Context of clinical care: the case of hepatitis C in underserved communities--a report from the Primary Care Multiethnic Network (PRIME Net) Consortium

HCV testing: Order and completion rates among baby boomers obtaining care from seven health systems in Florida, 2015-2017

Many U.S. residents infected with hepatitis C virus (HCV) are baby boomers (born 1945-1965), who remain undiagnosed. Past CDC and USPSTF guidelines recommended one-time HCV testing for all baby boomers, with newer guidelines recommending universal screening for all adults. This retrospective cohort study examined electronic medical records for patient visits from 2015 to 2017 within the OneFlorida Data Trust and University of South Florida Health system. We assessed percentages of HCV tests ordered and completed across four age groups (those born before 1945, 1945-1965, 1966-1985, and after 1985). In 2019, we used logistic regression to examine factors associated with HCV test ordering and completion among baby boomers, including age, race, sex, number of primary care visits, HIV status, hepatitis diagnosis, and liver cancer history. All age groups had low rates of HCV test orders. 4.4% of baby boomers had a test ordered in 2015, and 6.7% in 2016. Of those, 94.5% and 89.7% completed testing, respectively. All other races/ethnicities had lower likelihood of testing completion than Whites (Blacks (aOR 0.82, 95%, CI 0.75-0.91); Asians (0.69, 0.52-0.92); Hispanics (0.29, 0.26-0.32)), although test orders were higher for Asians (1.48, 1.37-1.61) and Blacks (1.78, 1.73-1.82). Tests ordered (11.42, 10.94-11.92) and completed (2.25, 1.94-2.60) were more likely among those with hepatitis history. Test orders were more likely for HIV-positive patients (3.68, 3.45-3.93), but completion was less likely (0.67, 0.57-0.78). Interventions are needed to increase testing rates so that HCV infections are treated early, mitigating HCV-related morbidity and mortality, especially related to liver cancer.

Predictive factors for not undergoing RNA testing in patients found to have hepatitis C serology and impact of an automatic alert

The process of diagnosis and linkage to care in cases of hepatitis C virus (HCV) infection remains an obstacle to disease control. The aims of this study were to evaluate predictive factors for not undergoing RNA testing among patients with positive HCV serology and impact of incorporating an automated electronic alert with recommendations in clinical practice. We collected HCV antibody tests requested from October 2011 to September 2014 to evaluate the rate of RNA testing and predictive factors for not undergoing RNA testing. Since October 2014, an automated alert notification has been implemented to remind physicians for testing RNA after a positive HCV test and referral to specialist care. 41 403 HCV antibody tests were requested from 34 073 patients. 870 (2.55%) patients tested positive. After a median of follow-up of 57.0 months (range 45.6-82.1), 37.6% did not have RNA testing. The independent predictors for not undergoing RNA testing were primary care serology requests (P < 0.001), no history of drug use (P = 0.005) and a lack of social support (P = 0.015). The intervention impact was evaluated in a pre-alert cohort (October 2011-September 2014) and a post-alert cohort (October 2014-September 2015). After the incorporation of the alert, the rate of RNA testing increased from 62.4% to 77.7% (P < 0.001). Incomplete assessment of HCV infection is a challenge in primary care. The implementation of an automated alert for recommending RNA testing after a positive HCV antibody test is feasible in clinical practice and increases the rate of patients with RNA testing.

Streamlining Screening to Treatment: The Hepatitis C Cascade of Care at Kaiser Permanente Mid-Atlantic States

Hepatitis C virus (HCV) screening is recommended for patients at risk and/or born during 1945-1965, but screening gaps persist. This new program screens target populations and enhances care linkage for chronically HCV-infected patients. Kaiser Permanente Mid-Atlantic States created a comprehensive HCV screening pathway, supported by a HCV care coordinator. The testing pathway includes HCV antibody (Ab), automatic HCV RNA for Ab-positive patients, coinfection and liver health tests, vibration-controlled transient elastography (VCTE), and a physician referral. A total of 11 200 patients were screened; 3.25% were HCV Ab positive, and 100% of Ab-positive patients received HCV RNA testing. Of HCV Ab-positive patients, 75.9% had chronic HCV, of which 80.8% underwent VCTE. HCV diagnosis was communicated to 94% of patients, and 70.9% had HCV documented in the electronic health record. The pathway shows promise in closing gaps, including improving HCV RNA testing, communicating diagnoses, and assessing liver fibrosis. Improved testing and linkage could increase curative treatment access.

Age cohort differences in illicit drug use and hepatitis C among African American substance users

Identifying prognostic indicators for undiagnosed Hepatitis C is crucial to attenuate the negative impact of this disease. This study explored the influence of recent and more distal injection drug use on biologically confirmed Hepatitis C infection among a sample (N = 260) of older and younger African Americans. Data from the baseline assessment of the NEURO-HIV epidemiologic study was analyzed using confounder adjusted regression techniques. Older adults were more likely to test positive for Hepatitis C (OR = 2.80, 95% CI = 1.53-5.11) due to lifetime injection drug use (AOR = 5.37, 95% CI = 3.10-9.28). Clinical implications are discussed.

Case-finding for hepatitis C in primary care: a mixed-methods service evaluation

BACKGROUND

Hepatitis C is often asymptomatic, presenting with liver failure and cancer decades after infection. People who inject drugs (PWID) and immigrant populations from countries with a moderate-to-high prevalence of hepatitis C virus (HCV) are the main risk groups. Deaths and hospital admissions due to HCV cirrhosis tripled between 1998 and 2010, but the majority of people with chronic HCV are unaware of it.

AIM

To identify patients at risk of developing hepatitis C using routine GP data, to determine the proportion not tested, and to explore GPs' views regarding testing.

DESIGN AND SETTING

Mixed-methods service evaluation (density-based selection of PWID) in six NHS practices in Bristol.

METHOD

Patients at risk of HCV were identified. The Health Protection Agency laboratory (now part of Public Health England) provided test results. Semi-structured interviews with 17 GPs were audiorecorded and thematic analyses conducted on anonymised transcripts.

RESULTS

Of 3765 patients identified as being at risk of developing hepatitis C, 3051 (81%) had no test result, including 53% of PWID and 93% of the 'ethnicity' group. All GPs said they usually test PWID. Most GPs test for HIV and hepatitis B in immigrants more often than they test for HCV. Barriers to testing included not questioning patients about risk factors, competing priorities, the chaotic lifestyle of PWID, difficulty extracting information from computerised records, and forgetting to address HCV.

CONCLUSION

Computer prompts and GP education on whom to test are warranted. Ensuring that country of origin and drug use is included on the new-patient questionnaire might also aid case-finding for HCV.

Awareness of biologically confirmed HCV among a community residing sample of drug users in Baltimore City

The present study sought to examine: (1) the prevalence and correlates of biologically confirmed Hepatitis C (HCV) and (2) the prevalence and correlates of prior HCV diagnosis and an unmet need for HCV treatment, among a community residing sample of drug users. The current study used a subset of HCV tested participants from the larger NEURO-HIV Epidemiologic Study from Baltimore, Maryland (M(age) = 34.81, SD = 9.25; 46% female). All participants were tested for HCV at baseline. Self-report was used to assess awareness of an HCV diagnosis and participation in treatment. Of the 782 participants tested for HCV, 19% reported having received an HCV diagnosis in the past while 48% tested positive for HCV. Only 6% reported having received treatment for any form of hepatitis. Of those who tested HCV positive, 63% reported never being diagnosed, and only 13% received any treatment for HCV. We found that only 35% of those who reported a prior HCV diagnosis received any treatment. The findings regarding lack of HCV awareness and diagnosis were considerable as expected. These deficits suggest that there are numerous gaps in patients' knowledge and beliefs regarding HCV that may interfere at multiple steps along the path from diagnosis to treatment. This study clearly demonstrates that a critical need exists to improve public knowledge of HCV risk factors, the need for testing, and the availability of effective treatment.

Cultivating a cycle of trust with diverse communities in practice-based research: a report from PRIME Net

PURPOSE

Practice-based research networks (PBRNs) are increasingly seen as important vehicles to translate research into practice, although less is known about the process of engaging diverse communities in PBRN research. The objective of this study was to identify strategies for successfully recruiting and retaining diverse racial/ethnic communities into PBRN research studies.

METHODS

This collaborative, multisite study engaged 5 of the 8 networks of the PRImary care MultiEthnic Network (PRIME Net) consortium that conducts research with traditionally underrepresented/underserved populations. We used a sequential, qualitative research design. We first conducted 1 key informant interview with each of 24 researchers experienced in recruiting research participants from 5 racial/ethnic communities (African American, Arab/Chaldean, Chinese, Hispanic, and Native American). Subsequently, we conducted 18 focus groups with 172 persons from these communities.

RESULTS

Participants' comments indicated that successful recruitment and retention of underrepresented populations in PBRN studies is linked to the overall research process. This process, which we termed the cycle of trust, entailed developing and sustaining relationships of trust during 4 interrelated stages: before the study, during study recruitment, throughout study conduct, and after study completion. Participants identified a set of flexible strategies within each stage and called for close engagement with clinic and community partners.

CONCLUSIONS

Our participants suggest that approaches to research that lay a foundation of trust, demonstrate respect for community members, and extend beyond the enrollment and data collection phases are essential to enhance the participation of diverse populations in PBRN research. These findings offer the PBRN community a guide toward achieving this important goal.

Formal hepatitis C education enhances HCV care coordination, expedites HCV treatment and improves antiviral response

BACKGROUND & AIMS

Formal Hepatitis C virus (HCV) education improves HCV knowledge but the impact on treatment uptake and outcome is not well described. We aimed to evaluate the impact of formal HCV patient education on primary provider-specialist HCV comanagement and treatment.

METHODS

Primary care providers within the San Francisco safety-net health care system were surveyed and the records of HCV-infected patients before and after institution of a formal HCV education class by liver specialty (2006-2011) were reviewed retrospectively.

RESULTS

Characteristics of 118 patients who received anti-HCV therapy were: mean age 51, 73% males and ~50% White and uninsured. The time to initiation of HCV treatment was shorter among those who received formal education (median 136 vs 284 days, P < 0.0001). When controlling for age, gender, race and HCV viral load, non-1 genotype (OR 6.17, 95% CI 2.3-12.7, P = 0.0003) and receipt of HCV education (OR 3.0, 95% CI 1.1-7.9, P = 0.03) were associated with sustained virologic treatment response. Among 94 provider respondents (response rate = 38%), mean age was 42, 62% were White, and 63% female. Most providers agreed that the HCV education class increased patients' HCV knowledge (70%), interest in HCV treatment (52%), and provider-patient communication (56%). A positive provider attitude (Coef 1.5, 95% CI 0.1-2.9 percent, P = 0.039) was independently associated with referral rate to education class.

CONCLUSIONS

Formal HCV education expedites HCV therapy and improves virologic response rates. As primary care provider attitude plays a significant role in referral to HCV education class, improving provider knowledge will likely enhance access to HCV specialty services in the vulnerable population.