Patient and provider‐level barriers to hepatitis C screening and linkage to care: A mixed‐methods evaluation

Abstract

Achieving practice change can be challenging when guidelines shift from a selective risk‐based strategy to a broader population health strategy, as occurred for hepatitis C (HCV) screening (2012‐2013). We aimed to evaluate patient and provider barriers that contributed to suboptimal HCV screening and linkage‐to‐care rates after implementation of an intervention to improve HCV screening and linkage‐to‐care processes in a large, public integrated healthcare system following the guidelines change. As part of a mixed‐methods study, we collected data through patient surveys (n = 159), focus groups (n = 9) and structured observation of providers and staff (n = 9). We used these findings to then inform domains for the second phase, which consisted of semi‐structured interviews with patients across the screening‐treatment continuum (n = 24) and providers and staff at primary care and hepatology clinics (n = 21). We transcribed and thematically analysed interviews using an integrated inductive and deductive framework. We identified lack of clarity about treatment cost, treatment complications and likelihood of cure as ongoing patient‐level barriers to screening and linkage to care. Provider‐level barriers included scepticism about establishing HCV screening as a quality metric given competing clinical priorities, particularly for patients with multiple comorbidities. However, most felt positively about adding HCV as a quality metric to enhance HCV screening and linkage to care. Provider engagement yielded suggestions for process improvements that resulted in increased stakeholder buy‐in and real‐time enhancements to the HCV screening process intervention. Systematic data collection at baseline and during practice change implementation may facilitate adoption and adaptation to improve HCV screening guideline implementation. Findings identified several key opportunities and lessons to enhance the impact of practice change interventions to improve HCV screening and treatment delivery.

A Qualitative Study of Implementing Universal Hepatitis C Screening Among Adults at an Urban Community-Based Health Provider in Delaware

“…17 A recent mixed-methods study that focused on HCV screening among primary care providers in a large, integrated health system revealed ongoing education for providers, and widespread patient barriers (e.g., financial cost of treatment, competing clinical priorities) as significant barriers to implementation. 18 In recognition of these findings, and to address gaps in the literature, we sought to better understand barriers to universal HCV screening and treatment among primary care providers in a federally qualified health center (FQHC) which presents unique challenges and opportunities compared to private medical practices. FQHCs are community-based health providers in the U.S. that receive federal funding to provide primary care services.…”

Clinician barriers, perceptions, and practices in treating patients with hepatitis C virus and substance use disorder in the United States

“…However, there is also evidence suggesting that, in general, clinicians involved in HCV care have little experience working with people with SUD, which often leads to distorted beliefs about the adherence capacity of these patients ( Trooskin et al, 2020 , Jatt et al, 2021 ) and unfounded concerns of reinfection ( Trooskin et al, 2020 ). These beliefs may be derived from stigmatization and discrimination ( Simoncini et al, 2021 , Trooskin et al, 2020 , Jatt et al, 2021 , Higashi et al, 2020 ). The lack of experience and the discomfort among clinicians were reflected in our findings.…”

Screening at a Federally Qualified Health Center in the Midwest for Hepatitis C Among People Who Inject Drugs, 2019–2020

“…Essential to the eradication of HCV is optimizing steps in the HCV care cascade, which includes diagnosis, curative therapy initiation, and confirmation of sustained virologic response (ie, cure). The number of patients sharply declines at each step of the care cascade in the US; the sharpest decline occurs between infection and diagnosis (Figure 1) (5). In 2015, 71 million people had HCV worldwide.…”

“…Approximately 14 million were diagnosed with HCV (20%), and 5 million were treated (7%). In 2019, the number of HCV infections worldwide remained at 71 million ( 6 ); this number is stagnant globally despite the availability of curative therapy ( 7 ).…”