The baby boomer generation, born between 1945

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1 High Priority for Hepatitis C Screening in Safety Net Hospitals: Results From a Prospective Cohort of 4582 Hospitalized Baby Boomers Barbara J. Turner, 1 Barbara S. Taylor, 1 Joshua Hanson, 1 Yuanyuan Liang, 2 Poornachand Veerapaneni, 3 Roberto Villarreal, 4 * Mary Perez, 5 Ludivina Hernandez, 3 Jasdeep Sandhu, 6 and Kristin Fiebelkorn 5 Low-income populations are disproportionately affected by hepatitis C virus (HCV) infection. Thus, implementing baby boomer screening (born ) for HCV may be a high priority for safety net hospitals. We report the prevalence and predictors of HCV infection and advanced fibrosis or cirrhosis based on the Fibrosis-4 score plus imaging for a baby boomer cohort admitted to a safety net hospital over a 21-month interval with >9 monthsof follow-up. Anti-HCV antibody testing was performed for 4582, or 90%, of all neverscreened patients, of whom 312 (6.7%) tested positive. odds ratios of testing anti- HCV-positive were 2.66 for men versus women (P < 0.001), 1.25 for uninsured versus insured (P ), 0.70 for Hispanics versus non-hispanic whites (P ), and 0.93 per year of age (P < 0.001). Among 287 patients tested for HCV RNA (91% of all anti-hcvpositive cases), 175 (61%) were viremic (3.8% overall prevalence in cohort), which was 5% less likely per year of age (P < 0.03). Noninvasive staging of 148 (84.6%) chronic HCV patients identified advanced fibrosis or cirrhosis in 50 (33.8%), with higher adjusted odds ratios of 3.21 for Hispanics versus non-hispanic whites/asians (P ) and 1.18 per year of age (P ). Other factors associated with significantly higher adjusted odds ratios of advanced fibrosis or cirrhosis were alcohol abuse/dependence, obesity, and being uninsured. Conclusion: In this low-income, hospitalized cohort, 4% of 4582 screened baby boomers were diagnosed with chronic HCV, nearly twice the rate in the community; one-third had noninvasive testing that indicated advanced fibrosis or cirrhosis, which was significantly more likely for Hispanics, those of older age, those with obesity, those with alcohol abuse/ dependence, and those who lacked insurance. (HEPATOLOGY 2015;62: ) The baby boomer generation, born between 1945 and 1965, accounts for 75% of the estimated 2.7 million persons with chronic hepatitis C virus (HCV) infection in the United States, 1 and half are believed to be unaware of having this disease. 2 Most baby boomers have been infected for decades and are increasingly developing complications including cirrhosis, liver failure, and hepatocellular carcinoma (HCC). 3 With the advent of better-tolerated, more effective therapies to treat chronic HCV infection, 4 one-time universal screening of baby boomers has been endorsed by the Centers for Disease Control and Prevention and the US Preventive Services Task Force. 5,6 Despite the recommendation for universal testing, health care settings that serve low-income persons are likely to have a higher priority for implementing baby boomer screening. According to the population-based National Health and Nutrition Examination Survey (NHANES), HCV prevalence is nearly four times greater in persons with family incomes below the federal poverty level versus Abbreviations: BMI, body mass index; CT, computed tomography; EMR, electronic medical record; FIB-4, Fibrosis-4 (score); HCC, hepatocellular carcinoma; HCV, hepatitis C virus; NHANES, National Health and Nutrition Examination Survey. From the 1 Department of Medicine and Center for Research to Advance Community Health, University of Texas Health Science Center at San Antonio, San Antonio, TX; 2 Department of Epidemiology and Biostatistics and Center for Research to Advance Community Health, University of Texas Health Science Center at San Antonio, San Antonio, TX; 3 Center for Research to Advance Community Health, University of Texas Health Science Center at San Antonio, San Antonio, TX; 4 University Health System, San Antonio, TX; 5 Department of Pathology, University of Texas Health Science Center at San Antonio, San Antonio, TX; 6 School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX Received June 22, 2015; accepted July 29, Supported by the Centers for Disease Control and Prevention CDC PS PPHF12. *[Correction added October 5, 2015, after first online publication: Roberto Villarreal s name was corrected from Villareal. ] 1388

2 HEPATOLOGY, Vol. 62, No. 5, 2015 TURNER ET AL those with incomes at least two times the federal poverty level. 7 The nation s estimated 800 safety net hospitals treat a disproportionate share of low-income patients and Medicaid enrollees 8 who often have poor access to primary care. 1,9 To our knowledge, no prospective study has been conducted of baby boomer HCV screening in this important health care setting. To address this question, we implemented an HCV screening and linkage to care infrastructure in a large safety net hospital serving all of South Texas. This program has been shown to be an excellent model of comprehensive screening, follow-up testing, and counseling/ linkage to care. 10,11 In this article, we examine the prevalence and predictors of anti-hcv antibody screening, indicating current or past infection and predictors of viremia among anti-hcv-positive patients as well as chronic HCV infection. Additionally, we examine patient characteristics associated with advanced fibrosis or cirrhosis based on the Fibrosis-4 (FIB-4) score in combination with imaging studies. These data offer valuable insights into the field and patient-related factors that are associated with HCV infection and more advanced disease at diagnosis within a population at increased risk of HCV infection but often with poor access to routine ambulatory care. Patients and Methods Study Design We examined a prospectively identified cohort of patients born between 1945 and 1965 admitted for any reason to University Hospital in Bexar County, Texas, from December 1, 2012, through August 30, This implementation project was reviewed by the University of Texas Health Science Center at San Antonio institutional review board and deemed to be exempt (HSC N). Setting and Procedures University Hospital is a 498-bed, academically affiliated hospital serving the indigent population of South Texas. The current study examined screening of eligible baby boomers from December 1, 2012, through August 30, 2014, and followed for subsequent evaluation of liver disease through June 1, Eligibility for screening was assessed by an algorithm applied to the electronic medical record (Allscripts Sunrise electronic medical record [EMR]) to identify patients born from 1945 through 1965 without any record of HCV testing up to 7 years before admission. The algorithm also excluded patients admitted to psychiatry, who may not be competent to consent to testing, and those with a poor prognosis, such as metastatic cancer (codes available from authors). HCV screening orders for patients without prior screening were added to admission order sets through an algorithm based on eligibility (for two-thirds of admissions) or placed by a team member (one-third of admissions). It was not possible to automate entry of the HCV screening order into all of the many types of admission order sets; therefore, it was also necessary for a team member to place orders in the EMR. Widely distributed signage and flyers in admission papers informed patients about HCV screening and offered the opportunity to opt out. For anti-hcv antibody testing, the Advia Centaur HCV Assay (Bayer HealthCare LLC, Tarrytown, NY) was used; its sensitivity is 99.9% and specificity is 97.5%. 12,13 Following expert guidelines 14 when the anti-hcv test was positive (reactive), a reflex HCV RNA assay was performed using the COBAS AmpliPrep/COBAS TaqMan HCV Test (Roche Molecular Systems, Pleasanton, CA). For most patients, both tests were performed on the same specimen. A bilingual HCV counselor informed patients of HCV test results and counseled anti-hcv-positive patients using an e-reader educational program about HCV transmission, epidemiology, and management. A follow-up plan was developed by a bilingual promotora (community health worker), who contacted patients with newly diagnosed chronic HCV infection after discharge and facilitated receipt of care by addressing barriers to HCV care, such as no insurance, no primary care provider, no access to HCV specialty care, and alcohol or drug abuse. The promotora assisted patients until they initiated anti-hcv therapy or December 10, 2014 whichever came first. Study Data Dependent Variables. Results of HCV tests were obtained from the EMR or reports from outpatient providers. For the first study outcome, results of anti-hcv testing were categorized as negative or positive (reactive). The second outcome was HCV RNA testing, Address reprint requests to: Barbara Turner, M.D., M.S.E.D., University of Texas Health Science Center at San Antonio, 7411 John Smith Road, Suite 1050, San Antonio, TX turner@uthscsa.edu. Copyright VC 2015 by the American Association for the Study of Liver Diseases. View this article online at wileyonlinelibrary.com. DOI /hep Potential conflict of interest: Nothing to report.

3 1390 TURNER ET AL. HEPATOLOGY, November 2015 categorized as negative or positive (viremic). The third outcome was advanced fibrosis determined by a combination of noninvasive tests. First, we examined imaging results from multiple gray scale liver or right upper quadrant ultrasound tests and/or 3-phase liver or serial axial abdominal computed tomographic (CT) scans. Results were categorized as cirrhosis based on imaging evidence of increased echogenicity, coarsened echotexture, diffusely echogenic with coarsening, and/or nodular contours. 15 Results were categorized as likely HCC when the CT scan showed an arterially enhancing lesion with wash out phenomenon. We also assessed liver disease staging using the FIB-4 index (based on age, alanine aminotransferase, aspartate aminotransferase, and platelet count), reflecting previously defined categories that have been correlated with advanced fibrosis or cirrhosis Patients were categorized as having advanced fibrosis or cirrhosis based on results from at least two noninvasive tests: (1) high FIB-4 (cut point > ,18 ) plus one or more imaging studies read as cirrhosis or HCC or (2) intermediate FIB-4 (cut point > ) plus CT or magnetic resonance imaging evidence of cirrhosis or HCC. By considering either high or intermediate FIB-4, our approach classifies more patients as having advanced fibrosis (i.e., those with intermediate FIB-4 with evidence of cirrhosis or HCC on CT or magnetic resonance imaging) compared with only high FIB-4. On the other hand, our approach requires multiple tests to support the diagnosis of advanced fibrosis or cirrhosis (e.g., high FIB-4 plus one or more imaging studies read as cirrhosis or HCC), which potentially increases specificity compared to the use of high FIB-4 alone. In summary, our approach of combining FIB-4 and imaging results has the potential of increasing the overall diagnostic accuracy. The role for using multiple tests has been advocated previously. 19 Independent Variables. Demographic characteristics including age, gender, and self-reported race/ethnicity were obtained from the EMR. Insurance status was also obtained from the EMR; patients with federal, commercial, or Veterans Health Administration insurance were categorized as insured, while those using selfpay or a county-based financial assistance program (CareLink) that requires them to pay for care at reduced rates were categorized as uninsured. For persons with chronic HCV infection, alcohol consumption was assessed from alcohol utilization categories in the hospital admission and discharge diagnoses (292.x, 303.x- 305.xx): (1) none (alcohol consumption denied), (2) current nonproblem use (occasional or yes without qualification), (3) prior alcohol consumption (report of quitting), and (4) alcohol abuse/dependence. Because of the association of body mass index (BMI) and diabetes mellitus with steatosis that can accelerate liver damage among persons with HCV, 20 we collected data on BMI from the EMR and identified diabetes from two outpatient or one patient diagnosis (042.x). 21 BMI was categorized as normal (<25), overweight (25-29), or obese (30) for analysis. Analyses Patient characteristics (demographics and insurance type) were examined in relation to anti-hcv test results and HCV RNA test results using the chi-square test or Student t test with unequal variance assumption as appropriate. In regard to predictors of advanced fibrosis or cirrhosis based on FIB-4 plus imaging studies, we examined the association of patient demographics and clinical factors including diabetes diagnosis, BMI (<25, 25-29, >30), and alcohol consumption using Fisher s exact test or the Student t test with unequal variance assumption as appropriate. Logistic regression models for the three dependent variables were estimated to examine associations with demographic characteristics and insurance status. Sensitivity analyses were conducted using age as a categorical variable defined by quartiles. Similar monotonic trends were observed across all age groups, supporting the specification of age as a continuous variable in the logistic regression models. All statistical tests were conducted at a two-sided significance level of 0.05, and all analyses were conducted using Stata/SE (version 13; StataCorp LP, College Station, TX). Results Over 21 months, 9037 unique patients were born from 1945 through 1965 and admitted to University Hospital with a mean age of 56.6 years (standard deviation 6.5 years): 44.7% were women, 59.1% were of Hispanic ethnicity, and 7.8% were African American. In this cohort, no screening was required for 993 (10.9%) patients with a documented HCV diagnosis or for 2957 (32.7%) patients who were previously tested for HCV (Fig. 1). Of the remaining 5087 persons, 4582 (90%) received anti-hcv testing; many patients who were not tested were excluded due to unstable mental health conditions or poor prognosis such as metastatic cancer. Over half of screened patients were men, and most were of Hispanic ethnicity (Table 1). Of screened patients, 316 (6.9%) were anti-hcv-positive, indicating current or prior HCV infection (Fig. 1). The highest prevalence of HCV infection was observed for men (9.4%) and African Americans (9.2%). After adjustment for demographics and insurance status, the odds of HCV infection were over two-fold higher for men than

4 HEPATOLOGY, Vol. 62, No. 5, 2015 TURNER ET AL Fig. 1. Flowchart of all baby boomer patients born 1945 to 1965 hospitalized from 12/1/2012 through 8/31/2014 with HCV screening eligibility, HCV tests, and results women but reduced for those of older age and Hispanics or Asians/other versus non-hispanic whites. African Americans did not differ significantly from non- Hispanic whites. Uninsured patients had 25% higher odds of HCV infection than insured patients, with a confidence interval of HCV RNA testing was performed for 90.8% of all patients testing anti-hcv-positive, of whom 175 (61% of all screened) were viremic (Fig. 1). Overall, 3.8% of all screened patients had chronic HCV infection, and the only significant predictor was age, with 5% lower adjusted odds per increasing year (P ) (Table 2). Among patients with chronic HCV infection, 148 (84.6%) received follow-up care with noninvasive staging. Treatment from a hepatologist was received by 65 patients (37.1%), and as of June 1, 2015, 14 had initiated or completed anti-hcv therapy. Forty patients (27.8%) had high FIB-4 (>3.25) as well as cirrhosis or HCC on imaging studies (11 ultrasound only, six CT only, one magnetic resonance imaging only, and 22 multiple imaging studies). Another 10 patients (6.9%) had an intermediate FIB-4 > plus cirrhosis or HCC for four patients on CT only and six on multiple imaging studies (Table 3). Thus, overall 50 patients (33.8%) with follow-up evaluation had advanced fibrosis or cirrhosis based on FIB-4 plus imaging studies. Biopsy was performed on seven patients, of whom three were F3-F4 and all were correctly classified with advanced fibrosis or cirrhosis based on FIB-4 >1.45 with cirrhosis or HCC on imaging. Among the 50 patients identified as having advanced fibrosis or cirrhosis, Hispanic ethnicity was significantly associated before and after adjustment with an adjusted odds ratio of 3.2 versus non-hispanic whites/asians. The adjusted odds of advanced fibrosis or cirrhosis increased by 18% for each additional year of age. The adjusted odds ratios for advanced fibrosis or cirrhosis were 3.7 (P ) for a BMI >30 and 2.4 (P ) for a BMI >25-29 versus <25, but diabetes was not significantly associated with the outcome. Alcohol abuse/ dependence was strongly associated, with nearly fourfold greater adjusted odds of advanced fibrosis or cirrhosis. In addition, uninsured subjects were over two-fold Table 1. Association of Patient Demographics and Insurance Status With Anti-HCV Antibody Test Results Characteristics All Patients n (%)* Anti-HCV-Positive Patients n (%) Anti-HCV-Negative Patients n (%) Unadjusted P Value Odds Ratio 95% Confidence Interval P Value Total 4582 (100) 316 (6.9) 4266 (93.1) Age, mean (SD) 57.0 (5.7) 54.7 (4.9) 57.2 (5.7) < < Women 1984 (43.3) 71 (3.6) 1913 (96.4) < Men 2598 (56.7) 245 (9.4) 2353 (90.6) < Non-Hispanic white Hispanic African American Asian/other 1527 (33.3) 2676 (58.4) 239 (5.2) 140 (3.1) 123 (8.1) 168 (6.3) 22 (9.2) 3 (2.1) 1404 (91.9) 2508 (93.7) 217 (90.8) 137 (97.9) Insured 2,513 (54.9) 156 (6.2) 2369 (94.3) Uninsured 2,069 (45.1) 172 (8.3) 1897 (91.7) *Column percent except for age. Row percent except for age. P value from two-sample t test with unequal variance assumption (birth year) or chi-squared test. for age, gender, race/ethnicity, and insurance status

5 1392 TURNER ET AL. HEPATOLOGY, November 2015 Table 2. Association of Patient Demographics and Insurance Status With HCV RNA Test Results Among Patients With HCV Infection (Anti-HCV-Positive) Characteristics HCV RNA Tested Patents n (%)* HCV RNA-Positive Patients n (%) HCV RNA-Negative Patients n (%) Unadjusted P Value Odds Ratio 95% Confidence Interval P Value Total 287 (100) 175 (61.0) 112 (39.0) Age, mean (SD) 54.6 (4.9) 54.1 (4.9) 55.5 (4.9) Women 65 (22.6) 36 (55.4) 29 (44.6) 1.00 Men 222 (77.4) 139 (62.6) 83 (37.4) Non-Hispanic white Hispanic African American Other 114 (39.7) 150 (52.3) 20 (7.0) 3 (1.0) 69 (60.5) 90(60.0) 15 (75.0) 1 (33.3) 45 (39.5) 60 (40.0) 5 (25.0) 2 (66.7) Insured 125 (43.6) 69 (55.2) 56 (44.8) Uninsured 162 (56.4) 106 (60.6) 56 (50.0) *Column percent except for age. Row percent except for age. P value from two-sample t test with unequal variance assumption (birth year) or chi-squared test. for age, gender, race/ethnicity, and insurance status more likely to have advanced fibrosis or cirrhosis (P ). Discussion The high prevalence of HCV infection in this prospective cohort of nearly 4600 patients admitted to a safety net hospital offers important evidence in support of preventive baby boomer HCV screening in similar hospitals serving low-income populations. Over 90% of never-screened baby boomers were tested for anti-hcv through this program, of whom 7% were positive. By contrast, 3.2% of baby boomers in the NHANES tested anti-hcv-positive. 7 Thus, this neverscreened cohort had over twice the prevalence of prior or current HCV infection compared with the national rate. Considering both newly diagnosed and known HCV-infected patients in our safety net hospital cohort, 18% have been infected with HCV. By comparison, the anti-hcv-positive prevalence was 16% among nearly Table 3. Association of Patient Characteristics With Advanced Liver Disease Characteristics All Staged Patients n (%)* Patients With Advanced Liver Disease n (%) Patients Without Advanced Liver Disease n (%) Unadjusted P Value Odds Ratio 95% Confidence Interval P Value 148 (100) 50 (33.8) 98 (66.2) Age, mean (SD) 54.5 (4.8) 55.5 (5.6) 53.9 (4.2) Women 26 (17.6) 4 (15.4) 22 (84.6) Men 122 (82.4) 46 (37.7) 76 (62.3) Race-ethnicity Non-Hispanic white/asian 56 (37.8) 12 (21.4) 44 (78.6) Hispanic 80 (54.1) 37 (46.3) 43 (53.8) African American 12 (8.1) 1 (8.3) 11 (91.7) Insured 55 (37.2) 13 (23.6) 42 (76.4) Uninsured 93 (62.8) 37 (39.8) 56 (60.2) BMI 0.03 <25 60 (40.5) 13 (21.7) 47 (78.3) (35.8) 22 (41.5) 31 (58.5) (23.7) 15 (42.9) 20 (57.1) Alcohol consumption None 27 (18.4) 5 (18.5) 22 (81.5) 1 Current use 45 (30.6) 10 (22.2) 35 (77.8) Past use 22 (15.0) 7 (31.8) 15 (68.2) Past or current heavy use 53 (36.1) 28 (52.8) 25 (47.2) Diabetes No diabetes 108 (73.0) 33 (30.6) 75 (69.4) 1 Diabetes 40 (27.0) 17 (42.5) 23 (57.5) *Column percent except for age. Row percent except for age. P value from two-sample t test with unequal variance assumption (birth year) or Fisher s exact test. for all covariates listed.

6 HEPATOLOGY, Vol. 62, No. 5, 2015 TURNER ET AL patients admitted to general medicine and trauma units in two hospitals in Philadelphia serving large numbers of publically insured patients. 22 An outpatient screening program in clinics serving low-income populations in Philadelphia found that 19% of baby boomers were anti-hcv-positive. 23 These data reinforce the extremely high prevalence of HCV in settings serving low-income populations. Follow-up HCV RNA testing was completed for 91% of anti-hcv-positive patients, with 3.8% of all screened patients found to be viremic compared with 2.8% of individuals aged from NHANES data. 1 An Alabama-based emergency department screening program for baby boomers completed anti-hcv screening for 66% of 2325 never-screened patients, and among those with a positive test 88% were tested for HCV RNA. Overall, 6.7% of 1529 tested patients had chronic infection in that study and 24% received or scheduled follow-up care. 24 By contrast, 85% of patients in our cohort received follow-up care and 37% received hepatology care. The superior performance of screening and linkage to follow-up care in the inpatient setting versus the emergency department may be due to a longer time frame days instead of hours in which to obtain screening, perform additional tests, and engage patients with follow-up care through counseling and case management. In particular, our case managers were able to facilitate enrollment in a health care financial assistance program, scheduling appointments, getting approvals for tests, and addressing personal challenges with diagnosis of a potentially socially stigmatizing disease. This study also offers additional evidence regarding the yield of HCV screening in low-income, uninsured populations. The prevalence of HCV infection in this cohort was 25% higher in the insured patients (P ), but the comparison group includes Medicaid enrollees who are considered underinsured in other studies. For example, in the Alabama emergency department study, the proportion of anti-hcv-positive results for underinsured as well as uninsured patients was over three times higher than that of insured patients. 24 A national analysis of the prevalence of HCV infection in 2013 by insurance type offers strong evidence for prioritizing HCV screening in uninsured persons. 25 Among 48 million uninsured persons, the prevalence of chronic HCV infection was estimated to be 2.08%, whereas among 164 million commercially insured persons, the estimated prevalence was 0.47%. Thus, screening programs should strive to operate outside the typical population of commercially insured patients to target populations with higher prevalence of HCV but poorer access to care. Furthermore, with the advent of the Affordable Care Act, which has increased access to care for the previously uninsured, our ability to address the HCV epidemic in this population has become more feasible. Although Texas has not participated in Medicaid expansion, many uninsured persons admitted to the study hospital can receive care through a local financial assistance program but the cost of this care is borne by county residents. In this predominantly Hispanic (Mexican origin) cohort, Hispanics had 30% lower adjusted odds of HCV infection than non-hispanic whites, but in the NHANES baby boomer study, the adjusted odds of HCV infection for these two groups did not differ. The lower prevalence in our cohort may reflect their Mexican origin. In the Hispanic Community Health Study/Study of Latinos, the prevalence of HCV infection was significantly lower for persons of Mexican or Central American origin compared with Puerto Ricans, among whom the HCV prevalence was over 11%. 26 In this prospective cohort, data on noninvasive staging for 148 patients with chronic HCV infection showed that over one-third had advanced fibrosis based on FIB-4 levels and imaging studies supporting cirrhosis. In a similar uninsured population, a low FIB-4 <1.45 effectively excluded advanced fibrosis. 27 In the Chronic Hepatitis Cohort Study, the mean FIB-4 level among persons with F3 (severe fibrosis) on International Association for the Study of the Liver classification based on biopsy was 2.32 and that for F4 (cirrhosis) was Because the sensitivity for liver cirrhosis has been reported to be only 38% for ultrasound alone but 77% for CT scan alone, 28 we required at least CT evidence of cirrhosis for patients with an intermediate elevation of FIB-4 (> ). 16 In the seven cases where biopsy was performed, the results concurred with our classification based on combined FIB-4 and imaging. Thus, an innovative aspect of this study is the use of data from multiple noninvasive studies to increase the accuracy of detecting advanced fibrosis or cirrhosis. The adjusted odds of advanced fibrosis or cirrhosis were over three-fold greater for Hispanics versus other racial/ethnic groups. Hispanics also had significantly more advanced fibrosis than non-hispanic whites in a convenience sample with chronic HCV in a Los Angeles county hepatology clinic. 29 Obesity and diabetes have also been associated with advanced fibrosis in HCV infection. 20 Both factors also increase the risk for nonalcoholic fatty liver disease, which is more prevalent in Hispanics, especially those of Mexican origin. 30,31 In our cohort, overweight or obese subjects were approximately three times more likely to have advanced fibrosis,

7 1394 TURNER ET AL. HEPATOLOGY, November 2015 while diabetes was not significantly associated. Not surprisingly, alcohol abuse or dependence increased the adjusted odds of advanced fibrosis by nearly four-fold. In this largely Hispanic cohort, one-third of persons with chronic HCV were diagnosed with alcohol abuse or dependence. National surveys report that heavy drinking is more common among Hispanic than non- Hispanic drinkers. 32 In addition, two-thirds of this predominantly Hispanic cohort was uninsured, which was associated with over two-fold greater adjusted odds of advanced fibrosis or cirrhosis. Taken together, these data reinforce the value of HCV screening in Hispanics because they have multiple risk factors for more advanced disease. This cohort study offers possible insights into contributory factors for chronic liver disease, which was the sixth most common cause of death in Hispanics in 2010 but not even among the top 10 for non-hispanic whites or African Americans. 33 In regard to other sequelae of HCV infection, Hispanics are disproportionately affected by HCC in national 34 and regional 35 studies. We acknowledge several limitations of our study. First, these data reflect HCV screening in one hospital, but this is one of the largest cohort studies of HCV screening in baby boomers in any setting. Second, African Americans were underrepresented in this cohort and have been widely reported to have an increased risk of chronic HCV infection. 1 Third, liver biopsy data were available for only seven patients, reflecting the fact that noninvasive staging has become the primary mode of staging for HCV. 36,37 Fourth, we did not adjust for some predictors such as HCV risk factors. Lastly, replicating this model may be cumbersome if the hospital s EMR requires a physician to place HCV screening orders. In summary, this prospective cohort study strongly supports implementation in similar hospital settings serving low-income patients. This hospital infrastructure can facilitate screening and engagement with treatment of persons who have increased risk of HCV infection but limited access to care. This study also found that advanced fibrosis or cirrhosis was significantly more common in Hispanics who need to be expeditiously linked to treatment to avert serious, life-threatening complications. References 1. Denniston MM, Jiles RB, Drobeniuc J, Klevens RM, Ward JW, McQuillan GM, et al. Chronic hepatitis C virus infection in the United States, National Health and Nutrition Examination Survey 2003 to Ann Intern Med 2014;160: Institute of Medicine Committee on the Prevention and Control of Viral Hepatitis Infection. Hepatitis and liver cancer: a national strategy for prevention and control of hepatitis B and C. Washington, DC: National Academies Press; Kanwal F, Hoang T, Kramer JR, Asch SM, Goetz MB, Zeringue A, et al. Increasing prevalence of HCC and cirrhosis in patients with chronic hepatitis C virus infection. Gastroenterology 2011;140: Liang TJ, Ghany MG. Current and future therapies for hepatitis C virus infection. N Engl J Med 2013;368: US Preventive Services Task Force. Screening for hepatitis C virus infection in adults: US Preventive Services Task Force recommendation statement. Ann Intern Med 2013;159: Centers for Disease Control and Prevention. Recommendations for the identification of chronic hepatitis C virus infection among persons born during MMWR Recomm Rep 2012;61: Smith BD, Beckett GA, Yartel A, Holtzman D, Patel N, Ward JW. 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