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HCV Outside of Hepatology: Screening in the Primary Care Setting
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The introduction of direct-acting antivirals and their significantly high cure rates are just one element in the formula for global elimination of hepatitis C. As important as successful treatment is, HCV cannot be eliminated without increased screening and diagnosis, especially considering the peaks of transmission related to the current opioid epidemic in the United States and limited resources in developing countries.
Implementing standard HCV screening in primary care settings and innovating techniques during medical procedures outside hepatology and gastroenterology specialist centers may provide a significant increase in identifying patients with HCV.
“The benefit of implementing hepatitis C in the primary care setting is that it can be linked together with standard health maintenance because many places already incorporate electronic health record prompts that remind providers, for example, to screen for breast cancer or colon cancer,” Robert Wong, MD, MS, director of GI education and research at Highland Hospital, California, told Healio Gastroenterology and Liver Disease. “It would be a fairly seamless way to implement hepatitis C screening based particularly on when the patient was born.”
Screening Outside of Specialty Practices
One simple and effective option to implement and increase HCV screening in primary care and outside specialist centers is the use of electronic health record prompts.
As many studies have shown, patients born between 1945 and 1965, or the ‘baby boomer generation,’ have an increased risk for HCV. EHR prompts for this birth cohort or other known risk factors could increase the rate of HCV diagnosis.
“We have found that incorporating screening alerts into the electronic health record greatly facilitates HCV screening since it reduces the workload required for screening,” Monica A. Konerman, MD, MSc, from the University of Michigan, told Healio Gastroenterology and Liver Disease. “These EHR alerts simplify workflow by first removing the need for the provider to remember when screening is indicated and providing pre-populated order sets for screening labs. Since this significantly decreases the time and effort needed to perform screening, screening rates significantly increased.”
Emergency room-based screening programs and outpatient procedures may be additional areas to implement HCV screening.
“Screening in the emergency room is a very valuable opportunity, because that type of population — especially when you’re dealing with high-risk, underserved populations that may or may not have primary care providers — it’s a population that’s enriched in hepatitis C risk factors,” Wong said.
According to Wong, his center has had success in screening during outpatient endoscopy, as many patients screened for colorectal cancer overlap with the baby boomer birth cohort.
“Provider education campaigns may also help raise awareness across a clinic or health system, and it may be especially useful to have a ‘warm line’ support if someone has a question about a patient he or she is seeing,” Christopher B. Hurt, MD, from the University of North Carolina and director of hepatitis C treatment services at UNC Infectious Diseases Clinic, told Healio Gastroenterology and Liver Disease.
Cost-effectiveness
Efforts to implement or increase new screening systems and programs, as well as linkage to care and treatment, will of course increase upfront costs. However, several studies have shown that early diagnosis and treatment of HCV has long-term cost benefits.
Konerman noted that in a study performed at her institution, she and her colleagues found that patients newly screened for HCV — many of whom were baby boomers — already had advanced fibrosis and cirrhosis.
“By preventing disease progression, you reduce and potentially eliminate the risk for additional complications such as cirrhosis, end-stage liver disease and liver cancer,” Wong said. “All of these downstream complications of untreated hepatitis C are costly for the system, costly for the patient, and require resources from the health care system.”
Linkage to Care
As important as screening for HCV is, equally important is follow-through with linkage to care. According to Wong, some of the major barriers between diagnosis and treatment include:
- Patients lacking awareness of the burden of HCV and available treatments;
- Physicians lacking awareness of available treatments or patient risk factors;
- Patients’ socioeconomic status and lifestyle factors including drug use; and
- System-level factors including complex referral and approval systems.
“The most important thing is to have a clearly articulated plan for where a patient with newly identified HCV infection will go for care,” Hurt said. “Because DAAs are so much better tolerated than previous HCV treatments, it’s becoming more and more feasible for primary care and other non-specialists to manage the screening, diagnosis and treatment of HCV all within their own practice. If these patients won’t be managed in-house, then it’s important to let referral partners know that screening programs are going to be implemented.”
Konerman added that between screening and linkage to care, it’s critical to ensure that positive screens are confirmed with HCV RNA.
“At our center, we were able to address the problem of lack of confirmatory testing by working with our pathology lab to incorporate reflex HCV RNA testing for any HCV antibody positive test,” Konerman said. “Once HCV RNA testing is complete, we then worked with primary care clinics to provide a detailed workflow that streamlined referral to our hepatology clinic and this resulted in 100% of newly diagnosed patients being referred to a hepatology clinic.”
The Next Step
“It’s important for any approaches to be as top-down as possible, meaning that front-line providers have a clear message that this is an institutional commitment or effort, and that others are screening too,” Hurt said.
Moving forward, hepatologists and gastroenterologists can do their part to educate their colleagues and improve awareness of HCV risk factors, screening methods and paths to treatment.
“You can do this,” Hurt concluded. “With just a little bit of training and planning upfront, it’s eminently doable for PCPs to manage HCV entirely within their practices in the era of DAA therapy.”
- For more information:
- Christopher B. Hurt, MD, can be reached at christopher_hurt@med.unc.edu.
- Monica A. Konerman, MD, MSc, can be reached at konerman@med.umich.edu.
- Robert Wong, MD, MS, can be reached at rowong@alamedahealthsystem.org.
Disclosures: Konerman, Hurt and Wong report no relevant financial disclosures.