Impact of Screening Implementing HCV Screening of Persons Born 1945-1965

Introduction

Hepatitis C virus (HCV) affects an estimated 3 to 5 million persons in the United States. In the United States, an estimated 75% of the national HCV burden occurs among persons born between 1945 and 1965, most of whom do not know they are infected. ¹ Data suggest that there is a substantial burden of HCV in the American Indian/Alaska Native (AI/AN) population with the highest acute HCV infection of any race/ethnicity, and 1 cohort of AI/AN patients in this birth cohort recording an antibody seroprevalence of 10%.^2,3

Warm Springs Health and Wellness Center (WSHWC) is a small Indian Health Service (IHS) clinic in the Pacific Northwest with a user population of approximately 6500 tribal members. WSHWC is part of a network of federal IHS health care facilities that is responsible for providing health service to approximately 2.1 million AI/AN people in 35 states. Most facilities are remote and rural primary health care clinics.

In August 2012, the Centers for Disease Control and Prevention (CDC) released recommendations that people born between 1945 and 1965 should receive a 1-time test for HCV without prior ascertainment of HCV risk. ⁴ In September 2012, WSHWC initiated a quality improvement (QI) project to increase screening for HCV based on CDC recommendations.

The QI project focused on improving HCV screening by broad inclusion of the following pillars of intervention: engaging community and health care facility leadership, developing and sustaining a successful and healthy workforce, developing policy and procedures, and optimizing clinical information systems.

These processes of interventions have proven effective in other preventive care metrics^5,6 and included training and discussions on the screening recommendation and its rationale with leadership and staff, pilot testing and deploying an electronic clinical reminder for all eligible patients with no history of HCV testing, and nurse orders of routine medical testing and delegation of screening responsibilities. Medical leadership also provided training on follow-up and linkage to care for HCV+ patients as a precursor to the increased case finding that was expected from screening implementation.

WSHCW sought to monitor the impact of its QI project on screening rates and communication with patients on HCV.

Methods

IHS monitors HCV screening prevalence using a standardized measure of persons born 1945-1965 with a history of at least 1 HCV test as a proportion of the total user population in the same age cohort. User population consists of patients residing in a catchment community with at least 1 clinical visit in the past 3 years. HCV screening and diagnosis definitions are nationally standardized in IHS, consisting of International Classification of Disease, ninth revision (ICD-9), Current Procedural Terminology (CPT), Logical Observation Identifiers Names and Codes (LOINC), and local laboratory test codes.

These data are uniformly defined and collected across all federal IHS facilities, which use a common electronic health record. Data on screening was collected and summarized via the IHS’ national Clinical Reporting System (http://www.ihs.gov/CRS/).

A short survey was given at the end of the 1 year project period to ascertain clinicians’ perceived impact of HCV screening on communication about the disease with patients, follow-up of initial test results and treatment of HCV. The impact was gauged on a Likert-type scale of 1 to 5, with ratings of poor, fair, good, very good, or excellent, as well as open-ended questions on the overall impact of HCV screening. The survey was administered by email to all clinicians, who received 2 email reminders over the course of 1 month to complete the questionnaire. Results were collected and analyzed on Survey Monkey (surveymonkey.com, Palo Alto, CA). Monitoring of HCV screening data and the clinician survey were approved by the Portland Area Tribal Health Board Intuitional Review Board.

Results

Unique patients with a history of being tested for HCV increased by more than 10-fold, with screening rates increasing from 5% (47/938) in September 2012 to 76% (593/785) in December 2014. Refusal rates were not recorded but considered negligible by clinical staff.

For the survey, 16/20 clinicians completed the questionnaire, for a response rate of 80%. All clinicians who answered (15/15, 100%) stated that the electronic health record reminder was helpful for HCV screening. Overall, respondents also felt prepared to treat HCV with 15/16 (94%) stating they were prepared, well prepared, or extremely prepared to treat HCV.

Respondents largely rated the impact of screening positively, (“good,” “very good,” or “excellent”). A strong majority of clinicians, 14/16 (88%, Likert scale 3.4), positively rated the impact of screening on the communication on HCV with persons born 1945-1965. Similarly, 13/15 (87%, Likert scale 2.9) clinicians positively rated the impact of screening on the communication of HCV with the general patient population. A slightly lower proportion of clinicians, 10/16 (63%, Likert scale 3.4), rated the impact of screening on the follow-up of HCV patients as positive, while 4/16 (25%) rated it as fair, and 2/16 (13%) stated it was not applicable.

Open-ended comments on the impact of screening included having more discussions about infectious disease transmission, and greater awareness of HCV among both clinicians and patients. Comments included “screening has made the awareness more out in the open,” “more easily discussed,” “raised awareness in the community,” and “opportunity to discuss ways people contract ID.”

All clinicians who responded (13/13, 100%) agreed that HCV could be treated in a primary care setting, although several respondents clarified that remote support from a specialist was a necessity.

Discussion

This primary care clinic used established intervention strategies to integrate HCV screening into primary care visits, increasing the number of unique patients screened by more than 1000% within 2 years. The high screening rate has allowed the clinic to have a fuller understanding of the HCV burden in their community and seek appropriate resources.

Clinicians were generally positive on what they perceived to be ancillary impact of screening such as more communication on HCV with patients—not only with people within targeted age range, but with the entire clinic population. Additional benefits of improved communication on HCV may include increased knowledge of transmission and prevention among patients, as well as decreased stigma for persons with HCV infection. Counseling on risk factors, patient education, and treatment can all contribute to the prevention of ongoing HCV transmission.

WSHWC staff was also positive about improved follow-up of HCV+ patients, and felt prepared to take a role in HCV treatment. The clinic currently collaborates with Seattle Extensions for Community Health Outcomes (ECHO) program for HCV telehealth consultations. As more people born between 1945 and 1965 are screened and require treatment, and as treatment options become more manageable, primary care physicians and small clinics have the option to treat for HCV.

While exact numbers cannot be disclosed for purposes of community confidentiality, HCV screening has resulted in new case detection in accordance with national estimates of seroprevalence in this birth cohort. In order to address the HCV caseload in the community, the clinic has been treating a small number of patients in-house for the past year and a half with support from Seattle-based specialists. WSHWC will continue to follow-up with newly identified HCV+ patients for counseling and treatment options and reduce HCV-related mortality to the greatest extent possible.

Further research is needed to examine patient and community perception of HCV screening and clinical services. In addition, it will need to be examined whether the clinical capacity to follow-up with HCV+ patients and provide treatment will be adequate to meet the clinical need as revealed by the new national screening recommendations.