Hepatitis C Screening in Commercially Insured U.S. Birth-cohort Patients: Factors Associated with Testing and Effect of an EMR-based Screening Alert

Factors associated with prior completion of colorectal cancer and hepatitis C virus screenings among community health center patients: a cross-sectional study to inform a multi-behavioral educational intervention

BACKGROUND

Colorectal cancer (CRC) and liver cancer are two of the leading causes of cancer death in the United States and persistent disparities in CRC and liver cancer incidence and outcomes exist. Chronic hepatitis C virus (HCV) infection is one of the main contributors to liver cancer. Effective screening for both CRC and HCV exist and are recommended for individuals based upon age, regardless of gender or sex assigned at birth. Recommendations for both screening behaviors have been recently updated. However, screening rates for both CRC and HCV are suboptimal. Targeting adoption of multiple screening behaviors has the potential to reduce cancer mortality and disparities.

OBJECTIVE

To examine psychosocial factors associated with completion of CRC and HCV screenings in order to inform a multi-behavioral educational intervention that pairs CRC and HCV screening information.

METHODS

A cross-sectional survey was conducted with participants (N = 50) recruited at two community health centers in Florida (United States). Kruskal-Wallis and Fisher's exact tests were used to examine associations between completion of both CRC and HCV screening, CRC and HCV knowledge, Preventive Health Model constructs (e.g., salience and coherence, response efficacy, social influence), and sociodemographic variables.

RESULTS

Most participants were White (84%), female (56%), insured (80%), and reported a household income of $25,000 or less (53%). 30% reported ever previously completing both CRC and HCV screenings. Prior completion of both screening behaviors was associated with higher educational attainment (p = .014), having health insurance (p = .022), being U.S.-born (p = .043), and higher salience and coherence scores for CRC (p = .040) and HCV (p = .004).

CONCLUSIONS

Findings demonstrate limited uptake of both CRC and HCV screenings among adults born between 1945 and 1965. Uptake was associated with multiple sociodemographic factors and health beliefs related to salience and coherence. Salience and coherence are modifiable factors associated with completion of both screening tests, suggesting the importance of incorporating these health beliefs in a multi-behavioral cancer education intervention. Additionally, health providers could simultaneously recommend and order CRC and HCV screening to improve uptake among this age cohort.

ICD-10-CM codes infrequently used to document human trafficking in 2019 Nationwide Emergency Department Sample

INTRODUCTION

People who experience human trafficking (HT) visit emergency departments (ED). The International Classification of Diseases, Clinical Modification (ICD-10-CM) introduced codes to document HT in June 2018. The aim of this study is to identify characteristics of ED patients who experienced forced labor or sexual exploitation as a documented external cause of morbidity in US visits.

METHODS

Nationally representative surveillance based on patient visits to 989 hospital-owned EDs in the Nationwide Emergency Department Sample in 2019 became available in 2021. Eight ICD-10-CM codes to classify HT as an external cause of morbidity were combined into one HT variable for analysis in 2021-2022.

RESULTS

A weighted count of 517 of 33.1 million ED visits (0.0016%) documented HT as an external cause of morbidity. Of them, sexual exploitation (71.6%) was documented more frequently than labor exploitation (28.4%). Most HT-related codes were visits by females (87.3%) from large metropolitan areas, and identified as white. Approximately 40% of visits were from ZIP codes with a median household income less than $48,000 annually. Relative to all other ED visits, patients with HT as an external cause of morbidity had higher odds of being female (OR = 6.54, 95% CI:3.59, 11.92) and being a minor (OR = 1.76, 95% CI:1.02, 3.04).

CONCLUSION

HT was rarely documented as an external cause of morbidity in 989 hospitals' ED visits from a nationally representative sample in 2019. Documentation of recently added HT ICD-10-CM codes does not appear to have been implemented sufficiently to yield an unbiased representation of those who experienced HT and presented in the ED. Efforts to enhance the utility of ICD-10-CM HT codes for surveillance and documentation must first address ED personnel training on identification and response to HT. In doing so, ED personnel also need to address ethical concerns (e.g. stigma, confidentiality, risk of patient harm) and allow for informed consent among trafficked patients in order to be scaled up responsibly.

Recommendations for the integral diagnosis of chronic viral hepatitis in a single analytical extraction

The Spanish Society of Digestive Pathology (SEPD), the Spanish Association for the Study of the Liver (AEEH), the Spanish Society of Infections and Clinical Microbiology (SEIMC) and its Viral Hepatitis Study Group (GEHEP), and with the endorsement of the Alliance for the Elimination of Viral Hepatitis in Spain (AEHVE), have agreed on a document to carry out a comprehensive diagnosis of viral hepatitis (B, C and D), from a single blood sample; that is, a comprehensive diagnosis, in the hospital and/or at the point of care of the patient. We propose an algorithm, so that the positive result in a viral hepatitis serology (B, C and D), as well as human immunodeficiency virus (HIV), would trigger the analysis of the rest of the virus, including the viral load when necessary, in the same blood draw. In addition, we make two additional recommendations. First, the need to rule out a previous hepatitis A virus (VHA) infection, to proceed with its vaccination in cases where IgG-type studies against this virus are negative and the vaccine is indicated. Second, the determination of the HIV serology. Finally, in case of a positive result for any of the viruses analyzed, there must be an automated alerts and initiate epidemiological monitoring.

Engaging Physicians and Systems to Improve Hepatitis C Virus Testing in Baby Boomers

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.

Efficacy of a Primary Care-Based Mobile Application to Increase Hepatitis C Screening Among Asian Americans: A Secondary Analysis of a Randomized Clinical Trial

Background

Hepatitis C virus (HCV) screening remains suboptimal. We assessed the efficacy of a mobile application and provider alert in enhancing HCV screening among Asian Americans.

Methods

A secondary analysis of a cluster-randomized clinical trial was performed during the birth cohort screening era to assess the efficacy of a Hepatitis App (intervention), a multilingual mobile application delivering interactive video education on viral hepatitis and creating a Provider Alert printout, at primary care clinics within 2 healthcare systems in San Francisco from 2015 to 2017. A comparison group received usual care and a similar intervention on nutrition and physical activity. The outcome was electronic health record (EHR) documentation of HCV screening along with patient-provider communication about testing and test ordering.

Results

Four hundred fifty-two participants (mean age 57 years, 36% male, 80% foreign-born) were randomized by provider clusters to the intervention (n = 270) or comparison groups (n = 182). At 3-month follow up, the intervention group was more likely than the comparison group to be aware of HCV (75% vs 59%, P = .006), to discuss HCV testing with their providers (63% vs 13%, P < .001), to have HCV testing ordered (39% vs 10%, P < .001), and to have EHR-verified HCV testing (30% vs 6%, P < .001). Within the intervention group, being born between 1945 and 1965 (odds ratio, 3.15; 95% confidence interval, 1.35-7.32) was associated with increased HCV testing.

Conclusions

The Hepatitis App delivered in primary care settings was effective in increasing HCV screening in a socioeconomically diverse Asian American cohort. This highlights the importance of mobile technology as a patient-centered strategy to address gaps in HCV care.

Successful Hepatitis C Birth Cohort Screening and Linkage to Care in a US Community Health System

CONTEXT

Birth cohort ("baby boomer") screening represents a well-validated strategy for the identification of asymptomatic hepatitis C-infected patients. However, successful linkage of newly diagnosed patients to antiviral therapy has been more difficult to accomplish.

OBJECTIVE

To analyze the results of a systemwide birth cohort screening program in a US community health care system.

DESIGN

We analyzed the data from an ongoing hepatitis C virus (HCV) screening and treatment program that was established at NorthShore University Health System in 2015. Hepatitis C virus screening by primary care providers was prompted through automated Best Practice and Health Maintenance alerts. Patient visits and screening orders were tracked using a customized HCV dashboard. Virologic, demographic, and treatment data were assessed and compared with those of a cohort of patients with previously established HCV infection.

RESULTS

Since program inception, 61 8161 (64.3%) of the entire NorthShore baby boomer population of 96 001 patients have completed HCV antibody testing, and 160 patients (0.26%) were antibody positive. Of 152 antibody-positive patients who underwent HCV RNA testing, 53 (34.2%) were viremic. A total of 39 of 53 patients (73.6%) underwent antiviral therapy and achieved a sustained virologic response. Compared with patients identified through screening, a comparison cohort of patients with previously established HCV had more advanced fibrosis and significantly lower dropout rates. The COVID-19 pandemic was associated with a decrease in the number of outpatient visits of screening-eligible patients and with a reduction in HCV screening rates.

CONCLUSION

Our data demonstrate the electronic medical records-assisted systemwide implementation of HCV birth cohort screening and successful linkage to antiviral therapy in a community-based US multihospital system.

Interventions to enhance testing, linkage to care, and treatment initiation for hepatitis C virus infection: a systematic review and meta-analysis

BACKGROUND

Despite the goal set by WHO to eliminate hepatitis C virus (HCV) as a public health threat, uptake of HCV testing and treatment remains low. To achieve this target, evidence-based interventions are needed to address the barriers to care for people with, or at risk of, HCV infection. We aimed to assess the efficacy of interventions to improve HCV antibody testing, HCV RNA testing, linkage to HCV care, and treatment initiation.

METHODS

In this systematic review and meta-analysis, we searched MEDLINE (PubMed), Scopus, Web of Science, the Cochrane Central Register of Controlled Trials, and PsycINFO without language restrictions for reports published between database inception and July 21, 2020, assessing the following primary outcomes: HCV antibody testing; HCV RNA testing; linkage to HCV care; and direct-acting antiviral treatment initiation. We also searched key conference abstracts. We included randomised and non-randomised studies assessing non-pharmaceutical interventions that included a comparator or control group. Studies were excluded if they enrolled only paediatric populations (aged <18 years) or if they conducted the intervention in a different health-care setting to that of the control or comparator. Authors were contacted to clarify study details and to obtain additional population-level data. Data were extracted from the records identified into a pre-piloted and standardised data extraction form and a random-effects meta-analysis was used to pool the effects of the interventions on study outcomes. This study is registered in PROSPERO, CRD42020178035.

FINDINGS

Of 15 342 unique records identified, 142 were included, which reported on 148 unique studies (47 randomised controlled trials and 101 non-randomised studies). Medical chart reminders, provider education, and point-of-care antibody testing significantly improved at least three study outcomes compared with a comparator or control. Interventions that simplified HCV testing, including dried blood spot testing, point-of-care antibody testing, reflex RNA testing, and opt-out screening, significantly improved testing outcomes compared with a comparator or control. Enhanced patient and provider support through patient education, provider care coordination, and provider education also significantly improved testing outcomes compared with a comparator or control. Integrated care and patient navigation or care coordination significantly improved linkage to care and the uptake of direct-acting antiviral treatment compared with a comparator or control.

INTERPRETATION

Several interventions to improve HCV care that address several key barriers to HCV care were identified. New models of HCV care must be designed and implemented to address the barriers faced by the population of interest. Further high-quality research, including rigorously designed randomised studies, is still needed in key populations.

FUNDING

None.

The impact of electronic medical record system implementation on HCV screening and continuum of care: a systematic review

INTRODUCTION AND OBJECTIVES

Hepatitis C (HCV) screening is imperative to meet WHO elimination targets including increased detection and reduced mortality. An electronic medical record (EMR) system can be utilized in health care centers to indicate if a patient should be targeted for HCV screening, thus increasing the number of those offered testing.

MATERIALS AND METHODS

We examined English language publications reporting on the impact of EMR system utilization on HCV screening and the HCV continuum of care. Relevant papers were identified using multiple search engines to search key terms. Clinical outcomes considered included any or no change in HCV screening rates following EMR system introduction, as well as any or no change in rates of patients progressing along the HCV cascade of care after diagnosis once an EMR system was implemented.

RESULTS

From a search pool of 18 studies, 11 meet inclusion criteria and reported on the selected clinical outcomes. Each outcome assessed indicated that use of an EMR system increased the proportion of patients offered and/or receiving HCV testing. We were unable to conclude if an EMR system had an impact on the number of patients progressing along the HCV cascade of care following a positive test result. Overall, all methods of implementation of an EMR system had the same outcome of increasing screening rates.

CONCLUSIONS

EMR system utilization had a positive impact on increasing HCV screening. However, the clinical effectiveness of utilizing an EMR system to help eliminate transmission and increase HCV treatment cure rates requires further study.

Digital Health Interventions to Enhance Prevention in Primary Care: Scoping Review

Background

Disease prevention is a central aspect of primary care practice and is comprised of primary (eg, vaccinations), secondary (eg, screenings), tertiary (eg, chronic condition monitoring), and quaternary (eg, prevention of overmedicalization) levels. Despite rapid digital transformation of primary care practices, digital health interventions (DHIs) in preventive care have yet to be systematically evaluated.

Objective

This review aimed to identify and describe the scope and use of current DHIs for preventive care in primary care settings.

Methods

A scoping review to identify literature published from 2014 to 2020 was conducted across multiple databases using keywords and Medical Subject Headings terms covering primary care professionals, prevention and care management, and digital health. A subgroup analysis identified relevant studies conducted in US primary care settings, excluding DHIs that use the electronic health record (EHR) as a retrospective data capture tool. Technology descriptions, outcomes (eg, health care performance and implementation science), and study quality as per Oxford levels of evidence were abstracted.

Results

The search yielded 5274 citations, of which 1060 full-text articles were identified. Following a subgroup analysis, 241 articles met the inclusion criteria. Studies primarily examined DHIs among health information technologies, including EHRs (166/241, 68.9%), clinical decision support (88/241, 36.5%), telehealth (88/241, 36.5%), and multiple technologies (154/241, 63.9%). DHIs were predominantly used for tertiary prevention (131/241, 54.4%). Of the core primary care functions, comprehensiveness was addressed most frequently (213/241, 88.4%). DHI users were providers (205/241, 85.1%), patients (111/241, 46.1%), or multiple types (89/241, 36.9%). Reported outcomes were primarily clinical (179/241, 70.1%), and statistically significant improvements were common (192/241, 79.7%). Results were summarized across the following 5 topics for the most novel/distinct DHIs: population-centered, patient-centered, care access expansion, panel-centered (dashboarding), and application-driven DHIs. The quality of the included studies was moderate to low.

Conclusions

Preventive DHIs in primary care settings demonstrated meaningful improvements in both clinical and nonclinical outcomes, and across user types; however, adoption and implementation in the US were limited primarily to EHR platforms, and users were mainly clinicians receiving alerts regarding care management for their patients. Evaluations of negative results, effects on health disparities, and many other gaps remain to be explored.

Clinical and economic impact of an alert system in primary care for the detection of patients with chronic hepatitis C

INTRODUCTION

Prevalence of chronic hepatitis C (CHC) is higher in patients born between 1955-1975. The aim was to perform an economic evaluation of an age-based electronic health record (EHR) alert in primary care to detect patients with undiagnosed CHC and its treatment in comparison with non-use of the alert system, in Valencian Community, Spain.

MATERIALS AND METHODS

Decision trees and Markov model were used to evaluate the diagnosis and progression of the disease, respectively. CHC was diagnosed by serology and viral load in seropositive subjects. Epidemiological data and diagnostic costs were extracted from public sources of the Valencian Community. Probabilities, utilities and costs of model states were obtained from the literature. The impact on mortality and hepatic complications avoided by the implementation of the alert were estimated, and efficiency was measured as an incremental cost-utility ratio (ICUR) based on quality-adjusted life years (QALYs) and the costs of both alternatives.

RESULTS

The EHR alert detected 269,548 patients, of whom 1,331 had CHC (vs. 23 patients with non-alert). Over the patients' lifetime, the alert would prevent 93% of decompensated cirrhosis cases, 87% of hepatocellular carcinomas, 90% of liver transplants, and 89% of liver related deaths compared to non-use of the alert system. In addition, it would obtain an additional 3.3 QALY per patient, with an incremental cost of €10,880 and an ICUR of €3,321.

CONCLUSIONS

The implementation of an age-based EHR alert in primary care to detect patients with CHC reduces hepatic complications and mortality and is an efficient strategy.

Sustained and cumulative impact of an electronic medical record-based alert on a hepatitis C birth cohort screening programme

The study aimed to assess the effect of an electronic medical record-embedded best practice alert (BPA) on HCV age cohort screening in primary care clinics. HCV testing by primary care physicians was monitored prior and subsequent to the implantation of the BPA. Four intervals of 9 months duration were analysed in detail, including a pre-BPA baseline analysis and three annual post-BPA assessments. Pre- and post-BPA orders consistently followed a power law distribution, characterized by small groups of physicians placing the majority of test orders. Significant correlations were present between the numbers of tests orders by each physician, suggesting that 'high' and 'low' screening performances tended to be physician-specific. Testing rates increased markedly in response to the BPA, resulting in completion of screening in 56.8% (50,468 of 88,914%) of the entire age cohort within less than 3 years. In conclusion, HCV age cohort testing by primary care physicians follows a power-law distribution, with high-performing physicians contributing disproportionately to the overall effort. A simple BPA resulted in a sufficient increase in testing to allow testing of the entire target population within a reasonable time frame.

Improving Care for Childhood Obesity: A Quality Improvement Initiative

Obesity affected 13.7 million children in the United States in 2015. The American Academy of Pediatrics (AAP) offers an evidence-based approach to obesity management, but adherence to recommendations is suboptimal. Our objective was to improve provider adherence to the AAP recommendations for care of patients with obesity by making systematic changes in our practice for patients of ages > 2 and younger than 19 years with a BMI > 95th percentile.

Behavioral interventions to improve population health outreach for hepatitis C screening: randomized clinical trial

OBJECTIVE

To evaluate whether opt out framing, messaging incorporating behavioral science concepts, or electronic communication increases the uptake of hepatitis C virus (HCV) screening in patients born between 1945 and 1965.

DESIGN

Pragmatic randomized controlled trial.

SETTING

43 primary care practices from one academic health system (Philadelphia, PA, USA) between April 2019 and May 2020.

PARTICIPANTS

Patients born between 1945 and 1965 with no history of screening and at least two primary care visits in the two years before the enrollment period.

INTERVENTIONS

This multilevel trial was divided into two studies. Substudy A included 1656 eligible patients of 17 primary care clinicians who were randomized in a 1:1 ratio to a mailed letter about HCV screening (letter only), or a similar letter with a laboratory order for HCV screening (letter+order). Substudy B included the remaining 19 837 eligible patients followed by 417 clinicians. Active electronic patient portal users were randomized 1:5 to receive a mailed letter about HCV screening (letter), or an electronic patient portal message with similar content (patient portal); inactive patient portal users were mailed a letter. In a factorial design, patients in substudy B were also randomized 1:1 to receive standard content (usual care), or content based on principles of social norming, anticipated regret, reciprocity, and commitment (behavioral content).

MAIN OUTCOME MEASURES

Proportion of patients who completed HCV testing within four months.

RESULTS

21 303 patients were included in the intention-to-treat analysis. Among the 1642 patients in substudy A, 19.2% (95% confidence interval 16.5% to 21.9%) completed screening in the letter only arm and 43.1% (39.7% to 46.4%) in the letter+order arm (P<0.001). Among the 19 661 patients in substudy B, 14.6% (13.9% to 15.3%) completed screening with usual care content and 13.6% (13.0% to 14.3%) with behavioral science content (P=0.06). Among active patient portal users, 17.8% (16.0% to 19.5%) completed screening after receiving a letter and 13.8% (13.1% to 14.5%) after receiving a patient portal message (P<0.001).

CONCLUSIONS

Opt out framing and effort reduction by including a signed laboratory order with outreach increased screening for HCV. Behavioral science messaging content did not increase uptake, and mailed letters achieved a greater response rate than patient portal messages.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03712553.

Human Immunodeficiency Virus and Hepatitis C Virus Infection Testing Among Commercially Insured Persons Who Inject Drugs, United States, 2010-2017

BACKGROUND

We assessed prevalence of testing for human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infection among persons who inject drugs (PWID).

METHODS

Using a nationwide health insurance database for claims paid during 2010-2017, we identified PWID by using codes from the International Classification of Diseases, Current Procedural Terminology, and National Drug Codes directory. We then estimated the percentage of PWIDs tested for HIV or HCV within 1 year of an index encounter, and we used multivariate logistic regression models to assess demographic and clinical factors associated with testing.

RESULTS

Of 844 242 PWIDs, 71 938 (8.5%) were tested for HIV and 65 188 (7.7%) were tested for HCV infections. Missed opportunities were independently associated with being male (odds ratios [ORs]: HIV, 0.50 [95% confidence interval {CI}, 0.49-0.50], P < .001; HCV, 0.66 [95% CI, 0.65-0.72], P < .001), rural residence (ORs: HIV, 0.67 [95% CI, 0.65-0.69], P < .001; HCV, 0.75 [95% CI, 0.73-0.77], P < .001), and receiving services for skin infections or endocarditis (adjusted ORs: HIV, 0.91 [95% CI, 0.87-0.95], P < .001; HCV, 0.90 [95% CI, 0.86-0.95], P < .001).

CONCLUSIONS

Approximately 90% of presumed PWIDs missed opportunities for HIV or HCV testing, especially male rural residents with claims for skin infections or endocarditis, commonly associated with injection drug use.

Effect of a Best Practice Alert on Birth-Cohort Screening for Hepatitis C Virus

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.

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.

Hepatitis C Screening Rates and Care Cascade in a Large US Insured Population, 2010-2016: Gaps to Elimination

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.

Assessing the Effectiveness of Strategies in US Birth Cohort Screening for Hepatitis C Infection

Chronic hepatitis C infection in the USA is a highly morbid condition and current guidelines recommend one-time screening among the birth cohort (1945-1965). Understanding strategies to optimize screening can help inform future hepatitis C virus (HCV) screening guidelines. A focused literature search was performed using PubMed and manual abstract review from major hepatology conferences over the past 2 years. The search strategy involved using Medical Subject Headings terms for hepatitis C, screening, birth cohort, baby boomers, and 1945-1965. The review was limited to data from the USA. A total of 327 articles were identified and 36 abstracts were included, with studies published between 2012-2019. Strategies including clinician education, electronic medical record alerts, reflex HCV RNA testing, point-of-care testing, multisite (outpatient, inpatient, emergency department, endoscopy suite) initiatives, direct patient solicitation, and utilization of non-physician providers have increased HCV screening rates. However, broad implementation remains less than optimal. Barriers include lack of patient acceptance to screening and engagement in the HCV care cascade. The Veterans Affairs Healthcare System has achieved higher birth cohort screening rates through an integrated approach requiring high-level engagement by leadership and institutional commitment. Multiple strategies for increasing birth cohort screening have been successful, but overall rates of HCV screening remain low. These strategies can inform public health efforts to implement emerging national recommendations for expansion of HCV screening to all U.S. adults age 18 or older.

Hepatitis C Virus Screening and Care: Complexity of Implementation in Primary Care Practices Serving Disadvantaged Populations

BACKGROUND

Hepatitis C virus (HCV) disproportionately affects disadvantaged communities.

OBJECTIVE

To examine processes and outcomes of Screen, Treat, Or Prevent Hepatocellular Carcinoma (STOP HCC), a multicomponent intervention for HCV screening and care in safety-net primary care practices.

DESIGN

Mixed-methods retrospective analysis.

SETTING

5 federally qualified health centers (FQHCs) and 1 family medicine residency program serving low-income communities in diverse locations with largely Hispanic populations.

PATIENTS

Persons born in 1945 through 1965 (baby boomers) who had never been tested for HCV and were followed through May 2018.

INTERVENTION

The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) model guided implementation and evaluation. Test costs were covered for uninsured patients.

MEASUREMENTS

All practices tested patients for anti-HCV antibody (anti-HCV) and HCV RNA. For uninsured patients with chronic HCV in 4 practices, quantitative data also enabled assessment of HCV staging, specialist teleconsultation, direct-acting antiviral (DAA) treatment, and sustained virologic response (SVR). Implementation fidelity and adaptation were assessed qualitatively.

RESULTS

Anti-HCV screening was done in 13 334 of 27 700 baby boomers (48.1%, varying by practice from 19.8% to 71.3%). Of 695 anti-HCV-positive patients, HCV RNA was tested in 520 (74.8%; 48.9% to 92.9% by practice), and 349 persons (2.6% of those screened) were diagnosed with chronic HCV. In 4 FQHCs, 174 (84.9%) of 205 uninsured patients with chronic HCV had disease staging, 145 (70.7%) had teleconsultation review, 119 (58.0%) were recommended to start DAA therapy, 82 (40.0%) initiated free DAA therapy, 74 (36.1%) completed therapy (27.8% to 60.0% by practice), and 70 (94.6% of DAA completers) achieved SVR. Implementation was promoted by multilevel practice engagement, patient navigation, and anti-HCV screening with reflex HCV RNA testing.

LIMITATION

No control practices were included, and data were missing for some variables.

CONCLUSION

Despite a similar framework for STOP HCC implementation, performance varied widely across safety-net practices, which may reflect practice engagement as well as infrastructure or cost challenges beyond practice control.

PRIMARY FUNDING SOURCE

Cancer Prevention & Research Institute of Texas and Centers for Medicare & Medicaid Services.

Evaluation of a Multifaceted Intervention to Reduce Health Disparities in Hepatitis C Screening: A Pre-Post Analysis

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.

The role of medical data in efficient patient care delivery: a review

Background

Implementing accurate data management systems ensure safe and efficient transfer of confidential health care data. However, health care professionals overlooked their important tasks of medical data processing. Hence, using high-quality electronic health record (EHR) applications in health care is important to minimize medical errors. Therefore, this review tries to indicate the roles of EHR in advancing quality health care service provisions.

Methods

The keywords identified were EHR, EMR, medical data processing, medical data retention, medical data destruction, health care, and patient care, and a few related terms with different combinations. PubMed (National Library of Medicine), Google Scholar, and Google search engine were used to search for articles from those databases. Searching was done using boolean words “AND”, “OR”, and “NOT” using all [All fields] and [MeSH Terms] searching strategies.

Results

Articles were screened using the title, checked by their abstract, and the remaining related full-text materials were included or excluded by two individuals deciding its eligibility. Finally, 73 materials issued from 2013–2018 were used for qualitatively synthesizing and reconciling the idea to produce this review article.

Conclusion

Poor medical data processing systems are the key reasons for medical errors. Employing standardized data management systems reduce errors and associated sufferings. Therefore, using electronic tools in the health care institution ensures safe and efficient data management. Therefore, it is important to establish appropriate medical data management systems for efficient health care delivery.