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

Jonas, Mary Cabell; Rodriguez, Carla V.; Redd, Jacquelyn L.; Sloane, Dana; Winston, Bradley; Loftus, Bernadette

doi:10.1093/cid/ciw086

Cited by 46 publications

(51 citation statements)

References 29 publications

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“…Although, HCV RNA and genotype testing rates have improved in recent years and are similar to those reported for HCV positive Veterans and Kaiser Permanente members in the United States (95%) and higher than for primary care in Canada and United States (47.0% to 60.9%), there is a further need to reduce the gap between those antibody diagnosed and those undergoing further testing (Maier et al, 2016, Jonas et al, 2016, Spradling et al, 2014, Viner et al, 2015). We demonstrated that people with high risk activities progress to RNA testing while men and older cohorts, especially those born in 1945–64 lacked RNA testing (Spradling et al, 2014, Cachay et al, 2014).…”

Section: Discussionmentioning

confidence: 69%

“…Although guidelines and education for primary care physicians are important instruments to bridge this gap, a single blood sample test strategy in which those testing positive for antibody are also tested for RNA (reflex testing) and possibly for genotype could be an effective structural intervention to bridge this gap. Reflex testing for RNA has been implemented in the VA system and recently in Kaiser Permanente system, and was associated with higher RNA testing rates (Maier et al, 2016, Jonas et al, 2016). …”

Section: Discussionmentioning

confidence: 99%

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The Population Level Cascade of Care for Hepatitis C in British Columbia, Canada: The BC Hepatitis Testers Cohort (BC-HTC)

Janjua

Kuo

et al. 2016

EBioMedicine

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BackgroundPopulation-level monitoring of hepatitis C virus (HCV) infected people across the cascade of care identifies gaps in access and engagement in care and treatment. We characterized a population-level cascade of care for HCV in British Columbia (BC), Canada and identified factors associated with leakage at each stage.MethodsThe BC Hepatitis Testers Cohort (BC-HTC) includes 1.5 million individuals tested for HCV, HIV, reported cases of hepatitis B, and active tuberculosis in BC from 1990 to 2013 linked to medical visits, hospitalizations, cancers, prescription drugs and mortality data. We defined six HCV cascade of care stages: 1) estimated population prevalence; 2) HCV diagnosed; 3) HCV RNA tested; 4) genotyped; 5) initiated treatment; and 6) achieved sustained virologic response (SVR).ResultsWe estimated that 73,203 people were HCV antibody positive in BC in 2012 (undiagnosed: 18,301, 25%; diagnosed: 54,902, 75%). Of these, 56%(40,656) had HCV RNA testing; 34%(26,300) were genotyped; 12%( 8532 ) had received interferon-based therapy and 7%(5197) had SVR. Males, older birth cohorts, and HBV coinfected were less likely to undergo HCV RNA testing. Among those with chronic HCV infection, 32% had received liver-related care. Retention in liver care was more likely in those with HIV, cirrhosis, and drug/alcohol use and less likely in males and HBV coinfected.ConclusionsAlthough there are gaps in HCV RNA testing and genotyping after HCV diagnosis, the major gap in the cascade of care was low treatment initiation. People with comorbidities progressed through the cascade of testing and care but few received treatment.

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Section: Discussionmentioning

confidence: 69%

Section: Discussionmentioning

confidence: 99%

The Population Level Cascade of Care for Hepatitis C in British Columbia, Canada: The BC Hepatitis Testers Cohort (BC-HTC)

Janjua

Kuo

et al. 2016

EBioMedicine

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“…The EHR intervention increased HCV screening similarly to electronic interventions in other studies [9, 10]. The simplicity and low cost of the EHR intervention and widespread use of EHR systems with health maintenance reminders or other CDS tools suggests that our EHR intervention may work across different health systems.…”

Section: Discussionmentioning

confidence: 70%

“…Jonas et al [9] described a prevalence of 3.25% in a Kaiser Permanente cohort from Maryland, Virginia, and the District of Columbia, and Goel et al [12] described a prevalence of 3.3% in a New York City university-based primary care cohort of persons born between 1945 and 1965; both groups showed a greater proportion of black and Hispanic patients. A review of HCV seroprevalence in state prisons showed a wide range of seroprevalence from 7.5% to 41.2% between states, and the prevalence among Hispanic subpopulations also varies by Hispanic/Latino background and city, with the highest prevalence described in the Bronx and lower prevalence in Chicago, Miami, and San Diego [3, 13].…”

Section: Discussionmentioning

confidence: 99%

Implementation of a Large System-Wide Hepatitis C Virus Screening and Linkage to Care Program for Baby Boomers

Castrejon

Chew

Javanbakht

et al. 2017

Open Forum Infectious Diseases

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BackgroundWe implemented and evaluated a large health system-wide hepatitis C virus (HCV) screening and linkage to care program for persons born between 1945 and 1965 (“baby boomers”).MethodsAn electronic health record (EHR) clinical decision support (CDS) tool for HCV screening for baby boomers was introduced in August 2015 for patients seen in the outpatient University of California, Los Angeles healthcare system setting. An HCV care coordinator was introduced in January 2016 to facilitate linkage to HCV care. We compared HCV testing in the year prior (August 2014–July 2015) to the year after (August 2015–July 2016) implementation of the CDS tool. Among patients with reactive HCV antibody testing, we compared outcomes related to the care cascade including HCV ribonucleic acid (RNA) testing, HCV RNA positivity, and linkage to HCV specialty care.ResultsDuring the study period, 19606 participants were screened for HCV antibody. Hepatitis C virus antibody screening increased 145% (from 5676 patients tested to 13930 tested) after introduction of the CDS intervention. Screening increased across all demographic groups including age, sex, and race/ethnicity, with the greatest increases among those in the older age groups. The addition of an HCV care coordinator increased follow-up HCV RNA testing for HCV antibody positive patients from 83% to 95%. Ninety-four percent of HCV RNA positive patients were linked to care postimplementation.ConclusionsIntroduction of an EHR CDS tool and care coordination markedly increased the number of baby boomers screened for HCV, rates of follow-up HCV RNA testing, and linkage to specialty HCV care for patients with chronic HCV infection.

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“…Numerous prior studies evaluating routine HIV and HCV testing initiatives in primary care settings have found that such efforts increase testing and can lead to large numbers of persons being screened [15–20]. However, data evaluating the impact of routine testing on HIV and HCV case finding, the outcome of greater importance, are more limited.…”

Section: Discussionmentioning

confidence: 99%

Impact of an Electronic Medical Record-Based System to Promote Human Immunodeficiency Virus/Hepatitis C Virus Screening in Public Hospital Primary Care Clinics

Golden

Duchin

Chew

et al. 2017

Open Forum Infectious Diseases

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Background.United States guidelines recommend that all adolescents and adults be tested for human immunodeficiency virus (HIV) and that persons born between 1945 and 1965 be tested for hepatitis C virus (HCV).Methods.We used electronic medical record (EMR) data to identify patients in 3 primary care clinics in Seattle, Washington who met national criteria for routine HCV or HIV testing and had no documented history of prior testing. Clinic staff received daily lists of untested patients with scheduled appointments. We used generalized linear models to compare the percentage of patients tested and newly diagnosed with HIV and HCV in the 18 months before and during the intervention.Results.A total of 16784 patients aged 18–64 and 9370 patients born between 1945 and 1965 received care from January 2011 to December 2015. Comparing the preintervention and intervention periods, the percentage of previously untested patients tested for HIV and HCV increased from 14.9% to 30.8% and from 18.0% to 35.5%, respectively (P < .0001 for both). Despite this increase in testing, there was no change in the percentage of patients newly diagnosed with HIV (0.7% in both periods, P = .96) or HCV (3.6% vs 3.7%, P = .81). We estimate that 1.2%–15% of HCV-infected primary care patients in our medical center are undiagnosed.Conclusions.EMR-based HCV/HIV testing promotion increased testing but not case finding among primary care patients in our medical center. In our institution, most HCV-infected patients are already diagnosed, primarily through risk-based and clinical screening, highlighting the need to concentrate future efforts on increasing HCV treatment.

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

Cited by 46 publications

References 29 publications

The Population Level Cascade of Care for Hepatitis C in British Columbia, Canada: The BC Hepatitis Testers Cohort (BC-HTC)

The Population Level Cascade of Care for Hepatitis C in British Columbia, Canada: The BC Hepatitis Testers Cohort (BC-HTC)

Implementation of a Large System-Wide Hepatitis C Virus Screening and Linkage to Care Program for Baby Boomers

Impact of an Electronic Medical Record-Based System to Promote Human Immunodeficiency Virus/Hepatitis C Virus Screening in Public Hospital Primary Care Clinics

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