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Hepatitis C Baby Boomer Screening and Linkage to Care Programs in the US

Hepatitis C Baby Boomer Screening and Linkage to Care Programs in the US. Camilla S. Graham, MD, MPH Division of Infectious Disease Beth Israel Deaconess Medical Center cgraham@bidmc.harvard.edu. Disclosures. I have no disclosures. Efficient Identification of Patients with HCV.

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Hepatitis C Baby Boomer Screening and Linkage to Care Programs in the US

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  1. Hepatitis C Baby Boomer Screening and Linkage to Care Programs in the US Camilla S. Graham, MD, MPH Division of Infectious Disease Beth Israel Deaconess Medical Center cgraham@bidmc.harvard.edu

  2. Disclosures • I have no disclosures

  3. Efficient Identification of Patients with HCV 4 -5 million people with HCV in US 50 million “risk identified” or ~80 million 1945-1965 cohort who need to be tested for HCV in US1 25% diagnosed with HCV Treatment and Management Improve Diagnosis 1Tomaszewski Am J Public Health 2012; 102 (11):e101

  4. Who Should Be Tested for HCV CDC Recommendations • Everyone born from 1945 through 1965 (one-time) • Persons who ever injected illegal drugs • Persons who received clotting factor concentrates produced before 1987 • Chronic (long-term) hemodialysis • Persons with persistently abnormal ALT levels. • Recipients of transfusions or organ transplantsprior to 1992 • Persons with recognized occupational exposures • Children born to HCV-positive women • HIV positive persons USPSTF Grade B Recs* • Everyone born from 1945 through 1965 (one-time) • Past or present injection drug use • Sex with an IDU; other high-risk sex • Blood transfusion prior to 1992 • Persons with hemophilia • Long-term hemodialysis • Born to an HCV-infected mother • Incarceration • Intranasal drug use • Receiving an unregulated tattoo • Occupational percutaneous exposure • Surgery before implementation of universal precautions *Only pertains to persons with normal liver enzymes; if elevated liver enzymes need HBV and HCV testing Smith at al. Ann Intern Med 2012; 157:817-822. Moyer et al. Ann Intern Med epub 25 June 2013

  5. Deaths Due to HCV Infections Now ExceedThose Due to HIV Infection 15,106 12,734 Number of HCV-related deaths may be over 60,000 because of under-reporting on death certificates Ly KN et al. Ann Intern Med. 21 February 2012;156(4):271-278; Mahajan, IDSA 2013

  6. Timing of Mortality Among Known HCV Cases in Massachusetts, 1992-2009 Median interval: 3 years Median age: 53 years 76,122 HCV diagnoses were reported to the MDPH between 1992 and 2009, 8,499 of these reported HCV cases died and are represented in the figure. Data as of 1/11/2011. Lijewski, et al, 2012

  7. Screening of Baby Boomers May Prevent >120,000 Deaths Due to HCV Infection • Birth-cohort screening in primary care would identify 86% of all undiagnosed cases in the birth cohort, compared with 21% under risk based screening1 • Cost effectiveness of HCV screening is comparable to cervical cancer or cholesterol screening (cost/QALY gained with protease inhibitor+IFN+RBV = $35,700) Markov chain Monte Carol simulation model of prevalence of hepatitis C antibody stratified by age, sex, race/ethnicity, history of injection drug use, and natural history of chronic hepatitis C.*With pegylated interferon and ribavirin plus DAA treatment.†Deaths due to decompensated cirrhosis or hepatocellular carcinoma within 1945-1965 birth cohort. 470,000 deaths under birth cohort screening vs 592,000 deaths under risk-based screening1. Rein D et al. Ann Intern Med. 2012;156(4):263-270; 2. McGarry LJ et al. Hepatology. 2012;55(5):1344-1355.

  8. BIDMC/CareGroup Experience • Network of academic hospitals, primary care practices, community health centers that share a common electronic medical record system • 5,500 clinicians and ~1.5 million patients • Implemented a prompt in EMR for a one-time anti-HCV test in all patients born from 1945-1965 who had no prior record of testing, while continuing risk-based testing • Went live on June 4, 2013 • In the first ten months, we tested a total of 20,000 people for HCV

  9. Steps to Implement Birth Cohort HCV Testing • Build a core team: Primary Care, Infectious Disease, Hepatology, Database Management, and Clinical Pathology • Implement a one-time electronic prompt for anti-HCV antibody testing for all patients born from 1945 through 1965 who have no record of HCV antibody testing • One-page educational tool for providers and one for patients(samples at KNOW MORE HEPATITIS/CDC and NVHR.org) • Email notification to affected clinicians • HCV nurse educator • Help facilitate patient referral in the Liver Center and Infectious Diseases Clinic • Slide deck for presentations to primary care providers about HCV (sample at NVHR.org) • Collaboration with Laboratory Services • Expand capacity for increased volume of HCV Aband RNA tests • Add language to results page (or a second prompt) for all positive HCV antibody tests informing clinicians to order an HCV RNA test to determine the presence of active HCV infection • Generates a report of all positive HCV antibody tests for follow up

  10. Address Primary Care Provider Concerns • Address misconceptions about hepatitis C: • Hepatitis C causes substantial morbidity and mortality • Patients can have normal labs and exam and have cirrhosis • It is nearly impossible to implement comprehensive risk-based screening in general population primary care • Hepatitis C is curable and most patients will not require IFN • Many patients will not require a liver biopsy • Expect that PCPs will test all patients with reactive anti-HCV Ab tests for HCV RNA • Engage PCPs for alcohol screening and counseling, vaccinations, transmission risk reduction, referral for addiction treatment and harm reduction counseling • Remind PCPs about value of identifying cirrhotic patients before they develop complications • Provide support (education/nursing support, emails, telemedicine)

  11. Initial Hepatitis C Testing and Evaluation STOP here if no concern for acute infection or severe immunosuppression. If so, check HCV RNA. • Who Should Be Tested for Hepatitis C? • New: Anyone born between 1945 and 1965 should be tested once, regardless of risk factors • In addition, patients with the following risk factors: • Elevated ALT (even intermittently) • A history of illicit injection drug use or intranasal cocaine use (even once) • Needle stick or mucosal exposure to blood • Current sexual partners of HCV infected persons • Received blood/organs before 1992 • Received clotting factors made before 1987 • Chronic hemodialysis • Infection with HIV • Children born to HCV-infected mothers Negative (-) Hepatitis C Antibody (HCV Ab)1 Positive (+) • These people are NOT chronically infected. • Detectable HCV Ab with negative HCV RNA can occur with spontaneous clearance of infection ( about 25% of people exposed to HCV will clear; verify HCV RNA negative in 4 to 6 months) or with treatment of HCV. Negative (-) Check HCV RNA (viral load) Positive (+) Hepatitis C infection • 1Example ICD-9 codes for HCV antibody testing: • V73.89: screening for other specified viral disease • 790.4: nonspecific elevation of levels of transaminase; use if patient ever had an elevated ALT • Why Test People Born Between 1945-1965? • 76% of the ~4 million people with HCV infection in the US are baby boomers • In the 1945-1965 cohort: • All: 1 out of 30 • Men: 1 out of 23 • African American men: 1 out of 12 • Up to 75% do not know they have HCV • 73% of HCV-related deaths are in baby boomers Evaluation and referral • Counsel Patients with HCV Infection About Reducing Risk of Transmission • Do not donate blood, body organs, other tissue, or semen • Do not share personal items that might have small amounts of blood (toothbrushes, razors, nail-grooming equipment, needles) and cover cuts and wounds • HCV is not spread by hugging, kissing, food or water, sharing utensils, or casual contact • If in short term or multiple relationships, use latex condoms. No condom use is recommended for long-term monogamous couples (risk of transmission is very low) • What Can Happen to People with Hepatitis C? • It is important to identify if patients have cirrhosis • Patients with cirrhosis are at risk for liver cancer (HCC) and liver decompensation (ascites, variceal bleed, hepatic encephalopathy, jaundice) • Hepatitis C is curable, and cure reduces the risk of severe complications, even with cirrhosis • Refer patients to a specialist who has experience treating hepatitis C to see if they need treatment • Initial Management • Evaluate alcohol use (CAGE, AUDIT-C) and recommend stopping use • Vaccinate for hepatitis A and hepatitis B if not previously exposed • Evaluate sources of support (social, emotional, financial) needed for HCV treatment Smith BD et al. MMWR. August 17, 2012/61(RR04); 1-18. Adapted from Winston et al. Management of hepatitis C by the primary care provider: Monitoring guidelines; 2010; http://www.hcvadvocate.org/hepatitis/factsheets_pdf/PCP_web_10.pdf

  12. PCP Education Example: Screening in Clinic 3 with more advanced fibrosis 1,000 adult patients 330 baby boomers 7 HCV RNA positive 10 HCV antibody positive 4 with mild fibrosis • Efficiently identify birth cohort 1945-1965: • Electronic prompt • 1 of 30 baby boomers • 1 of 23 men baby boomers • 1 of 12 African American men baby boomers Up to 25% of baby boomers may have cirrhosis 75% of cirrhotic patients are men ~1/3 of adults are in 1945-1965 cohort 15%-30% of HCV antibody patients will spontaneously clear Davis, Gastro 2010; 138: 513

  13. Number of HCV Antibody Tests Performed In Four Week Intervals Beth Israel Deaconess Medical Center, Boston, MA, Quality Outcomes Data, 1/22/14

  14. HCV Antibody Test Volume Increased after EMR Prompt Beth Israel Deaconess Medical Center, Boston, MA, Quality Outcomes Data, 6/5/14

  15. More Women Tested for HCV but More Men are Anti-HCV Positive Beth Israel Deaconess Medical Center, Boston, MA, Quality Outcomes Data, 6/5/14

  16. Examples of HCV Prompts in EHRs National Viral Hepatitis Roundtable (NVHR) HCV Testing Project

  17. RI HCV Birth Cohort Prompt in EPIC Courtesy of Lynn Taylor, Lifespan & RI Defeats Hep C

  18. RI HCV Birth Cohort Prompt in EPIC Courtesy of Lynn Taylor, Lifespan & RI Defeats Hep C

  19. Example: EPIC Resources • Pre-loaded content to support hepatitis C testing in the 1945 - 1965 birth cohort into the foundation system • Need to turn the functioning on as is, or with modifications • Uses the Health Maintenance reminders (modifiers) and Population Management tools • Standing orders for anti-HCV antibody test, patient reminders sent out to MyCharts, and development of reporting workbenches

  20. Example: EPIC Resources • EPIC Earth • EPIC "Community Library" has e • Examples of hepatitis C decision support programs from other EPIC users • EPIC podcast for providers about hepatitis C decision support: • https://userweb.epic.com/Thread/32100 • Powerpointpresentation of interventions in EPIC to improve HCV testing • Project team support

  21. AllScripts Hepatitis C Prompt Drexel’s “C a Difference” developed the following AllScripts alerts to help providers adhere to CDC Hepatitis C testing recommendations 1) All individuals who were born between 1945 and 1965 who have not been previously tested for HCV will have this alert in the chart: For these patients, type “hcvscreen” to order HCV antibody screening with reflex confirmatory PCR quantitative testing Courtesy of Stacey Trooskin, Drexel & HepCAP

  22. AllScripts Hepatitis C Prompt 2) All individuals who have had a reactive HCV antibody test or have an ICD-9 code consistent with chronic HCV infection, but have not had confirmatory PCR quantitative testing in the last 5 years will have this alert: For these patients, type “hcvconfirmatory” or “hcvconfirm” to order HCV RNA PCR quantitative testing Courtesy of Stacey Trooskin, Drexel & HepCAP

  23. FIB-4 Screening: Boston Healthcare for the Homeless - Centricity Courtesy of Maggie Beiser, BHCHP

  24. Additional Provider Resources for HCV Testing at NVHR • Importance of Screening in Uncertain Treatment Climate Fact Sheet for Providers • Primary Care Provider Handouts & Fact Sheets • Birth Cohort Prompt Implementation Support • Continuing Medical Education (CME) resources • Coding & Billing Details • Provider Training Modules • Links to Treatment Guidelines Website: http://nvhr.org/content/welcome-nvhr-hepatitis-c-baby-boomer-resources-page

  25. Similar Peak in HCV Prevalence at Age 55 (in 2005) Globally MohdHanafiah; Hepatology 2013; 57:1333

  26. Toward a world where diagnosis guides the wayto health for all people FIND : Turningcomplexdiagnostic challenges intosimplesolutions totransformlives andovercomediseases of poverty • Catalyze development • Lead dynamic needs definition • Support program for manufacturers • Scout technology • Match-make • Provide specimens • Guide use • & policy • Lead clinical trials • Define evidence needs • Support WHO development of guidelines • Accelerate access • Facilitatenational policyanddevelop- mentofrolloutplans • HelpMoHsidentify gaps,coordinate solutions,and deployexperts • DevelopQAtools • &strategies Shape the agenda • MeasureandcommunicateimpactofDx • ShapeDxecosystemtofosterwillingnesstoinvest/pay • LeadglobaldiscussiononemergingDxtopics PATIENTS SCIENCE PRODUCTSSOLUTIONS Barbara Bulc (bbulc@gd-impact.org); Foundation for Innovative New Diagnostics

  27. Thanks NVHR Community Partners: • HepCAP – Philadelphia • Caring Ambassadors – Chicago • Hep C Connection – Denver • Mass Viral Hepatitis Coalition • Hepatitis Education Project – Seattle • RI Defeats Hep C • Hep Free Hawaii Beth Israel Deaconess Medical Center HCV Birth Cohort Testing Team: • NidAfdhal • Rachel Baden • Gila Kriegel • Brian Halbert • Meredith Rourke • Gary Horowitz To join the collaboration with NVHR, contact Tina Broder, tbroder@nvhr.org

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