Hepatitis C Virus Screening and Care: Complexity of Implementation in Primary Care Practices Serving Disadvantaged
Barbara J Turner1, Andrea Rochat2, Sarah Lill2
1Joe R. and Teresa Lozano Long School of Medicine and Center for Research to Advance Community Health, University of Texas Health Science Center at San Antonio, San Antonio, Texas, and Keck Medical Center and Gehr Center for Health Systems Science and Innovation, University of Southern California, Los Angeles, California (B.J.T.).
Background:
Hepatitis C virus (HCV) disproportionately affects disadvantaged communities.
Objective:
To examine processes and outcomes of Screen, Treat, Or Prevent Hepatocellular Carcinoma (STOP HCC), a multicomponent intervention for HCV screening and care in safety-net primary care practices.
Design:
Mixed-methods retrospective analysis.
Setting:
5 federally qualified health centers (FQHCs) and 1 family medicine residency program serving low-income communities in diverse locations with largely Hispanic populations.
Patients:
Persons born in 1945 through 1965 (baby boomers) who had never been tested for HCV and were followed through May 2018.
Intervention:
The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) model guided implementation and evaluation. Test costs were covered for uninsured patients.
Measurements:
All practices tested patients for anti-HCV antibody (anti-HCV) and HCV RNA. For uninsured patients with chronic HCV in 4 practices, quantitative data also enabled assessment of HCV staging, specialist teleconsultation, direct-acting antiviral (DAA) treatment, and sustained virologic response (SVR). Implementation fidelity and adaptation were assessed qualitatively.
Results:
Anti-HCV screening was done in 13 334 of 27 700 baby boomers (48.1%, varying by practice from 19.8% to 71.3%). Of 695 anti-HCV-positive patients, HCV RNA was tested in 520 (74.8%; 48.9% to 92.9% by practice), and 349 persons (2.6% of those screened) were diagnosed with chronic HCV. In 4 FQHCs, 174 (84.9%) of 205 uninsured patients with chronic HCV had disease staging, 145 (70.7%) had teleconsultation review, 119 (58.0%) were recommended to start DAA therapy, 82 (40.0%) initiated free DAA therapy, 74 (36.1%) completed therapy (27.8% to 60.0% by practice), and 70 (94.6% of DAA completers) achieved SVR. Implementation was promoted by multilevel practice engagement, patient navigation, and anti-HCV screening with reflex HCV RNA testing.
Limitation:
No control practices were included, and data were missing for some variables.
Conclusion:
Despite a similar framework for STOP HCC implementation, performance varied widely across safety-net practices, which may reflect practice engagement as well as infrastructure or cost challenges beyond practice control.
Primary Funding Source:
Cancer Prevention & Research Institute of Texas and Centers for Medicare & Medicaid Services.
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