Research Team Works to Improve Identification of Hepatitis C.
Studies by a consortium led by a BU School of Public Health researcher have supported recent changes in the way patients are screened and tested for hepatitis C virus, the leading cause of liver-related deaths.
Mari-Lynn DrainoniTwo recent implementation studies established the effectiveness of using clinical reminders to prompt primary care providers to screen patients for Hepatitis C (HCV), which infects an estimated 3.2 million people in the U.S. but is chronically under-identified. The research team determined that two kinds of HCV screenings, one based on a brief risk assessment and the other based on age, helped to identify patients with HCV in primary care settings.
In one of the studies, published in the American Journal of Public Health and led by Mari-Lynn Drainoni, associate professor of health policy anh management, a 12-item risk screener was effective in increasing testing rates both overall and specifically among patients with identified risk factors for Hepatitis C. A related study by the research team found that patients born between 1945 and 1965 were four times more likely to have HCV than other age cohorts, confirming prior findings about a higher prevalence among ‘baby boomers.’ The studies were based at clinics affiliated with Montefiore Medical Center in the Bronx, NY.
“With more effective treatments now available, it is critical that the process of identification of HCV be improved, given that care and treatment cannot be offered without diagnosis,” Drainoni and her co-authors said. “Primary care is the front line of health care for most patients and an optimal location for simple risk screening.”
While the Institute of Medicine has recommended increased HCV testing, the practice of screening for the virus has varied, with physicians typically referring patients for testing who have injected drugs or had long-term hemodialysis or other risk factors. This summer, the Centers for Disease Control and Prevention issued new guidelines recommending that all people born between 1945 and 1965 get a one-time blood test for Hepatitis C.
To date, various studies have implicated numerous HCV risk factors, such as homelessness, incarceration or intranasal drugs. Because existing guidelines do not concur on what risk factors should trigger HPV testing, the research team developed the 12-item screening intervention in an effort to gauge whether it led to more testing and more positive screens.
The study found that when primary care providers were prompted to use the screening tool, they referred 55 percent of patients with risk factors for testing. The authors said there were a number of reasons why not all patients with risk factors were tested, including that testing required participating patients, in a clinic location, to go to a separate area and wait to have blood drawn.
Of all patients who were screened, 25 percent were subsequently tested for HCV, compared to just 6 percent of patients who were not screened at all.
Seven of the 12 factors on the questionnaire accounted for all of the HCV infections identified, the researchers said. Those factors were: injection drug use, intranasal drug use, elevated alanine aminotransferase, transfusions (before 1992), 20 or more lifetime sex partners, maternal HCV and existing liver disease.
Noting that current policy aims to expand the role of primary care providers (PCPs) in coordinating care, the authors said the screening tool was a way to “minimize the impact on already-overtaxed PCPs” by helping them to identify those factors most predictive of HCV positivity.
“We found that PCPs can perform effective HCV screening with a screener that includes many fewer risk factors than previously reported in the literature,” they concluded. They said future efforts should be made to validate a more “parsimonious” risk screener and determine whether ancillary staff could conduct the screening.
The study was funded by the CDC through the Agency for Health Care Research and Quality’s Accelerating Change and Transformation in Organizations and Networks (ACTION) program. BU is leading a partnership within the ACTION network that includes the Montefiore Medical Center.
Besides Drainoni, other BUSPH researchers on the study included: Elisa A. Koppelman, Cindy L. Christiansen and Allen L. Gifford.
Submitted by: Lisa Chedekel
chedekel@bu.edu