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A Goal to Improve the Continuum of HCV Care

Leaders come together to address challenges, ranging from provider capacity to measures of performance.

Issue: September 2014

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New treatment options and mandated screening of baby boomers should translate into a flood of new patients with hepatitis C virus entering the health care system, but adoption of new guidelines is often slow in health care. With a goal of achieving sustained virologic response in as many people living with hepatitis C virus as possible, the clinical community faces the challenge of identifying and keeping them engaged in the health care system, from initial visits through the cure of infection.

Recently, the Viral Hepatitis Action Coalition hosted the National Summit to Improve Access to HCV Testing, Treatment and Cure to address these issues and the myriad barriers that arise each step of the way.

It is important to “highlight the gaps in the health care delivery system at every stage, from testing all the way to cure,” Kiren Mitruka, MD, MPH, medical officer of care and treatment in the division of viral hepatitis at the CDC, said at the meeting.

The numbers reveal flaws in the continuum of HCV testing, care and cure. Among an estimated 3 million people in the United States living with HCV, 1.6 million had the virus detected, 1 million to 1.2 million were referred to care, 220,000 to 360,000 received treatment and 170,000 to 200,000 received successful treatment, according to data from the Chronic Hepatitis Cohort Study (CHeCS) and the National Health and Nutrition Examination Survey.

It is important to “focus on how to improve provider capacity to test and cure and deliver care,” Mitruka said.

Much emphasis has been placed on HCV screening, particularly in the baby boomer birth cohort, as an entry point to the continuum of care, but leveraging health care reform policy and educating both communities and providers will be critical to keep patients in the system, she said. The development of performance measures and clinical support tools through the use of electronic medical records (EMRs) is also important, as is improving the capacity for genotype testing and ensuring cure rates.

A Focus on Clinician Education

The Extension for Community Health Care Outcomes, more commonly known as Project ECHO, is one example of expanding provider capacity for patients with HCV. Developed by clinicians at the University of New Mexico, the goal of Project ECHO is to increase the capacity of primary care providers in the management of HCV in rural and underserved populations. The project uses videoconferencing between primary care physicians, HCV specialists and other members of a multidisciplinary team to share best practices and case-based learning through a secure, centralized database to monitor outcomes.

Data published in Morbidity and Mortality Weekly Report on May 9 suggest that Project ECHO is meeting that goal. Of 66 PCPs trained in the program, 93% had no previous experience with HCV care. Results demonstrate that 46% of the 280 patients with HCV included in this study received treatment. “This was more than twice that observed in other CDC studies,” Mitruka said. Other data published in The New England Journal of Medicine in 2011 show that patients treated through the Project ECHO model achieved comparable SVR rates and fewer adverse events than patients treated in clinics.

Despite these gains, a great deal of stigma continues to surround HCV infection, and health care providers contribute to this stigma, according to Camilla S. Graham, MD, MPH. “This is actually a huge barrier,” said Graham, assistant professor of medicine at Beth Israel Deaconess Medical Center and co-director of the Viral Hepatitis Center in the division of infectious diseases at Harvard Medical Center.

Camilla S. Graham

Misinformation in the clinical community is another barrier to improving the continuum of HCV care. Graham said some clinicians believe that testing the entire baby boomer birth cohort will result in the testing of too many people and will lead to increased costs. Some clinicians believe they can tell who has HCV simply by looking at the individual or that they should wait until the patient has clinically significant liver disease before testing, according to Graham. She also noted that some providers fail to realize that HCV can be cured and that less toxic and more tolerable therapies are now available. “Many also believe that patients will die with HCV, and not of HCV. Showing CDC mortality data has really helped undo that misconception,” she said during the summit. Data have shown that the birth cohort model of testing and linkage to care is cost-effective when fully implemented, Mitruka noted.

To combat this misinformation, she said education materials are becoming more widely available. “We are beginning to come to a consensus about what the best-practice education needs to look like for primary care providers,” Graham said.

Summit panel member Cynthia Jorgensen, DrPH, of the Communication, Education and Training Division of Viral Hepatitis at the CDC, said knowledge of HCV among providers has increased with time, but some remain unaware of the most basic facts, such as screening guidelines for baby boomers.

Broad Efforts Underway

Such knowledge gaps have prompted a variety of broader education efforts. One example is the Know More Hepatitis campaign, which was launched by the CDC in 2012 with an aim to increase awareness of HCV and encourage testing among those most affected by HCV. The target audience includes opinion leaders and policymakers along with PCPs and individuals born from 1945 to 1965.

Consumer research undertaken to help develop the campaign indicated a number of mistaken beliefs about HCV among the baby boomer birth cohort, according to Jorgensen. “There is little understanding of how HCV is spread and who is most affected. Many perceive their severity to be very low and they have little or no awareness of the link to liver cancer. Many patients believed that they had already been tested. More importantly, they believe that if they are infected, they would have symptoms,” she said.

Figure 1. The Continuum of HCV Testing, Care and Cure.

Source: Holmberg SD. N Engl J Med. 2013;368:859-861

So far, the effort has yielded 1.2 billion audience impressions, 18,550 donated public service announcement placements and almost half a million on the campaign website. “The Know More Hepatitis website has received $12.3 million in donated media value,” she said. “We are particularly proud of our online hepatitis risk assessment. People can get a tailored recommendation for testing or vaccination in the privacy of their own home, and we know that more than 125,000 people have visited the online risk-assessment website page.”

Other programs to improve HCV knowledge and education are also in place. At Beth Israel Deaconess Medical Center, Graham said steps being taken to improve birth cohort testing rates include one-page educational tools geared toward both providers and patients — one for each group — accessed at the point of care via linkage to the HCV antibody electronic prompt. “Additional language on the results page for all positive HCV antibody tests informs clinicians to order an HCV RNA test to determine the presence of active HCV infection,” she said. If HCV RNA is detected, clinicians are reminded to refer the patient to specialty care. A report of all positive tests is then generated.

Smaller education programs such as the tools implemented at Beth Israel Deaconess Medical Center complement larger efforts like the Know More Hepatitis campaign. Casting the net wide allows the clinical community to reach as many patients, and potential patients, as possible.

Improved Health Care Performance

Although HCV measures of performance are moving the field forward, they may fail to achieve the stated objectives without ongoing performance review. At the summit, John B. Wong, MD, chief of the division of clinical decision making at Tufts Medical Center in Boston, suggested that recognition of the need for performance improvement is an important first step toward improving the quality of HCV care.

John B. Wong

Wong highlighted data from Kanwal and colleagues published in the Annals of Internal Medicine in 2010 based on the first set of American Medical Association Physician Consortium for Performance Improvement (PCPI) quality measures, including confirmation of the presence of the virus, not just the antibody; vaccination; referral for consideration for antiviral treatment; and pretreatment confirmation of viral genotype and the presence of the virus. Quality measures such as vaccination rates ranged from just 20% to 40%, while genotype testing was performed in only 80% of patients prior to treatment. “Clearly, there is a performance gap,” Wong said.

Other findings from Liu and colleagues, who conducted a study in 491 patients with HCV antibodies at one institution, also demonstrate that a performance gap exists, according to Wong. “The result [of the HCV antibody test] was never acknowledged anywhere in the chart for one-third of the patients. Even if it was acknowledged, and the patients and providers went on to engage in HCV education or consultation, they never confirmed the viral positivity in 86% of those patients,” he said. In addition, just 15% of the patients in this study were referred to an HCV clinic. The referral rate among non-PCPs was just 3%.

It is, for these reasons, that AMA PCPI measures seek to enhance quality and patient safety, align patient-centered care with performance measures and quality improvement and develop clinically meaningful evidence-based performance measures, Wong said. He outlined a comprehensive plan that involves a cross section of process measures including confirmation of HCV viremia, paired genotype testing, alcohol screening and counseling, surveillance measures for patients with cirrhosis and referrals for patients identified. These measures reflect Institute of Medicine-recommended quality processes such as accurate assessment and timely follow-up, coordination of care for high-risk patient populations, management of risk factors, and patient engagement and activation. The range of outcomes associated with these processes includes everything from SVR to quality-of-life measures to promotion of shared decision-making between clinicians and patients.

The National Quality Forum will set standards for care performance and quality improvement moving forward, including recommending measures for payment and public reporting programs. “It is estimated that by 2017 nearly 10% of all Medicare payments will be performance-based,” Wong said.

Benefits, Challenges of New Technology

Bret Shillingstad, MD, FACS, a physician on the clinical informatics team at Epic Systems Corp. in Madison, Wis., discussed the use and integration of EMRs and decision support tools to increase testing for HCV.

EMRs and online applications clearly have a role in keeping patients and providers on task. As an example, Graham cited the early experience with a prompt in the EMR for a one-time anti-HCV test in all patients born from 1945 to 1965 who had no prior record of testing. The Beth Israel Deaconess Medical Center/CareGroup network comprises 5,500 clinicians and 1.5 million patients at academic hospitals, primary care practices and community health centers that share a common EMR system. The prompt went live on June 4, 2013. In the first 10 months, Graham and colleagues in the network tested 20,129 people for HCV, she said.

However, multiple barriers must be addressed before wide implementation of EMR prompts for HCV testing, according to the presenters. On the system end, there is a lack of uniform EMR use across health systems. On the clinician end, one concern is what Shillingstad called “alert fatigue” and what Graham referred to as “prompt burnout.” Warnings about drug-drug interactions or allergic reactions pile up, along with a host of other personal and professional reminders. “One of the things I see clinicians do most quickly and frequently is click past alerts,” Shillingstad said. “It is a matter of selling an effective alert to your organization, deciding who is going to see what alert and how they are going to act on it.” On the patient end, barriers may include lack of insurance and lack of access to primary care.

Barriers aside, Shillingstad provided technological solutions that have the potential to improve workflow. Possible approaches may include patient alerts through personal health records such as MyChart. Front desk staff or nurses may help share the responsibility of issuing reminders and scheduling tests, he said. “We have seen improvements [at our institution] in breast cancer because receptionists are reminding patients to get their mammograms scheduled. The nurse and the physician are not even involved,” he said. For physicians, Shillingstad suggested that focusing the alert on those most likely to perform the preventive care measure — PCPs, GI specialists, nursing staff, radiologists, for example — could increase the likelihood that the test or procedure will be performed. Point-of-care alerts have also demonstrated effectiveness, he said.

For Mitruka, the field is open. Individual clinicians and larger health systems are encouraged to explore all of these options, from Web alerts to patient-directed media campaigns.

“We would like to see development of innovative strategies to implement testing in primary care settings and for regular consultation between primary care doctors and specialists so that the linkage to care is seamless,” Mitruka said. — by Rob Volansky