Alerts Increase Hepatitis C Screening Among Baby Boomers

Baby boomers’ hepatitis C virus (HCV) screening rates jumped five-fold when a prompt in their electronic health records reminded a primary care provider to recommend testing, a new study shows.

“This intervention can be easily integrated into EHR systems to increase HCV diagnosis and linkage to care,” researchers at the University of Michigan — led by Monica A. Konerman, MD, MSc — wrote.

The baby boom generation born from 1945 to 1965 has a 5 times greater prevalence of HCV than individuals in other age groups, past research has shown. But fewer than 30% of boomers have been screened for the liver-attacking virus.

Konerman, a clinical lecturer in the department of internal medicine, said previous screening for HCV was "risk-based.” But studies have found that this approach has been unsuccessful, even as the US Centers for Disease Control and the US Preventative Services Task Force recommend a one-time universal screening for baby boomers to identify those missed under the risk approach.

“Unfortunately, screening rates in this population remain very low,” Konerman said.

Could primary care providers (PCP) help boost the number of screenings?

Konerman and her colleagues set out to see whether an EHR-based prompt would be effective. They created a “Best Practice Advisory” (BPA) that popped up in the record of a patient who met the age criteria and had not previously been tested or diagnosed with HCV. Educational materials and a lab order were provided. Newly diagnosed patients were offered streamlined access to specialty care.

In the 3 years before university-related primary care practices adopted the BPA alert, these clinics saw 52,660 baby boomers and ordered HCV screening for 28% of them. In the 6 months before the BPA prompts were set up, screening was ordered for only for 7.6% of eligible patients.

However, in the year after the BPA message was added to the boomers’ health records, screening was prescribed for 72% of them.

“This HCV screening rate among baby boomers is one of the highest cited in the literature to date,” the researchers wrote.

In addition, all 53 of the newly diagnosed patients were referred for specialty care. Eleven had advanced fibrosis or cirrhosis, 20 started treatment with direct-acting antiviral (DAA) drugs and 9 have achieved sustained virologic response so far, the researchers said. Others had pending appointments, declined follow-up visits or were no longer seen at the clinics.

“Primary care providers are uniquely positioned to have a high impact from HCV screening as continuity of care with patients facilitates follow-up,” Konerman said. “Unlike many EHR alerts that can be frustrating and slow down clinic work-flow, this EHR alert was efficient and helpful to both the providers and patients.”

Aftercare is important because previous estimates have shown that 30% to 50% of persons who test positive for the HCV antibody (anti-HCV) never receive confirmatory HCV RNA testing. Among those with a confirmed HCV diagnosis, only about 35% are connected with specialty care, the researchers reported.

In the Michigan study, most of the post-BPA newly diagnosed patients had early-stage disease. However, 20.7% had evidence of either cirrhosis or advanced fibrosis at the time of initial referral.

“These patients likely would have remained undiagnosed until they presented with decompensated liver disease had they not been screened as a result of the BPA,” the researchers wrote.

The team is currently investigating the impact of its electronic based prompt for hepatocellular carcinoma (HCC) screening among patients with cirrhosis. The researchers also may look into whether EHR-based reminders can work for other medical specialties at the university.

“Our screening rates for patients enrolled in the electronic reminder program are much higher than in standard practice,” Konerman said.

With HCV, screening ultimately may lead to fewer complications and deaths.