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‘Tweak’ in order set increases HCV screening among patients with HIV

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June 2, 2017

Adding hepatitis C virus screening to an automated order set for patients with HIV greatly increased hepatitis testing at a Massachusetts clinic, according to researchers.

In addition to adding the HCV testing at Tufts University Medical Center, the researchers educated clinicians on the importance of screening for the virus, the researchers wrote in Open Forum Infectious Diseases.

“We were able to effectively increase HCV screening in our infectious diseases clinic through education and simple modifications to electronic medical record laboratory ordering,” study researcher Alysse G. Wurcel, MD, MS, an attending physician in the division of infectious diseases and geographic medicine at Tufts School of Medicine, and colleagues wrote.

Their study included 350 patients with HIV, 57% of whom were white. Men comprised 80% of the cohort, 74% of whom were men who have sex with men (MSM). In addition, 15% of patients had a history of syphilis, and 90% had an undetectable HIV viral load.

The researchers added HCV screening to the hospital’s outpatient electronic laboratory ordering system, and the new order set was activated Jan. 1, 2014. Soon after, clinicians were informed via email about the “tweak” in the order set and were given updated screening guidelines. They also held conferences that month and in January 2015 to review the guidelines and discuss results.

Throughout 2014 and 2015, 287 (82%) of the patients visited the clinic, the researchers said. Of those, 229 (80%) were screened for HCV in either year. Most patients (62%) were screened in both years.

Seven patients (3.1%) tested positive for HCV (1.57 new cases per 100 person-years). That was triple the rate of HCV detection before the new program was started (0.46 new cases per 100 person-years).

An average of about 11% of patients per year were screened in the 4 years before activation of the new program, compared with 54% in the 2 years after activation. In addition, 75% of patients who underwent screening in 2014 did so in the first half of the year, compared with 60% of those screened in 2015. The researchers suggested that the program’s educational effort in January may have accounted for the clustering of screening early in the year.

They also said that race, MSM status and a history of syphilis were not associated with greater odds of HCV screening after the new program’s introduction, as they had been before.


“This would suggest that some of the risk assessment performed by providers was removed by the computer-based intervention, leading to more universal screening practices,” the researchers wrote.

They further stated that programs like the one they started at Tufts could improve patient outcomes.

“Early diagnosis and treatment of HCV in people living with HIV will decrease morbidity and mortality and will slow the HCV epidemic,” they advised. “The success of our intervention is encouraging, and we hope that the lessons learned will spread to other HIV practices nationally and internationally.” – by Joe Green

Disclosure: Wurcel reports receiving grant support from Merck and Bristol-Myers Squibb.

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Michael Horberg
Michael A. Horberg

This article by Wurcel and colleagues illustrates well how clinics are trying to improve testing for HCV and are finding new cases, as curative treatment that is easy to take with high success and relatively few adverse effects is now available. However, this relatively simple quality improvement does show that more testing can lead to extra (potentially "unnecessary") HCV tests being ordered.

Furthermore, unlike HIV antibody testing, HCV antibody testing is not complete unless positive tests are confirmed with HCV RNA levels. The authors do not note if that was automated or how that happened.

With that said, more program improvements like this one are needed in order to make sure we identify all patients who are HIV– and HCV–infected, so that we can make sure all of these patients get the care they need, including potential curing of HCV.

Michael A. Horberg, MD, FACP
Director for HIV/AIDS, Kaiser Permanente
Clinical lead for HIV/AIDS, Care Management Institute
Spokesman for the HIV Medicine Association
Disclosure: Horberg reports no relevant financial disclosures.