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Hepatitis C Testing and Liver Fibrosis Predictors in the Birth Cohort of a Primary Care Practice.

ABSTRACT: Objective:To determine the prevalence of and risk factors for advanced fibrosis in patients born from 1945 through 1965 (birth cohort) who underwent testing for hepatitis C virus (HCV). Patients and Methods:Data were extracted from the electronic health record of all patients receiving primary care at a single academic institution who underwent HCV testing between September 8, 2010, and March 5, 2018. The birth cohort patients were the primary focus of the study. Fibrosis 4 (FIB-4) and aspartate aminotransferase to platelet ratio index (APRI) scores were calculated to screen for fibrosis. Results:During the study period, 7097 birth cohort patients had HCV antibody testing, 3462 (48.8%) of whom were men, 6435 (91.0%) were white, 1028 (14.5%) had diabetes mellitus, 2,034 (36.5%) had an alanine aminotransferase (ALT) level greater than 30 U/L, and 2,396 (34.2%) had body mass index of 30 kg/m2 or greater. Hepatitis C virus antibody was present in 124 (1.7%), 33 (26.6%) of whom had HCV viremia. Estimated prevalence of METAVIR [Meta-analysis of Histological Data in Viral Hepatitis] stage 4 fibrosis was 4.1% (180 of 4433) by a FIB-4 score of 3.25 or greater and 4.3% (204 of 4763) by an APRI score greater than 1.0. The odds ratio (OR) for fibrosis, determined by APRI, was significant for HCV RNA positivity (OR, 15.98; 95% CI, 7.23-35.32; P<.001), diabetes mellitus (OR, 1.98; 95% CI, 1.40-2.79; P<.001), and ALT value greater than 30 U/L (OR, 15.07 U/L; 95% CI, 9.27-24.52 U/L; P<.001) but not for body mass index of 30 kg/m2 or greater (OR, 0.77; 95% CI, 0.56-1.06; P=.11). Conclusion:Hepatitis C virus viremia, diabetes mellitus, and elevated ALT levels were associated with increased odds for development of fibrosis. In addition to HCV testing, diabetes mellitus and elevated ALT level are potential parameters to use for recommending noninvasive testing for fibrosis.

SUBMITTER: Bersoux S

PROVIDER: S-EPMC7411155 | biostudies-literature | 2020 Aug

REPOSITORIES: biostudies-literature

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Hepatitis C Testing and Liver Fibrosis Predictors in the Birth Cohort of a Primary Care Practice.

Bersoux Sophie S Mi Lanyu L Aqel Bashar A BA Dickson Rolland C RC

Mayo Clinic proceedings. Innovations, quality & outcomes 20200715 4

<h4>Objective</h4>To determine the prevalence of and risk factors for advanced fibrosis in patients born from 1945 through 1965 (birth cohort) who underwent testing for hepatitis C virus (HCV).<h4>Patients and methods</h4>Data were extracted from the electronic health record of all patients receiving primary care at a single academic institution who underwent HCV testing between September 8, 2010, and March 5, 2018. The birth cohort patients were the primary focus of the study. Fibrosis 4 (FIB-4 ...[more]

PMID: 32793866

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Project description:BACKGROUND:In 2014, the Department of Veterans Affairs (VA) adopted a screening test policy for hepatitis C virus (HCV) in all "Baby Boomers" - those born between 1945 and 1965. About 1 in 12 Veterans were estimated to be infected with HCV yet approximately 34% of the birth cohort remained untested. Early HCV diagnosis and successful antiviral treatment decrease the risk of onward transmission, cirrhosis, hepatocellular carcinoma, liver transplant, and death. Implementing evidence-based HCV screening in primary care has great potential to reduce morbidity and mortality. To inform design and implementation of a quality improvement intervention, we studied primary care provider (PCP) perceptions of and experiences with HCV birth cohort testing. METHODS:We conducted a formative evaluation using qualitative semi-structured interviews guided by the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework. Twenty-two PCPs in six states across a large integrated US healthcare system were interviewed. Content analysis with a priori and emergent codes was performed on verbatim interview transcripts. RESULTS:We identified three themes related to primary care provider HCV testing and linkage practices, as mapped to i-PARIHS constructs: 1) evaluating cues to HCV testing (innovation/evidence), 2) framing HCV testing decisions (recipients), and 3) HCV testing and linkage to care in the new treatment era (context). The most frequently reported HCV testing cue was an electronic clinical reminder alert, followed by clinical markers and the presence of behavioral risk factors. Most PCPs saw testing as routine, but less urgent, leading to some reluctance. Providers largely saw themselves as performing guideline-concordant testing, yet no performance data were available to assess performance. Given the recent availability of new HCV medications, many PCPs were highly motivated to test and link patients to specialty care for treatment. CONCLUSIONS:Our results suggest a multi-component intervention around awareness and education, feedback of performance data, clinical reminder updates, and leadership support, would address both a significant need, and be deemed acceptable and feasible to primary care providers.

Project description:BACKGROUND:Birth cohort screening is recommended for hepatitis C virus (HCV) and underserved populations are disproportionally affected by HCV. Little is known about the influence of race on the HCV care continuum in this population. OBJECTIVE:To assess the cascade of HCV care in a large racially diverse and underserved birth cohort. DESIGN:Retrospective cohort study using electronic medical record data abstracted until August 31, 2017. PATIENTS:34,810 patients born between 1945 and 1965 engaged in primary care between October 1, 2014, and October 31, 2016, within the safety-net clinics of the San Francisco Health Network. MAIN MEASURES:Rate of hepatitis C testing, hepatitis C treatment, and response to therapy. RESULTS:Cohort characteristics were as follows: median age 59 years, 57.6% male, 25.5% White (20.6% Black, 17.7% Latino, 33.0% Asian/Pacific Islander (API), 2% other), and 32.6% preferred a non-English language. 99.7% had an HCV test (95.4% HCV antibody, 4.3% HCVRNA alone). Among HCV antibody-positive patients (N?=?4587), 22.9% were not tested for confirmatory HCVRNA. Among viremic patients (N?=?3673), 20.8% initiated HCV therapy, 90.6% achieved sustained virologic response (SVR) and 8.1% did not have a SVR test. HCV screening and treatment were highest in APIs (98.7 and 34.7% respectively; p?<?0.001). Blacks had the highest chronic HCV rate (22.2%; p?<?0.001). Latinos had the lowest SVR rate (81.3%; p?=?0.01). On multivariable analysis, API race (vs White, OR 1.20; p?=?0.001), presence of HIV co-infection (OR 1.58; p?=?0.02), presence of chronic kidney disease (OR 0.47; p?<?0.001), English (vs non-English) as preferred language (OR 0.54; p?=?0.002), ALT (OR 0.39 per doubling; p?<?0.001), and HCVRNA (OR 0.83 per 10-fold increase; p?<?0.001) were associated with HCV treatment. CONCLUSIONS:Despite near-universal screening, gaps in active HCV confirmation, treatment, and verification of cure were identified and influenced by race. Tailored interventions to engage and treat diverse and underserved populations with HCV infection are needed.

Project description:BackgroundLean management has been successfully employed in healthcare to improve outcomes and efficiencies. Facilitation is increasingly being used to support evidence-based practice uptake in healthcare. However, while both Lean and Facilitation are used in healthcare quality improvement, limited research has explored their integration and the sustainability of their combined effects.ObjectiveTo improve hepatitis C virus (HCV) screening rates among persons born between 1945 and 1965 through the design and evaluation of a multi-modal Lean-Facilitation intervention (LFI) for Department of Veterans Affairs primary care community clinics.DesignWe conducted a mixed methods quasi-experimental evaluation in eight clinics, guided by the integrated Promoting Action on Research Implementation in Health Services framework.ParticipantsWe engaged regional and local leadership (N = 9), implemented our LFI with clinicians and staff (N = 68), and conducted summative interviews with participants (N = 13).InterventionThe LFI included six implementation strategies: (1) external facilitation, (2) stakeholder engagement, (3) champion activation, (4) rapid process improvement sessions, (5) Plan-Do-Study-Act cycles, and (6) audit-feedback.MeasuresThe primary outcome was rate of new HCV screening among previously untested patients with a primary care visit. Using interrupted time series, we analyzed intervention and time effects on HCV testing rates, and administered organizational readiness surveys, conducted summative qualitative interviews, and tracked facilitation events.ResultsThe LFI was associated with significant, immediate, and sustained increases in HCV testing. No change was detected at matched comparison clinics. Staff accepted the LFI and the philosophy of "bottom-up" solution development yet had mixed feedback on its appropriateness and feasibility. Enablers of implementation and early sustainment included lower satisfaction with baseline HCV testing processes and staff culture, while later sustainment was related to implementation climate support, measurement, and evaluation.ConclusionsHigh-reach and relatively low effort, but persistent intervention led to significant improvement in guideline-concordant HCV testing rates which were sustained.Trial registrationClinicalTrials.gov Identifier: NCT02936648.

Project description:Background & aimsIndividuals with type 2 diabetes (T2DM) are at high risk of developing non-alcoholic fatty liver disease (NAFLD) and advanced fibrosis/cirrhosis. Screening patients with T2DM and normal liver enzymes for NAFLD in primary care remains contentious. Our aim was to develop and assess a primary care pathway integrating two-tier (Fib-4 then transient elastography [TE]) liver fibrosis assessment, irrespective of aetiology, into routine annual review of all patients with T2DM.MethodsAll patients aged >35 years with T2DM attending annual review at 2 primary care practices in North East England between April 2018 and September 2019 (n = 467) had Fib-4 requested via the electronic patient record. Those with a Fib-4 score above the 'high-sensitivity' threshold (>1.3 for ≤65 years and >2.0 for >65 years) underwent TE and were reviewed in secondary care if the liver stiffness measurement (LSM) was >8 kPa. The number of patients identified with advanced disease, service uptake, and predictors of advanced disease were assessed.ResultsA total of 85/467 (18.5%) patients had raised Fib-4; 27/467(5.8%) were excluded as a result of frailty or known cirrhosis. A total of 58/467 (12.2%) were referred for TE. Twenty-five of 58 (43.1%) had an LSM of >8 kPa and 13/58 (22.4%) had an LSM >15 kPa; 4/58 (6.7%) did not attend and 5/58 (9.3%) had an invalid reading. Twenty of 440 (4.5%) patients were found to have advanced liver disease following specialist review, compared to 3 patients previously identified through standard care (odds ratio [OR] 6.71 [2.0-22.7] p = 0.0022). Alcohol (OR 1.05 [1.02-1.08] p = 0.001) and BMI (OR 1.09 [1.01-1.17] p = 0.021) were predictors of advanced disease, particularly drinking >14/21 units/week (p <0.0001).ConclusionsIncorporating 2-tier assessment of liver fibrosis into routine annual diabetes review in primary care significantly improves identification of advanced liver disease in patients with T2DM.Lay summaryPeople with type 2 diabetes are at increased risk of developing non-alcoholic fatty liver disease and developing more significant complications. This study looks at introducing screening for advanced liver disease into the annual diabetes reviews performed routinely in primary care; we found that significantly more people were identified as having significant liver disease through this pathway than with current standard care.

Dataset Information

Hepatitis C Testing and Liver Fibrosis Predictors in the Birth Cohort of a Primary Care Practice.

Publications

Hepatitis C Testing and Liver Fibrosis Predictors in the Birth Cohort of a Primary Care Practice.

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