A Hepatitis C Screening Protocol That Works

Too often, news coverage of hepatitis C focuses on the cost of new drugs and not the importance of determining which patients have hepatitis C and getting them into effective care. I find this deeply troubling. What my colleagues and I see in our practice on a daily basis are patients who have no idea they might be infected with this silent but potentially fatal condition.

Three to 4 million individuals in the United States are chronically infected with the virus, according to the National Health and Nutrition Examination Survey. However, an estimated 50 percent to 80 percent of those individuals are unaware of their infection, increasing both the likelihood they will develop liver damage and the chances they will infect others.

Screening is recommended for all at-risk patients, including individuals with HIV or patients on kidney dialysis, men who have sex with men, people who’ve used drugs now or in the past, and those born between 1945 and 1965. But despite outreach efforts, screening gaps persist. And those gaps are not helped by news cycles that are swept up in the price of hepatitis C drugs and not the importance of making people aware they might need the medications.

There are gaps in the health care delivery system, as well. The literature reports that many patients are screened for hepatitis C but are never informed of their diagnosis. Oftentimes, the hepatitis C diagnosis is not even correctly documented in the medical record.

My colleagues and I at Kaiser Permanente of the Mid-Atlantic States are working to fix this imbalance. We have developed a screening protocol, supported by our advanced electronic medical record and dedicated care coordinators, which is working and can be scaled and replicated by other health care providers.

The model has five primary components:

• Automated electronic medical record best-practice alert to notify providers that patients are recommended for hepatitis C screening because they were born between 1945-1965 and have never been screened.
• Automated confirmatory laboratory testing (HCV RNA testing) for any patient who tests positive for the hepatitis C virus antibody to determine whether or not the person has an active infection. This ensures the patient has a complete diagnosis.
• A hepatitis C care coordinator to assist in ordering follow-up labs, scheduling liver-damage testing, and informing patients of their infection status and how to stay healthy.
• Integration of a noninvasive, pain-free test for measuring liver damage into the screening process.
• Connecting patients to physicians for ongoing care.

New peer-reviewed research by my colleagues at the Mid-Atlantic Permanente Medical Group shows us this integrated screening approach is working: To date, more than 30,000 Kaiser Permanente patients in Maryland, Virginia and Washington, D.C., have been screened using this model.

Of the population examined in our published manuscript (11,200), a total of 3.25 percent tested positive for the hepatitis C virus antibody, and 100 percent of antibody-positive patients received subsequent hepatitis C virus RNA testing. Of those patients who tested positive for the hepatitis C virus antibody, 75.9 percent had chronic hepatitis C virus, of which 80.8 percent underwent a non-invasive test to measure liver damage. Hepatitis C virus diagnosis was communicated to 94 percent of patients by direct person-to-person phone contact.

Our study shows the value of a comprehensive program to assist hepatitis C patients through each step of the care process, from screening to detection and monitoring. And there are many aspects of the Mid-Atlantic Permanente Medical Group protocol that can be replicated by independent physicians or health systems.

While the cost of treating hepatitis C is no doubt an important issue, we also need to pay attention to and champion screening advances that will help us do a better job of diagnosing and stopping the spread of this deadly virus.

Dr. Michael Horberg is executive director of research at the Mid-Atlantic Permanente Medical Group.