This [G8] researcher came up with questionnaire-based [G9] study

                              This prospective cohort study seeks to assess the real rate of hepatitis C virus (HCV) testing among patients with HCV risk factors and to recognizeG1  other prognostic factors related to testing in primary care clinical setting. In order to evaluate that researchers, choose four urban primary care clinics of Philadelphia, Pennsylvania. The aim of the study is not original as there has been another epidemiologic studG2 G3 y that has G4 done in primary care clinics to check the ratio of HCV risk assessment and prescribed related testing by the physicianG5 . They have been included only 2 main risk factors for HCV testing. However, data from these studies have been conflicting and offered little support for this association due to inadequate exposure variables for HCV risk assessment and questionable physician ability to evaluate HCV risk among patients via questionnaire.  A current prospective study was done to addingG6  power to in prior study and to get an effective G7 result, the G8 researcher came up with questionnaire-based G9 study with a list of exposures factorsG10  for HCV risk and not including an instruction to the physician to order HCV test if the patient having any risk factorG11 . Therefore, this study is original in terms of the results that were obtained, and it adds to the limited knowledge available on this subject. The study population is adequate, follow up is more complete and it fills the gap of the connection between other HCV risk defined variables in patient and physician knowledge about HCV testing.G12 G13 G14 G15 

         The prospective cohort study design is suitable for this study as it measures the risk of disease associated with exposures.G16  The study has been done among patients who were sitting in primary health care clinic’s waiting area, so direct involvement available which increase the validity of dataG17 .  The recruitment process consisted of people aged 18yr or older, who had not been seen in the clinic for 5 years and more. With this study, questionnaires can be G18 utilized to attain data and participants G19 can easily be questioned regarding exposure.  The trained investigators’ team followedG20  for 2 months of all patients who were detected positive for HCV risk factors to obtain outcome data. The study includes university-based primary clinics and community based primary G21 G22 clinics, so it includes multi-ethnic population and other demographic variables include such as age, gender, income statuG23 s, insurance status, different level of education, a total number of clinical visit within 2 months period after the initial visit.G24 G25  By using such randomized sources from the general population, the demographic gave a good representation of the type of subjects to study. A Questionnaire was copied and provide one copy to the physician during the patient appointment to record physician response. G26 G27 G28 G29 

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              Participants were excluded who had a prior diagnosis of HCV, incomplete data information and misplaced charts so out of 1848 individual only 578 patients with HCV risk factors included in the study. The way in which the sample size was calculated does make sense and the sample size is large enough to detect the G30 G31 G32 difference. However, in the study follow up time was short, it was 2 months only. It could be extended little long, so it would affect the result.G33  because after the first appointment if the patient had only 1 risk factors among listed all and had a history of medical comorbidity than physician more concentrate on severe condition rather than HCV testing.G34 G35 G36  Detection of the presence of HCV risk factors in the patient was identified by the answer to questionnaire questions but it failed to G37 G38 G39 explain the severity of disease among positive cases. Subjects who had comorbidities were divided into 4 categories: 1 comorbidity with HCV, 2 comorbidities with HCV, 3 comorbidities with HCV and more than 3 and came up with finding that patients who had more than 3 comorbidities were more likely to refer for HCV testing than who had no comorbidities. The study was assessed appropriately by the institutional review Board of Thomas Jefferson University Hospital. Investigator did not mention anything about patient data confidentiality in the study and there was not G40 any informed consent in a written manner addressed, instead of more likely it was in verbal. This study G41 could be replicated.

             The statistical approaches were described in detail in this study. chi-square test and T-test were used to calculate categorial factors regarding HCV tastings. In small sample size, investigators used Fisher’s exact test instead of chi-square test because p-value is <0.05. A binary logistic regression model was used to calculated odd ratio G42 G43 G44 G45 G46 G47 G48 to find possible factors for HCV testing. The odds ratio G49 was assessed with and without adjustment for confounding variables such as patient-provider ratio, appointment time, G50 physician ability to manage HCV, cost of testing and more. The same techniques were used to assess exposure and outcome for all participants as bot were attained from baseline questionnaires. Selection bias was accounted for by creating random sample groupG51 G52  from four urban primary care clinics. However, one bias that was not taken into consideration is recall bias. When participants were asked about exposed possible risk factors they G53 G54 had, they could have failed to recall or overlooked the situation.G55 G56 G57 G58 G59                  The result of the study was reported in adequate detail. Using the statistical approaches described above, the author met their aim to G60 rule out unidentified variables of the previous studyG61  which affecting the HCV testing in primary care clinical settings. In result portion, they have discussed HCV risk factor among different demographic variables but not found any statically difference in between them.                    The conclusion of this study is supported and justified by the result. The results clearly showed HCV risk factors and different variables for testing in primary clinics. Enough information was given to allow the readers to draw their own conclusions. The discussion properly puts the results in context. The author went into the detail about the reasons behind the results they obtained including the presence ofG62  medical comorbidities. They explained having more medical comorbidities were more like to undergo for HCV testing because those patients were having more attention of physician than any other and multiple tests performing on them so physician order test for easily with a rG63 equired blood test. Potential limitations were discussed and the impact on the result was described in study discussion part. Although there are few areas for improvement, this study was overallG64  appropriately conducted and demonstrated to find out actual rate of HCV testing and influencing factors on testing among patients in primary care settings.