December 03, 2019
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Despite intervention, USPSTF-recommended HCV screening varies in practices serving disadvantaged groups

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HCV screening varied among practices that served disadvantaged populations in the United States despite the implementation of an intervention to improve adherence to U.S. Preventive Services Task Force guidelines, according to a study published in the Annals of Internal Medicine.

“This study offers evidence regarding the difficulty of operationalizing national guidelines without substantial public policy and payment systems that support the full continuum of care for low-income and even uninsured patients,” Barbara J. Turner, MD, MSEd, a clinical professor of medicine in the Keck School of Medicine at the University of Southern California, told Healio Primary Care.

In 2013, the USPSTF recommended that physicians screen baby boomers — those born between 1945 and 1965. The task force has since called for the screening of all U.S. adults.

To improve physicians’ adherence to the 2013 USPSTF recommendation, Turner and colleagues implemented the Screen, Treat or Prevent Hepatocellular Carcinoma (STOP HCC) intervention. The intervention focused on identifying eligible patients who had never been tested for anti-HCV antibody using a best practice alert on the EHR with an order for testing that required clinician approval. In addition, physicians and staff participated in presentations about the benefits of screening patients for HCV to prevent cirrhosis and HCC. The intervention also defined the procedures and responsibilities of staff during HCV screening of uninsured patients. Additionally, health care providers and patients could access educational materials and clinical protocol information through a website.

Doctor Reviewing Chart 
HCV screening varied among practices that served disadvantaged populations in the United States despite the implementation of an intervention to improve adherence to U.S. Preventive Services Task Force guidelines, according to a study published in the Annals of Internal Medicine.
Source: Shutterstock

The researchers included in their study five federally qualified health care centers and a family medicine residency program that served low-income communities that had diverse, mostly Hispanic populations with high rates of cirrhosis and HCC.

Researchers found that in the year before STOP HCC was implemented in four health centers — in 2014 for two centers and in 2016 for two others — just 110 of 13,216 patients (0.8%) who were eligible based on the 2013 USPSTF guidelines were screened for HCV. Between 29 and 43 months after the intervention was implemented, 13,334 of 27,700 eligible patients (48.1%) were screened for HCV, with screening rates varying from 19.8% to 71.3% in participating practices.

Among 695 anti-HCV positive patients, 74.8% were tested for HCV RNA overall, with rates varying from 48.9% to 92.9% between practices.

A total of 349 (2.6%) of patients screened were diagnosed with chronic HCV.

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In four of the federally qualified health care centers, 84.9% of 205 uninsured patients diagnosed with chronic HCV had disease staging completed, 70.7% had a teleconsultation review with a PCP and a specialist, 58% received a recommendation to start direct-acting antiviral therapy, 40% initiated free direct-acting antiviral therapy and 36.1% completed therapy.

“In addition to guidelines for screening, we need to focus on developing the infrastructure to eradicate this treatable infection that causes many thousands of deaths annually in the United States through chronic liver disease and its complications,” Turner said.

Future USPSTF guidelines

In August 2019, USPSTF released a draft recommendation statement that called for HCV screening in adults aged 18 to 79 years.

“Given our research and others that have shown implementation of baby boomer HCV screening guidelines has been limited at best, especially in practices that serve the higher risk populations, it will be an even more significant challenge to implement these recommendations,” Turner told Healio Primary Care.

She explained that while most baby boomers are eligible for Medicare, which covers the cost of testing and treatment, Medicaid has restrictive guidelines for which patients with chronic HCV can receive treatment.

Although there are pharmaceutical assistance programs in place to help patients pay for treatment, Turner noted that “this is a fragile infrastructure that is unlikely to achieve the goals of diagnosing and treating chronic HCV infection in all adults, even though we know that HCV is increasingly being spread among younger age groups.” – by Erin Michael

Disclosure: Turner reports salary support from ACP and the University of Texas Health Science Center at San Antonio, grants from the Cancer Prevention & Research Institute of Texas and project support through the CMS Section 1115 Medicaid waiver program during the conduct of the study.