Steps to implement hepatitis C 1945-1965 testing
Both the Centers for Disease Control and Prevention (CDC) and US Preventative
Services Task Force recommend a one-time anti-HCV test for everyone born from
1945 through 1965 to complement risk-based testing. There is particular urgency to
identifying the baby boomers now since it is estimated that 25% of this population
already has cirrhosis and up to 75% of people with HCV infection have not been
diagnosed (*referenced fact sheet). Below is a summary of actions to consider.
1) Identify “champions” in the health care setting (clinic, hospital, health network)
that have a stake in implementing or gaining buy-in for increased HCV testing:
a) Primary Care (Family and Internal Medicine incl NP/PAs)
i) Educate colleagues about the burden of HCV in this health care setting
and why it is critical to identify patients now (*sample slide deck)
ii) Decide on level of HCV care to be provided in various primary care sites
(on-site academic practices with ready access to HCV providers may
choose not to provide antiviral therapy while those in community health
centers may). Levels of care could include:
(1) Baby boomer and risk based anti-HCV antibody testing, HCV RNA
testing, basic counseling, address mental health and/or addiction
needs or other barriers to adherence, identify insurance gaps, referral
to GI/ID for further care
(2) Perform #1 as well as initial lab testing to help facilitate more efficient
evaluation after referral, including HCV genotype, CBC, renal function,
LFTs, non-invasive test of liver fibrosis (FibroSure, Hepascore, FIB-4,
etc), iron studies, ANA, hepatitis A and B and HIV antibody testing,
vaccination for A and/or B if needed
(3) Perform #1 and #2 as well as diagnosis of severity of liver fibrosis
(cirrhosis or not), antiviral treatment. May be in conjunction with
ECHO/Telemedicine program (* Initial Treatment Guide)
iii) Integrate HCV education into resident and medical student teaching and
resident clinics
b) Gastroenterology and/or Hepatology (“GI”)
i) Ensure capacity to evaluate and provide care and antiviral treatment to
newly identified HCV patients
ii) Decide on which aspects of HCV care will performed or managed by
primary care, ID, and/or GI
iii) Educate primary care on general HCV, importance of baby boomer
testing, and support services offered by GI
iv) Help ID with broader educational activities in community
v) Coordinate long term care and monitoring for all cirrhotic patients
vi) Provide template intake form to ensure all data needed for prior
authorizations is collected correctly (*example intake)
vii) Provide templates for initial and follow up notes to improve efficiency
and ensure proper documentation/billing (*examples)
c)
d)
e)
f)
viii) Identify one specialty pharmacy that everyone will use (unless
constrained by insurance coverage) and establish expectations with SP
for assistance with prior authorizations, adherence monitoring,
addressing patient questions, refills, ongoing insurance company
requests
ix) If possible, provide staff that can track everyone started on HCV
medications, be a point person for questions from specialty pharmacy,
and track medication shipments to site for initiation of treatment
x) Provide Fibroscan testing to broader community
Infectious Disease
i) Ensure capacity for evaluation and antiviral treatment
ii) Decide on division of patients with GI (may have all cirrhotic patients or
all decompensated patients followed by GI and milder liver disease
followed by either division)
iii) Education of primary care practices
iv) Provide consultation on HIV antiretroviral medications for HIV/HCV
patients followed in GI or follow all HIV/HCV patients in ID with GI
support for those with advanced liver disease
v) Coordinate efforts with local and state Departments of Public Health and
state viral hepatitis coordinator to target efforts to areas with highest
HCV prevalence, promote broader HCV awareness and testing campaigns,
augment support services to help patients get insurance and navigate
health system
vi) Educate local government and private payers about importance of
identifying people with HCV and ensure fair coverage of antiviral
treatment
Behavioral Health
i) Help ensure that patients identified with HCV infection are good
treatment candidates, optimize adherence, and reduce the risk for
reinfection once cured
(1) Provide addiction services for patients identified with HCV who have
substance use disorders
(2) Provide mental health support
Clinical Laboratory
i) If outside lab (ie Quest, LapCorp) is used, ensure everyone understands
which specific tests should be selected. If there is an option for reflex HCV
RNA testing if anti-HCV antibody tests are reactive, select this option
ii) If local lab, discuss possibility for reflex HCV RNA testing (MMWR; May
10, 2013 / 62(18);362-365)
iii) Ensure laboratory personnel are aware of testing program and prepared
for an increased volume of tests
iv) Perform episodic quality analyses to identify any trends in gaps in testing
Electronic Medical Record IT team
i) Implement an EMR prompt for one-time anti-HCV antibody testing for all
patients born from 1945 through 1965
(1) May start with outpatient clinic settings
(2) If shared EMR, prompt may be seen by multiple care sites (ED,
inpatient) but expectation for testing in each setting can be decided on
ii) Facilitate review and approval of HCV prompt by EMR Committee
iii) See www.nvhr.org for examples of HCV testing prompts in various EMR
platforms as well as a generic configuration for EMR prompts
g) Health system leadership
i) Articulate strong support for importance of baby boomer HCV testing
within care system and as an important service to the community
ii) Facilitate coordination of care services between various department and
divisions listed above
iii) Provide space and time for ECHO/Telemedicine participation if
appropriate
2) Implement 1945-1965 HCV testing prompt with an announcement by email or
newsletter explaining program and support services
a) Consider holding a Grand Rounds or other educational “kick off” event
b) Be prepared to address concerns about testing, including that treatment is
too expensive
c) Tie awareness into Viral Hepatitis Testing Day or other community-wide
events
3) Track outcomes for quality assurance and address gaps in care:
a) HCV antibody testing percent for 1945-1965 cohort and non-boomers by
clinical care site, type of provider, patient demographics
i) Consider providing a “score card” so providers can see their performance
relative to (unnamed) peers
b) HCV RNA testing after positive anti-HCV antibody result
c) Address gaps in insurance
d) Referral to HCV providers
e) Appropriate management including staging of liver disease, vaccination for
hepatitis A and B, alcohol counseling
f) Initiation of antiviral treatment
g) SVR rates
h) Identification of patients with cirrhosis and rates of hepatocellular carcinoma
screening, EGD for gastroesophageal varices, vaccination for pneumococcus
4) Create centralized location for templates, patient education handouts, and
treatment guides with frequent updates