Expert Conversations: HCV Screening With EHR Prompts and Education
In this podcast, Danielle Wales, MD, and Carina Abreu talk about their study that implemented health care provider education and electronic health record prompts for hepatitis C virus screening, as well as how these interventions impacted hepatitis C virus screening rates.
- Abreu C, Wales DP, Eichelman A, Ata A, Ramani R, Waxman M. Evaluating hepatitis C screening rates and successful interventions at an outpatient medicine/pediatrics practice. Paper presented at: IDWeek 2020; October 21-25, 2020; Virtual. https://www.eventscribe.net/2020/idweek/fsPopup.asp?efp=VFhWUUpXVFA2ODg4&PosterID=291801&rnd=0.9922929&mode=posterinfo
Danielle Wales, MD, is an assistant professor of medicine and pediatrics at Albany Medical Center in Albany, New York.
Carina Abreu is a third-year medical student at Albany Medical College in Albany, New York.
Disclosure: Dr Wales received salary support from Gilead for this project.
Amanda Balbi: Hello everyone, and welcome to another installment of Podcasts360—your go-to resource for medical news and clinical updates. I’m your moderator, Amanda Balbi with Consultant360 Specialty Network.
Recent research has indicated that hepatitis C virus (or HCV) screening has remained below 25% among high-risk populations born between 1945 and 1965, despite updated guidelines published in 2013. In an effort to increase screening rates at their clinic, a research team from Albany Medical College implemented simple interventions in their outpatient clinic.
With me today to discuss the study and its implications is the lead author and presenting author:
Dr Danielle Wales: I’m Dr Danielle Wales. I’m an assistant professor of medicine and pediatrics at Albany Medical Center in Albany, New York.
Dr Carina Abreu: I’m Carina Abreu. I’m a third-year medical student at Albany Medical College in Albany, New York.
Amanda Balbi: Thank you both for joining me today. To start, can you give us some background as to why it’s important to screen for HCV?
Dr Abreu: 50% to 60% of people who are chronically infected with hepatitis C are unaware. And the birth cohort, which was the initial cohort that we were looking at based on the United States Preventive Services Task Force (USPSTF), they make up about 75% of HCV infections and 70% of associated mortality of hepatitis C, while only accounting for 27% of the population.
So that’s why it’s really important that we just screen that birth cohort. Actually, in 2020, the USPSTF updated their guidelines. And so, we are looking to expand the age range of screening for 18 to 79, based on these new recommendations.
Dr Wales: In 2018, it's estimated that there were over 50,000 new cases of infections with hepatitis C. We know about half of those people will develop chronic hepatitis C and will be at risk for liver cirrhosis and hepatocellular carcinoma.
In 2018, there were 15,000 deaths, where the death certificate listed hepatitis C as a contributing factor. So, it's certainly no small number there. And we know that in the US, there's about 2.4 million people living with hepatitis C in the last few years. It's quite a large proportion of the population and really speaks to why we need to be screening everybody, especially as the consequences of not screening and not catching HCV at an early stage is quite drastic.
We've had amazing therapies that have come out in the last 10 years that really cure people of this. It is truly a preventable disease. We can screen early, find hepatitis C, and prevent these just awful consequences like cirrhosis or cancer from happening.
Amanda Balbi: HCV infection rates among older adults (“Baby Boomers”) have decreased due to curative therapy. However, screening for HCV among this cohort is still important. Can you talk about how your practice implemented more HCV screening?
Dr Wales: Sure. I think it's important to know that, as it stands right now, Millennials and Baby Boomers have the highest rates of chronic hepatitis C infections in the US, both around 36% according to the most recent CDC data.
And so, as part of this project, we wanted to prioritize the Baby Boomer population. At the time we started this project, that was the USPSTF recommendation—to screen all patients born between 1945 and 1965 for hepatitis C with a one-time hepatitis C antibody test.
We did a few things to try and improve our rates. First of all, provider education was important, making sure providers knew that this was a recommendation that we should all be doing.
But, ultimately, what we did that most increased our rates was 2 main things. First was putting a prompt in our electronic health records. For example, when you saw a patient, an alert would come up and say, “This patient is due for hepatitis C screening.” And then you could order right off that prompt. The second thing that we did was we went back and reviewed all of our patients who were eligible who were in the Baby Boomer cohort and had not either had hepatitis C before or had not been screened for hepatitis C before.
We went back in and had our nurses put in, essentially, standing orders for these patients so if they ever came in for blood work at another time, we would be able to screen them when they came in for blood work.
Amanda Balbi: How did your team decide who to screen? Is this approach something other clinics can adopt as well?
Dr Wales: When we started this project, again back in 2018, we were only focusing on Baby Boomers, so those born between 1945 and 1965, because that was the recommendation at the time, again from the USPSTF.
Since then, this year actually as of March, the USPSTF has actually expanded their recommendation to include all patients between the ages of 18 and 79, again speaking to how rates are rising among the Millennial population likely due to the opioid epidemic in the United States.
This year actually, which is not discussed in our abstract, but we had actually increased our screening to any patient aged 18 to 79 as well, just one-time screening. Certainly, any patient who has ongoing risk factors such as IV drug use or has a history of a blood or organ transplant before 1992 or clotting factor transfusion before 1987 or HIV infection, we will screen them more frequently.
From our standpoint, we are looking at universal screening of our patient population. And this is something that I think many other primary care practices can do easily, as long as they have an electronic health record that allows them to identify patients who are eligible for screening.
Amanda Balbi: Talking a little bit more about the Millennial population, it’s very well known that Baby Boomers are in the high-risk group, but can you talk a little bit about why Millennials are considered high-risk now and what role the opioid epidemic has played in that?
Dr Wales: We know today that there are 4 times as many new hepatitis C cases as there were 10 years ago. When we look back and look at our population, particularly Millennials—those born between 1981 and 1996—when we look at their risk factors, the primary driver of their hepatitis C acquisition is actually through IV drug use.
We believe a lot of this has to do with these patients being given opiates in some form, whether prescription or illicit, and then being switched to IV drug use again to help satisfy that craving, that addiction to opiates. We do know that that is a primary risk factor for infection with hepatitis C.
Amanda Balbi: Your results showed that HCV screening rates increased after implementing the EMR prompt and nursing-generated orders. How do you hope your findings impact clinical practice and the future of HCV screening?
Dr Abreu: In terms of the impact on clinical practice in the future of HCV screening, I think it would be great if this were to be implemented in all outpatient clinics.
Our results show that after having interventions, particularly not only educational intervention for attending and residents, but also just the EMR prompts and the nurse-generated orders, that our screening rates increased drastically.
So, we hope that this is something that's implemented at any outpatient clinic, and hopefully we are catching patients who otherwise would not have been screened for HCV and then develop those complications that occur when hepatitis C goes undiagnosed, which could include hepatocellular carcinoma and cirrhosis and complications like those. We just hope that this kind of service catches patients that otherwise would be missed.
Dr Wales: I think the one thing that many practicing doctors and nurse practitioners and physicians’ assistants deal with every day is how they can use their electronic health record to maximize the population health in their practice—using the data that's in the electronic health record.
I think in our practice, we were able to successfully use our EHR to identify patients who needed screening, but not every electronic health record is created equal. I think what's important to know going forward as health care providers advocate for their needs in the practice. I think having electronic health record that's easily able to identify patients based on provider queries is incredibly important as well.
Amanda Balbi: Absolutely. What is the overall take-home message from your study?
Dr Abreu: I would say that the overall take-home message from our study is that implementing interventions, such as EHR alerts, nurse-generated orders, attending education and resident education increases the rate of HCV screening.
That is consistent with the studies that have been shown that this approach increases testing more than like the CDC and the USPSTF recommendations alone. Having these additional prompts really does help in terms of screening.
Additionally, there have been some disparities in HCV screening that we found in the literature and on the importance of having these kinds of prompts and education for those disparities don't exist. In our study, we found no disparities in either race, gender, or insurance. So we're very happy about that.
Amanda Balbi: Thank you both for joining me today and answering all my questions about your research.
Dr Wales: Thank you so much.
Dr Abreu: Thank you so much for having us.