From the 2019 HVPAA National Conference
Dr. Andrew Mertz (Walter Reed National Military Medical Center), Dr. Adam Barelski (Walter Reed National Military Medical Center), Dr. Brett Sadowski (Walter Reed National Military Medical Center), Dr. Jeffrey Gray (Walter Reed National Military Medical Center)
Background
Chronic hepatitis C viral (HCV) infection can lead to significant morbidity and mortality by increasing the risk of cirrhosis and hepatocellular carcinoma. These associated conditions can lead to recurrent hospitalizations, significant patient suffering, and ultimately death. In the past, treatment of HCV was associated with significant side effects and poor cure rates. Over the past several years, marked leaps in treatment options have led to cure rates over 90% in 8-12 weeks with minimal side effects. As a result, the United States Preventive Services Task Force (USPSTF) recommends that all individuals born between 1945 and 1965 receive one-time screening for HCV. At our institution, the screening rates in the patient-centered medical home (PCMH) at Walter Reed National Military Medical Center (WRNMMC) averaged between 50-60% across five Internal Medicine clinics.
Objective
The goal of this project is to improve HCV screening rates in the WRNMMC PCMH. Any patients who screen positive are referred to Hepatology to evaluate for direct-acting antiviral (DAA) treatment. As of now, the current screening rate for HCV at WRNMMC is 55.8%. Our aim is to increase the screening rate to 75% over 12 months, which would translate to over 2000 additional patients screened. Data will be collected monthly, and any adjustments to the protocol will be made if the intervention is not effective.
Methods
This is a prospective quality improvement project to improve HCV screening rates. Using Carepoint, a population-based clinical tool, the HCV screening status was determined for all patients born between 1/1/1945 and 12/31/1965 who were enrolled in the five Internal Medicine clinics at WRNMMC. For the first PDSA cycle, a small subset of unscreened patients in one of the five internal medicine clinics was identified for proof-of-concept. HCV serologies were ordered for those patients who were not yet screened, and those individuals were contacted via Relay Health (a secure electronic messaging platform) with a standard script. All individuals who tested positive are immediately referred to the Hepatology clinic at WRNMMC.
Results
Initial data show that as of the start of this quality improvement project, approximately 4000 eligible patients enrolled at WRNMMC were not screened for HCV. As a proof-of-concept pilot, the first PDSA cycle involved ten patients, and resulted in a 50% screening rate within 2 months after sending the secure Relay Health message. The second 100 patient pilot is now currently underway with pending results.
Conclusions
Chronic HCV infection can lead to significant morbidity and mortality. Recent advances in treatment have led to high cure rates with minimal side effects. Population-based HCV screening has been highly effective in the VA system. The use of population-based clinical assessment tools allows easy identification of eligible patients who have not been screened for HCV. This initiative ultimately improves outcomes via a patient-centered approach utilizing a secure messaging service to target eligible patients. To date, no definite conclusions can be made regarding the efficacy of facilitating guideline-directed HCV screening, but the preliminary data is encouraging that the process is both effective and convenient for both patients and providers.
Clinical Implications
Our ongoing quality improvement project is leveraging population based health tools to improve guideline-based HCV screening in a primary care population. We are currently in the second implementation cycle, but have already offered screening to over a hundred patients who are at risk for HCV.
