We identified three unique screening models across the five sites: one Community Clinic Model (CCM), one Community Outreach Model (COM), and one Partnership and Contract Model (PCM). The remaining two programs used elements of COM and PCM and were categorized as the Outreach and Partnership Model (OPM).
In the CCM, screening was integrated into the clinic's routine primary care services with indications for screening determined by the patient's risk for chronic hepatitis B infection. The clinic we observed created standing orders instructing physicians to screen all of their patients born in Bangladesh, Cambodia, the Philippines, Thailand, and Vietnam for HBsAg at the time of their next regularly scheduled visit. As part of the visit, physicians performed pretest education and counseling and sent patients to the in-facility laboratory for phlebotomy. HBsAg serologic testing was performed by a laboratory, with follow-up communication and referral activities performed by clinic staff.
In the COM, screening was performed in community, nonclinical settings by a not-for-profit organization, a university-based dedicated project director, a few staff, and volunteers. This organization targeted Asian immigrants by screening at Asian-oriented health fairs and community centers, but still tested anyone who requested screening. In the planning and recruitment stages, the director identified venues, hired a laboratory to provide phlebotomists and testing, allocated staff, and recruited volunteers to promote the screening event. Program staff and volunteers coordinated participant transportation, reviewed educational materials, and helped participants complete forms. Following screening, the COM staff received results from the laboratory, sent results to participants, and referred HBsAg-positive patients for medical evaluation.
The PCM contracted with for-profit general health screening companies to include HBsAg screening alongside other health screenings at Asian-oriented employee wellness campaigns or large trade events and conventions. The PCM also used subcontracts to community programs similar to but not including the COM we observed. The subcontracted programs performed screening at Asian-oriented community events and reported data back to the PCM manager. The PCM was responsible for identifying events at which to hold screenings, securing funding (primarily from charitable pharmaceutical corporation donations), and establishing contractual relationships. Planning, screening, follow-up, and referral activities were performed by subcontracted programs.
The OPM mixed the direct involvement aspect of the COM with the partnership and contract services element of the PCM. While these programs conducted screenings in settings similar to the COM, the planning and setup activities were completed by partnering with a separate community organization that had direct links to targeted community. The OPM hired phlebotomists and laboratory services to draw blood and process results and organized screening paperwork and materials. The OPM paid a partnering community organization to promote, plan, and set up the location of the screening. Their recruiting and screening locations included Asian-oriented community organization sites, civil associations, and churches. The OPM received completed test results and sent notification and referral letters to participants. Further follow-up with participants was completed by the partner organizations.
The models used different combinations of staff, volunteers, and contracted workers to perform the component tasks for each phase of screening, planning, implementation, and follow-up. The CCM did not require planning, promotion, or setup activities and used clinic staff for almost all component tasks except those involving laboratory services. Similarly, the COM used a combination of organization staff to perform all activities except for blood draws and laboratory processing. The PCM set up the contracts and partnerships, but the activities involved with screening were completed solely by contracted organizations. Finally, the OPM organized the clinical elements of screening but contracted with community groups to promote and implement the screening events.
As shown in , the five programs screened 1,623 participants during the period observed, the majority (94.7%) of whom were foreign-born, with 31.6% from South Korea, 21.6% from Vietnam, and 16.3% from China. More than half of the participants screened did not have insurance (54.2%) or a regular doctor (55.6%), and only 13.2% reported previously being tested for hepatitis B.
Characteristics of people screened for HBsAG by five observed hepatitis B screening organizations: U.S., July 2008 to January 2009
HBsAg prevalence rates varied according to participant country of birth. The prevalence was 1.7% among U.S.-born participants compared with 6.3% among foreign-born participants from countries with an HBV prevalence of ≥2%. Participants from China, Cambodia, Taiwan, and Vietnam had the highest prevalence rates (range: 7.4%–9.9%). We found no positive cases among the foreign-born participants who reported being born in a country with <2.0% prevalence. HBsAg prevalence ranged from 5.6% to 6.6% across the programs. Newly identified HBV prevalence was 4.9% in the CCM, 4.1% in the COM, 3.2% in the OPM, and 4.5% in the PCM (). Newly identified people comprised 55.2% to 73.9% of the HBsAg-positive participants screened by each program (data not shown).
A total of 291 participants reported prior to -screening that they had previously been tested for HBsAg. Of these, 22.7% self-reported that they were HBsAg positive, 50.9% reported that they were HBsAg negative, and 26.5% reported that they did not know their HBsAg status (77 respondents categorized as missing/don't know did not remember their HBsAg status). Of the 22.7% of participants who self-reported they were positive, 45.5% actually were determined to be positive based on the newly administered screening test. Of those who self-reported that they were negative, 2.7% tested positive; of those who reported that they did not know their status, 7.1% tested positive.
On the day of screening, all participants were asked whether they intended to seek care if they tested positive. Among those screened, 71% intended to seek care, 27% wanted to seek care but did not know if they could afford it, and 2% did not intend to seek care. The intention to seek care varied by setting: of participants testing positive for HBsAg, >85% in the CCM intended to do so, 58% in the COM intended to do so, 71% in the PCM intended to do so, and 72% in the OPM intended to do so. Of those who went on to test negative for HBsAg, 71% had indicated an intention to seek care if they tested positive compared with 58% for those who went on to test positive. When the analysis excluded individuals who were aware of their status prior to screening, the difference between intention to seek care among those who tested negative (71%) and those who tested positive (63%) was smaller. Because of inadequate follow-up data, we were unable to determine whether there were changes in intention to seek care after receipt of test results or whether intention to seek care predicted who sought medical evaluation and treatment.
Cost and outcome measures
The organizations screened varying numbers of participants during the six-month data collection period (). The CCM program screened the fewest participants (n=106) followed in increasing order by the COM program (n=233), the two OPM programs (n=519: 237 at Site A and 282 at Site B), and the PCM program (n=1,308; 765 observations used in cost analysis). Cost-per-outcome estimates for the PCM program were based on data from 765 participants for whom data were considered reliable. Those participants who would not have been recommended for screening by CDC recommendations but who were screened anyway were primarily participants born in the U.S. or participants who had been screened before and were aware of their HBsAg status.
Number of people screened, positive cases identified, and costs per screening and case identified observed among four hepatitis B screening models: U.S., July 2008 to January 2009
Screening costs per outcome varied substantially across program models. The CCM had the lowest cost per complete screen ($40) followed by the COM ($102), the OPM ($176, calculated by taking the weighted average costs across the two OPM organizations), and the PCM ($280). The costs per positive person identified varied widely, from $609 in the CCM to $4,657 in the PCM. Adjusting the results for differences in prevalence did not meaningfully alter these results.