expansion 2016
TRANSCRIPT
MedStar-wide HCV Testing and Linkage to Care:
Building an EHR-based Testing Program to Improve the HCV Cascade of Care
Alexander G. Geboy1, Stephen J. Fernandez1, Peter Basch1,2,3, Idene E. Perez1, Whitney L. Nichols1, Dawn A. Fishbein1,4
1MedStar Health Research Institute, 2MedStar Institute for Innovation, 3MedStar Quality and Safety Institute, 4MedStar Washington Hospital Center
80006
The HCV BC testing protocol went live on July 1, 2015. A breakdown of the
BC metrics follows as of February 18, 2016:
This protocol has the potential to be an important health initiative given the
number of patients who are potentially infected with HCV. Overall, however,
reactive cases were low with 1% (n=82) testing HCV Ab positive. This needs to
be explored considering with the MWHC rate under CDC testing at 7.6%, the
CDC BC prevalence rate of 3.25% and the Washington, D.C. rate of 2.5%.
Of those tested within the BC (n=4,858), 49% (n=2,392) went through the care
prompt. It is unclear whether the additional 51% (n=2,466) of orders were
influenced by the care prompt. Additionally, 46% (n=6,385) of the total actions
taken within the BC prompt are unaccounted for at this time (though likely to be
printing of the education handout). Testing trends are similar to other testing
initiatives: more women then men were tested (p<0.01, OR 1.4 [1.3-1.5]) and men
were more likely to be HCV Ab positive than women (p<0.01, OR 2.3 [1.4-3.9]).
Similarly for the Non BC group, more women than men were tested (p<0.01, OR
1.2 [1.1-1.4]), however there was no difference between those positive. This
cohort needs further analysis to identify what is driving testing. CMS covers a
yearly, risk-based HCV Ab test, however, risk factors are not always captured
within the EHR.
The next phase is to commence the linkage portion of this program,
characterize the geographic variations of HCV infection and identify factors that
may be facilitators or barriers to HCV care. We will conduct in-services with
both sites to ascertain barriers to testing and disseminate best practices of high
performing sites. We are partnering with SiTEL to develop a HCV module for
provider training that will launch within the year.
A major lesson learned from this, as well as from prior testing initiatives, is that
testing should be more automated to comply with CDC/USPSTF/CMS
recommendations.
RESULTSBACKGROUND
The “silent” hepatitis C virus (HCV) epidemic is no longer silent: it is
the most common blood-borne infection in the US and affects
approximately 185 million persons globally. The Centers for Disease
Control and Prevention (CDC) recommend all persons born within 1945
1965 should be tested for the hepatitis C virus (HCV).
The development of identification, testing and linkage to care protocols
within large health care systems is necessary to inform policy with
regard to the health of patients infected with HCV.
A MedStar-wide Electronic Health Record (EHR) protocol for identifying
those at risk for HCV infection is needed considering the reach of the
MedStar Health network.
The objectives of this program are to:
• Develop and implement a MedStar-wide HCV Birth Cohort (“BC”) and
risk-based EHR-based testing program in Primary Care Clinics
• Patients who test HCV antibody positive should be HIV tested (if no
recent test exists)
• A linkage program for persons previously tested positive and not in care.
METHODS
In January 2014, the HepC Linkage to Care Navigation program was funded
through Gilead FOCUS at MedStar Washington Hospital Center (MWHC).
An Explorys MedStar Database search found approximately 750,000 persons in
the MedStar system between the ages of 45 and 64 (Birth Cohort), 270,000
(36%) seen within the last 3 years in the outpatient system. The search revealed
23,210 persons with a listed ICD9 diagnosis of HCV, 15,000 have been seen at
an appointment in the last 3 years, 11,500 in the past year, 5,580 are deceased.
Applying the 3.25% MMWR estimate equates to over 24,000 persons infected.
However, applying the 7.6% found at MWHC, which is likely biased toward the
urban population, equates to over 57,000 HCV infected persons within the
MedStar system.
A proposal to implement a MedStar-wide HCV BC and risk-based EHR-based
testing program in Primary Care Clinics was proposed to the MedStar Health
Ambulatory Quality Best Practices Committee, and planning began to build an
integrated clinical decision-support system (CDSS) EHR protocol.
We used non-BC testing as a marker for patients at high-risk for HCV in that
group. HCV testing reports are generated monthly via SQL and data is
compiled in SAS.
A descriptive analysis is presented.
CONCLUSION
Alexander G. Geboy
MHRI
100 Irving St NW, EB 4111
Washington, DC 20010
267-322-1228
Funding:
Gilead FOCUS
Author Disclosures: Dawn A. Fishbein, MD has served on an Advisory Board for BMS, Gilead and serves as a Medical Advisor for Hepatitis Foundation
International; Alexander G. Geboy has served on an Advisory Board for Gilead Sciences, LLC. Both have grant funding from Gilead Sciences.
a) Unknown and in progress
b) Not Screened (see Fig.2)
c) *Screened but outside of order
d) *Screened with CDSS order
52,846
b) 22,406 (42%)
b) 14,663 (28%)
b) 13,911 (26%)
d) 2392* (5%)
c) 2466* (5%)
b) 2668 (5%)
a) 6385 (12%)
a) 752 (1%)
a) 7,743 (15%)
a) 30,440 (58%)
Patients seen in clinic born between 1945-
1965 AND no history of HCV
a) No action taken with protocols
b) View All Protocol (VAP) button clicked
(fig.1)
a) Other protocol action taken
b) HepC CDSS prompt accessed (fig.2)
a) No action taken in HepC Prompt
b) Took action within HepC Prompt
Figures 1 & 2. HCV Centricity CDSS Prompt
Table 1. MedStar-wide HCV Ab Test Results by Demographic Characteristics
*The percent HCV Ab positive among those tested is given next to each HCV Ab positive percentage (BC and Non BC)†The percent currently infected among those HCV Ab positive is given next to each RNA percentage (BC and Non BC)§Of those RNA positive (BC and Non BC), 7 patients are in care with a specialist (ID, GI, Hepatology) and 10 are not yet in care
2b) Non Birth Cohort
HCV Ab Tests by Provider Location No. %
Provider
Group Avg.
3294 100.00 -
MPP (19 Provider Groups) 1152 34.97 61
MMG (21 Provider Groups) 502 15.24 24
GSH (8 Provider Groups) 375 11.38 47
UMH (5 Provider Groups) 168 5.10 34
HHC (2 Provider Groups) 142 4.31 71
WHC (8 Provider Groups) 138 4.19 17
FSH (3 Provider Groups) 123 3.73 41
PC-ANN 2 0.06 2
MSMH 1 0.03 1
Unidentified 691 20.98
2a) Birth Cohort
HCV Ab Tests by Provider Location No. %
Provider
Group Avg.
4858 100.00 -
MPP (18 Provider Groups) 2407 49.55 134
MMG (22 Provider Groups) 1002 20.63 46
GUH (6 Provider Groups) 295 6.07 49
UMH (7 Provider Groups) 254 5.23 36
GSH (3 Provider Groups) 186 3.83 62
WHC (8 Provider Groups) 179 3.68 22
FSH (2 Provider Groups) 111 2.28 56
HHC (2 Provider Groups) 72 1.48 36
MSMH GM (2 Provider Groups) 3 0.06 2
Unidentified 349 7.18
Table 2a & 2b. MedStar-wide HCV Ab Tests by Cohort and Provider Practice Location
462
686 714
835758 731
457
430480
406
562491 507
333
0100200300400500600700800900
Jul Aug Sep Oct Nov Dec Jan
Nu
mb
er
of
Pa
tie
nts
Te
ste
d
Month
BC
Non BC
Figure 3. MedStar-wide HCV Ab Birth Cohort and Non Birth Cohort Tests Per Month
Birth Cohort Non Birth Cohort
HCV Ab Tested HCV Ab Positive* HCV RNA Positive† HCV Ab Tested HCV Ab Positive* HCV RNA Positive†
Characteristic No. (%) No (%) No. (%) No. (%) No. (%) No. (%)
Total 4858 64 (1.3) 15§ (23.4) 3294 19 (0.6) 2§ (10.5)
Mean Age + SD 59.4 + 5.7 59.4 + 5.0 59.7 + 4.9 36.8 + 14.0 39.2 + 12.1 50.4 + 12.5
Sex
Female 2824 (58.1) 24 (37.5) 6 (40.0) 1824 (55.4) 8 (42.1) 1 (50.0)
Male 2034 (41.9) 40 (62.5) 9 (60.0) 1470 (44.6) 11 (57.9) 1 (50.0)
Race/Ethnicity
Black, Non-Hispanic 2085 (42.9) 34 (54.8) 12 (80.0) 1433 (43.5) 6 (27.8)
Black, Hispanic 12 (0.2) 9 (0.3)
White, Non-Hispanic 1869 (38.5) 19 (30.7) 2 (13.3) 1046 (31.8) 12 (66.7) 2 (100.0)
White, Hispanic 34 (0.7) 33 (1.0)
Other/Non-Hispanic 804 (16.3) 9 (14.1) 1 (6.7) 676 (20.5) 1 (5.6)
Other/Hispanic 54 (1.4) 2 (3.1) 97 (2.9)
Primary Insurance Type
Public 1536 (31.6) 27 (42.9) 1066 (32.4) 9 (47.4) 2 (100.0)
Medicare 871 (17.9) 9 (14.3) 2 (15.3) 272 (8.3) 1 (5.3) 1 (50.0)
Medicaid 665 (13.7) 18 (28.6) 5 (33.3) 794 (24.1) 8 (42.1) 1 (50.0)
Private 3174 (65.3) 36 (57.1) 8 (53.3) 1972 (59.9) 9 (47.4)
Self Pay 68 (1.4) 126 (3.8)
Unspecified/Other 80 (1.6) 1 0 130 (3.9) 1 (5.3)