Uptake of hepatitis C screening, characteristics of patients tested, and intervention costs in the BEST‐C study

Abstract

Background From December 2012-March 2014, three randomized trials, each implementing a unique intervention in primary care settings (mail recruitment [repeated-mailing], an electronic health record best practice alert [BPA], and patient-solicitation [patient-solicitation]), evaluated HCV antibody testing, diagnosis, and costs for each of the interventions compared to standard-of-care testing. Multilevel multivariable models were used to estimate the adjusted risk ratio (aRR) for receiving an HCV antibody test, and costs were estimated using activity-based costing. Rationale To estimate the effects of interventions conducted as part of the Birth-cohort Evaluation to Advance Screening and Testing for Hepatitis C study on hepatitis C virus (HCV) testing and costs among persons of the 1945–1965 birth-cohort (BC). Main Results Intervention resulted in substantially higher HCV testing rates compared to standard-of-care (26.9% vs. 1.4% for repeated-mailing, 30.9% vs. 3.6% for BPA, and 63.5% vs. 2.0% for patient-solicitation), and significantly higher aRR for testing after controlling for sex, birth year, race, insurance type, and median household income (19.2 [95% Confidence Interval (CI) 9.7–38.2] for repeated-mailing, 13.2 [95% CI 3.6–48.6] for BPA, and 32.9 [95% CI 19.3–56.1] for patient-solicitation). The BPA intervention had the lowest incremental cost per completed test ($24 with fixed startup costs, $3 without) and also the lowest incremental cost per new case identified after omitting fixed startup costs ($1,691). Conclusion HCV testing interventions resulted in an increase in BC testing compared to standard-of-care but also increased costs. The effect size and incremental costs of BPA intervention (excluding startup costs) support more widespread adoption compared to the other interventions.

Impact of electronic reminder systems on hepatitis C screening in primary care

“…Our finding of a screening rate, in response to the EMR reminder, of 37%, is within the range of HCV testing frequency reported in other studies with EMR‐based prompts, which have ranged from 30% to 88% . It should be noted that our centre did not initiate a specific training programme, making the implementation of this approach very simple.…”

“…The seroprevalence of HCV among baby boomers undergoing EMR‐driven testing at our centre (1.6%) is comparable to the seroprevalence range (0.9%‐1.2%) reported by several urban healthcare centres that employed targeted HCV testing of the 1945‐1965 birth cohort, but lower than the 3.5% population estimate from NHANES . Several factors could account for this, including study population differences regarding race or ethnicity, birthplace, education, income, each of which is associated with differences in HCV seroprevalence, as well as differences in the NHANES era (1999‐2008) and the era in which targeted testing was performed (after 2013).…”

“…It should be noted that our centre did not initiate a specific training programme, making the implementation of this approach very simple. Brady et al compared, in 3 medical systems, the effect of a mailed patient reminder, an EMR‐based alert and direct patient solicitation at the time of a visit, and found all 3 approaches to increase testing dramatically over baseline . Further investigation of the utility of such strategies, along with systems that improve testing workflow in primary care settings, is needed.…”

Hepatitis C virus testing for case identification in persons born during 1945‐1965: Results from three randomized controlled trials

“…This degree of success likely depended, at least in part, on the staff and resources dedicated specifically to the trials. The trial that reported the highest testing rate did not integrate BC testing into the normal workflow but instead used a dedicated recruiter to perform direct patient invitation, an approach that may be less cost‐effective over a longer period . However, while the use of a recruiter dedicated to implementing a single health screening recommendation may represent a potentially prohibitive resource expense, population management (which often involves an assigned health professional working with patients) is increasingly being used in health systems to achieve population health goals .…”

Hepatitis C Testing Increased Among Baby Boomers Following The 2012 Change To CDC Testing Recommendations

“…10–12 Analyses of national trends in hepatitis C testing have shown significant increases in testing among the birth cohort in the period following the recommendation change, 13,14 but the specific causal impact of this policy change on clinical practice has not been evaluated. Improvements in testing can lead to increased case finding, decreased hepatitis C transmission, and earlier initiation of antiviral treatment among infected persons, thus reducing morbidity and mortality related to hepatitis C. 15–17 We analyzed hepatitis C screening rates in the United States in the period 2010–14, using a strong quasi-experimental design to determine the causal impact of the 2012 recommendation on rates of testing among people with commercial insurance in the birth cohort.…”