With the high prevalence of HCV among persons born during 1945-1965, the increasing morbidity and mortality associated with HCV, and reductions in liver cancer and HCV-related mortality when HCV is eradicated, it is critically important to identify persons with HCV and link them to appropriate care.
Background
The Centers for Disease Control and Prevention (CDC) recommends one-time hepatitis C virus (HCV) antibody testing for “Birth Cohort” adults born during 1945–1965.
Objective
To examine the impact of an electronic health record (EHR)-embedded best practice alert (BPA) for HCV testing among Birth Cohort adults.
Design
Cluster-randomized trial was conducted from April 29, 2013 to March 29, 2014.
Subjects and Setting
Ten community and hospital-based primary care practices. Participants were attending physicians and medical residents during 25,620 study-eligible visits.
Intervention
Physicians in all practices received a brief introduction to the CDC testing recommendations. At visits for eligible patients at intervention sites, physicians received a BPA through the EHR to order HCV testing or medical assistants were prompted to post a testing order for the physician. Physicians in control sites did not receive the BPA.
Main Outcomes
HCV testing; the incidence of HCV antibody positive tests was a secondary outcome.
Results
Testing rates were greater among Birth Cohort patients in intervention sites (20.2% vs. 1.8%, P < 0.0001) and the odds of testing were greater in intervention sites after controlling for imbalances of patient and visit characteristics between comparison groups [odds ratio (OR), 9.0; 95% confidence interval, 7.6–10.7). The adjusted OR of identifying HCV antibody positive patients was also greater in intervention sites (OR, 2.1; 95% confidence interval, 1.3–11.2).
Conclusions
An EHR-embedded BPA markedly increased HCV testing among Birth Cohort patients, but the majority of eligible patients did not receive testing indicating a need for more effective methods to promote uptake.
Background
Hepatitis C virus (HCV) testing guidance issued by the Centers for Disease Control and Prevention in 1998 recommends HCV antibody (anti-HCV) testing for persons with specified risk factors. The purpose of this study was to determine the prevalence and predictors of anti-HCV positivity among primary care outpatients and estimate the proportion of unidentified anti-HCV-positive (anti-HCV+) persons using risk-based testing.
Methods
We analyzed electronic medical record data from a 4-site retrospective study. Patients were aged ≥18 years, utilized ≥1 outpatient primary care service(s) between 2005 and 2010, and had no documented evidence of prior HCV diagnosis. Among persons tested for anti-HCV, we fit a multilevel logistic regression model to identify patient-level independent predictors of anti-HCV positivity. We estimated the proportion of unidentified anti-HCV+ persons by using multiple imputation to assign anti-HCV results to untested patients.
Results
We observed 209 076 patients for a median of 5 months (interquartile range, 1–23 months). Among 17 464 (8.4%) patients who were tested for anti-HCV, 6.4% (n = 1115) were positive. We identified history of injection drug use (adjusted odds ratio [95% confidence interval], 6.3 [5.2–7.6]), 1945–1965 birth cohort (4.4 [3.8–5.1]), and elevated alanine aminotransferase levels (4.8 [4.2–5.6]) as independently associated with anti-HCV positivity. We estimated that 81.5% (n = 4890/6005) of anti-HCV+ patients were unidentified using risk-based testing.
Conclusions
In these outpatient primary care settings, risk-based testing may have missed 4 of 5 newly enrolled patients who are anti-HCV+. Without knowing their status, unidentified anti-HCV+ persons cannot receive further clinical evaluation or antiviral treatment, and are unlikely to benefit from secondary prevention recommendations to limit disease progression and mortality.
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