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Hu TH, Luh DL, Tsao YY, Lin TY, Chang CJ, Su WW, Yang CC, Yang CJ, Chen HP, Liao PY, Su SL, Chen LS, Hsiu-Hsi Chen T, Yeh YP. Using the Diabetes Care System for a County-Wide Hepatitis C Elimination: An Integrated Community-Based Shared Care Model in Taiwan. Am J Gastroenterol 2024; 119:883-892. [PMID: 38084857 PMCID: PMC11062613 DOI: 10.14309/ajg.0000000000002624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 10/16/2023] [Indexed: 01/30/2024]
Abstract
INTRODUCTION Despite the serious risks of diabetes with hepatitis C virus (HCV) infection, this preventable comorbidity is rarely a priority for HCV elimination. We aim to examine how a shared care model could eliminate HCV in patients with diabetes (PwD) in primary care. METHODS There were 27 community-based Diabetes Health Promotion Institutes in each township/city of Changhua, Taiwan. PwD from these institutes from January 2018 to December 2020 were enrolled. HCV screening and treatment were integrated into diabetes structured care through collaboration between diabetes care and HCV care teams. Outcome measures included HCV care continuum indicators. Township/city variation in HCV infection prevalence and care cascades were also examined. RESULTS Of the 10,684 eligible PwD, 9,984 (93.4%) underwent HCV screening, revealing a 6.18% (n = 617) anti-HCV seroprevalence. Among the 597 eligible seropositive individuals, 507 (84.9%) completed the RNA test, obtaining 71.8% positives. Treatment was initiated by 327 (89.8%) of 364 viremic patients, and 315 (86.5%) completed it, resulting in a final cure rate of 79.4% (n = 289). Overall, with the introduction of antivirals in this cohort, the prevalence of viremic HCV infection dropped from 4.44% to 1.34%, yielding a 69.70% (95% credible interval 63.64%-77.03%) absolute reduction. DISCUSSION Although HCV prevalence varied, the care cascades achieved consistent results across townships/cities. We have further successfully implemented the model in county-wide hospital-based diabetes clinics, eventually treating 89.6% of the total PwD. A collaborative effort between diabetes care and HCV elimination enhanced the testing and treatment in PwD through an innovative shared care model.
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Affiliation(s)
- Tsung-Hui Hu
- Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, Kaohsiung City, Taiwan
| | - Dih-Ling Luh
- Department of Public Health, Chung Shan Medical University, Taichung, Taiwan
- Department of Family and Community Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Yo-Yu Tsao
- Changhua Public Health Bureau, Changhua, Taiwan
| | - Ting-Yu Lin
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | | | - Wei-Wen Su
- Changhua Christian Hospital, Changhua, Taiwan
| | - Chih-Chao Yang
- Changhua Hospital, Ministry of Health and Welfare, Changhua, Taiwan
| | - Chang-Jung Yang
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | | | | | - Shih-Li Su
- Changhua Christian Hospital, Changhua, Taiwan
| | - Li-Sheng Chen
- School of Oral Hygiene, College of Oral Medicine, Taipei Medical University, Taipei, Taiwan
| | - Tony Hsiu-Hsi Chen
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Yen-Po Yeh
- Changhua Public Health Bureau, Changhua, Taiwan
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
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Engaging Physicians and Systems to Improve Hepatitis C Virus Testing in Baby Boomers. Healthcare (Basel) 2023; 11:healthcare11020209. [PMID: 36673580 PMCID: PMC9858629 DOI: 10.3390/healthcare11020209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 12/16/2022] [Accepted: 01/06/2023] [Indexed: 01/12/2023] Open
Abstract
Approximately three million people in the United States have been exposed to the hepatitis C virus (HCV), with two-thirds of these having chronic HCV infection. Baby boomers (those born 1945-1965) have nearly five times the prevalence of HCV infection compared with other age groups. Despite clinical practice guidelines that recommend HCV testing in baby boomers, the testing rates remain low. We developed and tested a multilevel intervention to increase orders for HCV testing that included integrated clinical decision support within the electronic health record (EHR) and a physician education session to improve HCV physician knowledge in one Florida academic health system. In the year prior to the intervention, test order rates for encounters with baby boomers was 11.9%. During the intervention period (August 2019-July 2020) for providers that viewed a best practice alert (BPA), the ordering increased to 59.2% in Family Medicine and 64.6% in Internal Medicine. The brief physician education intervention improved total HCV knowledge and increased self-efficacy in knowledge of HCV risk factors. These findings suggest that interventions at the system and physician levels hold promise for increasing HCV testing rates. Future studies are needed to evaluate this intervention in additional clinical settings and to test the benefit of adding additional intervention components that are directed at patients.
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Carty PG, Teljeur C, De Gascun CF, Gillespie P, Harrington P, McCormick A, O'Neill M, Smith SM, Ryan M. Another Step Toward Hepatitis C Elimination: An Economic Evaluation of an Irish National Birth Cohort Testing Program. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022; 25:1947-1957. [PMID: 35778325 DOI: 10.1016/j.jval.2022.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 04/14/2022] [Accepted: 05/05/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES We aimed to evaluate the cost-effectiveness of offering once-off birth cohort testing for hepatitis C virus (HCV) to people in Ireland born between 1965 and 1985, the cohort with the highest reported prevalence of undiagnosed chronic HCV infection. METHODS Systematic and opportunistic HCV birth cohort testing programs, implemented over a 4-year timeframe, were compared with the current practice of population risk-based testing only in a closed-cohort decision tree and Markov model hybrid over a lifetime time horizon. Outcomes were expressed in quality-adjusted life-years (QALYs). Costs were presented from the health system's perspective in 2020 euro (€). Uncertainty was assessed via deterministic, probabilistic, scenario, and threshold analyses. RESULTS In the base case, systematic testing yielded the largest cost and health benefits, followed by opportunistic testing and risk-based testing. Compared with risk-based testing, the incremental cost-effectiveness ratio for opportunistic testing was €14 586 (95% confidence interval €4185-€33 527) per QALY gained. Compared with opportunistic testing, the incremental cost-effectiveness ratio for systematic testing was €16 827 (95% confidence interval €5106-€38 843) per QALY gained. These findings were robust across a range of sensitivity analyses. CONCLUSIONS Both systematic and opportunistic birth cohort testing would be considered an efficient use of resources, but systematic testing was the optimal strategy at willingness-to-pay threshold values typically used in Ireland. Although cost-effective, any decision to introduce birth cohort testing for HCV (in Ireland or elsewhere) must be balanced with considerations regarding the feasibility and budget impact of implementing a national testing program given high initial costs and resource use.
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Affiliation(s)
- Paul G Carty
- RCSI University of Medicine and Health Sciences, Dublin, Ireland; Health Information and Quality Authority, Dublin, Ireland.
| | - Conor Teljeur
- Health Information and Quality Authority, Dublin, Ireland
| | - Cillian F De Gascun
- National Virus Reference Laboratory, University College Dublin, Dublin, Ireland
| | - Paddy Gillespie
- Health Economics & Policy Analysis Centre, National University of Ireland Galway, Galway, Ireland; CÚRAM, The SFI Research Centre for Medical Devices (12/RC/2073_2), National University of Ireland Galway, Galway, Ireland
| | | | | | | | - Susan M Smith
- Department of Public Health and Primary Care, School of Medicine, Trinity College Dublin, Ireland
| | - Mairin Ryan
- Health Information and Quality Authority, Dublin, Ireland; Department of Pharmacology and Therapeutics, Trinity College Dublin, Trinity Health Sciences, St James's Hospital, Dublin, Ireland
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Wang AE, Hsieh E, Turner BJ, Terrault N. Integrating Management of Hepatitis C Infection into Primary Care: the Key to Hepatitis C Elimination Efforts. J Gen Intern Med 2022; 37:3435-3443. [PMID: 35484367 PMCID: PMC9551010 DOI: 10.1007/s11606-022-07628-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 04/18/2022] [Indexed: 11/24/2022]
Abstract
Elimination of hepatitis C virus (HCV), a leading cause of liver disease in the USA and globally, has been made possible with the advent of highly efficacious direct acting antivirals (DAAs). DAA regimens offer cure of HCV with 8-12 weeks of a well-tolerated once daily therapy. With increasingly straightforward diagnostic and treatment algorithms, HCV infection can be managed not only by specialists, but also by primary care providers. Engaging primary care providers greatly increases capacity to diagnose and treat chronic HCV and ultimately make HCV elimination a reality. However, barriers remain at each step in the HCV cascade of care from screening to evaluation and treatment. Since primary care is at the forefront of patient contact, it represents the ideal place to concentrate efforts to identify barriers and implement solutions to achieve universal HCV screening and increase curative treatment.
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Affiliation(s)
- Allison E Wang
- Department of Internal Medicine, University of Southern California, Los Angeles, CA, USA
| | - Eric Hsieh
- Department of Internal Medicine, University of Southern California, Los Angeles, CA, USA
| | - Barbara J Turner
- Department of Internal Medicine, University of Southern California, Los Angeles, CA, USA
| | - Norah Terrault
- Department of Internal Medicine, University of Southern California, Los Angeles, CA, USA.
- Division of Gastrointestinal and Liver Diseases, Department of Medicine, University of Southern California, Los Angeles, CA, USA.
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Halket D, Dang J, Phadke A, Jayasekera C, Kim WR, Kwo P, Downing L, Goel A. Targeted Electronic Patient Portal Messaging Increases Hepatitis C Virus Screening in Primary Care: a Randomized Study. J Gen Intern Med 2022; 37:3318-3324. [PMID: 35230622 PMCID: PMC9551157 DOI: 10.1007/s11606-022-07460-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 02/04/2022] [Indexed: 12/09/2022]
Abstract
IMPORTANCE Electronic health record (EHR) tools such as direct-to-patient messaging and automated lab orders are effective at improving uptake of preventive health measures. It is unknown if patient engagement in primary care impacts efficacy of such messaging. OBJECTIVE To determine whether more engaged patients, defined as those who have an upcoming visit scheduled, are more likely to respond to a direct-to-patient message with an automated lab order for hepatitis C virus (HCV) screening. DESIGN Randomized trial PARTICIPANTS: One thousand six hundred randomly selected Stanford Primary Care patients, 800 with an upcoming visit within 6 months and 800 without, born between 1945 and 1965 who were due for HCV screening. Each group was randomly divided into cohorts of 400 subjects each. Subjects were followed for 1 year. INTERVENTION One 400 subject cohort in each group received a direct-to-patient message through the EHR portal with HCV antibody lab order. MAIN OUTCOME AND MEASURE The EHR was queried on a monthly basis for 6 months after the intervention to monitor which subjects completed HCV screening. For any subjects screened positive for HCV, follow-up through the cascade of HCV care was monitored, and if needed, scheduled by the study team. KEY RESULTS Of 1600 subjects, 538 (34%) completed HCV screening. In the stratum without an upcoming appointment, 18% in the control group completed screening compared to 26% in intervention group (p<0.01). Similarly, in the stratum with an upcoming appointment, 34% in the control group completed screening compared to 58% in the intervention group (p<0.01). CONCLUSION Direct-to-patient messaging coupled with automated lab orders improved HCV screening rates compared to standard of care, particularly in more engaged patients. Including this intervention in primary care can maximize screening with each visit, which is particularly valuable in times when physical throughput in the healthcare system may be low.
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Affiliation(s)
- Douglas Halket
- Division of Primary Care and Population Health, Stanford University, Palo Alto, CA, USA.
| | - Jimmy Dang
- Population Health, Stanford Hospital and Clinics, Palo Alto, CA, USA
| | - Anuradha Phadke
- Division of Primary Care and Population Health, Stanford University, Palo Alto, CA, USA
| | | | - W Ray Kim
- Division of Gastroenterology & Hepatology, Stanford University, Palo Alto, CA, USA
| | - Paul Kwo
- Division of Gastroenterology & Hepatology, Stanford University, Palo Alto, CA, USA
| | - Lance Downing
- Department of Medicine, Center for Biomedical Informatics Research, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Aparna Goel
- Division of Gastroenterology & Hepatology, Stanford University, Palo Alto, CA, USA
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Pharmacist-led drug therapy management for Hepatitis C at a federally qualified healthcare center. J Am Pharm Assoc (2003) 2022; 62:1596-1605. [DOI: 10.1016/j.japh.2022.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 04/15/2022] [Accepted: 04/20/2022] [Indexed: 11/18/2022]
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Carty PG, Fawsitt CG, Gillespie P, Harrington P, O'Neill M, Smith SM, Teljeur C, Ryan M. Population-Based Testing for Undiagnosed Hepatitis C: A Systematic Review of Economic Evaluations. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2022; 20:171-183. [PMID: 34870793 DOI: 10.1007/s40258-021-00694-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/19/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND AND OBJECTIVES Recognising the significant public health threat posed by hepatitis C, international targets have been established by the World Health Organization with the aim of eradicating the hepatitis C virus (HCV) by 2030. With the availability of safe and effective therapies, the greatest challenge to achieving elimination is the identification and treatment of those currently undiagnosed. This systematic review aimed to identify and appraise the international literature on the cost-effectiveness of birth cohort, universal, and age-based general population testing for identifying people with undiagnosed chronic HCV infection. METHODS A comprehensive literature search was undertaken in Medline, Embase and grey literature sources to identify studies published between 1 January 2000 and 17 July 2020. Retrieved citations were independently reviewed by two reviewers according to pre-defined eligibility criteria. Data extraction and critical appraisal were completed in duplicate. Study quality, relevance and credibility were assessed using the Consensus for Health Economic Criteria and the ISPOR questionnaires. All costs were reported in 2019 Irish Euro following adjustment for inflation and purchasing power parity. Willingness-to-pay (WTP) thresholds of €20,000 and €45,000 were adopted as reference points for interpreting cost-effectiveness in the narrative synthesis. The systematic review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. RESULTS Overall, 4622 citations were retrieved in the literature search. Of these, 27 studies met the inclusion criteria. Six (22%) of the 27 studies were rated as low quality, 17 (63%) were moderate quality and four (15%) were high quality. Compared with no testing or risk-based testing: 14 of 16 (88%) cost-utility analyses found that birth cohort testing was cost effective, eight of nine (89%) analyses found that universal testing was cost effective, and eight of eight (100%) analyses found that age-based general population testing was cost effective. Cost effectiveness was influenced by disease prevalence and progression, testing and treatment uptake, treatment eligibility of those identified by testing, the cost of treatment and the proportion of those treated that achieve sustained virological response. CONCLUSION Overall, the international evidence supports the potential cost effectiveness of birth cohort, universal, and age-based general population testing, but is caveated by study generalisability, specifically the transferability of findings from one jurisdiction to another, and institutional variations in healthcare delivery systems and budgetary constraints. The cost effectiveness of each approach will vary according to population- and health system-specific characteristics such as epidemiological context, testing coverage, linkage to care and capacity to treat. Given issues regarding the transferability of economic evaluations (for example, model inputs and assumptions) and the significant resources required to implement these interventions, jurisdiction-specific economic evaluations and budget impact analyses will likely be required to inform investment and implementation decisions. REGISTRATION PROSPERO, CRD42019127159. Registered 29 April 2019.
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Affiliation(s)
- Paul G Carty
- RCSI University of Medicine and Health Sciences, Dublin, Ireland.
- Health Information and Quality Authority, Dublin, Ireland.
| | | | - Paddy Gillespie
- Health Economics and Policy Analysis Centre, CÚRAM, the SFI Research Centre for Medical Devices (12/RC/2073_2), National University of Ireland Galway, Galway, Ireland
| | | | | | - Susan M Smith
- Health Research Board Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, 123 St Stephens Green, Dublin, Ireland
| | - Conor Teljeur
- Health Information and Quality Authority, Dublin, Ireland
| | - Mairin Ryan
- Health Information and Quality Authority, Dublin, Ireland
- Department of Pharmacology and Therapeutics, Trinity College Dublin, Trinity Health Sciences, St James's Hospital, Dublin 8, Ireland
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Vadaparampil ST, Fuzzell LN, Rathwell J, Reich RR, Shenkman E, Nelson DR, Kobetz E, Jones PD, Roetzheim R, Giuliano AR. HCV testing: Order and completion rates among baby boomers obtaining care from seven health systems in Florida, 2015-2017. Prev Med 2021; 153:106222. [PMID: 32721414 PMCID: PMC7854771 DOI: 10.1016/j.ypmed.2020.106222] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 07/16/2020] [Accepted: 07/20/2020] [Indexed: 12/18/2022]
Abstract
Many U.S. residents infected with hepatitis C virus (HCV) are baby boomers (born 1945-1965), who remain undiagnosed. Past CDC and USPSTF guidelines recommended one-time HCV testing for all baby boomers, with newer guidelines recommending universal screening for all adults. This retrospective cohort study examined electronic medical records for patient visits from 2015 to 2017 within the OneFlorida Data Trust and University of South Florida Health system. We assessed percentages of HCV tests ordered and completed across four age groups (those born before 1945, 1945-1965, 1966-1985, and after 1985). In 2019, we used logistic regression to examine factors associated with HCV test ordering and completion among baby boomers, including age, race, sex, number of primary care visits, HIV status, hepatitis diagnosis, and liver cancer history. All age groups had low rates of HCV test orders. 4.4% of baby boomers had a test ordered in 2015, and 6.7% in 2016. Of those, 94.5% and 89.7% completed testing, respectively. All other races/ethnicities had lower likelihood of testing completion than Whites (Blacks (aOR 0.82, 95%, CI 0.75-0.91); Asians (0.69, 0.52-0.92); Hispanics (0.29, 0.26-0.32)), although test orders were higher for Asians (1.48, 1.37-1.61) and Blacks (1.78, 1.73-1.82). Tests ordered (11.42, 10.94-11.92) and completed (2.25, 1.94-2.60) were more likely among those with hepatitis history. Test orders were more likely for HIV-positive patients (3.68, 3.45-3.93), but completion was less likely (0.67, 0.57-0.78). Interventions are needed to increase testing rates so that HCV infections are treated early, mitigating HCV-related morbidity and mortality, especially related to liver cancer.
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Affiliation(s)
- Susan T Vadaparampil
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center, United States of America
| | - Lindsay N Fuzzell
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center, United States of America.
| | - Julie Rathwell
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center, United States of America; Center for Immunization and Infection Research in Cancer, H. Lee Moffitt Cancer Center, United States of America
| | - Richard R Reich
- Department of Biostatistics, H. Lee Moffitt Cancer Center, United States of America
| | | | - David R Nelson
- Department of Medicine, University of Florida, United States of America
| | - Erin Kobetz
- Sylvester Comprehensive Cancer Center, Department of Public Health Sciences, University of Miami School of Medicine, Miami, FL, United States of America
| | - Patricia D Jones
- Department of Medicine, Gastroenterology and Hepatology, University of Miami Miller School of Medicine, United States of America
| | - Richard Roetzheim
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center, United States of America; University of South Florida, Department of Family Medicine, United States of America
| | - Anna R Giuliano
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center, United States of America; Center for Immunization and Infection Research in Cancer, H. Lee Moffitt Cancer Center, United States of America
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Aboagye JK, Haut ER, Streiff MB, Hobson DB, Kraus PS, Shaffer DL, Holzmueller CG, Lau BD. Audit and Feedback to Surgery Interns and Residents on Prescribing Risk-Appropriate Venous Thromboembolism Prophylaxis. JOURNAL OF SURGICAL EDUCATION 2021; 78:2011-2019. [PMID: 33879395 DOI: 10.1016/j.jsurg.2021.03.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 03/19/2021] [Accepted: 03/20/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To evaluate the effectiveness of feedback using an emailed scorecard and a web-based dashboard on risk-appropriate VTE prophylaxis prescribing practices among general surgery interns and residents. DESIGN Prospective cohort study. SETTING The Johns Hopkins Hospital, an urban academic medical center. PARTICIPANTS All 45 trainees (19 post-graduate year [PGY] 1 interns and 26 PGY-2 to PGY-5 residents) in our general surgery program. INTERVENTION Feedback implementation encompassed three sequential periods: (1) scorecard (July 1, 2014 through June 30, 2015); (2) no feedback/wash-in (July 1 through October 31, 2015); and (3) web-based dashboard (November 1, 2015 through June 30, 2016). No feedback served as the baseline period for the intern cohort. The scorecard was a static document showing an individual's compliance with risk-appropriate VTE prophylaxis prescription compared to compliance of their de-identified peers. The web-based dashboard included other information (e.g., patient details for suboptimal prophylaxis orders) besides individual compliance compared to their de-identified peers. Trainees could access the dashboard anytime to view current and historic performance. We sent monthly emails to all trainees for both feedback mechanisms. Main outcome was proportion of patients prescribed risk-appropriate VTE prophylaxis, and mean percentages reported. RESULTS During this study, 4088 VTE prophylaxis orders were placed. Among residents, mean prescription of risk-appropriate prophylaxis was higher in the wash-in (98.4% vs 95.6%, p < 0.001) and dashboard (98.4 vs 95.6%, p < 0.001) periods compared to the scorecard period. There was no difference in mean compliance between the wash-in and dashboard periods (98.4% vs 98.4%, p = 0.99). Among interns, mean prescription of risk-appropriate VTE prophylaxis improved between the wash-in and dashboard periods (91.5% vs 96.4%, p < 0.001). CONCLUSIONS AND RELEVANCE Using audit and individualized performance feedback to general surgery trainees through a web-based dashboard improved prescribing of appropriate VTE prophylaxis to a near-perfect performance.
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Affiliation(s)
- Jonathan K Aboagye
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Elliott R Haut
- Division of Acute Care Surgery, Department of Surgery; Department of Anesthesiology and Critical Care Medicine; Department of Emergency Medicine; Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
| | - Michael B Streiff
- Division of Hematology, Department of Medicine; Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Deborah B Hobson
- Department of Nursing, The Johns Hopkins Hospital; Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Peggy S Kraus
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Dauryne L Shaffer
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine; Department of Nursing, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Christine G Holzmueller
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Brandyn D Lau
- Russell H. Morgan Department of Radiology and Radiological Science; Division of Health Sciences Informatics; Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Klein MD, Harrington BJ, East J, Cunningham J, Ifill N, Santos JL. Increasing Hepatitis C Screening in a Federally Qualified Health Center: A Quality Improvement Initiative. J Healthc Qual 2021; 43:312-320. [PMID: 34463670 PMCID: PMC8415006 DOI: 10.1097/jhq.0000000000000278] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
ABSTRACT Hepatitis C virus (HCV) is a chronic infection that can lead to severe liver damage if left untreated. With increased availability and affordability of curative treatments, screening for HCV has become an important first step in reducing morbidity and mortality. At a rural federally qualified health center in North Carolina, two quality improvement initiatives-an electronic health record (EHR) prompt and educational flyers-were implemented to improve HCV screening rates. We compared the proportion of eligible patients born from 1945 to 1965 who received HCV screening before, during, and after the initiatives. HCV screening rates were highest during the two initiatives (30% and 39%, respectively). Screening rates fell in the 6-month period after the initiatives' conclusion (12%) but remained higher than at baseline (6%). Although HCV screening can increase with simple interventions, more durable solutions are needed to maintain screening coverage.
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Affiliation(s)
- Melissa D. Klein
- University of North Carolina School of Medicine, University of North Carolina at Chapel Hill Chapel Hill, NC
- UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill Chapel Hill, NC
| | - Bryna J. Harrington
- University of North Carolina School of Medicine, University of North Carolina at Chapel Hill Chapel Hill, NC
| | - Joan East
- Piedmont Health Services, University of North Carolina at Chapel Hill Chapel Hill, NC
| | - Jennifer Cunningham
- Piedmont Health Services, University of North Carolina at Chapel Hill Chapel Hill, NC
| | - Nicole Ifill
- Piedmont Health Services, University of North Carolina at Chapel Hill Chapel Hill, NC
| | - Jan Lee Santos
- Piedmont Health Services, University of North Carolina at Chapel Hill Chapel Hill, NC
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Khan MQ, Belopolsky Y, Gampa A, Greenberg I, Beig MI, Imas P, Sonnenberg A, Fimmel CJ. Effect of a Best Practice Alert on Birth-Cohort Screening for Hepatitis C Virus. Clin Transl Gastroenterol 2021; 12:e00297. [PMID: 33522731 PMCID: PMC7806234 DOI: 10.14309/ctg.0000000000000297] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 11/23/2020] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION We assessed the influence of a best practice alert (BPA) embedded within the electronic medical record on improving hepatitis C virus (HCV) birth-cohort screening by primary care physicians (PCPs). METHODS Screening by 155 PCPs was monitored during 2 consecutive 9-month periods before and after implementation of the BPA. All tests were reviewed to differentiate true screening from other testing indications. RESULTS Of 155 PCPs, 131 placed screening orders before and after BPA. Twenty-two PCPs started testing after BPA (P = 0.02). The number of tests placed and screening rates per PCP increased from 16 to 84 and from 3.3% to 13.2%, respectively (P < 0.0001). Before BPA, most PCPs rarely ordered screening HCV tests, whereas a small group of physicians generated most tests, indicative of an underlying power-law distribution. After the BPA, a new group of high-performing PCPs emerged, whose screening patterns were again characterized by a power-law distribution. However, pre-BPA test rates of individual PCPs were not predictive of their post-BPA rates. Overall, the introduction of the BPA narrowed the gap between low- and high-performing testers, indicating that modest increases in testing by a large number of low-performing PCPs could drive substantial improvement in program implementation. DISCUSSION HCV birth-cohort screening by PCPs was shaped by an underlying power-law distribution. This distribution was preserved after the implementation of a BPA, although pre-BPA test rates were not predictive of post-BPA rates. Increases in test rates by high- and low-performing PCPs both contributed to the overall success of the BPA.
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Affiliation(s)
- Mohammad Qasim Khan
- Department of Gastroenterology, NorthShore University Health System, Evanston, Illinois, USA
| | - Yuliya Belopolsky
- Department of Medicine, NorthShore University Health System, Evanston, Illinois, USA
| | - Anuhya Gampa
- Department of Gastroenterology, NorthShore University Health System, Evanston, Illinois, USA
| | - Ian Greenberg
- Department of Medicine, NorthShore University Health System, Evanston, Illinois, USA
| | - Muhammad Imran Beig
- Department of Clinical Analytics, NorthShore University Health System, Skokie, Illinois, USA
| | - Polina Imas
- Department of Clinical Analytics, NorthShore University Health System, Skokie, Illinois, USA
| | - Amnon Sonnenberg
- Portland VA Medical Center and Oregon Health and Science University, Portland, Oregon, USA
| | - Claus J. Fimmel
- Department of Gastroenterology, NorthShore University Health System, Evanston, Illinois, USA
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12
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Thuluvath PJ, Trowell J, Zhang T, Alukal J, Lowe G. Universal HCV Screening of Baby Boomers is Feasible, but It is Difficult. J Clin Exp Hepatol 2021; 11:661-667. [PMID: 34866844 PMCID: PMC8617540 DOI: 10.1016/j.jceh.2021.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 02/18/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND/OBJECTIVE Our objective was to assess the impact of mass mailing and the inclusion of Best Practice Advisory (BPA) "Pop-Up" tool in the electronic medical record (EMR) on HCV screening rates. METHODS Between June 2015 and March 2020, two interventions were developed for primary care physicians (PCP). An educational letter along with a blood requisition form, signed on behalf of the PCPs, was sent to patients. We also developed a BPA "Pop-Up" screening tool to alert PCPs to order HCV screening tests on patients with no previous screening. Data were collected and analyzed prospectively. RESULTS When we started the screening program in June 2015, 33,736 baby boomers were eligible for screening, and the hospital system added an additional 26,027 baby boomers between June 2015 and March 2020. Of the 89 primary care providers employed by the hospital, 75 agreed to participate at different time periods. We screened 23,291 (43.5%) of 53,526 eligible patients during study period. Of these, 399 (1.7%) had HCV antibody, but HCV RNA was positive in only 195 (1%). HCV antibody positivity rates were higher in men, blacks, and in 1951-1960 birth cohorts. Spontaneous clearance rates appeared to be lower in men (OR 0.59, 95% CI 0.39-0.90, P = 0.015) and in blacks (OR 0.31, 95% CI 0.20-0.50, P < 0.001). CONCLUSION Although a formal screening program increased screening rates for HCV among baby boomers, about 50% of baby boomers remained unscreened. In this community screening program, we found that men and blacks are less likely to have spontaneous HCV clearance.
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Affiliation(s)
- Paul J. Thuluvath
- Institute of Digestive Health & Liver Diseases, Mercy Medical Center, Baltimore, MD, 21202, USA,Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, 21202, USA,Address for correspondence: Paul J. Thuluvath, MD, FAASLD, FRCP, Clinical Professor of Medicine, Institute of Digestive Health & Liver Diseases, Mercy Medical Center, Baltimore, MD, 21202, USA.
| | - Joshua Trowell
- Institute of Digestive Health & Liver Diseases, Mercy Medical Center, Baltimore, MD, 21202, USA
| | - Talan Zhang
- Institute of Digestive Health & Liver Diseases, Mercy Medical Center, Baltimore, MD, 21202, USA
| | - Joseph Alukal
- Institute of Digestive Health & Liver Diseases, Mercy Medical Center, Baltimore, MD, 21202, USA
| | - George Lowe
- Institute of Digestive Health & Liver Diseases, Mercy Medical Center, Baltimore, MD, 21202, USA
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13
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Kasting ML, Rathwell J, Gabhart KM, Garcia J, Roetzheim RG, Carrasquillo O, Giuliano AR, Vadaparampil ST. There's just not enough time: a mixed methods pilot study of hepatitis C virus screening among baby boomers in primary care. BMC FAMILY PRACTICE 2020; 21:248. [PMID: 33267799 PMCID: PMC7713319 DOI: 10.1186/s12875-020-01327-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 11/22/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Liver cancer rates are rising and hepatitis C virus (HCV) is the primary cause. The CDC recommends a one-time HCV screening for all persons born 1945-1965 (baby boomers). However, 14% of baby boomers have been screened. Few studies have examined primary care providers' (PCP) perspectives on barriers to HCV screening. This study examines current HCV screening practices, knowledge, barriers, and facilitators to HCV screening recommendation for baby boomers among PCPs. METHODS We conducted a mixed methods pilot study of PCPs. Quantitative: We surveyed PCPs from 3 large academic health systems assessing screening practices, knowledge (range:0-9), self-efficacy to identify and treat HCV (range:0-32), and barriers (range:0-10). Qualitative: We conducted interviews assessing patient, provider, and clinic-level barriers to HCV screening for baby boomers in primary care. Interviews were audio recorded, transcribed, and analyzed with content analysis. RESULTS The study sample consisted of 31 PCPs (22 survey participants and nine interview participants). All PCPs were aware of the birth cohort screening recommendation and survey participants reported high HCV testing recommendation, but qualitative interviews indicated other priorities may supersede recommending HCV testing. Provider knowledge of viral transmission was high, but lower for infection prevalence. While survey participants reported very few barriers to HCV screening in primary care, interview participants provided a more nuanced description of barriers such as lack of time. CONCLUSIONS There is a need for provider education on both HCV treatment as well as how to effectively recommend HCV screening for their patients. As HCV screening guidelines continue to expand to a larger segment of the primary care population, it is important to understand ways to improve HCV screening in primary care.
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Affiliation(s)
- Monica L Kasting
- Department of Public Health, Purdue University, 812 W. State Street, West Lafayette, IN, 47907, USA
- Center for Immunization and Infection Research in Cancer, H. Lee Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL, 33612, USA
| | - Julie Rathwell
- Center for Immunization and Infection Research in Cancer, H. Lee Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL, 33612, USA
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL, 33612, USA
| | - Kaitlyn M Gabhart
- Department of Public Health, Purdue University, 812 W. State Street, West Lafayette, IN, 47907, USA
| | - Jennifer Garcia
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center, 12902 Magnolia Drive MRC-COEE, Tampa, FL, 33612, USA
| | - Richard G Roetzheim
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center, 12902 Magnolia Drive MRC-COEE, Tampa, FL, 33612, USA
- Department of Family Medicine, University of South Florida, Tampa, USA
| | - Olveen Carrasquillo
- Division of General Internal Medicine, University of Miami, 1120 NW 14th Street, Miami, FL, 33136, USA
| | - Anna R Giuliano
- Center for Immunization and Infection Research in Cancer, H. Lee Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL, 33612, USA
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL, 33612, USA
| | - Susan T Vadaparampil
- Center for Immunization and Infection Research in Cancer, H. Lee Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL, 33612, USA.
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center, 12902 Magnolia Drive MRC-COEE, Tampa, FL, 33612, USA.
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14
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Materniak S, Bland S, Margeson A, Webster D, Smyth D, O’Brien M. Differences among hepatitis C patients seen in community and specialist outpatient care settings. CANADIAN LIVER JOURNAL 2020; 3:286-293. [DOI: 10.3138/canlivj-2019-0003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 10/25/2019] [Indexed: 11/20/2022]
Abstract
Background: In the province of New Brunswick, care for patients infected with hepatitis C is provided in both community-based care settings and specialist-based care settings, but little is known about the differences between these populations. The aim of the current study is to characterize the demographic, socioeconomic, mental health and substance use factors of patients seen in these settings. Methods: Enrolling sites for this study included four specialist office-based clinics and one community-based clinic in three communities in New Brunswick. Personal health data was collected with informed consent via questionnaires and medical records. Non-incarcerated patients seen between April 2014 and April 2016 were included in the analysis. Results: A total of 374 patients were included (34.8% community versus 65.2% specialist office). Patients seen in the community care setting were younger (median age 43.7 versus 49.1 years), less likely to have a primary care provider ( p = .007), rely on social assistance as regular source of income ( p <.001), have been incarcerated ( p = .007), reported sharing drug paraphernalia ( p = .025), had recent injection drug use ( p <.001), reported snorting drugs recently ( p <.001) and reported prior overdose ( p = .025). Community clinic patients also had significantly younger mean age at first use of alcohol (13.6 versus 14.7 years, p = .044), marijuana (14.6 versus 15.8, p = .040), and opioids (23.9 versus 26.5 years, p = .036) over those seen in specialist offices. Conclusions: Unique differences exist between patients seen in community and specialist care settings in New Brunswick. Understanding these differences is an essential first step in developing patient-centred care models.
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Affiliation(s)
- Stefanie Materniak
- Division of Infectious Diseases, Horizon Health Network, Saint John, New Brunswick, Canada
| | | | - Alyssa Margeson
- Division of Infectious Diseases, Horizon Health Network, Moncton, New Brunswick, Canada
| | - Duncan Webster
- Division of Infectious Diseases, Horizon Health Network, Saint John, New Brunswick, Canada
- Dalhousie University, Nova Scotia, Canada
| | - Daniel Smyth
- Dalhousie University, Nova Scotia, Canada
- Division of Infectious Diseases, Horizon Health Network, Moncton, New Brunswick, Canada
| | - Meaghan O’Brien
- Dalhousie University, Nova Scotia, Canada
- Department of Internal Medicine, Horizon Health Network, Upper River Valley, New Brunswick, Canada
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15
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Higashi RT, Jain MK, Quirk L, Rich NE, Waljee AK, Turner BJ, Lee SC, Singal AG. Patient and provider-level barriers to hepatitis C screening and linkage to care: A mixed-methods evaluation. J Viral Hepat 2020; 27:680-689. [PMID: 32048397 PMCID: PMC7299760 DOI: 10.1111/jvh.13278] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 01/22/2020] [Accepted: 01/24/2020] [Indexed: 12/14/2022]
Abstract
Achieving practice change can be challenging when guidelines shift from a selective risk-based strategy to a broader population health strategy, as occurred for hepatitis C (HCV) screening (2012-2013). We aimed to evaluate patient and provider barriers that contributed to suboptimal HCV screening and linkage-to-care rates after implementation of an intervention to improve HCV screening and linkage-to-care processes in a large, public integrated healthcare system following the guidelines change. As part of a mixed-methods study, we collected data through patient surveys (n = 159), focus groups (n = 9) and structured observation of providers and staff (n = 9). We used these findings to then inform domains for the second phase, which consisted of semi-structured interviews with patients across the screening-treatment continuum (n = 24) and providers and staff at primary care and hepatology clinics (n = 21). We transcribed and thematically analysed interviews using an integrated inductive and deductive framework. We identified lack of clarity about treatment cost, treatment complications and likelihood of cure as ongoing patient-level barriers to screening and linkage to care. Provider-level barriers included scepticism about establishing HCV screening as a quality metric given competing clinical priorities, particularly for patients with multiple comorbidities. However, most felt positively about adding HCV as a quality metric to enhance HCV screening and linkage to care. Provider engagement yielded suggestions for process improvements that resulted in increased stakeholder buy-in and real-time enhancements to the HCV screening process intervention. Systematic data collection at baseline and during practice change implementation may facilitate adoption and adaptation to improve HCV screening guideline implementation. Findings identified several key opportunities and lessons to enhance the impact of practice change interventions to improve HCV screening and treatment delivery.
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Affiliation(s)
- Robin T. Higashi
- Department of Population and Data Sciences, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390-9066,Harold C. Simmons Comprehensive Cancer Center, 2201 Inwood Rd., Dallas TX 75390
| | - Mamta K. Jain
- Harold C. Simmons Comprehensive Cancer Center, 2201 Inwood Rd., Dallas TX 75390,Department of Internal Medicine, UT Southwestern Medical Center, 5939 Harry Hines Blvd., Dallas, TX 75390-9124,Parkland Health and Hospital System, 5201 Harry Hines Blvd., Dallas, TX 75235
| | - Lisa Quirk
- Department of Population and Data Sciences, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390-9066
| | - Nicole E. Rich
- Department of Internal Medicine, UT Southwestern Medical Center, 5939 Harry Hines Blvd., Dallas, TX 75390-9124,Parkland Health and Hospital System, 5201 Harry Hines Blvd., Dallas, TX 75235
| | - Akbar K. Waljee
- Department of Internal Medicine, University of Michigan, 3110 Taubman Center, SPC 5368, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5368,VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Rd, Ann Arbor, MI 48105,Institute for Healthcare Policy and Innovation, University of Michigan, 2800 Plymouth Rd, Ann Arbor, MI 48109,Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP) 2800 Plymouth Road, Ann Arbor, MI 48109
| | - Barbara J. Turner
- Department of Family & Community Medicine, UT Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229,ReACH: Center for Research to Advance Community Health, UT Health Science Center at San Antonio, 7411 John Smith Rd., Suite 1050, San Antonio, TX 78229
| | - Simon Craddock Lee
- Department of Population and Data Sciences, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390-9066,Harold C. Simmons Comprehensive Cancer Center, 2201 Inwood Rd., Dallas TX 75390
| | - Amit G. Singal
- Harold C. Simmons Comprehensive Cancer Center, 2201 Inwood Rd., Dallas TX 75390,Department of Internal Medicine, UT Southwestern Medical Center, 5939 Harry Hines Blvd., Dallas, TX 75390-9124,Parkland Health and Hospital System, 5201 Harry Hines Blvd., Dallas, TX 75235
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16
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Cole AM, Keppel GA, Baldwin LM, Gilles R, Holmes J, Vance C, Kriesgman B, Linares A, Hornecker J, Paddock E, Gerrish W, Alto W, Gould D, Neher J. Room for Improvement: Rates of Birth Cohort Hepatitis C Screening in Primary Care Practices-A WWAMI Region Practice and Research Network Study. J Prim Care Community Health 2020; 10:2150132719884298. [PMID: 31658872 PMCID: PMC6820173 DOI: 10.1177/2150132719884298] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Introduction: An estimated 2.4 million people in the United States live with hepatitis C. Though there are effective treatments for chronic hepatitis C, many infected individuals remain untreated because 40% to 50% of individuals with chronic hepatitis C are unaware of their hepatitis C status. In 2013, the United States Preventive Services Task Force (USPSTF) recommended that adults born between 1945 and 1965 should be offered one-time hepatitis C screening. The purpose of this study is to describe rates of birth cohort hepatitis C screening across primary care practices in the WWAMI region Practice and Research Network (WPRN). Methods: Cross-sectional observational study of adult patients born between 1945 and 1965 who also had a primary care visit at 1 of 9 participating health systems (22 primary care clinics) between July 31, 2013 and September 30, 2015. Data extracted from the electronic health record systems at each clinic were used to calculate the proportion of birth cohort eligible patients with evidence of hepatitis C screening as well as proportions of screened patients with positive hepatitis C screening test results. Results: Of the 32 139 eligible patients, only 10.9% had evidence of hepatitis C screening in the electronic health record data (range 1.2%-49.1% across organizations). Among the 4 WPRN sites that were able to report data by race and ethnicity, the rate of hepatitis C screening was higher among African Americans (39.9%) and American Indians/Alaska Natives (23.2%) compared with Caucasians (10.7%; P < .001). Discussion: Rates of birth cohort hepatitis C screening are low in primary care practices. Future research to develop and test interventions to increase rates of birth cohort hepatitis C screening in primary care settings are needed.
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Affiliation(s)
| | | | | | | | | | | | | | - Adriana Linares
- Family Medicine Residency Program of Southwest Washington, Vancouver, WA, YSA
| | - Jaime Hornecker
- University of Wyoming Family Practice Residency Program, Casper, WY, USA
| | - Elizabeth Paddock
- Family Medicine Residency Program of Western Montana, Missoula, MT, USA
| | | | | | | | - Jon Neher
- Valley Family Medicine Residency Program, Renton, WA, USA
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17
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Tran JN, Wong RJ, Lee JS, Bancroft T, Buikema AR, Ting J, Terrault N. Hepatitis C Screening Rates and Care Cascade in a Large US Insured Population, 2010-2016: Gaps to Elimination. Popul Health Manag 2020; 24:198-206. [PMID: 32392454 DOI: 10.1089/pop.2019.0237] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Understanding the health care system's ability to move patients through the hepatitis C virus (HCV) care cascade from screening to treatment is essential for HCV elimination. This retrospective study describes real-world HCV screening rates and care cascade steps to identify gaps in care for patients with HCV in the United States. Eligible patients were aged ≥18 years as of the measurement year (calendar year between January 1, 2010-December 31, 2016) and were commercial and Medicare Advantage with Part D members in the Optum Research database with continuous health plan enrollment 5 years prior to and during the measurement year. Incident and prevalent screening rates were calculated for each measurement year. Care cascade steps were analyzed via Kaplan-Meier analysis and logistic regression among patients with a positive HCV ribonucleic acid test. Cohorts were selected based on birth year (pre-1945 birth cohort, 1945-1965 birth cohort, post-1965 birth cohort). Among the 1945-1965 birth cohort, incident and prevalent screening rates increased from 1.6% to 4.7% and 10% to 18%, respectively, from 2010 to 2016. The proportion of patients attaining each independent cascade step within 1 year of screening increased significantly over time for genotype testing (P = 0.0283) and receipt of treatment (P < 0.0001). Median time from screening to treatment decreased from 1627 days (95% CI 1335-1871) in 2010 to 282 days (95% CI 223-498) in 2015. HCV screening and completion of the care cascade has improved for certain patient populations; however, gaps remain, highlighting the urgent need to address barriers to meeting HCV elimination goals.
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Affiliation(s)
- Josephine Nhu Tran
- Health Economics and Outcomes Research, Optum, Eden Prairie, Minnesota, USA
| | - Robert J Wong
- Gastroenterology/Hepatology, Alameda Health System-Highland Hospital, Oakland, California, USA
| | - Janet S Lee
- Health Economics and Outcomes Research, Gilead Sciences, Inc., Foster City, California, USA
| | - Tim Bancroft
- Health Economics and Outcomes Research, Optum, Eden Prairie, Minnesota, USA
| | - Ami R Buikema
- Health Economics and Outcomes Research, Optum, Eden Prairie, Minnesota, USA
| | - Jie Ting
- Health Economics and Outcomes Research, Gilead Sciences, Inc., Foster City, California, USA
| | - Norah Terrault
- Gastroenterology & Hepatology, University of Southern California, Los Angeles, California, USA
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18
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Ramsey SD, Unger JM, Baker LH, Little RF, Loomba R, Hwang JP, Chugh R, Konerman MA, Arnold K, Menter AR, Thomas E, Michels RM, Jorgensen CW, Burton GV, Bhadkamkar NA, Hershman DL. Prevalence of Hepatitis B Virus, Hepatitis C Virus, and HIV Infection Among Patients With Newly Diagnosed Cancer From Academic and Community Oncology Practices. JAMA Oncol 2020; 5:497-505. [PMID: 30653226 DOI: 10.1001/jamaoncol.2018.6437] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Universal screening of patients with newly diagnosed cancer for hepatitis B virus (HBV), hepatitis C virus (HCV), and HIV is not routine in oncology practice, and experts disagree about whether universal screening should be performed. Objective To estimate the prevalence of HBV, HCV, and HIV infection among persons with newly diagnosed cancer. Design, Setting, and Participants Multicenter prospective cohort study of patients with newly diagnosed cancer (ie, identified within 120 days of cancer diagnosis) at 9 academic and 9 community oncology institutions affiliated with SWOG (formerly the Southwest Oncology Group) Cancer Research Network, a member of the National Clinical Trials Network, with enrollment from August 29, 2013, through February 15, 2017. The data analysis was conducted using data available through August 17, 2017. Main Outcomes and Measures The accrual goal was 3000 patients and the primary end point was the presence of HBV infection (previous or chronic), HCV infection, or HIV infection at enrollment. Patients with previous knowledge of infection as well as patients with unknown viral viral status were evaluated. Results Of 3092 registered patients, 3051 were eligible and evaluable. Median (range) age was 60.6 (18.2-93.7) years, 1842 (60.4%) were female, 553 (18.1%) were black, and 558 (18.3%) were Hispanic ethnicity. Screened patients had similar clinical and demographic characteristics compared with those registered. The observed infection rate for previous HBV infection was 6.5% (95% CI, 5.6%-7.4%; n = 197 of 3050 patients); chronic HBV, 0.6% (95% CI, 0.4%-1.0%; n = 19 of 3050 patients); HCV, 2.4% (95% CI, 1.9%-3.0%; n = 71 of 2990 patients); and HIV, 1.1% (95% CI, 0.8%-1.6%; n = 34 of 3045). Among those with viral infections, 8 patients with chronic HBV (42.1%; 95% CI, 20.3%-66.5%), 22 patients with HCV (31.0%; 95% CI, 20.5%-43.1%), and 2 patients with HIV (5.9%; 95% CI, 0.7%-19.7%) were newly diagnosed through the study. Among patients with infections, 4 patients with chronic HBV (21.1%; 95% CI, 6.1%-45.6%), 23 patients with HCV (32.4%; 95% CI, 21.8%-44.5%), and 7 patients with HIV (20.6%; 95% CI, 8.7%-37.9%) had no identifiable risk factors. Conclusions and Relevance Results of this study found that a substantial proportion of patients with newly diagnosed cancer and concurrent HBV or HCV are unaware of their viral infection at the time of cancer diagnosis, and many had no identifiable risk factors for infection. Screening patients with cancer to identify HBV and HCV infection before starting treatment may be warranted to prevent viral reactivation and adverse clinical outcomes. The low rate of undiagnosed HIV infection may not support universal screening of newly diagnosed cancer patients.
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Affiliation(s)
- Scott D Ramsey
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Joseph M Unger
- Fred Hutchinson Cancer Research Center, Seattle, Washington.,SWOG (formerly the Southwest Oncology Group) Statistics and Data Management Center, Seattle, Washington
| | | | - Richard F Little
- Cancer Therapy and Evaluation Program, National Cancer Institute, Bethesda, Maryland
| | - Rohit Loomba
- Division of Gastroenterology, University California San Diego Moores Cancer Center, San Diego
| | - Jessica P Hwang
- Department of General Internal Medicine, University of Texas, MD Anderson Cancer Center, Houston
| | - Rashmi Chugh
- Rogel Cancer Center, University of Michigan, Ann Arbor
| | | | - Kathryn Arnold
- Fred Hutchinson Cancer Research Center, Seattle, Washington.,SWOG (formerly the Southwest Oncology Group) Statistics and Data Management Center, Seattle, Washington
| | - Alex R Menter
- Department of Oncology, Kaiser Permanente-Lonetree, Lonetree, Colorado
| | - Eva Thomas
- Department of Oncology, Kaiser Permanente Medical Center, Oakland, California
| | - Ross M Michels
- National Cancer Institute Community Oncology Research Program of the Carolinas, Greenville Health System National Cancer Institute Community Oncology Research Program, Greenville, South Carolina
| | - Carla Walker Jorgensen
- National Cancer Institute Community Oncology Research Program of the Carolinas, Greenville Health System National Cancer Institute Community Oncology Research Program, Greenville, South Carolina
| | - Gary V Burton
- Gulf South Minority-Underserved National Cancer Institute Community Oncology Research Program, Louisiana State University Health Sciences Center, Shreveport
| | - Nishin A Bhadkamkar
- Department of General Oncology, University of Texas, MD Anderson Cancer Center, Houston
| | - Dawn L Hershman
- Division of Hematology/Oncology, Herbert Irving Comprehensive Cancer Center, Columbia University, New York, New York
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19
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Tapp H, Ludden T, Shade L, Thomas J, Mohanan S, Leonard M. Electronic medical record alert activation increase hepatitis C and HIV screening rates in primary care practices within a large healthcare system. Prev Med Rep 2020; 17:101036. [PMID: 31970042 PMCID: PMC6965743 DOI: 10.1016/j.pmedr.2019.101036] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 12/03/2019] [Accepted: 12/27/2019] [Indexed: 01/10/2023] Open
Abstract
The electronic medical record alert improved screening for HCV and HIV. 91% of HCV and 100% of HIV positive patients were linked into care. Low post-intervention screening rates suggest additional interventions are required.
Societal and economic burdens of hepatitis C virus (HCV) and human immunodeficiency virus (HIV) continue to grow. The Centers for Disease Control and Prevention recommends a one-time HCV screen for individuals in the Baby Boomer population (those born between 1945 and 1965) and a one-time HIV screen for all individuals between ages 13–64 years regardless of risk factors, with more frequent screening for both conditions based on individual risk factors. This study took place at Atrium Health, a healthcare system with approximately 12 million patient encounters per year. The aims of this study were to assess the impact of the HCV and HIV electronic medical record (EMR) alerts recently implemented on screening rates and linkage to care. Data were collected from 12 primary care practices. Implementation of EMR alerts increased HCV and HIV screening from 1,934 of 59,632 (3.2%) to 13,726 of 60,422 (22.7%) and 6,950 of 112,813 (6.2%) to 12,379 of 109,173 (11.3%) respectively. The HCV screening resulted in an increase of patients with antibody positive results having a subsequent RNA test from 68% (122/179) to 98% (430/442). 74 of 81 (91%) of HCV and 15 of 15 (100%) of HIV positive patients were linked into care. The addition of an EMR alert was associated with improved screening for HCV and HIV in primary care practices. Screening all patients decreases testing stigma since there is a lowered risk of disease transmission for those who test positive. However, post-intervention screening rates indicate further opportunities exist for additional interventions to increase screening rates.
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Affiliation(s)
- Hazel Tapp
- Department of Family Medicine, Atrium Health, 2001 Vail Avenue, Suite 400B, Charlotte, NC 28207, United States
| | - Thomas Ludden
- Department of Family Medicine, Atrium Health, 2001 Vail Avenue, Suite 400B, Charlotte, NC 28207, United States
| | - Lindsay Shade
- Department of Family Medicine, Atrium Health, 2001 Vail Avenue, Suite 400B, Charlotte, NC 28207, United States
| | - Jeremy Thomas
- Department of Family Medicine, Atrium Health, 2001 Vail Avenue, Suite 400B, Charlotte, NC 28207, United States
| | - Sveta Mohanan
- Department of Family Medicine, Atrium Health, 2001 Vail Avenue, Suite 400B, Charlotte, NC 28207, United States
| | - Michael Leonard
- Department of Infectious Diseases, Atrium Health, 4539 Hedgemore Drive, Suite 100, Charlotte, NC 28209, United States
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20
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Bakhai S, Nallapeta N, El-Atoum M, Arya T, Reynolds JL. Improving hepatitis C screening and diagnosis in patients born between 1945 and 1965 in a safety-net primary care clinic. BMJ Open Qual 2019; 8:e000577. [PMID: 31637319 PMCID: PMC6768492 DOI: 10.1136/bmjoq-2018-000577] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 08/06/2019] [Accepted: 09/07/2019] [Indexed: 12/18/2022] Open
Abstract
Individuals born between 1945-1965 represent 81% of all persons chronically infected with hepatitis C virus (HCV) in the USA and are largely unaware of their positive status. The baseline HCV screening rate in this population in an academic internal medicine clinic at a US hospital was less than 3.0%. The goal was to increase the rate of HCV screening in patients born between 1945 and 1965 to 20% within 24 months. The quality improvement team used the Plan Do Study Act Model. Outcome measures included HCV antibody screening, HCV RNA positive rate and linkage to hepatology care. Process measures included HCV antibody order and completion rates. The quality improvement team performed a root cause analysis and identified barriers for HCV screening and linkage to care. The key elements of interventions included redesigning nursing workflow, use of health information technology and educating patients, physicians and nursing staff about HCV. The HCV screening rate was 30.3% (391/1291) within 24 months. The HCV antibody positive rate was 43.5% (170/391), and HCV RNA positive rate was 95.3% (162/170). HCV infection was diagnosed in 12.5% (162/1291) of patients or 41.4% (162/391) of the screened population. Of those positive, 70% (114/162) were linked to hepatology care within the 24-month project timeframe. Eighty percent of patients seen by a hepatologist were treated with direct-acting antivirals agents. The HCV screening rate was sustained at 25.4% during the post-project 1-year period. Engagement of a multidisciplinary team and education to patients, physicians and nursing staff were the key drivers for success.
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Affiliation(s)
- Smita Bakhai
- Department of Internal Medicine, University at Buffalo – The State University of New York, Buffalo, New York, USA
| | - Naren Nallapeta
- Department of Internal Medicine, University at Buffalo – The State University of New York, Buffalo, New York, USA
| | - Mohammad El-Atoum
- Department of Internal Medicine, University at Buffalo – The State University of New York, Buffalo, New York, USA
| | - Tenzin Arya
- Department of Internal Medicine, University at Buffalo – The State University of New York, Buffalo, New York, USA
| | - Jessica L Reynolds
- Department of Medicine, University at Buffalo – The State University of New York, Buffalo, New York, USA
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21
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Calner P, Sperring H, Ruiz-Mercado G, Miller NS, Andry C, Battisti L, Scrudder K, Shea F, Chan A, Schechter-Perkins EM. HCV screening, linkage to care, and treatment patterns at different sites across one academic medical center. PLoS One 2019; 14:e0218388. [PMID: 31291275 PMCID: PMC6619669 DOI: 10.1371/journal.pone.0218388] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 06/01/2019] [Indexed: 12/20/2022] Open
Abstract
Background It is unclear whether sites that screen large numbers of patients for Hepatitis C Virus but achieve limited follow-up are more or less effective at having patients succeed through linkage and treatment than lower volume sites that have higher linkage percentages. The objective was to compare the rates of HCV identification, linkage to care, and treatment success between different study sites including the Emergency Department, 3 outpatient clinics with unique patients, and the inpatient setting at one medical center Methods This is a descriptive analysis of 2 years of data from a protocol that integrated HCV screening and treatment into clinical services throughout multiple departments in one medical center. The program used a best practice advisory to prompt testing at all sites, with different triggers for it to fire at each site, and one central navigation program that attempted to link all patients diagnosed with hepatitis C virus to outpatient care. Outcomes included volume of tests performed in each site, Antibody and RNA rates at each site, demographic data, navigation and linkage outcomes, and post-linkage treatment completion. Results 28,435 patients were screened across 5 clinical locations. RNA+ rates and absolute numbers linked to MD (linkage rates among all RNA+) were: ED 7.2% RNA+, 224 (22.6%) linked; Inpatient 14.8% RNA+, 27 (17.6%) linked, General Internal Medicine 3.9% RNA+, 269 (65.8%) linked, Infectious Diseases 4.0% RNA+, 34(70.8%) linked, Family Medicine 2.0% RNA+, 28 (75.7%) linked. Demographics, linkage barriers, and treatment initiation rates were different at all sites. Conclusion Among sites there were differences in the sociodemographic characteristics of patients diagnosed with HCV, as well as differences in the success linking patients to outpatient care. At this medical center, the ED screened the most patients, the inpatient area had the highest RNA positivity rate, the FM clinic had the highest linkage rate, GIM linked the most patients by absolute number, and GIM also had the highest number of patients start treatment.
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Affiliation(s)
- Paul Calner
- Department of Emergency Medicine, Boston University Medical Center, Boston, Massachusetts, United States of America
| | - Heather Sperring
- Boston University Master’s Program in Public Health, Section of Infectious Disease, Department of General Internal Medicine, Boston University Medical Center, Boston, Massachusetts, United States of America
| | - Glorimar Ruiz-Mercado
- Center for Infectious Diseases and Public Health Programs Section of Infectious Diseases, Department of General Internal Medicine Boston University Medical Center, Boston, Massachusetts, United States of America
| | - Nancy S. Miller
- Clinical Microbiology & Molecular Diagnostics Laboratory Medicine, Boston University Medical Center, Department of Pathology & Laboratory Medicine, Boston, Massachusetts United States of America
| | - Chris Andry
- Clinical Microbiology & Molecular Diagnostics Laboratory Medicine, Boston University Medical Center, Department of Pathology & Laboratory Medicine, Boston, Massachusetts United States of America
| | - Leandra Battisti
- Department of Pharmacy Operations & Project Management, Boston Medical Center, Boston, Massachusetts, United States of America
| | - Katy Scrudder
- Center for Infectious Diseases and Public Health Programs Section of Infectious Diseases, Department of General Internal Medicine Boston University Medical Center, Boston, Massachusetts, United States of America
| | - Fiona Shea
- Center for Infectious Diseases and Public Health Programs Section of Infectious Diseases, Department of General Internal Medicine Boston University Medical Center, Boston, Massachusetts, United States of America
| | - Angelica Chan
- Center for Infectious Diseases and Public Health Programs Section of Infectious Diseases, Department of General Internal Medicine Boston University Medical Center, Boston, Massachusetts, United States of America
| | - Elissa M. Schechter-Perkins
- Department of Emergency Medicine, Boston University Medical Center, Boston, Massachusetts, United States of America
- * E-mail:
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22
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Jain MK, Rich NE, Ahn C, Turner BJ, Sanders JM, Adamson B, Quirk L, Perryman P, Santini NO, Singal AG. Evaluation of a Multifaceted Intervention to Reduce Health Disparities in Hepatitis C Screening: A Pre-Post Analysis. Hepatology 2019; 70:40-50. [PMID: 30950085 DOI: 10.1002/hep.30638] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 03/25/2019] [Indexed: 12/30/2022]
Abstract
Hepatitis C virus (HCV) testing in persons born from 1945 to 1965 has had limited adoption despite guidelines, particularly among racial/ethnic minorities and socioeconomically disadvantaged patients, who have a higher prevalence of disease burden. We examined the effectiveness of a multifaceted intervention to improve HCV screening in a large safety-net health system. We performed a multifaceted intervention that included provider and patient education, an electronic medical record-enabled best practice alert, and increased HCV treatment capacity. We characterized HCV screening completion before and after the intervention. To identify correlates of HCV screening, we performed logistic regression for the preintervention and postintervention groups and used a generalized linear mixed model for patients observed in both preintervention and postintervention time frames. Before the intervention, 10.1% of 48,755 eligible baby boomer patients were screened. After the intervention, 34.6% of the 34,093 eligible baby boomers were screened (P < 0.0001). Prior to the intervention, HCV screening was lower among older baby boomers and providers with large patient panels and higher in high-risk subgroups including those with signs of liver disease (e.g., elevated transaminases, thrombocytopenia), human immunodeficiency virus-positive patients, and homeless patients. Postintervention, we observed increased screening uptake in older baby boomers, providers with larger patient panel size, and patients with more than one prior primary care appointment. Conclusion: Our multifaceted intervention significantly increased HCV screening, particularly among older patients, those engaged in primary care, and providers with large patient panels.
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Affiliation(s)
- Mamta K Jain
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX.,Parkland Health & Hospital System, Dallas, TX
| | - Nicole E Rich
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX.,Parkland Health & Hospital System, Dallas, TX
| | - Chul Ahn
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX
| | - Barbara J Turner
- Department of Internal Medicine, UT Health Science Center, San Antonio, TX
| | - Joanne M Sanders
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX
| | - Brian Adamson
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX
| | - Lisa Quirk
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX
| | - Patrice Perryman
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX
| | - Noel O Santini
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX.,Parkland Health & Hospital System, Dallas, TX
| | - Amit G Singal
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX.,Parkland Health & Hospital System, Dallas, TX.,Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX
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23
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Wray D, Coppin JD, Scott D, Jacob DA, Jinadatha C. Increased HCV Screening Yields Discordant Gains in Diagnoses Among Urban and Rural Veteran Populations in Texas: Results of a Statewide Quality Improvement Initiative. Jt Comm J Qual Patient Saf 2018; 45:112-122. [PMID: 30266248 DOI: 10.1016/j.jcjq.2018.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 06/21/2018] [Accepted: 06/28/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Chronic hepatitis C virus (HCV) infection is a significant health burden among military veterans. Our goals were to increase monthly HCV screenings, diagnoses, and sustained virologic responses (SVR) among 88,652 unscreened birth cohort Veterans in Texas. METHODS The interventions were enabled within six of the eight healthcare systems (HCSs) that compose Veteran's Integrated Service Network 17. The remaining two HCSs served as controls. The HCSs were separated into two groups: urban and rural; each composed of a control and three interventional HCSs. Decision support programming was embedded within the Computerized Patient Record System that prompted HCV screening among previously unscreened birth cohort patients. Clinical process design and educational efforts were enacted to enhance treatment capacity. RESULTS Monthly screenings increased 4.89 times (p < 0.001) and 2.97 times (p < 0.001) during the postinterventional period relative to control for urban and rural HCSs, respectively. For urban HCSs, diagnoses increased 1.58 (p < 0.001) times more than the control group during the postinterventional period, but there was no difference in number of diagnoses in the rural HCSs (p = 0.86). Monthly SVR increased 2.69 times more than the control group during the postinterventional period (p < 0.001). CONCLUSION Decision support improved HCV screening among birth cohort patients in both urban and rural HCSs. Increased screening boosted the monthly number of diagnoses in the urban HCSs, but not in the rural HCSs; which rebuts the utility of birth cohort screening among rurally residing veterans. These interventions significantly improved the rate of SVR achievement relative to control.
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24
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MacLean CD, Berger C, Cangiano ML, Ziegelman D, Lidofsky SD. Impact of electronic reminder systems on hepatitis C screening in primary care. J Viral Hepat 2018; 25:939-944. [PMID: 29478306 DOI: 10.1111/jvh.12885] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 01/02/2018] [Indexed: 01/27/2023]
Abstract
Screening for hepatitis C virus (HCV) was recommended in 2012 by the Centers for Disease Control (CDC) for the population born between 1946 and 1965. Reminder systems are effective at promoting HCV screening, but the yield of positive tests among various population subgroups and the linkage to specialty HCV treatment is not well understood. We sought to determine: (i) the effect of the CDC recommendation alone, and the effect of an electronic medical record (EMR) reminder on the proportion of the population screened; (ii) the yield of positive HCV tests as screening strategies have evolved, and according to a patient's history of serum aminotransferase testing; (iii) the proportion of positive cases followed up for HCV treatment. This retrospective cohort study included 60 000 primary care patients at a northeast US academic medical centre serving an urban and rural population in which an EMR reminder was instituted in 2014. Results demonstrated an increase in proportion tested for HCV from 12% prior to the CDC recommendation to 37% after the reminder system. The yield of positive HCV antibody (HCV Ab) tests decreased from 7% in the "case-finding" era to 1.6% after the EMR reminder prompted screening of a lower risk population (P < .001). Patients with a history of abnormal aminotransferase tests had a fivefold higher rate of positive HCV Ab testing (6.7% vs 1.5%, P < .001). Ninety per cent of patients with confirmed HCV infection were seen in specialty care.
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Affiliation(s)
- C D MacLean
- Division of General Internal Medicine, Robert Larner, MD College of Medicine at the University of Vermont, Burlington, VT, USA
| | - C Berger
- Division of General Internal Medicine, Robert Larner, MD College of Medicine at the University of Vermont, Burlington, VT, USA
| | - M L Cangiano
- Department of Family Medicine, Robert Larner, MD College of Medicine at the University of Vermont, Burlington, VT, USA
| | - D Ziegelman
- Division of General Internal Medicine, Robert Larner, MD College of Medicine at the University of Vermont, Burlington, VT, USA
| | - S D Lidofsky
- Division of Gastroenterology, Robert Larner, MD College of Medicine at the University of Vermont, Burlington, VT, USA
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25
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Yeboah-Korang A, Beig MI, Khan MQ, Goldstein JL, Macapinlac DM, Maurer D, Sonnenberg A, Fimmel CJ. Hepatitis C Screening in Commercially Insured U.S. Birth-cohort Patients: Factors Associated with Testing and Effect of an EMR-based Screening Alert. J Transl Int Med 2018; 6:82-89. [PMID: 29984203 PMCID: PMC6032190 DOI: 10.2478/jtim-2018-0012] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Hepatitis C virus (HCV) testing rates among U.S. birth-cohort patients have been studied extensively, limited data exists to differentiate birth-cohort screening from risk- or liver disease-based testing. This study aims to identify factors associated with HCV antibody (HCV-Ab) testing in a group of insured birth cohort patients, to determine true birth cohort testing rates, and to determine whether an electronic medical record (EMR)-driven Best Practice Alert (BPA) would improve birth cohort testing rates. METHODS All birth-cohort outpatients between 2010 and 2015 were identified. HCV-Ab test results, clinical, and demographic variables were extracted from the EMR, and factors associated with testing were analyzed by logistic regression. True birth-cohort HCV screening rates were determined by detailed chart review for all outpatient visits during one calendar month. An automated Best Practice Alert was used to identify unscreened patients at the point of care, and to prompt HCV testing. Screening rates before and after system-wide implementation of the BPA were compared. RESULTS The historic HCV-Ab testing rate was 11.2% (11,976/106,753). Younger age, female gender, and African American, Asian, or Hispanic ethnicity, and medical comorbidities such as chronic hemodialysis, HIV infection, and rheumatologic and psychiatric comorbidities were associated with higher testing rates. However, during the one-month sampling period, true age cohort-based testing was performed in only 69/10,089 patients (0.68%). Following the system-wide implementation of the HCV BPA, testing rates increased from 0.68% to 10.76% (P<0.0001). CONCLUSIONS We documented low HCV-Ab testing rates in our baby boomers population. HCV testing was typically performed in the presence of known risk factors or established liver disease. The implementation of an EMR-based HCV BPA resulted in a marked increase in testing rates. Our study highlights current HCV screening gaps, and the utility of the EMR to improve screening rates and population health.
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Affiliation(s)
| | | | | | | | | | | | - Amnon Sonnenberg
- Portland VA Medical Center and Oregon Health & Science University, Portland, OR, USA
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26
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Konerman MA, Thomson M, Gray K, Moore M, Choxi H, Seif E, Lok ASF. Impact of an electronic health record alert in primary care on increasing hepatitis c screening and curative treatment for baby boomers. Hepatology 2017; 66:1805-1813. [PMID: 28714196 PMCID: PMC5696058 DOI: 10.1002/hep.29362] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 07/07/2017] [Indexed: 12/13/2022]
Abstract
Despite effective treatment for chronic hepatitis C, deficiencies in diagnosis and access to care preclude disease elimination. Screening of baby boomers remains low. The aims of this study were to assess the impact of an electronic health record-based prompt on hepatitis C virus (HCV) screening rates in baby boomers in primary care and access to specialty care and treatment among those newly diagnosed. We implemented an electronic health record-based "best practice advisory" (BPA) that prompted primary care providers to perform HCV screening for patients seen in primary care clinic (1) born between 1945 and 1965, (2) who lacked a prior diagnosis of HCV infection, and (3) who lacked prior documented anti-HCV testing. The BPA had associated educational materials, order set, and streamlined access to specialty care for newly diagnosed patients. Pre-BPA and post-BPA screening rates were compared, and care of newly diagnosed patients was analyzed. In the 3 years prior to BPA implementation, 52,660 baby boomers were seen in primary care clinics and 28% were screened. HCV screening increased from 7.6% for patients with a primary care provider visit in the 6 months prior to BPA to 72% over the 1 year post-BPA. Of 53 newly diagnosed patients, all were referred for specialty care, 11 had advanced fibrosis or cirrhosis, 20 started treatment, and 9 achieved sustained virologic response thus far. CONCLUSION Implementation of an electronic health record-based prompt increased HCV screening rates among baby boomers in primary care by 5-fold due to efficiency in determining needs for HCV screening and workflow design. Streamlined access to specialty care enabled patients with previously undiagnosed advanced disease to be cured. This intervention can be easily integrated into electronic health record systems to increase HCV diagnosis and linkage to care. (Hepatology 2017;66:1805-1813).
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Affiliation(s)
- Monica A. Konerman
- University of Michigan, Department of Internal Medicine, Division of Gastroenterology and Hepatology, Ann Arbor, Michigan, USA
| | - Mary Thomson
- University of Michigan, Department of Internal Medicine, Division of Gastroenterology and Hepatology, Ann Arbor, Michigan, USA
| | - Kristen Gray
- Population and Health Management Ambulatory Care Services Team, Ann Arbor, Michigan, USA
| | - Meghan Moore
- Population and Health Management Ambulatory Care Services Team, Ann Arbor, Michigan, USA
| | - Hetal Choxi
- University of Michigan, Department of Family Medicine, Ann Arbor, Michigan, USA
| | - Elizabeth Seif
- Population and Health Management Ambulatory Care Services Team, Ann Arbor, Michigan, USA
| | - Anna SF Lok
- University of Michigan, Department of Internal Medicine, Division of Gastroenterology and Hepatology, Ann Arbor, Michigan, USA
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27
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Fitch DN, Dharod A, Campos CL, Núñez M. Use of electronic health record clinical decision support tool for HCV birth cohort screening. J Viral Hepat 2017; 24:1076. [PMID: 28544048 DOI: 10.1111/jvh.12729] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- D N Fitch
- Department of Internal Medicine, Wake Forest School of Medicine, Section on General Internal Medicine, Winston Salem, NC, USA
| | - A Dharod
- Department of Internal Medicine, Wake Forest School of Medicine, Section on General Internal Medicine, Winston Salem, NC, USA
| | - C L Campos
- Department of Internal Medicine, Wake Forest School of Medicine, Section on General Internal Medicine, Winston Salem, NC, USA
| | - M Núñez
- Department of Internal Medicine, Wake Forest School of Medicine, Section on Infectious Diseases, Winston Salem, NC, USA
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28
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Castrejón M, Chew KW, Javanbakht M, Humphries R, Saab S, Klausner JD. Implementation of a Large System-Wide Hepatitis C Virus Screening and Linkage to Care Program for Baby Boomers. Open Forum Infect Dis 2017; 4:ofx109. [PMID: 28752101 PMCID: PMC5527269 DOI: 10.1093/ofid/ofx109] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 05/26/2017] [Indexed: 01/14/2023] Open
Abstract
Background We implemented and evaluated a large health system-wide hepatitis C virus (HCV) screening and linkage to care program for persons born between 1945 and 1965 (“baby boomers”). Methods An electronic health record (EHR) clinical decision support (CDS) tool for HCV screening for baby boomers was introduced in August 2015 for patients seen in the outpatient University of California, Los Angeles healthcare system setting. An HCV care coordinator was introduced in January 2016 to facilitate linkage to HCV care. We compared HCV testing in the year prior (August 2014–July 2015) to the year after (August 2015–July 2016) implementation of the CDS tool. Among patients with reactive HCV antibody testing, we compared outcomes related to the care cascade including HCV ribonucleic acid (RNA) testing, HCV RNA positivity, and linkage to HCV specialty care. Results During the study period, 19606 participants were screened for HCV antibody. Hepatitis C virus antibody screening increased 145% (from 5676 patients tested to 13930 tested) after introduction of the CDS intervention. Screening increased across all demographic groups including age, sex, and race/ethnicity, with the greatest increases among those in the older age groups. The addition of an HCV care coordinator increased follow-up HCV RNA testing for HCV antibody positive patients from 83% to 95%. Ninety-four percent of HCV RNA positive patients were linked to care postimplementation. Conclusions Introduction of an EHR CDS tool and care coordination markedly increased the number of baby boomers screened for HCV, rates of follow-up HCV RNA testing, and linkage to specialty HCV care for patients with chronic HCV infection.
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Affiliation(s)
| | - Kara W Chew
- Department of Medicine, Division of Infectious Diseases
| | - Marjan Javanbakht
- Department of Epidemiology, University of California, Los Angeles Fielding School of Public Health
| | | | - Sammy Saab
- Department of Medicine, Division of Digestive Diseases, David Geffen School of Medicine, University of California, Los Angeles; and
| | - Jeffrey D Klausner
- Department of Medicine, Division of Infectious Diseases.,Department of Epidemiology, University of California, Los Angeles Fielding School of Public Health
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