A Population-Based Intervention to Improve Care Cascades of Patients With Hepatitis C Virus Infection

Abstract

Hepatitis C virus (HCV) infection is common in the United States and leads to significant morbidity, mortality, and economic costs. Simplified screening recommendations and highly effective direct-acting antivirals for HCV present an opportunity to eliminate HCV. The objective of this study was to increase testing, linkage to care, treatment, and cure of HCV. This was an observational, prospective, population-based intervention program carried out between September 2014 and September 2018 and performed in three community health centers, three large multiclinic health care systems, and an HCV patient education and advocacy group in King County, WA. There were 232,214 patients included based on criteria of documented HCV-related diagnosis code, positive HCV laboratory test or prescription of HCV medication, and seen at least once at a participating clinical site in the prior year. Electronic health record (EHR) prompts and reports were created. Case management linked patients to care. Primary care providers received training through classroom didactics, an online curriculum, specialty clinic shadowing, and a telemedicine program. The proportion of baby boomer patients with documentation of HCV testing increased from 18% to 54% during the project period. Of 77,577 baby boomer patients screened at 87 partner clinics, 2,401 (3%) were newly identified HCV antibody positive. The number of patients staged for treatment increased by 391%, and those treated increased by 1,263%. Among the 79% of patients tested after treatment, 95% achieved sustained virologic response. Conclusion: A combination of EHR-based health care system interventions, active linkage to care, and clinician training contributed to a tripling in the number of patients screened and a more than 10-fold increase of those treated. The interventions are scalable and foundational to the goal of HCV elimination.

Fig. 1

Flow and classification of patients residing in King County identified by HCV‐TAC partner organizations from September 30, 2013, to September 29, 2018. ^*Includes all patients identified by each HCV‐TAC partner organization; individuals seen at more than one health care system are counted more than once in the total number. Records for patients with hepatitis C were deduplicated in the public health surveillance database. ^†Numbers may not match the next step because of lack of public health information, deduplication, and exclusion of persons not residing in King County. Abbreviation: Ab, antibody.

Fig. 2

Percentage of baby boomer patients residing in King County with visits to HCV‐TAC partner clinics who have been screened for HCV antibody, by project year (September 30, 2013, to September 29, 2018).

Fig. 3

Percentage of baby boomer patients screened for HCV in partner primary care clinics. Abbreviation: FQHC, federally qualified health center.

Fig. 4

Hepatitis C care cascade for patients with HCV RNA‐positive results residing in King County and seen at partner clinics during the project period September 30, 2013, to September 29, 2018 (n = 8,270).

Fig. 5

Comparison of hepatitis C care cascade at end of baseline year (September 30, 2013, to September 29, 2014) and end of year 4 (September 30, 2017, to September 29, 2018).