligible) suggest that the established hepatitis education, prevention, and referral services are valued and accepted by patients. In addition, the high attendance rates for follow-up booster shots (85.9% at 1 month and 60.0% at 6 months) provide an excellent opportunity to follow up on patients who are positive for hepatitis C to promote further behavior change. The RN asks them if they attended their hepatitis clinic intake appointment, supports their continued involvement with the clinic if they did attend, or offers to reschedule them if they did not attend. The RN is also able to reinforce efforts to change substance use behaviors by stressing the positive impact of abstinence on the health of their liver. 4.1. Barriers to implementing a healthy liver program and lessons learned These results confirm that a program to provide education, screening, and referral for hepatitis infections
can be successfully integrated into an SUD clinic. However, the barriers to establishing such a program are great and require a great deal of time, effort, and commitment to overcome. Probably the most significant barrier that must be addressed is the limitation on necessary staff time and financial resources to add a new service to an established program. It is essential that the clinic leadership views the establishment of such a program as a priority so that staff will be allowed to have time designated to the development and implementation of the program and will be provided with necessary resources. During program development, streamlining of processes for running the program will reduce the amount of additional staff time required. For example, the Minneapolis stakeholder group developed the following tools to reduce staff time: (1) a treatment algorithm was created to assist nursing staff in interpreting laboratory results and recommending the appropriate vaccination series; (2) standing orders were created and approved to allow nursing staff to administer vaccinations without requesting a physician’s order for each patient; and (3) a treatment note template was created so that nursing staff could document patient visits with a few mouse clicks rather than compose an entire note for each patient. A second significant barrier is the resistance of staff to adding yet another responsibility to the clinic. This may involve both a resistance to an additional responsibility in general and a belief that providing services to address hepatitis infections is outside the scope of care traditionally provided by SUD clinics. Regarding the first issue, it is important to establish buy-in from most staff so that they can feel a sense of ownership regarding the new program. The Minneapolis group addressed this issue by recruiting representatives for the stakeholder group from multiple levels of clinic staff, including leadership, administration, psychiatry, nursing, and support. Clinic staff who were not members of the stakeholder group were kept informed regarding the group’s plans through in-services presented by stakeholder group members, announcements at staff meetings, and e-mails. Once a reasonably final plan for the program was selected, it was presented to the clinic staff and an opportunity was given for staff to comment on the plan and to raise concerns about how the program would function or how it would impact their work responsibilities. Revisions were made to the final program plan to take into account these comments and concerns. The second issue, that services regarding hepatitis infection are not part of an SUD clinic’s primary mission, was dealt with primarily through staff education. Information regarding the potential for improving SUD treatment retention and outcomes by providing medical services and referrals to patients was used to help convince clinicians of the utility of screening and testing for viral infections. For example, Rifai, Moles, Lehman, and Van der Linden (2006) recently showed that patients who were screened and tested positive for hepatitis C in an SUD clinic were more likely to complete a 28-day SUD program and were more likely to be abstinent at
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the 6-month follow-up as compared with those who tested negative for the virus. A third major barrier is the lack of established lines of communication between clinics that traditionally have not had strong collaborations, in this case between the SUD clinic and the hepatitis clinic. Again, it is important to invite participants for the stakeholder group from other clinics that will need to be involved in the program to ensure its success. In addition to creating a stakeholder group that was composed of both SUD and hepatitis clinic staff, the Minneapolis stakeholder group also focused on developing plans to streamline communication between the two clinics. Examples of specific procedures that were developed include the following: (1) establishing formal lines of communication so that staff from each clinic knew who to contact with day-to-day questions about the functioning of the Healthy Liver Program or to follow up on patients from the Healthy Liver Program who had been referred to the hepatitis clinic; (2) allowing the RN running the Healthy Liver Program to schedule patients directly into the hepatitis clinic; and (3) soliciting the help of hepatitis clinic staff in designing the Healthy Liver Group note template so that the note would contain the information that would be most helpful for them when they received a referral. These coordination efforts also created a situation in which SUD treatment staff became more aware and supportive of patients’ attendance and involvement with hepatitis C treatment and in which hepatitis C treatment staff became more aware and supportive of patients’ attendance and involvement with SUD treatment. In addition to learning about these barriers and strategies to overcome them, the stakeholder group learned the value of developing a system for evaluating the impact of the new program. A baseline chart audit allowed the stakeholder group to determine exactly what was occurring in the clinic. Clinic policy stated that all patients would be tested for hepatitis C at intake and that those who tested positive would be referred to the hepatitis clinic. However, the baseline chart audit revealed that this was not occurring in a consistent fashion. The baseline chart audit allowed the stakeholder group to set specific goals for improvement of services that could then be monitored with follow-up chart audits. The follow-up chart audits were completed at several points over the course of the first year of operation of the Healthy Liver Program and were used to identify problems and continually improve the functioning of the program. Once again, the follow-up chart audits revealed that what had been laid out as clinic policy was not necessarily actually occurring. Problems such as difficulties with getting patients routinely scheduled into the Healthy Liver Program and those with getting laboratory tests routinely drawn in a timely fashion were revealed, and changes in processes were implemented to address these issues. The challenge, again, is finding the staff time to complete such evaluations. Whereas the Minneapolis group was fortunate to have a research assistant who could complete the chart audits, a small sample of charts can be selected and divided among
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members of the stakeholder group so that each participant may only have to complete a few chart reviews on a quarterly basis to collect this valuable information.
5. Conclusions The Healthy Liver Program provides a model for how services for hepatitis infections can be integrated into an existing SUD clinic and how the impact of these services can be assessed and monitored over time. The Healthy Liver Program can also be viewed as a more general model for how other types of medical health services could be integrated into an SUD clinic. Examples might be a health promotion program or an infectious disease program that would focus on HIV/AIDS and hepatitis. The Healthy Liver Program model could easily be expanded to promote more general health among SUD patients in a number of ways. Additional screening laboratory tests could be drawn to assess patients’ general health status. Education components on the benefits of diet and exercise could be added. It also would be fairly straightforward to incorporate HIV screening, education, counseling, and treatment referral into the model. Such a program would address the new Centers for Disease Control and Prevention recommendation that all health care providers, including those working in substance abuse treatment clinics, include HIV testing as a routine part of their patients’ health care to promote earlier access to treatment and reduce the risk to partners (http://www.cdc.gov/hiv/topics/testing/healthcare/index.htm). Future plans for the Liver Health Initiative involve disseminating the procedures and tools developed for the pilot Healthy Liver Program to additional VHA SUD clinics through 2-day training workshops with follow-up contacts for support and problem solving. Additional clinics will likely have to modify the specifics of the Healthy Liver Program for it to fit into their own existing structures and culture. Through this process, the Liver Health Initiative hopes to develop a menu of possible models for integrating hepatitis screening, prevention, and referral services into SUD clinics as well as guidance for choosing the most appropriate model based on the organizational characteristics of individual clinics. In addition, the Liver Health Initiative sponsors (SUD QUERI and HCRC) plan to determine how best to expand the Liver Health Initiative into an Infectious Disease Initiative and to include HIV/ AIDS services in the program. We hope that our experience would help guide others who wish to provide hepatitis services in their SUD clinics. The establishment of a healthy liver program as that developed for this project may be more difficult for SUD treatment clinics that are outside of the VHA or, more specifically, outside of a major medical center, mainly because stand-alone community clinics would face the additional challenge of developing relationships with other health care providers. During the planning phase for the
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implementation of a healthy liver program, stand-alone clinics would need to identify other health care providers that they would like to partner with, solicit the participation of those partners, and include them in the planning process so that smooth procedures for communication, referrals, and care collaboration can be specified before the implementation of the program. Although the ideal situation would be for a community clinic to implement all elements of the program described in this report, it may not be feasible for all clinics. However, at a minimum, it is vital that SUD treatment clinics raise awareness among their treatment staff and patients about the importance of diagnosing and preventing viral hepatitis infections. A community-based clinic could certainly incorporate an educational component that would raise awareness among its patients regarding hepatitis infections, the need for testing, and the value of vaccinations. Community clinics could also develop a list of resources that patients could access to further pursue screening, vaccinations, or treatment services. Acknowledgments This work was supported by Grant No. SUB04-393 from the Health Services Research Division of the U.S. Department of Veterans Affairs. We thank the VHA HCRC Program and the QUERI Program for supporting the Liver Health Initiative. References Abraham, H. D., Degli-Esposti, S., & Marino, L. (1999). Seroprevalence of hepatitis C in a sample of middle class substance abusers. Journal of Addictive Diseases, 18, 77 – 87. Almasio, P. L., & Amoroso, P. (2003). HAV infection in chronic liver disease: A rationale for vaccination. Vaccine, 21, 2238 – 2241. Astone, J., Strauss, S. M., Vassilev, Z. P., & Des Jarlais, D. C. (2003). Provision of hepatitis C education in a nationwide sample of drug treatment programs. Journal of Drug Education, 33, 107 – 117. Centers for Disease Control and Prevention. (1998). Recommendations for prevention and control of hepatitis C virus (HCV) infection and HCVrelated chronic liver disease. Morbidity and Mortality Weekly Report, 47, 1 – 39. Centers for Disease Control and Prevention. (2002). Hepatitis A and hepatitis B. Epidemiology and prevention of vaccine-preventable diseases, (7th ed.) 156 – 186. Chitwood, D. D., McBride, D. C., French, M. T., & Comerford, M. (1999). Health care need and utilization: A preliminary comparison of injection drug users, other illicit drug users, and nonusers. Substance Use and Misuse, 34, 727 – 746. Contoreggi, C., Rexroad, V. E., & Lange, W. R. (1998). Current management of infectious complications in the injecting drug user. Journal of Substance Abuse Treatment, 15, 95 – 106. Dhopesh, V. P., & Taylor, K. R. (2000). Survey of hepatitis B and C in addiction treatment unit. American Journal of Drug and Alcohol Abuse, 26, 703 – 707. El-Serag, H. B., Kunik, M., Richardson, P., & Rabeneck, L. (2002). Psychiatric disorders among veterans with hepatitis C infection. Gastroenterology, 123, 476 – 482.
Fingerhood, M. I., Jasinski, D. R., & Sullivan, J. T. (1993). Prevalence of hepatitis C in a chemically dependent population. Archives of Internal Medicine, 153, 2025 – 2030. Heintges, T., & Wands, J. R. (1997). Hepatitis C virus: Epidemiology and transmission. Hepatology, 26, 521 – 526. Keeffe, E. G. (1995). Is hepatitis A more severe in patients with chronic hepatitis B and other chronic liver diseases? American Journal of Gastroenterology, 90, 201 – 205. Keeffe, E. B. (1999). Vaccination against hepatitis A and B in chronic liver disease. Viral Hepatitis Review, 5, 77 – 88. Kelen, G. D., Green, G. B., Purcell, R. H., Chan, D. W., Qaqish, B. F., Sivertson, K. T., et al. (1992). Hepatitis B and hepatitis C in emergency department patients. New England Journal of Medicine, 326, 1399 – 1404. Koff, R. S. (2001). Risks associated with hepatitis A and hepatitis B in patients with hepatitis C. Journal of Clinical Gastroenterology, 33, 20 – 26. Mendenhall, C. L., Moritz, T., Rouster, S., Rossele, G., Polito, A., Quan, S., et al. (1993). Epidemiology of hepatitis C among veterans with alcoholic liver disease. The VA Cooperative Study Group 275. American Journal of Gastroenterology, 88, 1022 – 1026. Nguyen, H. A., Miller, A. I., Dieperink, E., Willenbring, M. L., Tetrick, L. L., Durfee, J. M., et al. (2002). Spectrum of disease in U.S. veteran patients with hepatitis C. American Journal of Gastroenterology, 97, 1813 – 1820. Rifai, M. A., Moles, J. K., Lehman, L. P., & Van der Linden, B. J. (2006). Hepatitis C screening and treatment outcomes in patients with substance use/dependence disorders. Psychosomatics, 47, 112 – 121. Reiss, G., & Keeffe, E. B. (2004). Review article: Hepatitis vaccination in patients with chronic liver disease. Alimentary Pharmacology and Therapeutics, 19, 715 – 727. Rosman, A. S., Waraich, A., Galvin, K., Casiano, J., Paronetto, F., & Lieber, C. S. (1996). Alcoholism associated with hepatitis C but not hepatitis B in an urban population. American Journal of Gastroenterology, 91, 498 – 505. Shim, M., Khaykis, I., Park, J., & Bini, E. J. (2005). Susceptibility to hepatitis A in patients with chronic liver disease due to hepatitis C virus infection: Missed opportunities for vaccination. Hepatology, 42, 688 – 695. Simonetti, R. G., Camma, C., & Fiorello, F. (1992). Hepatitis C virus infection as a risk factor for hepatocellular carcinoma in patients with cirrhosis: A case–control study. Annals of Internal Medicine, 116, 97 – 102. Sorensen, J. L., Masson, C. L., & Perlman, D. C. (2002). HIV/Hepatitis prevention in drug abuse treatment programs: Guidance from research. Science and Practice Perspectives, 4 – 12. Strauss, S. M., Astone, J. M., Hagan, H., & Des Jarlais, D. C. (2004). The content and comprehensiveness of hepatitis C education in methadone maintenance and drug-free treatment units. Journal of Urban Health, 18, 38 – 47. Strauss, S. M., Falkin, G. P., Vassilev, Z., Des Jarlais, D. C., & Astone, J. (2002). A nationwide survey of hepatitis C services provided by drug treatment programs. Journal of Substance Abuse Treatment, 22, 55 – 62. Tortu, S., Neaigus, A., McMahon, J., & Hagen, D. (2001). Hepatitis C among noninjecting drug users: A report. Substance Use and Misuse, 36, 523 – 534. Vento, S., Garofano, T., Renzini, C., Cainelli, F., Casali, F., Ghironzi, G., et al. (1998). Fulminant hepatitis associated with hepatitis A superinfection in patients with chronic hepatitis C. New England Journal of Medicine, 338, 286 – 290. Yu, M. D., Tong, M. J., & Corsaget, P. (1990). Prevalence of hepatitis B and C viral markers in Black and White patients with hepatocellular carcinoma in the United States. Journal of the National Cancer Institute, 82, 1038 – 1041.
Regular article
Integrating hepatitis prevention services into a substance use disorder clinic Hildi Hagedorn, (Ph.D.)a,b,4, Eric Dieperink, (M.D.)a,b,c, Debra Dingmann, (R.N.)a, Janet Durfee, (N.P.)a,b,c, Samuel B. Ho, (M.D.)a,b,c, Carl Isenhart, (Psy.D.)a,b, Nancy Rettmann, (M.S.)a, Mark Willenbring, (M.D.)d a
Minneapolis Veterans Affairs Medical Center, Minneapolis, MN 55417, USA b University of Minnesota, Minneapolis, MN 55455, USA c Veterans Affairs Hepatitis C Resource Center, Minneapolis, MN 55417, USA d National Institute on Alcohol Abuse and Alcoholism, Rockville, MD 20892, USA Received 24 May 2006; received in revised form 3 October 2006; accepted 24 October 2006
Abstract The Healthy Liver Program, established at the Minneapolis Veterans Affairs Medical Center Substance Use Disorder Clinic, provides screening for exposure to hepatitis infections, a group education class, and an individual nursing appointment to review screening results, give vaccinations for hepatitis A and hepatitis B, and make referrals to the hepatitis clinic as appropriate. A patient chart audit was completed 11 months after the establishment of the Healthy Liver Program. The attendance rate for the educational group and individual feedback sessions was 66.9%, with 94.1% of attendees accepting recommended hepatitis A and/or hepatitis B vaccinations. All patients with chronic hepatitis C who attended the Healthy Liver Program received a referral for evaluation in the hepatitis clinic, as compared with only 50% of patients with chronic hepatitis C who were identified before the establishment of the program. The importance of providing comprehensive educational sessions and recommendations for how patients with substance use disorders can access hepatitis screening, vaccination, and treatment resources are stressed. D 2007 Elsevier Inc. All rights reserved. Keywords: Substance abuse treatment programs; Hepatitis C infections; Hepatitis services; Implementation; Vaccinations
1. Introduction Nearly 4 million people in the United States are infected with hepatitis C. Although the numbers of new cases are declining, there are still 30,000 new cases of hepatitis C diagnosed each year. Most hepatitis C infections become chronic, and, despite their declining incidence, the burden from these infections is expected to increase markedly as those who were infected 20–30 years ago present with
The opinions expressed in this article are those of the authors and do not represent those of the U.S. Department of Veterans Affairs or the VHA. 4 Corresponding author. Minneapolis Veterans Affairs Medical Center, One Veterans Drive (116A9), Minneapolis, MN 55417, USA. Tel.: +1 612 467 3875; fax: +1 612 467 5265. E-mail address: [email protected] (H. Hagedorn). 0740-5472/06/$ – see front matter D 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.jsat.2006.10.004
advanced liver disease (Centers for Disease Control and Prevention, 2002). Most people infected with chronic hepatitis C may not be aware that they are infected because they are not clinically ill (Heintges & Wands, 1997). This results in delayed identification that increases the risk for transmission to others and delays treatment until serious complications arise (Simonetti, Camma, & Fiorello, 1992; Yu, Tong, & Corsaget, 1990). Injection drug use currently accounts for up to 60% of hepatitis C transmissions in the United States (Centers for Disease Control and Prevention, 1998). Although the rate of infection in the general population in the United States is lower than 2%, individuals who participate in injection drug use are at a particularly high risk, with rates of infection reported to be between 50% and 90% (Abraham, Degli-Esposti, & Marino, 1999; Dhopesh & Taylor, 2000;
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Fingerhood, Jasinski, & Sullivan, 1993; Kelen et al., 1992; Sorensen, Masson, & Perlman, 2002). Although intravenous drug use appears to be the major risk factor associated with substance use disorders (SUDs), rates of infection among drug- and alcohol-dependent individuals reporting no history of intravenous drug use also have been shown to be higher than those among the general population (Abraham et al., 1999; Dhopesh & Taylor, 2000; Rosman et al., 1996; Tortu, Neaigus, McMahon, & Hagen, 2001). Dhopesh and Taylor reported a rate of hepatitis C infection of 24% among individuals presenting for SUD treatment who reported no history of intravenous drug use. Abraham et al. reported a hepatitis C infection rate of 12.5% among a middle class sample of individuals presenting for SUD treatment who reported no history of intravenous drug use. Because of common risk factors, individuals at high risk for hepatitis C are also at higher risk for exposure to hepatitis A and hepatitis B. In addition, several systematic reviews of the literature have demonstrated that patients already compromised by chronic liver disease, as a result of either hepatitis C or alcoholic liver disease, are at a much higher risk for poor outcomes, including fatality if coinfected with acute hepatitis A or hepatitis B (Almasio & Amoroso, 2003; Keeffe, 1995, 1999; Koff, 2001; Reiss & Keeffe, 2004; Vento et al., 1998). Therefore, it is imperative that these patients receive vaccination against these infections. However, Shim, Khaykis, Park, and Bini (2005) reported that, despite published recommendations to vaccinate chronic hepatitis C-positive patients against hepatitis A, hepatitis A testing and vaccination rates were low in clinical practice, representing missed opportunities to provide a potentially life-saving intervention. The Department of Health and Human Services has set goals for the reduction of viral hepatitis in highrisk groups as part of its Healthy People 2010 goals (http://www.healthypeople.gov/document/html/volume1/ 14immunization.htm). Included in these goals are the following recommendations: 1.
2.
3.
To identify hepatitis C-infected individuals so they can be counseled to prevent further transmissions, vaccinated against hepatitis A and hepatitis B to prevent additional liver damage, evaluated for chronic liver disease and possible antiviral therapy, and counseled to avoid potential hepatotoxins, such as alcohol, that may increase the severity of hepatitis C-related liver disease. To immunize adults presenting to settings with high rates of infection, including SUD treatment clinics, against hepatitis B. To immunize high-risk groups, including illicit drug users, against hepatitis A.
Substance use disorder treatment clinics represent an ideal venue to target screening, prevention, and treatment referral services for hepatitis infections. In fact, because
individuals with SUDs are often medically underserved (Chitwood, McBride, French, & Comerford, 1999; Contoreggi, Rexroad, & Lange, 1998), SUD treatment clinics may represent a unique opportunity to provide these individuals with services related to infectious diseases. Currently, SUD treatment clinics are not taking full advantage of this opportunity. According to nationwide surveys of SUD treatment clinics, although most clinics provide education to at least some of their patients, important information and services are commonly missed (Astone, Strauss, Vassilev, & Des Jarlais, 2003; Strauss, Astone, Hagan, & Des Jarlais, 2004; Strauss, Falkin, Vassilev, Des Jarlais, & Astone, 2002). For example, only approximately half of clinics educate patients about the importance of hepatitis A and hepatitis B vaccinations for patients at high risk and, although most units educate patients about the importance of being tested for hepatitis C, offering testing or actively encouraging patients to be tested is less common. Only 7% of units tested all clients, and 22% did not test any client. The Veterans Health Administration (VHA) is an ideal medical system through which to begin to address this gap in services. In Fiscal Year 2004, more than 200,000 VHA outpatients were diagnosed with an SUD. Veterans with SUDs have been shown to be the patient group within the VHA with the highest prevalence of hepatitis C and the highest risk for alcoholic liver disease (El-Serag, Kunik, Richardson, & Rabeneck, 2002; Nguyen et al., 2002). Mendenhall et al. (1993) reported a hepatitis C infection rate of 18.4% among patients with chronic alcoholism within the VHA system. Finally, many VHA SUD clinics exist within medical centers that have access to laboratory, pharmacy, and gastroenterology services. The Liver Health Initiative is a program jointly sponsored by the VHA SUD Quality Enhancement Research Initiative (SUD QUERI) and the Minneapolis VHA Hepatitis C Resource Center (HCRC). The broad goal of the Liver Health Initiative is to improve access to services for the prevention, identification, and treatment of viral hepatitis infections among patients seeking treatment at VHA SUD clinics. The specific goals of the Liver Health Initiative are to (1) implement testing for hepatitis B and hepatitis C infections and for prior exposure to hepatitis A and hepatitis B, (2) provide comprehensive structured patient education on liver health, (3) provide access to hepatitis A and hepatitis B vaccinations, and (4) increase rates of successful referrals of hepatitis B- and hepatitis C-positive patients to hepatitis treatment providers for evaluation, all within the context of SUD treatment clinics. As an initial step toward these goals, a pilot project was conducted at the Minneapolis Veterans Affairs (VA) Medical Center to establish a healthy liver program that would provide the services described above. In July 2004, a stakeholder group that included clinical and administrative staff from both the SUD clinic and the hepatitis clinic as well as consultants from the SUD QUERI and the HCRC
H. Hagedorn et al. / Journal of Substance Abuse Treatment 32 (2007) 391 – 398
was convened. The goals of the stakeholder group were to conduct a baseline assessment of services currently offered in the clinic, identify specific service improvement goals, and develop policies, procedures, and tools for meeting those improvement goals. A small research grant provided support for the initial 6-month planning phase of the project. The research funds were used to support a research assistant who was responsible for conducting chart reviews and developing educational materials for patients and providers based on instructions from the stakeholder group. The research funds also provided for the supplies, such as color printing and copying, required to create educational materials. Research funds were not requested to cover clinical expenses because the goal of this project was to create a program that would be sustainable beyond initial research funding. All clinical services for the program (e.g., laboratory testing, vaccinations, and nursing staff) were obtained through standard medical center operating procedures.
Diagnostics, Indianapolis, IN, USA), hepatitis B (hepatitis B surface antigen, VITROS ECI Chemiluminescence Assay, Ortho-Clinical Diagnostics), immunity to hepatitis A (hepatitis A antibody, HAV Total Assay, Bio-Rad laboratories, Hercules, CA, USA), and immunity to hepatitis B (hepatitis B surface antibody, VITROS ECI Chemiluminescence Assay, Ortho-Clinical Diagnostics). The baseline testing information was used to determine the percentage of those tested who were positive for chronic hepatitis B and hepatitis C and prior exposure to hepatitis A and hepatitis B. The percentage of those who tested positive for chronic hepatitis B and hepatitis C who received a referral to the hepatitis clinic for evaluation was also determined. Based on the results of the baseline assessment, which are presented in detail below, the stakeholder group identified five specific practice improvement goals: 1. 2.
2. Methods
3.
2.1. The Minneapolis VA Medical Center SUD Clinic The Minneapolis VA Medical Center SUD Clinic serves approximately 2,300 unique patients per year. It offers several treatment tracks, including the following: (1) the Intensive Outpatient Program, which meets 5 days per week (20 hours per week) for 3–5 weeks; (2) the Life Skills Program, which meets for 3 days per week (12 hours per week) for 8 weeks; and (3) the Recovery Training Program, which includes two 1.5-hour sessions per week and is open-ended. All these tracks also include individual case management and/or addiction psychiatry appointments. After the completion of their intensive treatment program, patients are expected to complete at least 12 weeks of continuing care, including a weekly group session, case management, and addiction psychiatry clinic appointments. Patients who are unable to maintain abstinence despite intensive treatment interventions are not discharged but are followed up in care management and addiction psychiatry clinics using a harm reduction approach. 2.2. The baseline assessment of services The baseline assessment of services included a review of current clinic policies related to the identification, prevention, and treatment of hepatitis infections. The baseline assessment also included a chart audit of 104 consecutive intakes into the SUD treatment clinic. The purpose of conducting the chart review was to determine the percentage of patients being tested for hepatitis C (hepatitis C antibody, VITROS ECI Chemiluminescence Assay, Ortho-Clinical Diagnostics, Raritan, NJ, USA, and hepatitis C confirmatory, Cobas Amplicor Hepatitis C Virus Test, version 2.0, Roche
393
4. 5.
Improve the percentage of patients who are tested for hepatitis C; Implement routine testing for hepatitis B infection and prior exposure to hepatitis A and hepatitis B; Develop standardized procedures to ensure feedback of test results to patients and referral to the hepatitis clinic for evaluation of hepatitis B- and hepatitis Cpositive patients; Develop a liver health education program available to patients entering SUD treatment; and Develop procedures for providing hepatitis A and hepatitis B vaccinations within the SUD clinic.
2.3. The Healthy Liver Program From June through December 2004, the stakeholder group discussed and debated different intervention models, identified potential barriers to implementation, enlisted staff from specific areas (e.g., pharmacy, administration, and clerical) to identify solutions to barriers, developed patient and provider educational materials, and provided educational in-services to promote the intervention among the SUD clinic staff. The Healthy Liver Program was officially launched in January 2005. The first component of the Healthy Liver Program is that testing for hepatitis B and hepatitis C infections and prior exposure to hepatitis A and hepatitis B was added to the routine blood work conducted on patients attending an intake appointment in the SUD clinic. The second component is that patients completing an intake into the SUD clinic are scheduled to attend a Healthy Liver Group session approximately 3–4 weeks after their intake appointment. The Healthy Liver Group is a 60-minute intervention staffed by an RN who is a member of the SUD clinic staff. The intervention consists of a 30-minute group educational session followed by individualized meetings with the RN to review laboratory results. Educational sessions and individual RN appointments were all held in the SUD clinic to facilitate patient attendance. During the educational
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Table 1 Medicare reimbursement rates for laboratory tests provided as part of the Healthy Liver Program Laboratory test Hepatitis Hepatitis Hepatitis Hepatitis Hepatitis
C antibodyb C confirmatoryc B surface antigend B surface antibodye A antibodyf
Medicare 2006 national limitation amounta $19.94 $21.64 $14.43 $15.01 $17.31
a
Rates available at the Centers for Medicare and Medicaid Services Web site, accessed October 2, 2006 (http://www.cms.hhs.gov/ClinicalLab FeeSched/). b Tests for the presence of antibodies to hepatitis C virus; a positive result indicates exposure to hepatitis C virus. c A positive result confirms chronic infection with hepatitis C virus. d A positive result confirms chronic infection with hepatitis B virus. e Tests for the presence of antibodies to hepatitis B virus; a positive result indicates prior exposure to and immunity to hepatitis B virus. f Tests for the presence of antibodies to hepatitis A virus; a positive result indicates prior exposure to and immunity to hepatitis A virus.
session, the patients watch a 15-minute video and then have 15 minutes for questions and answers. See Box 1 for a list of topics covered in the educational session. Box 1: Components of the Healthy Liver Group Educational Session ! What are hepatitis A, hepatitis B, and hepatitis C infections? ! How are hepatitis infections transmitted? ! How can I protect myself from hepatitis infections? ! How does alcohol use affect the health of my liver? ! If I have hepatitis C, what can I do to maintain my health and to protect others from infections?
Liver Group session are sent a letter stating that they missed their Healthy Liver Group appointment and providing them with a phone number to call if they would like to reschedule. This is a standard procedure for all missed appointments in the Minneapolis VA Medical Center SUD Clinic. 2.4. Time and costs associated with the Healthy Liver Program For an SUD clinic of this size, the RN responsible for the Healthy Liver Program spends approximately 4 hours per week on tasks related to the program. These include running two 1-hour group sessions per week, preparing for the group sessions, and completing required documentation. The LPN, who occasionally assists with the group sessions, spends no more than 1 hour per week on the program assisting with vaccinations for 30 minutes for each group. All patients receive serological testing, which includes the hepatitis C antibody, hepatitis B surface antigen, hepatitis B surface antibody, and hepatitis A antibody tests. Patients testing positive for hepatitis C antibody undergo the hepatitis C confirmatory test. Table 1 shows the Medicare reimbursement rates for these tests. Table 2 shows the Centers for Disease Control and Prevention purchasing prices and the private sector purchasing prices for the various vaccinations used in the Healthy Liver Program. A follow-up chart audit of the 171 patients scheduled into a Healthy Liver Group session between January 1 and November 30, 2005, was completed to assess the impact of the Healthy Liver Program. 3. Results 3.1. The patient population
During the individualized meeting with the RN, the RN reviews each patient’s laboratory work, including hepatitis B and hepatitis C status, hepatitis A and hepatitis B immunity status, liver function test results, and any abnormal findings from additional routine laboratory tests. The RN also recommends vaccinations for hepatitis A and hepatitis B depending on a patient’s immunity status. Patients who are interested in receiving vaccinations are given their first vaccine and scheduled to return to the Healthy Liver Group at appropriate intervals to receive their booster shots. Patients returning for boosters are given their shots by the RN while the new patients are watching the educational video. Finally, if patients are positive for hepatitis B or hepatitis C, the RN has the authority to directly schedule them into the hepatitis clinic group intake so that the patients can leave the Healthy Liver Group with an appointment card for an intake appointment. By using a group format, one RN (assisted by an LPN for larger groups) can provide education, feedback, vaccinations, and referrals for up to 12 patients during the 1-hour group session. Patients who do not attend their scheduled Healthy
Two hundred seventy-five patient charts (104 at baseline and 171 during follow-up) were reviewed to assess the impact of the Healthy Liver Program. To provide an overview of the demographics of the patient population at the Minneapolis VA Medical Center SUD Clinic, we also reviewed a random sample of 25% of the 275 patient charts (n = 69) for demographic information. Typical of VHA patient populations, this sample was predominantly male (95.7%) and predominantly Caucasian (58.0%) and African American (36.2%). The patients’ mean age was 49.2 years, Table 2 Costs of vaccinations provided as part of the Healthy Liver Program Vaccine (brand name)
CDC cost per dosea
Private sector cost per dosea
Hepatitis A (HavrixR) Hepatitis B (ENGERIX-BR) Hepatitis A–Hepatitis B (TwinrixR)
$19.33 $25.25 $38.57
$54.38 $50.35 $78.16
Note. CDC indicates Centers for Disease Control and Prevention. a Rates available on the CDC Web site, accessed September 7, 2006 (http://www.cdc.gov/nip/vfc/cdc_vac_price_list.htm).
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and their mean number of years in school was 13.2 years. Most patients were not working as a result of unemployment, disability, or retirement (62.3%). Most patients were either divorced or never married (72.4%). The most frequent diagnosis at intake was alcohol dependence (82.6%); the second most frequent diagnosis was cocaine dependence (27.5%). Other diagnoses included marijuana (7.2%), opioid (5.8%), and methamphetamine (4.3%) dependence. These percentages add to more than 100% because 30.4% of the patients received more than one diagnosis. 3.2. The baseline assessment of services At baseline, clinic policies indicated that all new patients were to be tested for hepatitis C infection. However, there was no policy in place to ensure that patients received their testing results or, if they were positive for hepatitis C, that they received a referral to the hepatitis clinic for evaluation. Education regarding hepatitis infections was a standard part of the Intensive Outpatient Program curriculum. However, patients who entered less intensive programming were not targeted for education regarding hepatitis infections. No procedure to routinely test for hepatitis B infection or prior exposure to hepatitis A and hepatitis B was in place. There was also no procedure for providing hepatitis A and hepatitis B vaccinations in the SUD clinic. As seen in Table 3, the baseline chart audit indicated that 72.1% (75/104) of the patients were tested for hepatitis C at intake. Therefore, although clinic policy stated that all patients should be tested, there was significant room for improvement. In addition, the chart audit indicated a high risk for established infection with hepatitis C (22.7% positive for hepatitis C antibody and 13.3% positive for hepatitis C confirmatory). These results confirm that this is a high-risk population with the potential to benefit from targeted screening, prevention, and referral services. Finally, of the six patients who screened positive for hepatitis C and did not have an indication in their chart that they had been previously diagnosed, only three (50%) had documentation in their chart that they received feedback on their test results and a referral to the hepatitis clinic. As expected, baseline testing rates for chronic hepatitis B and prior exposure to Table 3 Baseline and intervention hepatitis testing rates and results Laboratory test
Baseline
Patients tested [n (%)] Hepatitis C antibody 75/104 (72.1) Hepatitis B surface antigen 20/104 (19.2) Hepatitis A antibody 13/104 (12.5) Hepatitis B surface antibody 14/104 (13.5) Patients who tested positive [n (%)] Hepatitis C antibody 17/75 (22.7) Hepatitis C confirmatory 10/75 (13.3) Hepatitis B surface antigen 0 (0) Hepatitis A antibody 7/13 (53.8) Hepatitis B surface antibody 4/14 (28.6)
Intervention 113/115 113/115 113/115 113/115 19/113 14/113 1/113 34/113 17/113
(98.3) (98.3) (98.3) (98.3) (16.8) (12.4) (0.9) (30.1) (15.0)
395
Table 4 Acceptance of vaccinations for hepatitis A and hepatitis B Vaccination status
n (%)
Appropriate for vaccination Accepted vaccination as recommended by RN Declined recommended vaccination Returned for 1-month booster Returned for 6-month booster
101/113 (89.4) 95/101 (94.1) 6/101 (5.9) 73/85 (85.9) 57/95 (60.0)
hepatitis A and hepatitis B were much lower. No cases of chronic hepatitis B were identified. The rates of prior exposure to or vaccination for hepatitis A and hepatitis B were 53.8% and 28.6%, respectively. 3.3. Follow-up results One hundred seventy-one patients were scheduled to attend a Healthy Liver Group session between January 1 and November 30, 2005. Of these 171 patients, 115 attended the group session, for an attendance rate of 66.9%. Table 3 shows the results of hepatitis testing for the 115 patients who attended a Healthy Liver Group session. One hundred thirteen of the 115 scheduled patients (98.3%) had their laboratory work completed before attending their scheduled group session. Nineteen (16.8%) of these patients were positive for hepatitis C antibody and 14 (12.4%) were positive for hepatitis C confirmatory, confirming the high rate of hepatitis C infection found in the baseline assessment. One patient (0.9%) was found to have chronic hepatitis B infection. The rates of prior exposure to or vaccination for hepatitis A and hepatitis B were 30.1% and 15.0%, respectively. Table 4 shows the results regarding vaccinations for hepatitis A and hepatitis B received by patients attending a Healthy Liver Group session. One hundred one of the 113 patients attending a Healthy Liver Group session (89.4%) were appropriate for vaccination for hepatitis A, hepatitis B, or both. The additional 12 patients (10.6%) who attended a Healthy Liver Group session tested positive for prior exposure to both hepatitis A and hepatitis B and therefore were not appropriate for vaccination. Of patients who received a recommendation from the RN for vaccination, 94.1% (95/101) started a vaccination series. Of those who started a vaccination series that required a 1-month booster shot, 85.9% (73/85) returned for their 1-month booster. Sixty percent of patients who started a vaccination series (57/95) returned for their 6-month booster. Table 5 Outcomes for hepatitis C-positive patients Hepatitis C status
n (%) a
No prior knowledge of hepatitis C-positive status Referred to hepatitis intake clinicb Attended hepatitis intake appointmentb a b
9 (64.3) 9 (100) 7 (77.8)
Total number of hepatitis C-positive patients identified, 14. Of 9 patients not yet receiving treatment in the hepatitis C clinic.
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Table 5 shows the outcomes for the patients who were identified as positive for hepatitis C. Of the 14 patients who were confirmed as positive for hepatitis C, 9 (64.3%) had no prior knowledge of their hepatitis C-positive status. The remaining 5 patients were already receiving treatment in the hepatitis clinic. All of the 9 patients with no prior knowledge of their hepatitis C-positive status (including the 1 patient also diagnosed with chronic hepatitis B) were referred for a hepatitis clinic group intake appointment. Seven of the 9 patients (77.8%) attended their intake appointment.
4. Discussion The results of this project confirm that patients entering SUD treatment have a high risk for hepatitis C infection and a low rate of immunity to hepatitis A and hepatitis B, highlighting the importance of establishing a mechanism for addressing the issue of hepatitis infections among patients who present for SUD treatment. The project was successful in meeting its goal of improving testing rates for hepatitis C infection from 72.1% to 98.3% and in implementing routine testing for hepatitis B infection and prior exposure to hepatitis A and hepatitis B. Rates of testing for hepatitis A and hepatitis B improved from less than 20% to 98.3%. The project was also highly successful in establishing a standardized mechanism for communicating these test results to patients and referring patients with hepatitis B and hepatitis C to the hepatitis clinic. Referrals of newly diagnosed chronic hepatitis C patients to the hepatitis clinic improved from 50% to 100%. Finally, the project was successful in establishing an educational program and a clinic for administration of hepatitis A and hepatitis B immunizations within the SUD clinic. The rate of patient attendance at the Healthy Liver Group session and the vaccination rate (94.1% of those eligible) suggest that the established hepatitis education, prevention, and referral services are valued and accepted by patients. In addition, the high attendance rates for follow-up booster shots (85.9% at 1 month and 60.0% at 6 months) provide an excellent opportunity to follow up on patients who are positive for hepatitis C to promote further behavior change. The RN asks them if they attended their hepatitis clinic intake appointment, supports their continued involvement with the clinic if they did attend, or offers to reschedule them if they did not attend. The RN is also able to reinforce efforts to change substance use behaviors by stressing the positive impact of abstinence on the health of their liver. 4.1. Barriers to implementing a healthy liver program and lessons learned These results confirm that a program to provide education, screening, and referral for hepatitis infections
can be successfully integrated into an SUD clinic. However, the barriers to establishing such a program are great and require a great deal of time, effort, and commitment to overcome. Probably the most significant barrier that must be addressed is the limitation on necessary staff time and financial resources to add a new service to an established program. It is essential that the clinic leadership views the establishment of such a program as a priority so that staff will be allowed to have time designated to the development and implementation of the program and will be provided with necessary resources. During program development, streamlining of processes for running the program will reduce the amount of additional staff time required. For example, the Minneapolis stakeholder group developed the following tools to reduce staff time: (1) a treatment algorithm was created to assist nursing staff in interpreting laboratory results and recommending the appropriate vaccination series; (2) standing orders were created and approved to allow nursing staff to administer vaccinations without requesting a physician’s order for each patient; and (3) a treatment note template was created so that nursing staff could document patient visits with a few mouse clicks rather than compose an entire note for each patient. A second significant barrier is the resistance of staff to adding yet another responsibility to the clinic. This may involve both a resistance to an additional responsibility in general and a belief that providing services to address hepatitis infections is outside the scope of care traditionally provided by SUD clinics. Regarding the first issue, it is important to establish buy-in from most staff so that they can feel a sense of ownership regarding the new program. The Minneapolis group addressed this issue by recruiting representatives for the stakeholder group from multiple levels of clinic staff, including leadership, administration, psychiatry, nursing, and support. Clinic staff who were not members of the stakeholder group were kept informed regarding the group’s plans through in-services presented by stakeholder group members, announcements at staff meetings, and e-mails. Once a reasonably final plan for the program was selected, it was presented to the clinic staff and an opportunity was given for staff to comment on the plan and to raise concerns about how the program would function or how it would impact their work responsibilities. Revisions were made to the final program plan to take into account these comments and concerns. The second issue, that services regarding hepatitis infection are not part of an SUD clinic’s primary mission, was dealt with primarily through staff education. Information regarding the potential for improving SUD treatment retention and outcomes by providing medical services and referrals to patients was used to help convince clinicians of the utility of screening and testing for viral infections. For example, Rifai, Moles, Lehman, and Van der Linden (2006) recently showed that patients who were screened and tested positive for hepatitis C in an SUD clinic were more likely to complete a 28-day SUD program and were more likely to be abstinent at
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the 6-month follow-up as compared with those who tested negative for the virus. A third major barrier is the lack of established lines of communication between clinics that traditionally have not had strong collaborations, in this case between the SUD clinic and the hepatitis clinic. Again, it is important to invite participants for the stakeholder group from other clinics that will need to be involved in the program to ensure its success. In addition to creating a stakeholder group that was composed of both SUD and hepatitis clinic staff, the Minneapolis stakeholder group also focused on developing plans to streamline communication between the two clinics. Examples of specific procedures that were developed include the following: (1) establishing formal lines of communication so that staff from each clinic knew who to contact with day-to-day questions about the functioning of the Healthy Liver Program or to follow up on patients from the Healthy Liver Program who had been referred to the hepatitis clinic; (2) allowing the RN running the Healthy Liver Program to schedule patients directly into the hepatitis clinic; and (3) soliciting the help of hepatitis clinic staff in designing the Healthy Liver Group note template so that the note would contain the information that would be most helpful for them when they received a referral. These coordination efforts also created a situation in which SUD treatment staff became more aware and supportive of patients’ attendance and involvement with hepatitis C treatment and in which hepatitis C treatment staff became more aware and supportive of patients’ attendance and involvement with SUD treatment. In addition to learning about these barriers and strategies to overcome them, the stakeholder group learned the value of developing a system for evaluating the impact of the new program. A baseline chart audit allowed the stakeholder group to determine exactly what was occurring in the clinic. Clinic policy stated that all patients would be tested for hepatitis C at intake and that those who tested positive would be referred to the hepatitis clinic. However, the baseline chart audit revealed that this was not occurring in a consistent fashion. The baseline chart audit allowed the stakeholder group to set specific goals for improvement of services that could then be monitored with follow-up chart audits. The follow-up chart audits were completed at several points over the course of the first year of operation of the Healthy Liver Program and were used to identify problems and continually improve the functioning of the program. Once again, the follow-up chart audits revealed that what had been laid out as clinic policy was not necessarily actually occurring. Problems such as difficulties with getting patients routinely scheduled into the Healthy Liver Program and those with getting laboratory tests routinely drawn in a timely fashion were revealed, and changes in processes were implemented to address these issues. The challenge, again, is finding the staff time to complete such evaluations. Whereas the Minneapolis group was fortunate to have a research assistant who could complete the chart audits, a small sample of charts can be selected and divided among
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members of the stakeholder group so that each participant may only have to complete a few chart reviews on a quarterly basis to collect this valuable information.
5. Conclusions The Healthy Liver Program provides a model for how services for hepatitis infections can be integrated into an existing SUD clinic and how the impact of these services can be assessed and monitored over time. The Healthy Liver Program can also be viewed as a more general model for how other types of medical health services could be integrated into an SUD clinic. Examples might be a health promotion program or an infectious disease program that would focus on HIV/AIDS and hepatitis. The Healthy Liver Program model could easily be expanded to promote more general health among SUD patients in a number of ways. Additional screening laboratory tests could be drawn to assess patients’ general health status. Education components on the benefits of diet and exercise could be added. It also would be fairly straightforward to incorporate HIV screening, education, counseling, and treatment referral into the model. Such a program would address the new Centers for Disease Control and Prevention recommendation that all health care providers, including those working in substance abuse treatment clinics, include HIV testing as a routine part of their patients’ health care to promote earlier access to treatment and reduce the risk to partners (http://www.cdc.gov/hiv/topics/testing/healthcare/index.htm). Future plans for the Liver Health Initiative involve disseminating the procedures and tools developed for the pilot Healthy Liver Program to additional VHA SUD clinics through 2-day training workshops with follow-up contacts for support and problem solving. Additional clinics will likely have to modify the specifics of the Healthy Liver Program for it to fit into their own existing structures and culture. Through this process, the Liver Health Initiative hopes to develop a menu of possible models for integrating hepatitis screening, prevention, and referral services into SUD clinics as well as guidance for choosing the most appropriate model based on the organizational characteristics of individual clinics. In addition, the Liver Health Initiative sponsors (SUD QUERI and HCRC) plan to determine how best to expand the Liver Health Initiative into an Infectious Disease Initiative and to include HIV/ AIDS services in the program. We hope that our experience would help guide others who wish to provide hepatitis services in their SUD clinics. The establishment of a healthy liver program as that developed for this project may be more difficult for SUD treatment clinics that are outside of the VHA or, more specifically, outside of a major medical center, mainly because stand-alone community clinics would face the additional challenge of developing relationships with other health care providers. During the planning phase for the
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implementation of a healthy liver program, stand-alone clinics would need to identify other health care providers that they would like to partner with, solicit the participation of those partners, and include them in the planning process so that smooth procedures for communication, referrals, and care collaboration can be specified before the implementation of the program. Although the ideal situation would be for a community clinic to implement all elements of the program described in this report, it may not be feasible for all clinics. However, at a minimum, it is vital that SUD treatment clinics raise awareness among their treatment staff and patients about the importance of diagnosing and preventing viral hepatitis infections. A community-based clinic could certainly incorporate an educational component that would raise awareness among its patients regarding hepatitis infections, the need for testing, and the value of vaccinations. Community clinics could also develop a list of resources that patients could access to further pursue screening, vaccinations, or treatment services. Acknowledgments This work was supported by Grant No. SUB04-393 from the Health Services Research Division of the U.S. Department of Veterans Affairs. We thank the VHA HCRC Program and the QUERI Program for supporting the Liver Health Initiative. References Abraham, H. D., Degli-Esposti, S., & Marino, L. (1999). Seroprevalence of hepatitis C in a sample of middle class substance abusers. Journal of Addictive Diseases, 18, 77 – 87. Almasio, P. L., & Amoroso, P. (2003). HAV infection in chronic liver disease: A rationale for vaccination. Vaccine, 21, 2238 – 2241. Astone, J., Strauss, S. M., Vassilev, Z. P., & Des Jarlais, D. C. (2003). Provision of hepatitis C education in a nationwide sample of drug treatment programs. Journal of Drug Education, 33, 107 – 117. Centers for Disease Control and Prevention. (1998). Recommendations for prevention and control of hepatitis C virus (HCV) infection and HCVrelated chronic liver disease. Morbidity and Mortality Weekly Report, 47, 1 – 39. Centers for Disease Control and Prevention. (2002). Hepatitis A and hepatitis B. Epidemiology and prevention of vaccine-preventable diseases, (7th ed.) 156 – 186. Chitwood, D. D., McBride, D. C., French, M. T., & Comerford, M. (1999). Health care need and utilization: A preliminary comparison of injection drug users, other illicit drug users, and nonusers. Substance Use and Misuse, 34, 727 – 746. Contoreggi, C., Rexroad, V. E., & Lange, W. R. (1998). Current management of infectious complications in the injecting drug user. Journal of Substance Abuse Treatment, 15, 95 – 106. Dhopesh, V. P., & Taylor, K. R. (2000). Survey of hepatitis B and C in addiction treatment unit. American Journal of Drug and Alcohol Abuse, 26, 703 – 707. El-Serag, H. B., Kunik, M., Richardson, P., & Rabeneck, L. (2002). Psychiatric disorders among veterans with hepatitis C infection. Gastroenterology, 123, 476 – 482.
Fingerhood, M. I., Jasinski, D. R., & Sullivan, J. T. (1993). Prevalence of hepatitis C in a chemically dependent population. Archives of Internal Medicine, 153, 2025 – 2030. Heintges, T., & Wands, J. R. (1997). Hepatitis C virus: Epidemiology and transmission. Hepatology, 26, 521 – 526. Keeffe, E. G. (1995). Is hepatitis A more severe in patients with chronic hepatitis B and other chronic liver diseases? American Journal of Gastroenterology, 90, 201 – 205. Keeffe, E. B. (1999). Vaccination against hepatitis A and B in chronic liver disease. Viral Hepatitis Review, 5, 77 – 88. Kelen, G. D., Green, G. B., Purcell, R. H., Chan, D. W., Qaqish, B. F., Sivertson, K. T., et al. (1992). Hepatitis B and hepatitis C in emergency department patients. New England Journal of Medicine, 326, 1399 – 1404. Koff, R. S. (2001). Risks associated with hepatitis A and hepatitis B in patients with hepatitis C. Journal of Clinical Gastroenterology, 33, 20 – 26. Mendenhall, C. L., Moritz, T., Rouster, S., Rossele, G., Polito, A., Quan, S., et al. (1993). Epidemiology of hepatitis C among veterans with alcoholic liver disease. The VA Cooperative Study Group 275. American Journal of Gastroenterology, 88, 1022 – 1026. Nguyen, H. A., Miller, A. I., Dieperink, E., Willenbring, M. L., Tetrick, L. L., Durfee, J. M., et al. (2002). Spectrum of disease in U.S. veteran patients with hepatitis C. American Journal of Gastroenterology, 97, 1813 – 1820. Rifai, M. A., Moles, J. K., Lehman, L. P., & Van der Linden, B. J. (2006). Hepatitis C screening and treatment outcomes in patients with substance use/dependence disorders. Psychosomatics, 47, 112 – 121. Reiss, G., & Keeffe, E. B. (2004). Review article: Hepatitis vaccination in patients with chronic liver disease. Alimentary Pharmacology and Therapeutics, 19, 715 – 727. Rosman, A. S., Waraich, A., Galvin, K., Casiano, J., Paronetto, F., & Lieber, C. S. (1996). Alcoholism associated with hepatitis C but not hepatitis B in an urban population. American Journal of Gastroenterology, 91, 498 – 505. Shim, M., Khaykis, I., Park, J., & Bini, E. J. (2005). Susceptibility to hepatitis A in patients with chronic liver disease due to hepatitis C virus infection: Missed opportunities for vaccination. Hepatology, 42, 688 – 695. Simonetti, R. G., Camma, C., & Fiorello, F. (1992). Hepatitis C virus infection as a risk factor for hepatocellular carcinoma in patients with cirrhosis: A case–control study. Annals of Internal Medicine, 116, 97 – 102. Sorensen, J. L., Masson, C. L., & Perlman, D. C. (2002). HIV/Hepatitis prevention in drug abuse treatment programs: Guidance from research. Science and Practice Perspectives, 4 – 12. Strauss, S. M., Astone, J. M., Hagan, H., & Des Jarlais, D. C. (2004). The content and comprehensiveness of hepatitis C education in methadone maintenance and drug-free treatment units. Journal of Urban Health, 18, 38 – 47. Strauss, S. M., Falkin, G. P., Vassilev, Z., Des Jarlais, D. C., & Astone, J. (2002). A nationwide survey of hepatitis C services provided by drug treatment programs. Journal of Substance Abuse Treatment, 22, 55 – 62. Tortu, S., Neaigus, A., McMahon, J., & Hagen, D. (2001). Hepatitis C among noninjecting drug users: A report. Substance Use and Misuse, 36, 523 – 534. Vento, S., Garofano, T., Renzini, C., Cainelli, F., Casali, F., Ghironzi, G., et al. (1998). Fulminant hepatitis associated with hepatitis A superinfection in patients with chronic hepatitis C. New England Journal of Medicine, 338, 286 – 290. Yu, M. D., Tong, M. J., & Corsaget, P. (1990). Prevalence of hepatitis B and C viral markers in Black and White patients with hepatocellular carcinoma in the United States. Journal of the National Cancer Institute, 82, 1038 – 1041.