less likely to initiate it; they were also more likely to discontinue treatment early, and discontinuation of treatment was associated with alcohol use (Cheung et al., 2005).

The risk of developing hepatocellular carcinoma (HCC) is a serious concern for patients who are infected with HBV or HCV, and providers should initiate regular monitoring for HCC (Bruix and Sherman, 2005). Patients who have chronic HBV infection and are at the highest risk for HCC include those who have first-degree relatives who developed HCC, persons who have cirrhosis, men 40 years old and older, and women 50 years old and older. Of patients who have chronic HCV infection, only those who have cirrhosis or advanced liver fibrosis (that is, bridging fibrosis) should be monitored for HCC. Monitoring of patients at high risk for HCC should be performed every 6 months.

Studies have found ethnic disparities in HCC treatment rates and mortality (Davila and El-Serag, 2006; Siegel et al., 2008; Sonnenday et al., 2007). Blacks and Hispanics had significantly higher HCC-related mortality than other racial and ethnic populations. Even after adjustment for stage of HCC and other demographic characteristics, blacks were 40% less likely than whites to receive local or surgical therapy. Another study found that blacks and Hispanics were 24–27% less likely than whites to receive surgical therapy (Sonnenday et al., 2007). A study that looked at liver transplants necessitated by HCC found that in 1998–2002, black and Asian patients were significantly less likely than white patients to receive a liver transplant (Siegel et al., 2008). Once researchers controlled for receipt of treatment, the difference in mortality in black patients was no longer significant (Davila and El-Serag, 2006). Those data on racial and ethnic disparities in the outcomes of and treatments for chronic hepatitis underscore the need for additional research to understand the biologic and societal basis of the disparities. They also indicate the urgency of new policies that ensure that optimal medical care is given to all without regard to race or ethnicity.

The economic costs of chronic hepatitis B and hepatitis C are high. In 2004, the average annual medical-care costs of chronic HBV infection and its complications per infected person in the United States were as follows: chronic HBV infection, $761; compensated cirrhosis, $227; decompensated cirrhosis, $11,459; liver transplantation, $86,552; transplantation care more than 12 months after transplantation, $12,560; and hepatocellular carcinoma, $7,533 (Lee et al., 2004). Medication costs were the largest proportion of the chronic HBV infection and compensated cirrhosis states and hospitalization costs made up the largest proportion of the other health states. In the same year, Chesson et al. (2004) estimated the annual net cost per case of chronic liver disease at $32,837 in the United States.

Although treatment costs are high, some studies have found that treatment can be cost-effective. In particular, several studies compared the costs



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