NR 586NP Week 5 Screening Program Appraisal Example

Screening Program Appraisal: Universal One-Time Hepatitis C Screening of Adults at a Three-Site Community Health Center, From Prevalence Through Predictive Value to the People Made Worse Off

Student Name

College of Nursing, Chamberlain University

NR 586NP: Population Health and Epidemiology for Advanced Nursing Practice

Instructor Name

Month Day, Year

Screening Program Appraisal: Universal One-Time Hepatitis C Screening of Adults at a Three-Site Community Health Center, From Prevalence Through Predictive Value to the People Made Worse Off

The Program

Since January 2022, the Hollis County health center has offered a one-time hepatitis C antibody test to every adult patient who has not had one, following the national recommendation (Schillie et al., 2020). Positive antibody samples are tested for RNA automatically from the same blood draw. Patients with a positive RNA result are scheduled with a nurse practitioner, who orders pretreatment tests and prescribes direct-acting antiviral treatment.

Prevalence Sets Everything

In 2025, 197 of 4,210 screened adults were antibody-positive (4.7%), and 128 had current infection by RNA (3.0%). Antibody prevalence in this group is several times the estimated national figure for adults, which is about 1% (Hofmeister et al., 2019). Every calculation below depends on that difference.

Positive Predictive Value, Worked

For working figures, I use a sensitivity of 98% and a specificity of 99% for the antibody test, close to those reported for current laboratory assays.

At the health center's prevalence of 4.7%, per 10,000 screened adults:

Truly antibody-positive: 470. Detected: 0.98 x 470 = 461.

Truly antibody-negative: 9,530. False positives: 0.01 x 9,530 = 95.

Positive predictive value: 461 / (461 + 95) = 461 / 556 = 83%.

At a prevalence of 0.5%, closer to a suburban practice with few risk factors:

Truly positive: 50. Detected: 49.

Truly negative: 9,950. False positives: 0.01 x 9,950 = 100.

Positive predictive value: 49 / (49 + 100) = 49 / 149 = 33%.

At the health center, about five of every six positive antibody results are true. At low prevalence, two of every three would be false. The same test, used the same way, gives very different meanings to a positive result depending on who is screened.

A true antibody result also does not mean current infection. About a third of antibody-positive patients at the health center had cleared the virus. The automatic RNA test is therefore what turns an antibody result into a diagnosis, and it also resolves false antibody positives, because they will have no detectable RNA.

Benefit, Stated as What Changes for Someone

Earlier detection changes what happens to the patient when treatment works. Direct-acting antiviral regimens cure most people treated, with sustained virologic response rates above 90% in trials and in practice (Falade-Nwulia et al., 2017). Cure stops further liver damage and removes the chance of passing the virus to others, including to an infant at birth. Without screening, many infections would be found only when liver disease was already advanced.

The Bias That Flatters Screening

A screened patient diagnosed at 30 will appear to survive longer after diagnosis than an unscreened patient diagnosed with cirrhosis at 55, even if treatment changed nothing, simply because the clock started earlier. This is lead-time bias. Any claim that screening improves survival after diagnosis must be checked against it. For hepatitis C, the benefit rests on cure, which can be measured directly, rather than on survival from diagnosis.

Harms as Events

For the roughly 95 false positives per 10,000: a second blood test for RNA from the same sample, so no extra needle, and a phone call explaining the result. Some patients worry between the call and the explanation.

For true positives with cleared infection, about a third: the same call, plus an explanation that the antibody will stay positive for life, which matters if they are screened again elsewhere.

For true positives with current infection: an appointment, more blood tests, often a liver scan, an eight- to twelve-week course of tablets and a test after treatment to confirm cure. Some patients face questions from family about how they were infected.

For all screened: a result in the record that may be seen by insurers and other clinicians.

Follow-Up and Capacity

The program works only if people found are treated. In 2025, of 128 patients with current infection, 101 saw a nurse practitioner, 61 started treatment within six months, 52 completed treatment and were tested for cure, and 50 were cured. The program diagnosed far more than it cured. The step from diagnosis to treatment is where most patients were lost, and it is where capacity is thinnest: two nurse practitioners prescribe treatment, and Medicaid prior authorization adds about two weeks.

Who Is Made Worse Off

Patients who learn they are infected but cannot get treatment, because of prior authorization delays or because they lose contact, carry the knowledge and the label without the cure. In 2025, that was 67 of 128 patients with current infection at six months. Patients with a false positive carry a short worry. Patients screened at a low-prevalence site, if the program were copied there, would face more false positives for each true one.

Reach

In 2025, the health center saw about 9,800 adult patients. Of those due for a first test, 4,210 were screened, about 70% of those eligible by the center's count. The rest declined, were missed during busy visits or left before blood was drawn. Adults who never visit the health center are not reached at all; the jail and the syringe program screen some of them, but no program screens adults who use no service. Reach is therefore the program's second limit, after follow-up.

Would Targeted Screening Do Better?

Before 2020, screening was aimed at people with known risk factors. At the health center, targeted screening missed many infections, because patients do not always disclose drug use and some were infected long ago. Universal screening finds those patients at the cost of testing many people at low risk. At this prevalence, the number tested per infection found is about 33, which is low by screening standards. At a prevalence of 0.5%, it would be about 200. Universal screening is clearly justified here; whether it is worth the effort in a low-prevalence practice is a different question.

Ethics of Screening Without Treatment

Screening is justified when something can be done for those found. At this health center, treatment is available, but fewer than half of those diagnosed started it within six months. A program that diagnoses without treating carries an ethical cost, because it gives people a diagnosis they cannot act on. The answer is not to screen less, but to make sure each person found has a route to treatment, which the later intervention plan addresses.

Verdict

The test is accurate enough at this prevalence, and the automatic RNA step handles its errors. As a program, it finds most infections among patients who come in, but it treats fewer than half of those it finds within six months and does not reach people who never visit. The program is worth continuing; its weakness is after the test, not in it.

References

Falade-Nwulia, O., Suarez-Cuervo, C., Nelson, D. R., Fried, M. W., Segal, J. B., & Sulkowski, M. S. (2017). Oral direct-acting agent therapy for hepatitis C virus infection: A systematic review. Annals of Internal Medicine, 166(9), 637-648. https://doi.org/10.7326/M16-2575

Hofmeister, M. G., Rosenthal, E. M., Barker, L. K., Rosenberg, E. S., Barranco, M. A., Hall, E. W., Edlin, B. R., Mermin, J., Ward, J. W., & Ryerson, A. B. (2019). Estimating prevalence of hepatitis C virus infection in the United States, 2013-2016. Hepatology, 69(3), 1020-1031. https://doi.org/10.1002/hep.30297

Schillie, S., Wester, C., Osborne, M., Wesolowski, L., & Ryerson, A. B. (2020). CDC recommendations for hepatitis C screening among adults: United States, 2020. MMWR Recommendations and Reports, 69(2), 1-17. https://doi.org/10.15585/mmwr.rr6902a1