New Strategies Increase HCV Testing in Primary Care, ER and Linkages to Care

Given how common the viral infection is, routine Hepatitis C virus (HCV) testing is not performed often enough. The majority of those infected are unaware of their status and many infected patients are diagnosed late—after decades of infection when HCV-related complications have set in.

Previous surveys identified barriers providers cite for not implementing testing, like the one-time, universal testing of baby boomers recommended by the U.S. Centers for Disease Control and Prevention (CDC). These barriers include the time required to identify risk factors from a patient history; the need to discuss sensitive or stigmatized behaviors; uncertainty that insurance would not cover HCV testing or treatment; and concern that identified patients could access HCV care.

But new models to increase routine testing and improve linkages to follow-up care may be scalable. Two new studies published in the June special supplement issue of Public Health Reports show that HCV testing can be expanded in both primary care and the hospital and effectively linked to follow-up care.

Testing in Federally Qualified Health Centers
As part of CDC’s Hepatitis Testing and Linkage to Care initiative, the National Nursing Centers Consortium (Philadelphia, Penn.) integrated routine, opt-out HCV testing and linkage-to-care model at five Federally Qualified Health Centers (FQHCs) in Philadelphia (Oct. 1, 2012, to June 30, 2014). The model included medical assistant-initiated testing, reflex laboratory-based HCV tests, and electronic health record alerts. Two centers serving patients at high risk for HCV conducted universal testing, while three health centers serving patients at low risk for HCV conducted risk-based testing.

The researchers found that 4,207 unique patients received HCV antibody (anti- HCV) testing, with 11.6 percent testing positive. Of those testing anti-HCV positive, 88.7 percent received a confirmatory HCV RNA polymerase chain reaction (PCR) test, with 72.3 percent of these patients (n=313) diagnosed with current infection (overall prevalence, 7.4 percent). Ultimately, 77.6 percent of HCV RNA-positive received their test results and 38.7%) were linked to care.

The authors cite several lessons learned that led to adjustments to further promote testing and improve clinic protocols.

• Bundling HCV and HIV tests resulted in a 52.7 percent increase in HCV tests performed between the 11 months before (1,786 tests performed) and after (2,728 tests performed) dual HCV/HIV testing started.
• As of June 2014, all health centers adopted universal testing. To do this, an EHR query runs each evening to identify adult patients with next-day appointments who have no HCV diagnosis or HCV test result in their chart.
• To combat testing fatigue and to accommodate new staff, a project manager visits each clinic weekly to report the total numbers of tests performed and address any training issues. An average of 211 more anti-HCV tests were performed monthly—a 63.9 percent increase—between the five months before and the five months after this adjustment.

Hospital-Based Testing
In December 2012, a South Texas safety-net hospital launched an HCV screening program for patients born between 1945 and 1965 with no HCV diagnosis or prior HCV test. An HCV screening laboratory order was automatically added upon admission for anti-HCV tests combined with reflex HCV RNA PCR confirmatory testing for identified age-eligible patients.

The researchers found that over the program’s first 10 months, 2,327 patients were screened for HCV, with an anti-HCV positive prevalence of 8 percent. Of the 167 (out of 192) anti-HCV-positive patients who received follow-up HCV RNA PCR testing nearly two-thirds had detectable HCV RNA indicating chronic HCV infection, yielding an overall prevalence of detected chronic HCV infection of 5 percent.

A program review revealed that more than 60 percent of screening-eligible patients did not have the test performed because nurses were not engaging in the informed-consent process with patients for testing. The informed-consent process was deemed too onerous for nurses during intake evaluations. So, the screening protocol was adjusted to opt-out consent, with patients learning about the program from hung posters and flyers in admission packets. Following this change, monthly program evaluations demonstrated three-quarters of eligible patients had the HCV screening added to their admission orders and fewer than 5 percent of patients opted out of testing.

Takeaway: Scaling HCV testing in FQHCs and safety net hospitals is an important way to identify large numbers of people with previously undiagnosed HCV and link infected patients to follow-up care.