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The American Journal of Managed Care May 2018
Impact of Emergency Physician–Provided Patient Education About Alternative Care Venues
Pankaj B. Patel, MD; David R. Vinson, MD; Marla N. Gardner, BA; David A. Wulf, BS; Patricia Kipnis, PhD; Vincent Liu, MD, MS; and Gabriel J. Escobar, MD
Monitoring the Hepatitis C Care Cascade Using Administrative Claims Data
Cheryl Isenhour, DVM, MPH; Susan Hariri, PhD; and Claudia Vellozzi, MD, MPH
Delivery of Acute Unscheduled Healthcare: Who Should Judge Whether a Visit Is Appropriate (or Not)?
Adam Sharp, MD, MSc, and A. Mark Fendrick, MD
Impact of Formulary Restrictions on Medication Intensification in Diabetes Treatment
Bruce C. Stuart, PhD; Julia F. Slejko, PhD; Juan-David Rueda, MD; Catherine E. Cooke, PharmD; Xian Shen, PhD; Pamela Roberto, PhD; Michael Ciarametaro, MBA; and Robert Dubois, MD
Characteristics and Medication Use of Veterans in Medicare Advantage Plans
Talar W. Markossian, PhD, MPH; Katie J. Suda, PharmD, MS; Lauren Abderhalden, MS; Zhiping Huo, MS; Bridget M. Smith, PhD; and Kevin T. Stroupe, PhD
Rural Hospital Transitional Care Program Reduces Medicare Spending
Keith Kranker, PhD; Linda M. Barterian, MPP; Rumin Sarwar, MS; G. Greg Peterson, PhD; Boyd Gilman, PhD; Laura Blue, PhD; Kate Allison Stewart, PhD; Sheila D. Hoag, MA; Timothy J. Day, MSHP; and Lorenzo Moreno, PhD
Understanding Factors Associated With Readmission Disparities Among Delta Region, Delta State, and Other Hospitals
Hsueh-Fen Chen, PhD; Adrienne Nevola, MPH; Tommy M. Bird, PhD; Saleema A. Karim, PhD; Michael E. Morris, PhD; Fei Wan, PhD; and J. Mick Tilford, PhD
Changes in Specialty Care Use and Leakage in Medicare Accountable Care Organizations
Michael L. Barnett, MD, MS, and J. Michael McWilliams, MD, PhD
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Increasing Hepatitis C Screening in a Large Integrated Health System: Science and Policy in Concert
Carla V. Rodriguez, PhD; Kevin B. Rubenstein, MS; Benjamin Linas, MD; Haihong Hu, MS; and Michael Horberg, MD
Introduction of Cost Display Reduces Laboratory Test Utilization
Kim Ekblom, MD, PhD, and Annika Petersson, MSc, PhD

Increasing Hepatitis C Screening in a Large Integrated Health System: Science and Policy in Concert

Carla V. Rodriguez, PhD; Kevin B. Rubenstein, MS; Benjamin Linas, MD; Haihong Hu, MS; and Michael Horberg, MD
The success of recommendations to improve screening often rests on the availability of efficacious therapies, coverage policies, and other factors that enable and justify screening.

Objectives: To evaluate whether the updated 2013 US Preventive Services Task Force (USPSTF) hepatitis C virus (HCV) screening recommendations, related Affordable Care Act provisions, and the impending availability of efficacious therapies were associated with increased screening in an integrated health system.

Study Design: We analyzed 665,339 records of adult patients visiting Kaiser Permanente Mid-Atlantic States clinics from 2003 to 2014.

Methods: We used Cox proportional hazards to estimate time to HCV screening and confirmation after June 1, 2013, compared with prior.

Results: HCV screening steadily increased over time, but it jumped 29% (P <.01) from 2013 to 2014 versus 4% (<.01) from 2012 to 2013. The adjusted hazard ratio for HCV screening since June 2013 was 2.40 (95% CI, 2.34-2.47) times higher than it was pre-intervention among the birth cohort (those born 1945-1965) and 2.00 (95% CI, 1.96-2.04) times higher in those born in other years, representing a 1.20-fold (95% CI, 1.17-1.24) greater increase in the screening rate among the birth cohort. We also identified variability in those thought to be at higher risk of HCV infection.

Conclusions: HCV screening has been increasing in our healthcare system, more so since June 2013 and among the birth cohort. The availability of efficacious therapies and coverage policies coincident with the USPSTF recommendations may have facilitated access to screening and treatment in ways that were absent at the time of the 2012 CDC recommendations. Health systems must also be poised to make resources available to clinicians and patients in order to incentivize screening. Future research should inform a better understanding of incentives and barriers to screening and linkage to care from all stakeholder perspectives.

Am J Manag Care. 2018;24(5):e134-e140
Takeaway Points

This was an observational study to measure the increase in hepatitis C screening since the implementation of revised national screening guidelines and wide availability of novel direct-acting antivirals (DAAs) starting in June 1, 2013, compared with prior. The availability of effective treatment may have facilitated a greater increase in screening than screening guidelines alone:
  • In the year following the revised US Preventive Services Task Force (USPSTF) recommendations and availability of novel DAAs (2013), hepatitis C screening increased by 29%.
  • In comparison, hepatitis C screening increased just 4% in the year after the release of updated screening guidelines by the CDC in 2012.
  • Overall, we observed a 2-fold increase in hepatitis C screening since June 1, 2013, compared with prior and adjusting for factors that influence screening.
  • The screening increase was even greater among those born between 1945 and 1965 (defined as the birth cohort), who were the target of the 2013 USPSTF recommendations.
Between 45% and 85% of the approximately 4 million people in the United States with hepatitis C virus (HCV) infection are unaware of their infection and may infect others and experience disease progression.1-3 Furthermore, incomplete patient follow-up impedes the provision of appropriate care. In a large cohort study of patients with chronic hepatitis B and/or C, 38% of HCV antibody–positive patients had no follow-up HCV RNA testing documented in the electronic health record (EHR).4 Larger care gaps exist for patients coinfected with HIV and HCV5 and for persons of color.6 Enabling patients to reach each step of the HCV cascade of care (including screening, confirmation, medical management, treatment, and cure) affords them the full benefit of appropriate treatment.7,8

In response to growing evidence of a “silent epidemic,” the CDC updated its guidelines in 2012 to recommend universal HCV screening of all persons born from 1945 to 1965, the “birth cohort” with the highest burden of disease.9 The 2012 recommendations also recommended confirmatory RNA testing for all patients with positive HCV antibody results. However, the US Preventive Services Task Force (USPSTF) did not update its ranking of birth cohort screening to a B grade until June 2013.10,11 The USPSTF update initiated coverage requirements without additional expense to the insured under the Affordable Care Act (ACA).12 The ACA also eliminated exclusions for pre-existing conditions, prohibited insurers from rescinding coverage, and put an end to lifetime and annual coverage limits, further reducing barriers to diagnosis and linkage to care. Lastly, the 2013 USPSTF recommendations were released just months before the rollout of the first highly efficacious direct-acting antivirals (DAAs) to hit the US market: simeprevir (November) and sofosbuvir (December).13 We previously analyzed trends in HCV screening from 2004 to 2012 and found a steady increase in HCV screening over time prior to the 2013 interventions.14 Two other descriptive studies using commercial laboratory and insurance databases to examine changes in HCV screening over time found increases.15,16 However, these studies were ecological and did not formally test differences in screening rates before and after seminal events that were intended to increase screening and treatment of HCV.

The objective of this study was to describe whether HCV screening and confirmatory testing, particularly among the birth cohort, were elevated after June 1, 2013, compared with prior. June 1, 2013, marks the contemporaneous introduction of the USPSTF recommendations, ACA protections, and DAAs in the United States. We describe trends for (1) antibody screening and (2) confirmatory RNA and genotype testing. This study will be the first to describe outcomes associated with these collective initiatives to increase screening.


Study Design, Setting, and Participants

We conducted an observational study among patients 18 years and older with at least 8 months of enrollment in the Kaiser Permanente Mid-Atlantic States (KPMAS) health insurance plan and who attended at least 1 clinical visit from January 1, 2003, to February 28, 2015. For the screening analysis, patients were followed from the date of this first clinic visit during the study period through December 31, 2014. Patients testing positive for HCV antibodies were followed through February 28, 2015, for confirmatory RNA or genotype testing. The investigation followed the guidelines of the HHS regarding protection of human subjects. The study protocol was approved and renewed annually by the KPMAS Institutional Review Board.

KPMAS is well positioned to describe changes along the HCV care continuum over time. The average retention of patients in the health system is more than 4 years.14 Clinical expertise, comprehensive service, and competitive pricing are incentives to seek care within the health system. A robust EHR ensures near-complete capture of all clinical and demographic data, including diagnosis, pharmacy, laboratory, behavioral, and insurance data for patients seeking care in our integrated multispecialty practices and clinics.

Study Variables

All study data were collected from the KPMAS EHR. Primary outcomes were (1) antibody screening and (2) RNA or genotype (confirmatory) testing. A priori factors of interest included birth cohort status, race, gender, hepatitis B virus (HBV) or HIV coinfection, area median household income (defined by the residential Census block), primary clinic location (DC/suburban Maryland, northern Virginia, or Baltimore/other), provider type at first encounter during the study period (adult medicine, emergency/urgent care, obstetrics/gynecology [OB/GYN], pediatrics, or specialty/other), and prior visit to a gastroenterology or infectious disease (ID) specialist who provided HCV care in our system. HBV and HIV coinfections were identified through the KPMAS HBV and HIV registries, respectively. During regular clinical care, patients are asked about their history of ever using illicit drugs (including marijuana) and men having sex with men (MSM) status, and results are recorded in the EHR. We included these variables in descriptive tables and a sensitivity analysis, but we excluded them from our main analysis because of a high number with missing values (~30% for both variables). We used the Bayesian Improved Surname Geocoding algorithm to impute racial probabilities in those missing reported race/ethnicity.17

Statistical Analysis

We estimated the annual screening rate as the number of antibody-tested patients per patients enrolled in KPMAS from January 1 to December 31 of each year. We removed those who had been screened in previous years from subsequent year denominators. Significant differences in screening rates between years were compared using a z test for difference in proportions.

In separate models, we used Kaplan-Meier curves, log-rank tests, and multivariable Cox proportional hazards with robust standard errors18 to assess time to antibody testing among all patients and time to confirmatory testing among those who tested HCV antibody–positive. We followed patients in calendar time from the first office visit (for screening analysis) and from positive antibody test (for the confirmatory testing analysis) until the time of event, disenrollment from the health plan, death, or the administrative end of study, whichever occurred first. Covariates were assessed prior to the event and up to 1 month after first visit for the screening analysis and up to 14 days after the antibody test for the confirmatory testing analysis. We categorized time before and after June 1, 2013 (the earliest date of the USPSTF recommendations/ACA protections and DAA release). We created an interaction term between birth cohort status and pre- and postintervention time to directly compare changes in screening and confirmatory testing before and after the intervention by birth cohort status. For time to screening, we also stratified the analysis by clinic location to describe practice differences across locations. As a sensitivity analysis, we include MSM and illicit drug use, along with all other variables, in a complete-case analysis.

Data compilation, annual time series, and graphs were conducted in SAS 9.2 (SAS Institute; Cary, North Carolina). The stcox function in Stata 13 (StataCorp; College Station, Texas) was used for proportional hazards modeling. Figures were created in Stata 13 and Microsoft Excel and Word (Microsoft; Redmond, Washington).

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