HCV universal EHR prompt successfully increases screening, highlights potential disparities

Abstract

Background & objectives Screening for hepatitis C virus is the first critical decision point for preventing morbidity and mortality from HCV cirrhosis and hepatocellular carcinoma and will ultimately contribute to global elimination of a curable disease. This study aims to portray the changes over time in HCV screening rates and the screened population characteristics following the 2020 implementation of an electronic health record (EHR) alert for universal screening in the outpatient setting in a large healthcare system in the US mid-Atlantic region. Methods Data was abstracted from the EHR on all outpatients from 1/1/2017 through 10/31/2021, including individual demographics and their HCV antibody (Ab) screening dates. For a limited period centered on the implementation of the HCV alert, mixed effects multivariable regression analyses were performed to compare the timeline and characteristics of those screened and un-screened. The final models included socio-demographic covariates of interest, time period (pre/post) and an interaction term between time period and sex. We also examined a model with time as a monthly variable to look at the potential impact of COVID-19 on screening for HCV. Results Absolute number of screens and screening rate increased by 103% and 62%, respectively, after adopting the universal EHR alert. Patients with Medicaid were more likely to be screened than private insurance (ORadj 1.10, 95% CI: 1.05, 1.15), while those with Medicare were less likely (ORadj 0.62, 95% CI: 0.62, 0.65); and Black (ORadj 1.59, 95% CI: 1.53, 1.64) race more than White. Conclusions Implementation of universal EHR alerts could prove to be a critical next step in HCV elimination. Those with Medicare and Medicaid insurance were not screened proportionately to the national prevalence of HCV in these populations. Our findings support increased screening and re-testing efforts for those at high risk of HCV.

Hepatitis C in Black Individuals in the US

“… In an academic health care system with 2.7 million annual outpatient visits, electronic health record prompts for universal HCV screening was associated with an increase in screening tests from 2052/month to 4169/month. Compared with White race, Black race was associated with 59% increased odds of being screened (9044/156 288 screened postalert vs 4612/141 955 screened prealert implementation compared with 8698/258 498 postalert vs 4371/217 342 prealert for White patients; aOR, 1.59 [95% CI, 1.53-1.64]) . In a stepped-wedge randomized clinical trial of people born between 1945 and 1965 (28% Black) who were hospitalized at 1 of 2 US academic centers in 2020-2021, a default order for HCV screening resulted in a 69.9% (2257/3229) screening rate compared with 38.1% (1679/4405) using an electronic prompt for HCV screening (OR, 3.18 [95% CI, 2.59-3.89]; P < .001) …”

Successes and challenges of best practice alerts to identify and engage individuals living with hepatitis C virus

“…Another review by Haridy et al, which included 29 studies evaluating EMR alerts targeted toward the birth cohort or at-risk screening, highlighted increased screening rates ( 14 ). Through a literature search of articles published between 2020 and 2023, our group identified six additional studies that used BPAs to identify people living with HCV ( 15 – 20 ). While studies consistently reported an increase in screening rates, only a few examined whether the use of BPAs via an EMR system assisted in linking HCV patients to care ( 16 , 17 ).…”