1 Journal Club Alcohol, Other Drugs, and Health: Current Evidence March–April 2012

2 Featured Article The Increasing Burden of Mortality From Viral Hepatitis in the United States between 1999 and 2007 Ly KN, et al. Ann Intern Med. 2012;156(4):271–278.

3 Study Objective To examine the health burden and mortality from infection with hepatitis B virus (HBV), hepatitis C virus (HCV), and, for comparison, HIV.

4 Study Design Investigators analyzed 1999–2007 US National Center for Health Statistics multiple-cause mortality data from all 50 states and the District of Columbia to assess age-adjusted mortality from HBV, HCV, and HIV. Approximately 22 million decedents were included in the analysis.

5 Assessing Validity of an Article About Harm Are the results valid? What are the results? How can I apply the results to patient care?

6 Are the Results Valid? Did the investigators demonstrate similarity in all known determinants of outcomes? Did they adjust for differences in the analysis? Were exposed patients equally likely to be identified in the two groups? Were the outcomes measured in the same way in the groups being compared? Was follow-up sufficiently complete?

7 Did the investigators demonstrate similarity in all known determinants of outcomes? Did they adjust for differences in the analysis? Logistic regression analyses of 2007 data generated 4 independent models per outcome (HCV- or HBV- related death), each of which was controlled for 1 of 4 comorbid conditions: –HIV infection. –chronic liver disease. –alcohol-related illness. –co-infection with HBV or HCV. All controlled for sociodemographic characteristics including age, race or ethnicity, sex, education, and marital status.

8 Were exposed patients equally likely to be identified in the groups? Exposure was based upon International Classification of Diseases (ICD) (10 th ed.) codes as listed on death certificates. Death certificates are often completed by someone other than the attending physician (e.g., a medical examiner, or a coroner); therefore exposure surveillance may not have been uniform or accurate.

9 Were the outcomes measured in the same way in the groups being compared?  Yes; the primary outcome was death.

10 What are the Results? How strong is the association between exposure and outcomes? How precise is the estimate of the risk?

How strong is the association between exposure and outcome? How precise is the estimate of the risk? Infection with HBV was listed as the underlying cause of 724 deaths (0.03%) and as the single underlying or contributing cause of 1815 deaths (0.07%) (age-adjusted mortality rate, 0.56 deaths per 100,000 persons per year [CI, 0.54–0.59]). Infection with HCV was listed as the underlying cause of 6605 deaths (0.27%) and as the underlying or contributing cause of 15,106 deaths (0.62%) (age-adjusted mortality rate, 4.58 deaths per 100,000 persons per year [CI, 4.50–4.67]). Infection with HIV was listed as the underlying cause of 11,332 deaths (0.47%) and as the underlying or contributing cause of 12,734 deaths (0.52%) (age-adjusted mortality rate, 4.16 deaths per 100,000 persons per year [CI, 4.09–4.24]).

12 How Can I Apply the Results to Patient Care? Were the study patients similar to the patients in my practice? Was the duration of follow-up adequate? What was the magnitude of the risk? Should I attempt to stop the exposure?

13 Were the study patients similar to the patients in my practice? Results were based on data from the National Center for Health Statistics, a nationally representative system.

14 Was the duration of follow-up adequate? Mortality data were analyzed over a 9-year period. No information is made to provide data on the duration of HBV, HCV or HIV exposure.

15 What was the magnitude of the risk? Infection with HBV was the underlying or contributing cause of 0.56 deaths per 100,000 persons per year [CI, 0.54–0.59]). Infection with HCV was the underlying or contributing cause 4.58 deaths per 100,000 persons per year [CI, 4.50–4.67]). Infection with HIV was the underlying or contributing cause of 4.16 deaths per 100,000 persons per year [CI, 4.09–4.24]).

16 Should I attempt to stop the exposure? Yes; vaccination against HBV is available, and multiple strategies are available to help patients protect against HCV and HIV infection.