Objective: To assess the attendance, outcome, compliance with treatment, and response to interferon alfa in patients with chronic hepatitis C who attended during 1995 and were treated according to a biopsy based algorithm. Design: Retrospective audit of all patients with chronic hepatitis C attending outpatient clinics over one year. Setting: The liver unit at a London teaching hospital. Subjects: 255 patients with chronic hepatitis C. Main outcome measures: Patient survival, attendance, and compliance with diagnostic and therapeutic regimens. Response to interferon alfa treatment, based on loss of viraemia three months after cessation of treatment. Results: A large proportion of patients (39%) with newly diagnosed chronic hepatitis C infection do not want to undergo further investigation. Of those patients who do attend for further treatment, a large proportion with severe hepatic fibrosis (42%) do not want to undergo currently available treatment. The response rate to interferon (21%) in treated patients was similar to that previously reported in a trial setting. There was no significant difference in response rates in patients with or without severe fibrosis not amounting to cirrhosis. In patients with cirrhosis there was a high incidence of hepatocellular carcinoma (18%) over a follow up period of 20 months. Conclusion: Current strategies aimed at investigating and treating patients with chronic hepatitis C are not acceptable to a large proportion of patients. Many patients with cirrhosis related to hepatitis C infection develop hepatic neoplasms, and management strategies to deal with this problem are urgently required. The optimal management for patients with chronic hepatitis C is controversial This study reviews the outcome of patients managed accordingly to algorithm based on liver biopsy results Many patients with chronic hepatitis C infection either do not want to undergo further investigation or decline treatment with interferon Management according to an algorithm based on biopsy results is acceptable to patients and leads to response rates (21%) in line with those of clinical trials A large proportion of patients with cirrhosis related to hepatitis C (18%) developed an hepatocellular carcinoma during follow up of 20 months