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

We acknowledge some limitations to this study. Although the screening recommendations, ACA protections, and availability of DAAs were universally available to all patients in the study, we were unable to quantify how much each of these played a role in individual clinician or patient decisions to screen. Future research that includes interviews with staff and patients might elucidate a more specific understanding of the individual motivations of patients and providers to promote and accept screening.

Also, we did not study the effects of MSM and substance abuse because they were missing in approximately 30% of the sample. This omission may have biased the results away from the null if MSM or substance abuse were associated with birth cohort status, time, and screening, for example. However, results from a complete-case analysis that included these variables were robust for all outcomes and showed that patients with a history of MSM and illicit drug use were screened at higher rates compared with those without such a history. Future studies should describe strategies that allow for improved communication between patients and providers on risk factors for transmission and disease progression, as well as educate providers on ways to improve documentation of risk factors.

We did not include data from outside the KPMAS health system (ie, external referrals) in this analysis. As such, some diagnostic and visit data were missing. KPMAS has been working to internalize ID specialties. We will consider including data from external referrals in future analyses.

We recognize that linkage to care is an important follow-up to screening that we did not address. Provider, patient, and health system factors play important roles in linkage to care, which are beyond the scope of the present analysis. We focused this analysis on screening because it is the most proximal effect of the interventions being investigated. We intend to investigate linkage to care in future work.
Finally, a limitation of any health system–based cohort study is limited generalizability to those without insurance, the homeless, and institutionalized populations. Medicaid expansion from 2015 to 2018 under the ACA increased our capture of higher-need patients and enables us to examine the effect of interventions in this population.


HCV screening has been increasing in our healthcare system, especially among the birth cohort, since June 2013 when the USPSTF updated its HCV screening recommendation (invoking provisions under the ACA) and DAAs became widely available in the United States. The availability of efficacious therapies and access to care and treatment often justifies and facilitates disease screening. Additionally, health systems must be poised to harness such resources and inform clinicians of their availability. By the end of 2014, we screened just 22% of the KPMAS birth cohort. Based on known HCV prevalence (2.3%), there may have been as many as 13,000 undiagnosed HCV cases in the KPMAS population. Health systems need to do much more to improve HCV screening in populations with risk factors for and high burden of HCV. A better understanding of physician and patient motivations and barriers to screening is a natural extension of this work that will improve the implementation of guidelines and maximize available incentives to screen and treat patients with HCV. 


The authors thank Drs Andres Mendez, Cabell Jonas, Dana Sloan, and Bernadette Loftus for their critical review of the manuscript and Michelle Turner, MPH, for her help with manuscript preparation.

Author Affiliations: Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States (CVR, KBR, HH, MH), Rockville, MD; Department of Epidemiology, School of Public Health, Boston University (BL), Boston, MA; HIV Epidemiology and Outcomes Research Unit, Section of Infectious Diseases, Boston Medical Center (BL), Boston, MA.

Source of Funding: This work was supported by grants from the National Institutes of Health: R01 DA031059-04, P30 AI042853, and P30 DA040500.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (CVR, BL, MH); acquisition of data (HH); analysis and interpretation of data (CVR, KBR, BL, MH); drafting of the manuscript (CVR, BL); critical revision of the manuscript for important intellectual content (KBR, BL, HH, MH); statistical analysis (CVR, KBR); provision of patients or study materials (HH); obtaining funding (BL); administrative, technical, or logistic support (CVR); and supervision (CVR).

Address Correspondence to: Carla V. Rodriguez, PhD, Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, 2101 E Jefferson St, 3W, Rockville, MD 20852. Email:
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