HCV screening, linkage to care, and treatment patterns at different sites across one academic medical center

Hepatitis C testing and linkage to care in a safety-net hospital emergency department

BACKGROUND AND PURPOSE

In 2020, the CDC expanded hepatitis C (HCV) screening recommendations to include universal screening for persons 18 and older. We implemented universal screening in the emergency department (ED) within a safety-net health system. We aimed to measure HCV prevalence and linkage to care (LTC) outcomes in the ED and compare them to the outpatient clinics within the same health system.

METHODS

Patients aged 18-79 without HCV qualified for screening. We measured prevalence of both anti-HCV+ (exposure) and HCV RNA+ (active infection). Those with active HCV were flagged for LTC and their charts were followed for outcomes. HCV prevalence and LTC in the ED were compared to those in outpatient clinics over the same time.

RESULTS

9511 patients were screened for HCV from 2019 to 2022 in the ED. 6.9 % (659) were anti-HCV+. 54.9 % (320 of 582) of anti-HCV+ individuals or 3.4 % of those screened (320 of 9511) were HCV RNA+. The LTC rate was 24.1 % (77 of 320) and a total of 56 individuals (17.8 % of all HCV RNA+ ED patients, 72.7 % of those linked) initiated treatment. HCV prevalence was higher in the ED compared to the outpatient clinic setting. Demographics and LTC rates also significantly differed between these two cohorts.

CONCLUSIONS

We identified a higher HCV prevalence in the ED relative to the outpatient clinic setting and significant need for improvement in LTC and HCV treatment initiation. Our findings suggest universal screening is an important tool to diagnose HCV infections but may require novel strategies for improved LTC and treatment initiation.

Barriers to recruitment of an observational SARS-CoV-2 emergency department cohort at Boston Medical Center

BACKGROUND

Successful recruitment of study participants is a challenging component of research, and recruitment barriers are amplified in safety-net hospital (SNH) settings. However, engaging historically underrepresented groups in research is critically important to improve health disparities and outcomes. We summarize challenges we encountered while recruiting patients with COVID-19 from the emergency department (ED), actions to improve inclusivity, and implementation hurdles in an SNH setting.

METHODS

We conducted an observational study at the largest safety-net hospital in New England, recruiting patients in the ED with confirmed COVID-19. Investigators prioritized recruitment inclusivity through language translations of study materials, compensation (including transport and travel reimbursement), flexible sample delivery options, and clinical staff engagement. We identified and categorized major impediments to recruitment success.

RESULTS

Recruitment and retention efforts were largely unsuccessful (n = 4 enrolled of n = 113 eligible by electronic medical record (EMR) review). Barriers to recruitment success included clinical teams' perception of good candidacy, persistent language barriers, limited consent capacity, burden of participation, and ED discharge logistics.

CONCLUSIONS

Despite efforts to improve opportunities to participate in research, SNH EDs present unique challenges for recruitment. Study teams should prioritize clinical staff engagement and work with institutions to promote inclusivity and community engagement efforts to improve research engagement in these settings.

CLINICAL TRIAL NUMBER

Not applicable.

Enhancing Hepatitis C Virus Testing, Linkage to Care, and Treatment Commencement in Hospitals: A Systematic Review and Meta-analysis

Background

The hospital-led interventions yielding the best hepatitis C virus (HCV) testing and treatment uptake are poorly understood.

Methods

We searched Medline, Embase, and Cochrane databases for studies assessing outcomes of hospital-led interventions for HCV antibody or RNA testing uptake, linkage to care, or direct-acting antiviral commencement compared with usual care, a historical comparator, or control group. We systematically reviewed hospital-led interventions delivered in inpatient units, outpatient clinics, or emergency departments. Random-effects meta-analysis estimated pooled odds ratios [pORs] measuring associations between interventions and outcomes. Subgroup analyses explored outcomes by intervention type.

Results

A total of 7872 abstracts were screened with 23 studies included. Twelve studies (222 868 participants) reported antibody testing uptake, 5 (n = 4987) reported RNA testing uptake, 7 (n = 3185) reported linkage to care, and 4 (n = 1344) reported treatment commencement. Hospital-led interventions were associated with increased antibody testing uptake (pOR, 5.83 [95% confidence interval {CI}, 2.49-13.61]; I 2 = 99.9%), RNA testing uptake (pOR, 10.65 [95% CI, 1.70-66.50]; I 2 = 97.9%), and linkage to care (pOR, 1.75 [95% CI, 1.10-2.79]; I 2 = 79.9%) when data were pooled and assessed against comparators. Automated opt-out testing (5 studies: pOR, 16.13 [95% CI, 3.35-77.66]), reflex RNA testing (4 studies: pOR, 25.04 [95% CI, 3.63-172.7]), and care coordination and financial incentives (4 studies: pOR, 2.73 [95% CI, 1.85-4.03]) showed the greatest increases in antibody and RNA testing uptake and linkage to care, respectively. No intervention increased uptake at all care cascade steps.

Conclusions

Automated antibody and reflex RNA testing increase HCV testing uptake in hospitals but have limited impact on linkage to treatment. Other interventions promoting linkage must be explored.

Characteristics and Outcomes of Direct-Acting Antiviral Experienced Patients with Hepatitis C Undergoing Retreatment at an Essential Hospital in the United States

Background

Hepatitis C virus (HCV) guidelines recommend direct-acting antiviral (DAA) rescue regimens in cases of treatment failure, and first-line regimens for reinfection. In patients with barriers to follow-up after treatment, it is difficult to determine if HCV viremia represents failure or reinfection. Patients are often retreated with rescue regimens despite higher costs. We compared the outcome of first-line vs rescue therapy in DAA experienced patients whose prior outcome was indeterminate.

Methods

This retrospective cohort study included DAA experienced adults undergoing retreatment at a hospital in Massachusetts between January 2016 and May 2022. We used descriptive statistics to characterize the population. For patients with an indeterminate prior HCV treatment outcome, we compared the groups' characteristics and outcomes.

Results

We included 112 patients. The mean age was 52 years (SD: 12.2), 80.4% were male, and 42.9% were White. Nearly 1 in 4 (25%) reported active substance use. Outcomes of prior DAA treatment included sustained virologic response at 12 weeks in 39.3% (n = 44) and treatment failure in 27.7% (n = 31). The prior treatment outcome was indeterminate in 33% (n = 37). We compared the outcomes of patients with an indeterminate treatment outcome retreated with first-line vs rescue therapy. Sustained virologic response at 12 weeks (66.7 vs 52.7%), treatment failure (0% vs 10.5%), and indeterminate outcome (33.3% vs 36.8%) were similar between the groups (P = .502).

Conclusions

Outcomes with first-line DAAs were comparable to rescue medications for retreatment of patients with DAA experience and an indeterminate prior treatment outcome. Our findings can help decrease treatment-level barriers for HCV treatment.

Simple, direct amplification of RNA-containing paper discs for diagnosing the hepatitis C virus

Nucleic acid extraction (NAE) is crucial for molecular diagnostics but presents challenges in point-of-care testing (POCT) and decentralized settings. We developed a streamlined, paper-based NAE method for hepatitis C virus (HCV) RNA amplification, suitable for integration into POCT and lab-on-a-chip systems. This method uses Fusion 5 paper discs, completing extraction in under 30 min without centrifugation. The nucleic acids on the disc can be directly used or eluted for amplification. We validated this method's compatibility with reverse transcription-polymerase chain reaction (RT-PCR), real-time quantitative PCR (RQ-PCR), and loop-mediated isothermal amplification (LAMP), demonstrating versatility across amplification platforms. Clinical evaluation (n = 60) showed 100% sensitivity and specificity with a low detection limit of ~101 IU/mL. Results matched those from standard HCV RQ-PCR, confirming accuracy. Additionally, incorporating polyethylene glycol (PEG) improves extraction efficiency, eliminating the need for ethanol treatment and washing/drying steps. This modification enhances performance and suitability for field applications. Our paper-based HCV amplification is affordable and user-friendly, making it valuable for decentralized HCV detection and supporting global health initiatives.

Variability of Hepatitis C Treatment Cascade Outcomes among People Who Inject Drugs across Geographically Diverse Clinics in the US: The HERO Study

Heterogeneity of outcomes across different clinical trial study sites is often inevitable. Understanding how outcomes differ by site is important for planning future programs and studies. We examined the extent of heterogeneity of hepatitis C virus (HCV) treatment cascade outcomes among persons who inject drugs (PWIDs) across sixteen clinical sites utilized in the HERO Study-a pragmatic randomized trial of HCV treatment support. Treatment cascade outcomes included averages of overall treatment adherence and proportions of treatment initiation, treatment completion, sustained virologic response (SVR) test completion, and SVR achievement. The HERO study utilized 16 clinical sites across the United States (US): eight opioid treatment programs (OTPs) and eight community health centers (CHCs). Variability of the outcomes across the 16 clinical sites was assessed using ranges and intraclass correlation coefficients (ICC) estimated from mixed-effects linear or logistic regression models. Treatment initiation was analyzed in the intention-to-treat (ITT) sample (N = 755); treatment completion, adherence, and SVR test completion in the modified ITT (mITT) sample, which is the sample that initiated treatment (N = 623); and SVR achievement in the mITT and per-protocol (PP, N = 501) samples. Across the 16 clinical sites, the range observed in the averages of overall treatment adherence was from 68% to 81% [ICC = 0.026 (0.005, 0.054)], and the ranges of proportions observed were from 68% to 96% for treatment initiation [ICC (95% CI) = 0.086 (0.051, 0.155)], 60% to 100% for treatment completion [ICC = 0.049 (0.008, 0.215)], 54% to 95% for SVR test completion [ICC = 0.096 (0.006, 0.177)], 46% to 90% for SVR achievement in the mITT sample [ICC = 0.070 (0.014, 0.122)], and 76% to 100% for SVR achievement in the PP sample [ICC = 0.143 (0.021, 0.422)]. The variability of the outcomes across 16 US sites treating HCV among PWIDs appears to be substantial in view of the ranges and ICC values of the outcomes. It is imperative to develop tailored interventions to target the sources of variability and reduce barriers at the patient, provider, clinic, and state policy levels to facilitate more equitable access to HCV treatment and reduce heterogeneity in treatment outcomes.

No Patient Left Behind: A Novel Paradigm to Fulfill Hepatitis C Virus Treatment for Rural Patients

Background

This study evaluates a novel multidisciplinary program providing expanded access to hepatitis C virus (HCV) treatment for rural Appalachian patients in South Carolina. This program identified patients via an opt-out emergency department screening program, and it aimed to achieve HCV cure by using community paramedics (CPs) to link and monitor patients from treatment initiation through 12-week sustained virologic response (SVR).

Methods

Patients aged ≥18 years who were HCV RNA positive were eligible for enrollment if they failed to appear for a scheduled HCV appointment or reported barriers to accessing office-based treatment. CPs provided home visits (initial and 4, 12, and 24 weeks) using a mobile Wi-Fi hotspot to support telemedicine appointments (compliant with the Health Insurance Portability and Accountability Act) and perform focused physical assessments, venipuncture, and coordinated home delivery of medications. Statistics described participant characteristics, prevalence of SVR, and patient satisfaction results at 12 weeks posttreatment.

Results

Thirty-four patients were eligible for SVR laboratory tests by 31 August 2023; the majority were male (61.7%) and White (64.7%) with an average age of 56 years (SD, 11.7). Twenty-eight (82.4%) completed treatment and achieved 12-week SVR. Six (17.6%) were lost to follow-up. Two-thirds strongly agreed that they were satisfied with the overall care that they received, and half strongly agreed that their overall health had improved.

Conclusions

This CP-augmented treatment program demonstrated success curing HCV for rural patients who lacked access to office-based treatment. Other health care systems may consider this novel delivery model to treat hard-to-reach individuals who are HCV positive.

A Potential Screening Strategy to Identify Probable Syphilis Infections in the Urban Emergency Department Setting

Background

Syphilis diagnosis in the emergency department (ED) setting is often missed due to the lack of ED-specific testing strategies. We characterized ED patients with high-titer syphilis infections (HTSIs) with the goal of defining a screening strategy that most parsimoniously identifies undiagnosed, untreated syphilis infections.

Methods

Unlinked, de-identified remnant serum samples from patients attending an urban ED, between 10 January and 9 February 2022, were tested using a three-tier testing algorithm, and sociodemographic variables were extracted from ED administrative database prior to testing. Patients who tested positive for treponemal antibodies in the first tier and positive at high titer (≥1:8) for nontreponemal antibodies in the second tier were classified as HTSI. Human immunodeficiency virus (HIV) status was determined with Bio-Rad enzyme-linked immunosorbent assay and confirmatory assays. Exact logistic regression and classification and regression tree (CART) analyses were performed to determine factors associated with HTSI and derive screening strategies.

Results

Among 1951 unique patients tested, 23 (1.2% [95% confidence interval, .8%-1.8%]) had HTSI. Of those, 18 (78%) lacked a primary care physician, 5 (22%) were HIV positive, and 8 (35%) were women of reproductive age (18-49 years). CART analysis (area under the curve of 0.67) showed that using a screening strategy that measured syphilis antibodies in patients with HIV, without a primary care physician, and women of reproductive age would have identified most patients with HTSI (21/23 [91%]).

Conclusions

We show a high prevalence of HTSI in an urban ED and propose a feasible, novel screening strategy to curtail community transmission and prevent long-term complications.

Improving the hepatitis C virus care cascade with the in-hospital Reflex tEsting ALarm-C (REAL-C) model

BACKGROUND

The World Health Organization (WHO) has set targets to eliminate viral hepatitis, including hepatitis C virus (HCV) infection, by 2030. We present the results of the in-hospital Reflex tEsting ALarm-C (REAL-C) model, which incorporates reflex HCV RNA testing and sending alerts to physicians.

METHODS

We conducted a retrospective study analysing the data of 1730 patients who newly tested positive for anti-HCV between March 2020 and June 2023. Three distinct periods were defined: pre-REAL-C (n = 696), incomplete REAL-C (n = 515) and complete REAL-C model periods (n = 519). The primary outcome measure was the HCV RNA testing rate throughout the study period. Additionally, we assessed the referral rate to the gastroenterology department, linkage time for diagnosis and treatment and the treatment rate.

RESULTS

The rate of HCV RNA testing increased significantly from 51.0% (pre-REAL-C) to 95.6% (complete REAL-C). This improvement was consistent across clinical departments, regardless of patients' comorbidities. Among patients with confirmed HCV infection, the gastroenterology referral rate increased from 57.1% to 81.1% after the REAL-C model. The treatment rate among treatment-eligible patients was 92.4% during the study period. The mean interval from anti-HCV positivity to HCV RNA testing decreased from 45.1 to 1.9 days. The mean interval from the detection of anti-HCV positivity to direct-acting antiviral treatment also decreased from 89.5 to 49.5 days with the REAL-C model.

CONCLUSION

The REAL-C model, featuring reflex testing and physician alerts, effectively increased HCV RNA testing rates and streamlined care cascades. Our model facilitated progress towards achieving WHO's elimination goals for HCV infection.

Implementing a Surveillance-Based Approach to Create a Statewide Viral Clearance Cascade for Hepatitis C Among People With HIV and HCV Coinfection in Connecticut

OBJECTIVES

Highly effective direct-acting antiviral medications have made it feasible to achieve elimination of hepatis C virus (HCV), including for people with HIV and HCV coinfection. The Centers for Disease Control and Prevention offers guidance for a laboratory surveillance-based HCV viral clearance cascade, which allows public health departments to track the outcomes of people with HCV based on the following steps: ever infected, virally tested, initial infection, and cured or cleared. We examined the feasibility of this approach among people with HIV and HCV coinfection in Connecticut.

METHODS

We matched an HIV surveillance database, which included cases from the enhanced HIV/AIDS Reporting System as of December 31, 2019, and the HCV surveillance database, the Connecticut Electronic Disease Surveillance System, to define a cohort of coinfected people. We used HCV laboratory results obtained from January 1, 2016, through August 3, 2020, to determine HCV status.

RESULTS

Of 1361 people who were ever infected with HCV as of December 31, 2019, 1256 (92.3%) received HCV viral testing, 865 of 1256 people tested (68.9%) were HCV infected, and 336 of 865 infected people (38.8%) were cleared or cured. People who had undetectable HIV viral loads at most recent HIV test (<200 copies/mL) were more likely than those with detectable HIV viral loads to achieve HCV cure (P = .02).

CONCLUSIONS

A surveillance-based approach that includes data based on the Centers for Disease Control and Prevention HCV viral clearance cascade is feasible to implement, can help track population-level outcomes longitudinally, and can help identify gaps to inform HCV elimination strategies.

Reflex Hepatitis C Virus Viral Load Testing Following an Initial Positive Hepatitis C Virus Antibody Test: A Global Systematic Review and Meta-analysis

BACKGROUND

Many people who have a positive hepatitis C virus (HCV) antibody (Ab) test never receive a confirmatory HCV RNA viral load (VL) test. Reflex VL testing may help address this problem. We undertook a systematic review to evaluate the effectiveness of reflex VL testing compared with standard nonreflex approaches on outcomes across the HCV care cascade.

METHODS

We searched 4 databases for studies that examined laboratory-based reflex or clinic-based reflex VL testing approaches, with or without a nonreflex comparator, and had data on the uptake of HCV RNA VL test and treatment initiation and turnaround time between Ab and VL testing. Both laboratory- and clinic-based reflex VL testing involve only a single clinic visit. Summary estimates were calculated using random-effects meta-analyses.

RESULTS

Fifty-one studies were included (32 laboratory-based and 19 clinic-based reflex VL testing). Laboratory-based reflex VL testing increased HCV VL test uptake versus nonreflex testing (RR: 1.35; 95% CI: 1.16-1.58) and may improve linkage to care among people with a positive HCV RNA test (RR: 1.47; 95% CI: .81-2.67) and HCV treatment initiation (RR: 1.03; 95% CI: .46-2.32). The median time between Ab and VL test was <1 day for all laboratory-based reflex studies and 0-5 days for 13 clinic-based reflex testing.

CONCLUSIONS

Laboratory-based and clinic-based HCV reflex VL testing increased uptake and reduced time to HCV VL testing and may increase HCV linkage to care. The World Health Organization now recommends reflex VL testing as an additional strategy to promote access to HCV VL testing and treatment.

CLINICAL TRIALS REGISTRATION

PROSPERO CRD42021283822.

Impact of an interdisciplinary patient care model and routine screening on clinical outcomes in patients with hepatitis C

Testing for hepatitis C in hospital emergency departments (ED) and linkage to care to clinics have been reported to provide the most opportunity for screening patients and facilitating continuum of care. Treatment model initiatives have expanded to include telehealth services and open treatment capacity to non-physician providers, such as pharmacists. This study's objective was to assess the impact of implementing automated routine screening for hepatitis C virus (HCV) and a clinical pharmacist into the interdisciplinary care model on HCV diagnosis and treatment outcomes. This retrospective cohort study compared outcomes in a pre-intervention and post-intervention group. Patients were screened and diagnosed with HCV at Jersey City Medical Center (JCMC) and completed linkage to care at JCMC Center for Comprehensive Care. Interventions were the implementation of automated routine HCV screening in the ED and addition of a clinical pharmacist to the interdisciplinary patient care model. Primary endpoints analyzed the number of patients who have achieved sustained virologic response after 12 weeks of treatment (SVR12) and patients who have completed treatment with no reported record of SVR12. Secondary endpoints analyzed the number of patients lost to follow-up, appointment type, time spent in appointments, and clinical pharmacist specialist interventions. Data was collected as categorical variables and chi-squared tests assessed if there were differences between the two samples. Data was collected from 46 patients in the pre-intervention group and 37 patients in the post-intervention group. Patients consisted of mostly males. Ages ranged from 27 to 83 years old. Race included Black, White, Asian, and Other. This study's results showed the positive impact on implementation of routine screening, telehealth services, and an interdisciplinary team approach to HCV diagnosis and management. Given the timeframe, it also showed the potential positive impact on these interventions during a global pandemic.

Sustained virologic response from hepatitis C from an emergency department screening & linkage program: A retrospective review

INTRODUCTION

The role of the Emergency Department (ED) as a vital constituent in Hepatitis C (HCV) screening has become increasingly evident. A key component of the ED's role in HCV screening is the ability to effectively link HCV-RNA positive patients to definitive, HCV-specific care, to include direct-acting antiviral (DAA) medication with resultant sustained virologic response (SVR). We sought to consider the rate of HCV-specific linkage, DAA initiation, and SVR obtained in HCV patients identified from an ED screening program.

METHODS

A retrospective chart review was conducted in February of 2022 of all individuals who participated in an opt-out ED-based HCV screening program between January 2018 and December 2019. Data was disaggregated by race, gender, age/birth cohort, insurance status, and achievement of sustained virologic response (SVR). Bivariate analysis using Pearson's chi-square was utilized to compare outcomes based on insurance status, race, sex, and birth cohort.

RESULTS

Of 66,634 individuals screened for HCV during the study period, 885 (1.33%) patients were RNA-positive. Of those individuals, 121 (13.67%) were linked to HCV-specific care. Of those linked, the majority (66.9%) were male, white (66.1%; 33.1% Black), baby boomers or older (53.7%) and publicly insured (57.9%; private insurance 23.1%, self-pay 19%). Among linked patients, 88 (72.7%) started DAA medication. Mirroring linked demographics, majority were male (64.8%), white (64.8%), baby boomers or older (52.3%), and publicly insured (57.6%). White patients initiated on DAA were more likely to obtain SVR (64.9% versus 41.9% Black; p = .04) and uninsured patients were more likely to obtain SVR (82.4% versus 50.7% insured; p = .02). Bivariate consideration of SVR-patients specifically demonstrates that Black patients tended to be older, with significant overrepresentation of Baby boomers (77.5%) as compared to whites (37.5%; p < .0001). Black patients were also more likely to be publicly insured (82.5%) while white patients were more likely to have private insurance (28.8%) or be uninsured (26.3%) than their Black counterparts (12.5% and 5% respectively; p < .05).

CONCLUSION

An ED-based HCV screening program can result in successful HCV-specific linkage and care, to include DAA initiation and ultimately, SVR. Among linked patients, specific cohort considerations may demonstrate differences in age and insurance status which may have implications on DAA application and adherence, and therefore, individual ability to achieve SVR.

Innovating the Model for Student Pharmacists to Increase Access to Hepatitis C Testing (Project IMPACT)

BACKGROUND

Previous initiatives have described the feasibility of conducting point-of-care testing (POCT) for hepatitis C virus (HCV) within community pharmacies. Limited research has been conducted to evaluate the role of student pharmacists and technicians in providing these services.

OBJECTIVE

Describe the implementation of a student pharmacist-run HCV POCT initiative within an independent community pharmacy and evaluate the linkage to care process.

PRACTICE DESCRIPTION

One specialty and 3 community pharmacies managed by one independent pharmacy chain.

PRACTICE INNOVATION

Pharmacy students screened participants for HCV and referred those with a reactive result or reporting untreated HCV to a partnering medical facility for confirmatory testing. Individuals with confirmed HCV had the option to receive their prescriptions, along with monthly telephonic monitoring services from the independent pharmacy's specialty pharmacy.

EVALUATION METHODS

Researchers evaluated the number of participants who screened reactive or reported current HCV infection, successful referrals to medical care, and prescriptions dispensed by the specialty pharmacy for HCV treatment.

RESULTS

From September 2020 to September 2022, 236 individuals were screened for HCV at the pharmacy, of whom 11 screened reactive (4.7%) and 4 participants reported untreated HCV infection. In total, 15 participants were referred to care and 4 of these participants (26.7%) were successfully linked. One participant received prescriptions and telephonic monitoring for HCV treatment from the specialty pharmacy as a direct result of Project IMPACT (Innovating the Model for Student Pharmacists to Increase Access to Hepatitis C Testing).

PRACTICE IMPLICATIONS AND CONCLUSIONS

Project IMPACT demonstrated that community pharmacies can increase access to HCV screenings by using student pharmacists and technicians. Potential strategies to improve the linkage to care process include enhancing the quality of patient education and implementing telehealth services.

Patient Navigation Increases Linkage to Care and Receipt of Direct-acting Antiviral Therapy in Patients with Hepatitis C

BACKGROUND & AIMS

Patient navigation interventions can improve health outcomes in underserved, low-income, and racial and ethnic minority groups, who often experience health disparities. We examined the effectiveness of patient navigation to improve linkage to hepatitis C virus (HCV) treatment receipt in a socioeconomically disadvantaged, racially diverse patient population.

METHODS

We performed a pre-post analysis evaluating the effectiveness of a patient navigation program among baby boomers who tested positive for HCV in a safety-net health system. The usual care group (June 2013 to May 2015) and patient navigation group (January 2016 to December 2017) were balanced using a stabilized inverse probability of treatment weighting approach. We used logistic regression analyses to evaluate associations between patient navigation and linkage to care for HCV treatment evaluation, treatment initiation, and sustained virologic response.

RESULTS

Among 1353 patients (62% black, 61% uninsured, 16% homeless), 769 were in the usual care group, and 584 were in the patient navigation group. The patient navigation group had significantly higher odds of linkage to care (odds ratio [OR], 3.7; 95% confidence interval [CI], 2.9-4.8) and treatment initiation (OR, 3.2; 95% CI, 2.3-4.2) within 6 months. The patient navigation group continued to have increased linkage to care (OR, 3.4; 95% CI, 2.7-4.3) and treatment initiation (OR 2.3; 95% CI, 1.7-3.0) at 12 months. However, there was no significant difference in sustained virologic response between the groups (86.9% vs 86.1%; P = .78).

CONCLUSIONS

Patient navigation was associated with significantly increased linkage to care and treatment initiation among patients with HCV infection. Patient navigation programs can be used to promote HCV elimination among traditionally difficult-to-reach patient populations.

Racial Disparity in HCV Demographics and Treatment Between Interferon Era (2002-2003) and Direct Acting Anti-viral Era (2019)

Introduction  Direct-acting antiviral (DAA) treatment increased the sustained viral response (SVR) rate of patients with the hepatitis C virus (HCV) and eliminated response disparities between African American (AA) and non-AA patients seen with interferon (IFN). The aim of this study was to compare 2019 HCV patients (DAA era) to patients from January 1, 2002 and December 31, 2003 (IFN era) in our predominantly AA clinic population. Methods We extracted data on 585 HCV patients seen in 2019 (DAA era) and compared them to 402 patients seen in the IFN era. Results Most HCV patients were born between 1945 and 1965, but in the DAA era more younger patients were identified. Non-AA patients in both eras were less likely to be infected with genotype 1 compared to AA (95% vs 54%, P<0.001). Fibrosis was not increased in the DAA Era as compared to the IFN era as assessed either by serum-based assays (APRI, FIB-4) or transient elastography (FibroScan) (DAA era) vs biopsy (IFN era). More patients were treated in 2019 compared to 2002-2003 (159/585=27% vs 5/402=1%). For untreated patients, subsequent treatment within one year of the initial visit was low and similar in both eras (35%). Conclusion There continues to be a need to screen patients born between 1945 and 1965 for HCV as well as to identify increasing numbers of patients below this age cohort. Even though current therapies are oral, highly effective, and can be 8-12 weeks in duration, significant numbers of patients were not treated within a year of first visit.

Using Community Paramedicine to Treat Hepatitis C Virus in Upstate South Carolina

OBJECTIVES

Hepatitis C virus (HCV) is an infection of the liver that can lead to significant liver damage and hepatocellular carcinoma. Individuals born between 1945 and 1965 and individuals with intravenous drug use represent the largest HCV demographics and often experience barriers to treatment. In this case series, we discuss a novel partnership between community paramedics (CPs), HCV care coordinators, and an infectious disease physician to provide HCV treatment to individuals with barriers accessing care.

METHODS

Three patients tested positive for HCV within a large hospital system in the upstate region of South Carolina. All of the patients were contacted to discuss their results and scheduled for treatment by the hospital's HCV care coordination team. Patients who expressed barriers to attending in-person appointments or were lost to follow-up were offered a telehealth appointment facilitated by CPs performing a home visit with the added ability to draw blood and perform a physical assessment guided by the infectious disease physician. All of the patients were eligible for and prescribed treatment. The CPs assisted with follow-up visits, blood draws, and other patient needs.

RESULTS

Two of the three patients connected to care had an undetectable HCV viral load following 4 weeks of treatment, whereas the third was undetectable after 8 weeks. Only one patient reported a mild headache that was potentially linked to the medication, whereas the others did not report any adverse effects.

CONCLUSIONS

This case series highlights the barriers experienced by some HCV-positive patients and a distinctive plan to address impediments to access for HCV treatment.

A Microsimulation Study of the Cost-Effectiveness of Hepatitis C Virus Screening Frequencies in Hemodialysis Centers

BACKGROUND

National guidelines recommend twice-yearly hepatitis C virus (HCV) screening for patients receiving in-center hemodialysis. However, studies examining the cost-effectiveness of HCV screening methods or frequencies are lacking.

METHODS

We populated an HCV screening, treatment, and disease microsimulation model with a cohort representative of the US in-center hemodialysis population. Clinical outcomes, costs, and cost-effectiveness of the Kidney Disease Improving Global Outcomes (KDIGO) 2018 guidelines-endorsed HCV screening frequency (every 6 months) were compared with less frequent periodic screening (yearly, every 2 years), screening only at hemodialysis initiation, and no screening. We estimated expected quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICERs) between each screening strategy and the next less expensive alternative strategy, from a health care sector perspective, in 2019 US dollars. For each strategy, we modeled an HCV outbreak occurring in 1% of centers. In sensitivity analyses, we varied mortality, linkage to HCV cure, screening method (ribonucleic acid versus antibody testing), test sensitivity, HCV infection rates, and outbreak frequencies.

RESULTS

Screening only at hemodialysis initiation yielded HCV cure rates of 79%, with an ICER of $82,739 per QALY saved compared with no testing. Compared with screening at hemodialysis entry only, screening every 2 years increased cure rates to 88% and decreased liver-related deaths by 52%, with an ICER of $140,193. Screening every 6 months had an ICER of $934,757; in sensitivity analyses using a willingness-to-pay threshold of $150,000 per QALY gained, screening every 6 months was never cost-effective.

CONCLUSIONS

The KDIGO-recommended HCV screening interval (every 6 months) does not seem to be a cost-effective use of health care resources, suggesting that re-evaluation of less-frequent screening strategies should be considered.

Evaluation of a pilot emergency department linkage to care program for patients previously diagnosed with Hepatitis C

There is a significant number of Emergency Department (ED) patients with known chronic hepatitis C virus (HCV) infection who have not been treated with directly acting antivirals. We implemented a pilot ED-based linkage-to-care program to address this need and evaluated the impact of the program using the HCV Care Continuum metrics. Between March 2015 and May 2016, dedicated patient care navigators identified HCV RNA-positive patients in an urban ED and offered expedited appointments with the on-site viral hepatitis clinic. Patient demographics and care continuum outcomes were abstracted from the EMR and analysed to determine significant factors influencing linkage-to-care (LTC) and treatment initiation rates. The ED linkage-to-care program achieved a 43% linkage-to-care rate (165/384), 22% treatment rate (84/384) and 16% sustained virologic response rate (63/384). Significant associations were found between linkage-to-care and increasing age (OR = 1.03), Medicare insurance (OR = 2.21) and having a primary care physician (PCP) (OR = 4.03). For patients who were linked, the odds of initiating treatment were also positively significantly associated with increasing age (OR = 1.04) and having a PCP (OR = 2.77). For patients who initiated treatment, the odds of sustained virologic response were marginally associated with having a PCP (OR = 4.92).Our ED linkage-to-care program utilized care coordination to successfully link nearly half of approached HCV RNA-positive patients to care. This design can be feasibly replicated by other EDs given limited non-clinical training required for linkage-to-care staff. Adoption of similar programs in other EDs may improve the rates of LTC and treatment initiation for previously diagnosed HCV patients.

Early cost-utility analysis of hepatitis C virus testing for emergency department attendees in France

Testing for hepatitis C virus (HCV) is currently targeted towards those at high-risk in France. While universal screening was recently rejected, a growing body of research from other high-income countries suggests that HCV testing in emergency departments (ED) can be effective and cost-effective. In the absence of any studies on the effectiveness of HCV testing in ED attendees in France, this study aimed to perform an early economic evaluation of ED-based HCV testing. A Markov model was developed to simulate HCV testing in the ED versus no ED testing. The model captured costs from a French health service perspective, presented in 2020 euros, and outcomes, presented as quality-adjusted life years (QALYs), over a lifetime horizon. Incremental cost-effectiveness ratios (ICER) were calculated as costs per QALYs gained and compared to willingness-to-pay thresholds of €18,592 and €33,817 per QALY. Value of information analyses were also performed. ED testing for HCV was cost-effective at both thresholds when assuming ED prevalence of 1.1%, yielding an ICER of €3,800 per QALY. Testing remained cost-effective when the HCV prevalence amongst ED attendees remained higher than in the general population (0.3%). The maximum value of future research ranged from €10 to €79 million, depending on time horizons and willingness-to-pay thresholds. Our analysis suggests ED-based HCV testing may be cost-effective in France, although there is uncertainty due to the lack of empirical studies available. Further research is of high value, suggesting seroprevalence surveys and pilot studies in French ED settings are warranted.

Projected Long-Term Impact of the Coronavirus Disease 2019 (COVID-19) Pandemic on Hepatitis C Outcomes in the United States: A Modeling Study

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic disrupted access to and uptake of hepatitis C virus (HCV) care services in the United States. It is unknown how substantially the pandemic will impact long-term HCV-related outcomes.

METHODS

We used a microsimulation to estimate the 10-year impact of COVID-19 disruptions in healthcare delivery on HCV outcomes including identified infections, linkage to care, treatment initiation and completion, cirrhosis, and liver-related death. We modeled hypothetical scenarios consisting of an 18-month pandemic-related disruption in HCV care starting in March 2020 followed by varying returns to pre-pandemic rates of screening, linkage, and treatment through March 2030 and compared them to a counterfactual scenario in which there was no COVID-19 pandemic or disruptions in care. We also performed alternate scenario analyses in which the pandemic disruption lasted for 12 and 24 months.

RESULTS

Compared to the "no pandemic" scenario, in the scenario in which there is no return to pre-pandemic levels of HCV care delivery, we estimate 1060 fewer identified cases, 21 additional cases of cirrhosis, and 16 additional liver-related deaths per 100 000 people. Only 3% of identified cases initiate treatment and <1% achieve sustained virologic response (SVR). Compared to "no pandemic," the best-case scenario in which an 18-month care disruption is followed by a return to pre-pandemic levels, we estimated a smaller proportion of infections identified and achieving SVR.

CONCLUSIONS

A recommitment to the HCV epidemic in the United States that involves additional resources coupled with aggressive efforts to screen, link, and treat people with HCV is needed to overcome the COVID-19-related disruptions.

Estimating the causal effect of treatment with direct-acting antivirals on kidney function among individuals with hepatitis C virus infection

Background

Direct-acting antivirals (DAA) are highly effective at treating Hepatitis C virus (HCV) infection, with a cure rate >95%. However, the effect of DAAs on kidney function remains debated.

Methods

We analyzed electronic health record data for DAA-naive patients with chronic HCV infection engaged in HCV care at Boston Medical Center between 2014 and 2018. We compared the following hypothetical interventions using causal inference methods: 1) initiation of DAA and 2) no DAA initiation. For patients with normal kidney function at baseline (eGFR>90 ml/min/1.73m²), we estimated and compared the risk for reaching Stage 3 chronic kidney disease (CKD) (eGFR≤60 ml/min/1.73m²) under each intervention. For patients with baseline CKD Stages 2–4 (15<eGFR≤90 ml/min/1.73m²), we estimated and compared the mean change in eGFR at 2 years after baseline under each intervention. We used the parametric g-formula to adjust our estimates for baseline and time-varying confounders.

Results

First, among 1390 patients with normal kidney function at baseline the estimated 2-year risk difference (95% CI) of reaching Stage 3 CKD for DAA initiation versus no DAA was -1% (-3, 2). Second, among 733 patients with CKD Stage 2–4 at baseline the estimated 2-year mean difference in change in eGFR for DAA initiation versus no DAA therapy was -3 ml/min/1.73m² (-8, 2).

Conclusions

We found no effect of DAA initiation on kidney function, independent of baseline renal status. This suggests that DAAs may not be nephrotoxic; furthermore, in the short-term, HCV clearance may not improve CKD.

Using the Electronic Health Record to Characterize the Hepatitis C Virus Care Cascade

OBJECTIVES

Chronic hepatitis C virus (HCV) infection is one of the main causes of hepatocellular carcinoma. Before initiating a multilevel HCV screening intervention, we sought to (1) describe concordance between the electronic health record (EHR) data warehouse and manual medical record review in recording aspects of HCV testing and treatment and (2) estimate the percentage of patients with chronic HCV infection who initiated and completed HCV treatment using manual medical record review.

METHODS

We examined the medical records for 177 patients (100 randomly selected patients born during 1945-1965 without evidence of HCV testing and 77 adult patients of any birth cohort who had completed HCV testing) with a primary care or relevant specialist visit at an academic health care system in Tampa, Florida, from 2015 through 2018. We used the Cohen κ coefficient to examine the degree of concordance between the searchable data warehouse and the medical record review abstractions. Descriptive statistics characterized referral to and receipt of treatment among patients with chronic HCV infection from medical record review.

RESULTS

We found generally good concordance between the data warehouse abstraction and medical record review for HCV testing data (κ ranged from 0.66 to 0.87). However, the data warehouse failed to capture data on HCV treatment variables. According to medical record review, 28 patients had chronic HCV infection; 16 patients were prescribed treatment, 14 initiated treatment, and 9 achieved and had a reported posttreatment undetected HCV viral load.

CONCLUSIONS

Using data warehouse data provides generally reliable HCV testing information. However, without the use of natural language processing and purposeful EHR design, manual medical record reviews will likely be required to characterize treatment initiation and completion.

Treating the Hardest to Treat: Reframing the Hospital Admission as an Opportunity to Initiate Hepatitis C Treatment

BACKGROUND

Chronic hepatitis C (CHC) is traditionally treated in the outpatient setting. Despite the excellent tolerability, shortened treatment duration, and high cure rates of newer direct-acting antivirals (DAAs), many vulnerable patients remain untreated due to issues with linkage to care.

AIMS

This study sought to reframe and establish the hospital admission as a unique opportunity to initiate antiviral treatment for patients with CHC, particularly those with psychosocial or linkage to care issues.

METHODS

Patients with untreated CHC were identified either on the Psychiatry or Med/Surg wards at the Veterans Affairs Palo Alto Health Care System (VAPAHCS). If found to be appropriate for treatment initiation, patients were started on antivirals during their hospitalization and followed closely while inpatient and after discharge to assess for sustained virologic response (SVR), treatment tolerability, and treatment completion.

RESULTS

Overall, 36% (23) of potential treatment candidates were initiated on DAA treatment during their hospitalization. Of these patients, 91.3% had documented treatment completion with an intention-to-treat and modified intention-to-treat SVR rate of 91.3% and 100%, respectively.

CONCLUSIONS

We establish the hospital admission as a valuable opportunity for HCV treatment initiation, yielding excellent treatment outcomes in those who would not otherwise be treated and achieved a modified intention-to-treat response rate of 100%.

Risk Factors for Syphilis at a Large Urban Emergency Department

BACKGROUND

The prevalence of syphilis is increasing in the United States. The emergency department (ED) is an important setting to screen and treat underserved populations. To tailor testing protocols to the local population, we aimed to identify risk factors for syphilis positivity in ED patients.

METHODS

We performed a retrospective analysis of ED patients who were screened for syphilis between November 2018 and August 2020. Patients were screened for Treponema pallidum antibody using a multiplex flow immunoassay, and positive results were confirmed by rapid plasma reagin or T. pallidum particle agglutination. Risk factors for new syphilis diagnoses were identified using multiple logistic regression.

RESULTS

We screened 1974 patients for syphilis (mean age, 37 ± 16 years; 56% female). We identified 201 patients with new infections without previous treatment. Independent risk factors for a new diagnosis of syphilis included housing status (undomiciled, 23% [60 of 256]; domiciled, 9% [133 of 1559]; adjusted odds ratio [aOR], 1.9 [95% confidence interval {CI}, 1.2-3.0]), history of HIV (positive, 44% [28 of 63]; negative, 9% [173 of 1893]; aOR, 5.8 [95% CI, 3.0-11.2]), tobacco use (positive, 15% [117 of 797]; negative, 4% [29 of 665]; aOR, 2.4 [95% CI, 1.5-3.9]), and illicit drug use (positive, 14% [112 of 812]; negative, 8% [52 of 678]; aOR, 2.2 [95% CI, 1.0-2.5]).

CONCLUSIONS

Undomiciled housing status, history of HIV, history of tobacco use, and history of illicit drug use were independently associated with a new diagnosis of syphilis in the ED. Broadening targeted syphilis screening algorithms beyond sexually transmitted disease-related complaints could help identify new syphilis cases for treatment.

Utilizing Telemedicine and Modified Fibrosis Staging Protocols to Maintain Treatment Initiation and Adherence Among Hepatitis C Patients During the COVID-19 Pandemic

The COVID-19 pandemic exacerbated the decline in Hepatitis C Virus (HCV) screening and treatment globally in part due to lockdowns and restrictions at healthcare centers. The goal of this retrospective cohort study was to assess the effectiveness of an updated workflow implemented at Boston Medical Center (BMC) HCV clinics. Revised workflow incorporated appointments via telemedicine, transitioning to blood test-based fibrosis scoring, and delivering medication by mail to mitigate the lack of in-person services. We compared 2 cohorts of patients who attended at least the initial intake appointment at BMCHCV clinics: 170 before the pandemic and 133 after the pandemic. Outcome variables included treatment starts, fibrosis lab tests completed, appointment attendance, and SVR achievement. Proportions for outcome variables were compared between groups by use of χ2 and 2-sample t-tests where appropriate. Our results showed a 14.43% decrease in completing fibrosis scoring tests (P-value: <.001) and a 15.21% decrease in medication initiation (P-value: <.001) among the patients who initiated care during the pandemic (modified workflow group). Furthermore, we found a 18.56% decrease in sustained virologic response (SVR) among the modified workflow group when compared to the controls. Overall, these results align with current trends of patients' decreasing engagement in HCV care but show higher retention than other published data. Furthermore, these figures support how appointments via telemedicine, transitioning to blood test-based fibrosis scoring, and medication delivery by mail can serve as tools to increase access to HCV care and successful HCV treatment completion even after COVID restrictions are lifted.

Screening, confirmation, and treatment rates of hepatitis C virus infection in a tertiary academic medical center in South Korea

BACKGROUND AND AIM

Several barriers prevent the proper screening, diagnosis, and treatment of hepatitis C virus (HCV) infection. We aimed to evaluate the status of HCV screening, confirmation, and treatment rates in a tertiary academic medical center in Korea.

METHODS

Patients who visited Severance Hospital between 2015 and 2019 were eligible in this retrospective study. The testing and positivity rates for anti-HCV antibodies and HCV RNA were sequentially analyzed.

RESULTS

Between 2015 and 2019, 252 057 patients (117 131 men, 46.5%) who underwent anti-HCV antibody testing were retrospectively reviewed. The median age of the study population was 51.0 years. Patients with positive anti-HCV antibody test results (n = 2623, 1.0%) showed a higher proportion of liver cirrhosis (17.6% vs 2.0%) and unfavorable laboratory test results (all P < 0.05). The positivity rates were 1.3% and 0.8% in the medical and surgical departments, respectively. HCV RNA was tested in 1628 (62.1%) patients, with a 57.4% (n = 928) positivity rate. The medical department had a higher HCV RNA testing rate than the surgical department (75.4% vs 40.8%). Among the 928 patients who showed positivity for HCV RNA, 847 (90.7%) underwent genotype testing (mostly 1 and 2 [95.4%]). The treatment rate was 66.9% (n = 567); it was higher in the gastroenterology department (70.8%) than in the non-gastroenterology departments (62.3%).

CONCLUSIONS

A considerable proportion of patients testing positive for anti-HCV antibodies were not referred for proper management. Systematic and automated screening and referral systems, which may help identify patients requiring treatment for HCV infection, are necessary even in tertiary academic medical centers.

Effect of relaxing hepatitis C treatment restrictions on direct-acting antiviral use in a Medicaid program: an interrupted time series analysis

BACKGROUND: Although direct-acting antivirals (DAA) have revolutionized the treatment of chronic hepatitis C virus (HCV), many state Medicaid programs have limited coverage because of their expense. In 2015, the Centers for Medicare & Medicaid Services (CMS) notified states about the legality of Medicaid coverage limitations, particularly within managed care programs. OBJECTIVES: To (1) examine how relaxation and alignment of hepatitis C policies within the Oregon Medicaid program affected DAA utilization and (2) describe changes in DAA coverage policies and patient characteristics of treated individuals over time. METHODS: We manually collected DAA Medicaid drug policies in the state of Oregon before and after the CMS notification was released. After categorizing DAA policies into 2 groups based on baseline prior authorization criteria (restrictive and permissive), we evaluated how changes in these DAA policies affected utilization over 3 time periods (pre-CMS period, post-CMS period, and fibrosis policy alignment). Immediate and gradual changes in trend were assessed using an interrupted time series regression model. Finally, we examined patient characteristics and liver disease complications over time as policy restrictions were removed and aligned with one another. RESULTS: From 2014 to 2018, Oregon's coordinated care organizations and fee-for-service drug policies relaxed liver fibrosis and substance abstinence coverage criteria leading to immediate increases in DAA use in 2016 (0.62 prescriptions per 10,000 enrollees per month; 95% CI = 0.17 to 1.08) and 2018 (1.07 prescriptions per 10,000 enrollees per month; 95% CI = 0.63 to 1.51) among more restrictive coordinated care organizations at baseline. This was followed by a decrease in trend after the 2016 and 2018 impact (-0.05; 95% CI = -0.11 to -0.001 and -0.07; 95% CI = -0.13 to -0.02, respectively). Over the 3 periods, there was a decrease in treated individuals with liver-related complications (P < 0.0001) and an increase in those with a substance use diagnosis (P = 0.0013). CONCLUSIONS: Reducing coverage limitations resulted in treatment of patients with fewer liver-related complications and more substance use disorders. Expanding access to treatment did not result in sustained increases in utilization, and additional interventions may be necessary to meet HCV elimination goals. DISCLOSURES: This study was funded in part by AbbVie Pharmaceuticals, which did not have any role in the study design, collection, analysis and interpretation of data, writing the report, or the decision to submit the report for publication. Hartung received support for his work on this study via a grant from AbbVie Pharmaceuticals. The other authors did not receive any financial support for their contributions to this study. The authors have no other financial disclosures to report. This study was presented at the Academy Health Annual Research Meeting in Washington, DC, on June 3, 2019.

Missed linkage to care for patients who screened positive for Hepatitis C in a tertiary care centre: Results of the Telepass project

Italy is one of the countries on track with the WHO's agenda to eliminate hepatitis C virus (HCV) by 2030. Healthcare facilities play a crucial role in seeking patients who are infected but have not yet been treated. We assessed the effectiveness of a recall strategy, named 'Telepass' project, for patients exposed to HCV infection who have not yet been linked to care in a large tertiary care centre. The 'Telepass' project was structured in two phases: (a) a retrospective analysis first identified all anti-HCV-positive subjects among patients who underwent pre-operative assessment in the facility in the course of one year; (b) a following prospective phase, aimed to recall patients in need either of further diagnostic tests (ie HCV-RNA) or treatment. A total of 12246 records of patients tested for HCV antibodies were reviewed. The overall prevalence of anti-HCV-positive subjects was 1.83% (224/12246) with a male/female ratio of 2.07. Out of the 224 anti-HCV-positive patients, 123 (54.91%) did not have documented HCV-RNA tests and were therefore selected for recall. Of these, 123 were reachable and 26 (21.13%) were successfully linked to care. Ten patients (38.46%) tested HCV-RNA positive and initiated treatment with direct-acting antivirals (DAAs). The Telepass study highlights that a recall strategy starting from internal hospital databases can help identify patients with chronic HCV infection who have not yet been linked to care, and provides an epidemiological insight into the prevalence of HCV infection in Italy in the late DAAs era.

The performance of hepatitis C virus (HCV) antibody point-of-care tests on oral fluid or whole blood and dried blood spot testing for HCV serology and viral load among individuals at higher risk for HCV in South Africa

BACKGROUND AND AIMS

To enhance screening and diagnosis in those at-risk of hepatitis C virus (HCV), efficient and improved sampling and testing is required. We investigated the performance of point-of-care (POC) tests and dried blood spots (DBS) for HCV antibody and HCV RNA quantification in individuals at higher risk for HCV (people who use and inject drugs, sex workers and men who have sex with men) in seven South African cities.

METHODS

Samples were screened on the OraQuick HCV POC test (471 whole blood and 218 oral fluid); 218 whole blood and DBS paired samples were evaluated on the ARCHITECT HCV antibody (Abbott) and HCV viral load (COBAS Ampliprep/COBAS TaqMan version 2) assays. For HCV RNA quantification, 107 dB were analyzed with and without normalization coefficients.

RESULTS

POC on either whole blood or oral fluid showed an overall sensitivity of 98.5% (95% CI 97.4-99.5), specificity of 98.2% (95% CI 98.8-100) and accuracy of 98.4% (95% CI 96.5-99.3). On the antibody immunoassay, DBS showed a sensitivity of 96.0% (95% CI 93.4-98.6), specificity of 97% (95% CI 94.8-99.3) and accuracy of 96.3% (95% CI 93.8-98.8). A strong correlation (R 2 = 0.90) between viral load measurements for DBS and plasma samples was observed. After normalization, DBS viral load results showed an improved bias from 0.5 to 0.16 log10 IU/mL.

CONCLUSION

The POC test performed sufficiently well to be used for HCV screening in at-risk populations. DBS for diagnosis and quantification was accurate and should be considered as an alternative sample to test. POC and DBS can help scale up hepatitis services in the country, in light of our elimination goals.

Characteristics and Specialist Linkage to Care of Patients Diagnosed With Chronic Hepatitis C Across Different Settings in an Urban Academic Hospital: Implications for Improving Diagnosis and Linkage to Care

Introduction

Chronic hepatitis C virus (HCV) infection is a significant public health problem. Strategies to identify more HCV infections and improve linkage to care (LTC) are needed. We compared characteristics, treatment and LTC among chronic HCV patients in different health care settings.

Methods

Newly diagnosed HCV antibody positive (anti-HCV+) patients within settings of acute care, inpatient and outpatient in one health system were studied. Proportion of LTC and treatment were analyzed only for HCV RNA positive patients. Chi-square, one-way ANOVA and logistic regression were used to compare the characteristics and outcomes in the three care settings. Patients in acute care settings were excluded from multivariate analyses due to low sample size.

Results

About 43, 368, and 1159 anti-HCV+ individuals were identified in acute care, inpatient, and outpatient, respectively. Proportion of RNA positivity in acute, inpatient, and outpatient were 47.8, 60.3 and 29.2%, respectively (p < 0.01). After adjusting for age, insurance type, race, and gender, outpatients had higher odds of LTC and of treatment (OR 4.7 [2.9, 7.6] and 4.5 [2.8, 7.3]).

Conclusions

Inpatients had lower proportion of LTC and treatment compared to outpatients. Use of LTC coordinators and the provision of integrated service for specialty care may improve outcomes.

CHRONIC HEPATITIS C PATIENTS LOST IN THE SYSTEM: PREDICTIVE FACTORS OF NON-REFERRAL OR LOSS OF FOLLOW UP TO HEPATOLOGY UNITS

INTRODUCTION

Several barriers remain in the hepatitis C care cascade, which need to be removed in order to eliminate Chronic Hepatitis C. These barriers include deficiencies in screening and confirmatory diagnosis as well as difficulties in accessing treatment.

AIMS

To identify factors associated with the non-referral of patients with positive HCV-antibody and to identify factors associated with loss of follow-up or non-attendance of these patients to specialist consultation after their referral.

METHODS

Observational and retrospective single-centre-study, including all positive HCV serologies performed between January 2013 and May 2018 in the Virgen Macarena health area before implementing the one-step diagnosis. Non-referred patients and patients who were lost to follow-up after being referred were identified.

RESULTS

A total of 54 (77.4%) patients diagnosed in PC and 54 (22.2%) from hospital specialists were not referred (p <0.001). Predictors for non-referral were: stay in prison/ institutionalized (p = 0.04), suffering COPD (p = 0.07), a normal AST value (p = 0.034) or test requested by PCP (p = 0.004). Patients referred from PC were more likely to be lost to follow-up than those referred from hospital specialists (p <0.001). Predictors for loss of follow-up included: opioid replacement therapy (p = 0.034), absence of high blood pressure (p = 0.039) and test requested by PCP (p = 0.049).

CONCLUSIONS

A high percentage of patients with positive HCV serology were not referred or lost follow-up, mainly those belonging to high risk social groups or those with associated comorbidities. Patients with average values of transaminases or those diagnosed in primary care were also less referred.

Universal HCV Screening of Baby Boomers is Feasible, but It is Difficult

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.

Impact of the 2020 COVID-19 Pandemic on Ambulatory Hepatitis C Testing

Introduction:

Coronavirus disease 2019 (COVID-19) has led to unprecedented modifications to healthcare delivery in the U.S. To preserve resources in preparation for a COVID-19 surge, Boston Medical Center (BMC) implemented workflows to decrease ambulatory in-person visits effective March 16th, 2020. Telemedicine was incorporated into clinical workflows and much preventive care, including Hepatitis C (HCV) testing, was not routinely performed.

Objective:

To explore the impact that the COVID-19 rapid restructuring response has had on HCV testing and identification hospital-wide and in ambulatory settings.

Methods:

BMC utilizes reflex confirmatory testing for HCV. When a sample is HCV Ab positive, it is automatically reflexed for confirmatory RNA and genotype testing. HCV test results for patients were collected daily. We compared unique patient tests for 3.5 month periods before and after March 16th, 2020. Descriptive statistics showed total tests and total new HCV RNA+ before versus after, both hospital-wide and in ambulatory clinics alone. Mean daily tests completed were compared.

Results:

Hospital-wide, total HCV testing decreased by 49.6%, and new HCV+ patient identification decreased by 42.1%. In ambulatory clinics, testing decreased by 71.9%, and new HCV+ identification decreased by 63.3%. Hospital-wide, mean daily tests decreased by 22.9 tests per day (95% CI: 17.9-28.0, P < .001), and mean daily new HCV+ identification decreased by 0.36 (95% CI: 0.20-0.53, P < .001). In ambulatory clinics, mean daily tests decreased by 22.1 tests per day (95% CI: 17.5-26.7, P < .001) and mean daily HCV+ decreased by 1.40 (95% CI: 1.03-1.76, P < .001).

Conclusion:

The COVID-19 systematic emergency response led to decreased HCV testing and identification, and in this regard telemedicine acts as a barrier to HCV care. Other public health initiatives must be monitored in the context of telemedicine workflows. Continued monitoring of HCV screening trends is vital, and adaptive approaches to work toward the goal of HCV elimination are needed.

Clarifying the volume of estimated need for public health and prevention services within an emergency department population

OBJECTIVES

Emergency departments (EDs) are called to implement public health and prevention initiatives, such as infectious disease screening. The perception that ED resources are insufficient is a primary barrier. Resource needs are generally conceptualized in terms of total number of ED encounters, without formal calculation of the number of encounters for which a service is required. We illustrate potential differences in the estimated volume of service need relative to ED census using the examples of HIV and hepatitis C (HCV) screening.

METHODS

This cross-sectional analysis adjusted the proportion of ED encounters in which patients are eligible for HIV and HCV screening according to a cascade of successively more restrictive patient selection criteria, presuming full implementation of each criterion. Parameter estimates for the proportion satisfying each selection criterion were derived from the electronic health records of an urban academic facility and its ED HIV and HCV screening program during 2 time periods. The primary outcome was the estimated reduction in proportion of ED visits eligible for screening after application of the entire cascade.

RESULTS

There were 76,104 ED encounters during the study period. Applying all selection criteria reduced the number of required screens by 97.1% (95% confidence interval, 97.0-97.2) for HIV and 86.1% (95% confidence interval, 85.9-86.3) for HCV.

CONCLUSIONS

Using the example of HIV and HCV screening, the application of eligibility metrics reduces the volume of service need to a smaller, more feasible number than estimates from ED census alone. This approach might be useful for clarifying perceived service need and guiding operational planning.

The Clinical Microbiology Laboratory and the Opioid Epidemic: Challenges and Opportunities

Increased infections from injection drug use harm patients and are costly to the health care system. The impact on clinical microbiology laboratories is less recognized. Microbiology laboratories face increased test volume and test complexity from the spectrum and burden of pathogens associated with injection drug use, which lead to diagnostic challenges and overtaxed resources. We describe stressed workflows, pathogens that defy protocols, and limits of current technologies. Laboratories may benefit from protocol revisions, additional resources, workflow oversight, and improved communication with clinical providers to optimally meet challenges associated with this public health crisis.

Epidemiology of Hepatitis C in Delaware

Infection with hepatitis C virus (HCV) is pervasive throughout the United States of America as we fight the ongoing urban and rural opioid epidemics and rising rates of fatal and non-fatal overdoses. While risk factors for incident HCV abound, our country and the State of Delaware have increasing access to highly effective, short-course, curative HCV treatments. Despite unprecedented medical advances for HCV, as well as expanded HCV screening guidelines calling for universal adult HCV screening and screening during every pregnancy, the epidemiology of HCV at the national and statewide levels continues to be lacking. In attempting to gather, interpret, and present the highest quality available data, we conclude that HCV remains a pressing public and individual health concern for Delawareans, and our nation at large. We urge stakeholders in Delaware to make concerted efforts to fill in the many remaining gaps of HCV epidemiology in order to better inform public health resource allocation, educate the public and healthcare professionals regarding viral hepatitis, and ultimately improve the HCV care continuum, spanning from increasing rates of universal HCV screening and diagnosis to linkage to care to treatment initiation all the way to cure and beyond.

The emergency department as a setting-specific opportunity for population-based hepatitis C screening: An economic evaluation

BACKGROUND AND AIMS

The World Health Organization's hepatitis C virus (HCV) elimination strategy recognizes the need for interventions that identify populations most affected by infection. The emergency department (ED) has been suggested as a setting for HCV screening. The study objective was to explore the health and economic impact of HCV screening in the ED setting.

METHODS

We used a microsimulation model to conduct a cost-utility analysis evaluating two ED setting-specific strategies: no screening, and screening and subsequent treatment. Strategies were examined for two populations: (a) the general ED patient population; and (b) ED patients born between 1945 and 1975. The analysis was conducted from a healthcare payer perspective over a lifetime time horizon. A reference and high ED HCV seroprevalence measure were examined in the Canadian healthcare setting.US costs of chronic infection were used for a scenario analysis of screening in the US healthcare setting.

RESULTS

For birth cohort screening, in comparison to no screening, one liver-related death was averted for every 760 and 123 persons screened for the reference and high seroprevalence measures. For general population screening, one liver-related death was averted for every 831 and 147 persons screened for the reference and high seroprevalence measures. In comparison to no screening, birth cohort screening was cost-effective at CAN$25,584/quality-adjusted life year (QALY) and US$42,615/QALY. General population screening was cost-effective at CAN$19,733/QALY and US$32,187/QALY.

CONCLUSIONS

ED screening may represent a cost-effective component of population-based strategies to eliminate HCV. Further studies are warranted to explore the feasibility and acceptability of this approach.

Predictors of linkage to care for a nontargeted emergency department hepatitis C screening program

OBJECTIVE

We implemented a nontargeted, opt-out HCV testing and linkage to care (LTC) program in an academic tertiary care emergency department (ED). Despite research showing the critical role of ED-based HCV testing programs, predictors of LTC have not been defined for patients identified through the nontargeted ED testing strategy. In order to optimize health outcomes for patients with HCV, we sought to identify predictors of LTC failure.

METHODS

This was a retrospective cohort study of adult patients who were tested for HCV in the ED between August 2015 and September 2018 and were confirmed to have chronic HCV infection through RNA testing. We used logistic regression to assess the relationship between candidate predictors and the primary outcome, LTC failure, which was defined as a patient not being seen by an HCV treating provider after discharge from the ED.

RESULTS

Of 53,297 patients tested, 1,674 (3.1%) had HCV on confirmatory testing, and 355 (21%) linked to care. Predictors of LTC failure included younger age (OR 0.96, 95% CI 0.95-0.97), white race (OR 1.65, 95% CI 1.23-2.22), homelessness (OR 1.91, 95% CI 1.19-3.08), substance use (OR 1.77, 95% CI 1.34-2.34), and comorbid psychiatric illness (OR 2.16, 95% CI 1.59-2.94). Patients with significant medical comorbidities (OR 0.57, 95% CI 0.41-0.78) or HIV co-infection (OR 0.11, 95% CI 0.03-0.46) were less likely to experience LTC failure.

CONCLUSIONS

One in five HCV-infected patients identified by ED-based nontargeted testing successfully linked to an HCV treating provider. Predictors of LTC failure may guide the development of targeted interventions to improve LTC success.