Leveraging the electronic health record to eliminate hepatitis C: Screening in a large integrated healthcare system

Abstract

Highly efficacious and tolerable treatments that cure hepatitis C viral (HCV) infection exist today, increasing the feasibility of disease elimination. However, large healthcare systems may not be fully prepared for supporting recommended actions due to knowledge gaps, inadequate infrastructure and uninformed policy direction. Additionally, the HCV cascade of care is complex, with many embedded barriers, and a significant number of patients do not progress through the cascade and are thus not cured. The aim of this retrospective cohort study was to evaluate a large healthcare system’s HCV screening rates, linkage to care efficiency, and provider testing preferences. Patients born during 1945–1965, not previously HCV positive or tested from within the Electronic Health Record (EHR), were identified given that three-quarters of HCV-infected persons in the United States are from this Birth Cohort (BC). In building this HCV testing EHR prompt, non-Birth Cohort patients were excluded as HCV-specific risk factors identifying this population were not usually captured in searchable, structured data fields. Once completed, the BC prompt was released to primary care locations. From July 2015 through December 2016, 11.5% of eligible patients (n = 9,304/80,556) were HCV antibody tested (anti-HCV), 3.8% (353/9,304) anti-HCV positive, 98.1% (n = 311/317) HCV RNA tested, 59.8% (n = 186/311) HCV RNA positive, 86.6% (161/186) referred and 76.4% (n = 123/161) seen by a specialist, and 34.1% (n = 42/123) cured of their HCV. Results from the middle stages of the cascade in this large healthcare system are encouraging; however, entry into the cascade–HCV testing–was performed for only 11% of the birth cohort, and the endpoint–HCV cure–accounted for only 22% of all infected. Action is needed to align current practice with recommendations for HCV testing and treatment given that these are significant barriers toward elimination.

Decentralisation, integration, and task-shifting in hepatitis C virus infection testing and treatment: a global systematic review and meta-analysis

“…Similarly, in the meta-regression analyses (appendix p 51), we found no evidence of differences in outcomes according to level of decentralisation. [45][46][47]. The meta-regressions for both interferon-based and DAA regimens showed no evidence of differences between specialist-led and non-specialist-led treatment (appendix p 52).…”

“…Including costs would allow for comparative cost-effectiveness analyses. Additional and new strategies to promote testing and treatment access in LMICs that are currently being evaluated include the strategic use of point-of-care multi-platform technologies for measurement of HCV viral load such as GeneXpert, electronic medical record prompts, 45,46 use of mobile outreach services, especially in homeless populations, [47][48][49] pharmacy-led testing and treatment initiation, 50,51 and telementoring to support non-specialists. 52,53 This systematic review has several major policy and clinical management implications for the scale-up of testing and treatment that is needed to achieve global HCV elimination targets.…”

Hepatitis C and HIV combined screening in primary care: A cluster randomized trial

“…13,14 In addition, there may be some limiting factors for screening, such as patient non-reporting of current or historical risk, perceived irrelevance of risk-factor assessment to the primary care visit, and scepticism of the overall benefits outlined in the guidelines. 15 Due to similarity in risk factors and transmission, and the high prevalence of HCV/HIV coinfection, 6 an overlap in screening services has been proposed. This combined screening could effectively use existing resources to address both epidemics and facilitate the linkage of HCV-infected individuals to health care.…”

“…In the same sense, studies that examine primary care providers’ HCV testing practices revealed low screening rates 13,14 . In addition, there may be some limiting factors for screening, such as patient non‐reporting of current or historical risk, perceived irrelevance of risk‐factor assessment to the primary care visit, and scepticism of the overall benefits outlined in the guidelines 15 …”

Hepatitis C Testing and Liver Fibrosis Predictors in the Birth Cohort of a Primary Care Practice

“…A recent community-based study utilizing data from 2015 to 2016 from previously untested persons in the birth cohort found a prevalence of HCV antibody of 3.8% with 59.8% viremia. 11 These results suggest that many patients in our population could have been treated previously for HCV, but the medical records had not been accurately updated. The prevalence of active HCV infection of the birth cohort patients tested was low (46.X%); however, the implications of viremia in this population was high, as 53.1% to 59.4% of patients with viremia were predicted to have METAVIR stage 4 fibrosis.…”