Uptake of endoscopic screening for gastroesophageal varices and factors associated with variceal bleeding in patients with chronic hepatitis C infection and compensated cirrhosis, 2005‐2016: a national database linkage study

Abstract

Summary Background Primary measures for preventing morbidity and mortality associated with bleeding gastroesophageal varices in cirrhotic patients include endoscopic screening. Aim To identify factors associated with (a) screening and (b) first hospital admission for variceal bleeding among cirrhotic hepatitis C virus (HCV) patients attending specialist care in Scotland. Methods The Scottish Hepatitis C Clinical Database was linked to national hospitalisation and deaths records to identify all chronic HCV patients diagnosed with compensated cirrhosis in 2005‐2016 (n = 2741). The adjusted odds of being screened by calendar year period were estimated using logistic regression, and the adjusted hazard ratio (HR) of a first variceal bleed using Cox regression. Results About 34% were screened within the period starting 12 months before and ending 12 months after cirrhosis diagnosis. The proportion screened was stable in 2005‐2010 at 42%, declining to 37% in 2011‐2013 and 26% in 2014‐2016. Odds of screening were decreased for age‐groups <40 (OR = 0.61, 95% CI: 0.48‐0.77) and 60+ years (OR = 0.67, 95% CI: 0.48‐0.94), history of antiviral therapy (OR = 0.70, 95% CI: 0.55‐0.89), and cirrhosis diagnosis in 2014‐2015, compared with 2008‐2010 (OR = 0.67, 95% CI: 0.52‐0.86). Compared with 2008‐2010, there was no evidence for an increased/decreased relative risk of a first variceal bleed in any other period, but viral clearance was associated with a lower risk (HR = 0.56, 95% CI: 0.32‐0.97). Conclusions Overall screening uptake following cirrhosis diagnosis was low, and the decline in recent years is of concern. The stable bleeding risk over time may be attributable both to ongoing prevention initiatives and to changing diagnostic procedures creating a patient pool with milder disease in more recent years.

Population impact of direct-acting antiviral treatment on new presentations of hepatitis C-related decompensated cirrhosis: a national record-linkage study

“…The study population here was confined to patients who were recorded on the clinical database as having chronic HCV and had been diagnosed with cirrhosis since January 2011; those with evidence of decompensation or HCC at baseline were excluded. We confined the pre-DAA era to a period (since 2011) when transient elastography (FibroScan) was routinely used to diagnose cirrhosis, thereby minimising any bias arising through adoption of different modes of diagnosis across the study period 25…”

“…Covariates included in the regression were: sex, age group at cirrhosis diagnosis, risk group for HCV acquisition (person who injects drugs (PWID), non-PWID), alcohol consumption history (>50 units per week, ≤50 units per week/not known), genotype (1, 3, other/not known), antiviral treatment experience prior to cirrhosis diagnosis and Child-Pugh class (A, B). For the latter, the most recent laboratory test result (for bilirubin, albumin and prothrombin) within 120 days of cirrhosis diagnosis was used 25. Multiple imputation using chained equations was performed using the R package mice to impute missing data on risk group and laboratory measurements needed to compute Child-Pugh class 28 29…”

“…We confined the pre-DAA era to a period (since 2011) when transient elastography (FibroScan®) was routinely used to diagnose cirrhosis, thereby minimising any bias arising through adoption of different modes of diagnosis across the study period. 25…”

Editorial: screening for oesophageal varices after directly acting anti‐viral therapy—do not let your guard down

“…McDonald et al have made laudable efforts in this regard by reviewing the Scottish National Hepatitis C Clinical Database. They used the hospitalization diagnosis and procedure codes to assess the practice patterns of endoscopic screening for varices in 2741 patients with compensated hepatitis C related cirrhosis over a 11‐year period.…”

Commentary: elastography as a predictor of portal hypertension

“…Use of Baveno VI and its expanded criteria are now in widespread clinical use and offer help with the challenges of patients at risk of varices attending for surveillance. In Scotland those with HCV related cirrhosis had a 30%‐40% uptake of endoscopic surveillance following HCV cure . Use of the expanded Baveno VI criteria may help target those at highest risk and encourage attendance.…”