Novel Implementation of Hepatitis B to Hepatitis Delta Reflex Testing in a US Healthcare System

Hepatitis delta virus (HDV) is the most aggressive form of viral hepatitis, yet screening rates in the United States are low, and few institutions have attempted interventions to improve the screening cascade. We assessed barriers to reflex test implementation, including lack of a Food and Drug Administration-approved reflex test, and implemented hepatitis B surface antigen (HBsAg) to HDV antibody (HDV Ab) reflex testing in our large, urban, academic healthcare system.

We evaluated outcomes 1 year after implementation using summary statistics. Patient-level and clinic-level characteristics were investigated for association with receiving a reflex test vs standalone HBsAg test using multivariable logistic regression.

All patients with a reflex order and HBsAg-positive result received HDV Ab follow-up testing, and their time to HDV Ab result was significantly shorter than those whose HDV test required a separate order (2 vs 11 days, P < 0.0001). Uptake of the reflex order was highest in primary care, where it was embedded into existing workflows.

Reflex testing improved efficiency and reduced gaps in the HBsAg to HDV screening cascade. Disparities in reflex testing rates among different patient groups were found, highlighting the need for universal reflex testing.