Transforming Hepatitis B Care in Kaiser Permanente Mid-Atlantic States Through a Registry and Coordinator Supported Pathway

Transcription

1 Transforming Hepatitis B Care in Kaiser Permanente Mid-Atlantic States Through a Registry and Coordinator Supported Pathway V c Michael Horberg, MD, MAS, FACP, FIDSA Executive Director Research, Community Benefit, and Medicaid Strategy, Mid-Atlantic Permanente Medical Group, Executive Director, Mid-Atlantic Permanente Research Institute Cabell Jonas, PhD Senior Research Program Consultant, Operations Research Associate Investigator Mid-Atlantic Permanente Medical Group

2 Challenges with Hepatitis Diagnosis and Patient Management Chronic Hepatitis B virus (HBV) and chronic Hepatitis C virus (HCV) require multiple lab tests for an accurate diagnosis. Provider knowledge and awareness of these diseases is low. 1 Knowledge of risk for related disorders, specifically hepatocellular carcinoma (HCC) is also low. Several studies show underutilization of HCC surveillance, putting patients at risk for undetected HCC, which decreases treatment options and increases mortality. 2-4 The populations requiring HCC surveillance include all patients with cirrhosis, a subset of non-cirrhotic patients with chronic HBV (Asian males >40, Asian females >50, Black, family history of HCC 5 ) and other patients as deemed clinically necessary (chronic HCV with F3 on fibroscan or biopsy) Starting at age 10 yrs. Younger than index case or age 40, whichever first

3 We Sought to Improve our HBV Diagnosis Capture to Prepare to Improve HCC Surveillance We saw an area of opportunity to improve HCC Surveillance in KPMAS We sought to create a Coordinator supported program to support HCC surveillance Furthermore, our HCV Screening Pathway was resulting in more patients having an accurate and up-to-date HCV diagnosis; and the use of Fibroscan was making it easier to track fibrosis score and offering an opportunity to include HCV infected F3 patients in HCC surveillance. However, chart review on our HBV patients revealed that: Hepatitis B diagnoses were sometimes not documented, inaccurately documented, or not documented in a easy-to-find location in the EMR A subset of hepatitis B infected patients had never seen Gastroenterology or had not seen Gastroenterology in 2+ years Some data elements that power our HCC surveillance registry were not available: Race/Ethnicity was not captured in the correct area of the EMR Family History of Liver Cancer was not captured, or was not captured in the correct area of the EMR

4 Two New Programs to Support Liver Care in KPMAS Chronic Hepatitis B Pathway Coordinators support lab testing, ultrasound completion and GI telephone visit Goals: To obtain an accurate (and accurately documented) HBV diagnosis for those new to KP with suspected/known HBV through testing and a GI visit To obtain an updated diagnosis for those out of touch / fallen out of care To triage HBV patients who had never seen GI to a visit, so GI can review eligibility for medications and identify whether the patient needs HCC surveillance Hepatocellular Carcinoma Surveillance Program Provide support for ongoing screening for hepatocellular carcinoma Coordinators support lab testing, ultrasound every 6 months HCC: hepatocellular carcinoma

5 Two New Programs to Support Liver Care in KPMAS Chronic Hepatitis B Pathway Coordinators support lab testing, ultrasound completion and GI telephone visit Goals: To obtain an accurate (and accurately documented) HBV diagnosis for those new to KP with suspected/known HBV through testing and a GI visit To obtain an updated diagnosis for those out of touch / fallen out of care To triage HBV patients who had never seen GI to a visit, so GI can review eligibility for medications and identify whether the patient needs HCC surveillance Hepatocellular Carcinoma Surveillance Program Provide support for ongoing screening for hepatocellular carcinoma Coordinators support lab testing, ultrasound every 6 months HCC: hepatocellular carcinoma

6 HEPATITIS B PATHWAY 1. Providers order Referral GI, HBV Pathway, Chart Review Patients new to KP with HBV Patients whose HBV diagnosis is out of date Patients NOT under GI care already This pathway is not for HBV screening Lauren Williamson, RN Venus Alert, LPN 2. HBV Coordinators: Send a note to ordering physician acknowledging referral receipt Call patient to explain the goals of the testing pathway and update race/ethnicity and family history of HCC Order HBV labs & Abdominal Ultrasound Remind patient to complete labs, ultrasound 3. Once labs and ultrasound are in: HBV Coordinators schedule a GI Telephone Visit The Coordinators will not discuss test results Gastroenterologist: Conducts 15-min GI Telephone Visit, using the Smartset HBV SMARTSET-FROM PATHWAY to: Review Labs and Ultrasound Results, add/update/correct Problem List diagnosis of HBV Review HBV Medication (start, continue, stop), note whether the patient needs HCC surveillance GI note will designate accountability for next steps; next steps may be managed by PCP or GI based on results Patient s HBV diagnosis, treatment plan, and HCC surveillance status is up to date

7 EMR Features that Support the Program (Transferrable) HBV Orders

8 EMR Features that Support the Program (Transferrable) GI Tele Visit

9 EMR Features that Support the Program (Transferrable) Coordinator Reporting Workbench Workflow Tool for HBV and HCC Surveillance

10 Preliminary Results HBV Testing Pathway Referral GI, HBV Pathway, Chart Review order 1* 307 *Patients who engaged with the Coordinators via registry based outreach = 1,420 Patients with a Coordinator Telephone Visit (to order labs/ultrasound) 275 (93%) Patients with a Gastroenterology Visit 2 (telephone or clinic) 211 (77%) 1. Telephone contact dates on or before January 25, 2019 to enable sufficient time for follow up GI appt 2. Follow-up visit on or post coordinator Telephone visit contact date, Follow-up visit cannot have a provider of Coordinator, Follow-up GI provider had to be a physician, Follow-up visit can be any of the following: a) Appointment made by Coordinators, b) Appt reason like HEPAT (for Hepatitis), c) Department name like GASTRO)

11 Preliminary Results HBV Testing Pathway Referral GI, HBV Pathway, Chart Review order 1* 307 Patients with a Coordinator Telephone Visit (to order labs/ultrasound) 275 (93%) Patients with a Gastroenterology Visit 2 (telephone or clinic) 211 (77%) No longer insured with KP GI chart review (not visit) Refused Unreachable Out of the country Saw Infectious Disease or PCP (not GI) Did not have Hepatitis B or immune to HBV 1. Telephone contact dates on or before January 25, 2019 to enable sufficient time for follow up GI appt 2. Follow-up visit on or post coordinator Telephone visit contact date, Follow-up visit cannot have a provider of Coordinator, Follow-up GI provider had to be a physician, Follow-up visit can be any of the following: a) Appointment made by Coordinators, b) Appt reason like HEPAT (for Hepatitis), c) Department name like GASTRO)

12 Lessons Learned 1. We tried to improve upon our experience with HCV by eliminating the need for an initial order to access the pathway. The plan was to use a registry to identify eligible HBV patients on the back end (saving physician time). 2. Registry-based outreach to patients about HBV was not ideal

13 Registry-based Outreach to Patients We began this program using registry-based outreach to patients who had never seen GI or had not seen GI in 2+ years Screened 1,420 patients using this method Some patients liked the proactive outreach, others were confused Similar experience with physicians some were grateful to have assistance with HBV patients, some felt equipped to handle patients independently without Coordinator support There was no way for interested PCPs to refer patients into the program Registry sorted patients into high (never seen GI), medium (hadn t seen GI in 2 years), low categories for outreach Some physicians wanted their patients on the HBV Program immediately, even if they had seen GI in <2 years; there was no way to refer patients to the Coordinators To resolve, we launched an order to refer patients in: Referral GI, HBV Pathway, Chart Review (data shown earlier, n = 307) Now, only interested physicians are referring patients We could tell patients their doctor requested they complete this workup

14 Lessons Learned 1. Registry-based outreach to patients about HBV was not ideal 2. We were hoping our Coordinators could communicate the HBV diagnosis to patients, similar to our HCV Coordinators. Unlike HCV, a HBV diagnosis has nuance and requires review by a gastroenterologist

15 Lessons Learned 1. Registry-based outreach to patients about HBV was not ideal 2. A HBV diagnosis requires review by a gastroenterologist 3. Physicians needed CME educational refresher courses on Hepatitis B infection (acute and chronic) and hepatocellular carcinoma surveillance

16 HBV CMEs Were Important to Refresh Knowledge on HBV Lab Testing, Diagnosis

17 Lessons Learned 1. Registry-based outreach to patients about HBV was not ideal 2. A HBV diagnosis requires review by a gastroenterologist 3. Physicians needed CME educational refresher courses on Hepatitis B infection (acute and chronic) and hepatocellular carcinoma surveillance We applied these learnings to our HCC surveillance pathway which was launched after the HBV pathway (same Coordinators)

18 Two New Programs to Support Liver Care in KPMAS Chronic Hepatitis B Pathway Coordinators support lab testing, ultrasound completion and GI telephone visit Goals: To obtain an accurate (and accurately documented) HBV diagnosis for those new to KP with suspected/known HBV through testing and a GI visit To obtain an updated diagnosis for those out of touch / fallen out of care To triage HBV patients who had never seen GI to a visit, so GI can review eligibility for medications and identify whether the patient needs HCC surveillance Hepatocellular Carcinoma Surveillance Program Provide support for ongoing screening for hepatocellular carcinoma Coordinators support lab testing, ultrasound every 6 months HCC: hepatocellular carcinoma

19 Hepatocellular Carcinoma Surveillance Program a. Physician places initial order to designate which labs to do at 6 month intervals, all patients receive abdominal ultrasound b. Coordinators call patients to schedule ultrasound c. Coordinators call patients 4 days before to remind them to complete ultrasound and labs d. GI physician interprets results, if normal steps b-d repeat every 6 months (order must be placed again after 365 days have passed) A physician identifies patients eligible for HCC screening A specific HCC-Screening Order is placed Patient So far, so good! Currently interacting with 594 patients GI Physician: Reviews results Follows up as appropriate HBV Coordinators: Remind patient to complete labs + ultrasound every 6 mos.

20 Next Steps with Both Programs Chronic Hepatitis B Pathway Continue to refine the approach to ensure we are meeting primary care, gastroenterologist, and patient needs Continue to educate physicians about HBV HCC Surveillance Program Expand program to include all HCC surveillance eligible patients Determine opportunities for technology to support Coordinator activities Assess program effectiveness in collaboration with the research team

21 Thank You! Michael Horberg, MD, MAS, FACP, FIDSA Cabell Jonas, PhD Physician Collaborators: Gastroenterology Infectious Disease Adult & Family Medicine Coordinators: Lauren Williamson, RN Venus Alert, LPN Research (MAPRI): Kevin Rubenstein, MS Haihong Hu, MPH Eric Watson KP HealthConnect Team and Optimization Team: Frank Genova, MD Tirna Singh Ahmed Gahelrasoul Theresa McHugh, RN Our 45-page HCV Pathway toolkit provides the resources to implement the HCV Pathway program in your region. We also have a Coordinator training manual available. HBV and HCC EMR resources also available Cabell.Jonas@kp.org