Hepatitis C Screening For Baby Boomers in Primary Care. Nicole Mesick DO, RD NHAFP Conference May 18 th, 2018

Transcription

1 Hepatitis C Screening For Baby Boomers in Primary Care Nicole Mesick DO, RD NHAFP Conference May 18 th, 2018

2 Disclosures No disclosures

3 Objectives Recognize the importance of diagnosing Hepatitis C (HCV) Explain how to counsel regarding HCV Review HCV recommendations for screening Determine how we can apply this knowledge to improve screening rates

4 Introduction million people in the world have HCV infection An estimated million people in the United States have chronic HCV

5 Introduction 5 HCV infection is a major cause of chronic liver disease and cirrhosis Transmission through blood, bodily fluids Screening is recommended for all adults with high risk of infection and one time screening for those born between

6 Hepatitis C Virus 5

7 Implications of Chronic HCV 6 Fibrosis Cirrhosis Hepatocellular Carcinoma (with cirrhosis) Fibrosis Chronic HCV infection can lead to the development of fibrous scar tissue within the liver HCC Cancer of the liver can develop after years of chronic HCV infection Cirrhosis Over time, fibrosis can progress, causing severe scarring of the liver, restricted blood flow, impaired liver function, and eventually liver failure

8 Hepatitis C for the Primary Care Provider

9 Who should be screened IVDU Persistently abnormal ALT levels History of Blood Transfusions before 1987 Everyone born from 1945 through 1965 Recipients of organ transplants prior to 1992 Long-term hemodialysis Persons with hemophilia HIV positive persons Occupational Exposure Surgery before implementation of universal precautions Children born to HCV positive women Incarceration Unregulated Tattoos

10 Screening U.S. Preventative Services Task Force (USPSTF) and Centers for Disease Control and Prevention (CDC) recommend: Periodic HCV screening for all adults at high risk One-time screening in adults born between

11 100 HCV infected individuals

12 Baby Boomers ,3 Account for 75% of HCV in the US Only 50% are aware they are infected Have a 5x increased prevalence than other adults

13 1.6 Estimated Prevalence by Age Group Number with chronic HCV (millions) < s 1930s 1940s 1950s 1960s 1970s 1980s Birth Year Group

14 100 Baby Boomers with HCV

15

16 A Public Health Problem

17 A Public Health Problem

18 Literature Review-screening programs 4 Hospital Based Screening program Lessons from implementing HIV screening Provider/staff education EMR integration with exclusions Anti-HCV antibody test with reflex HCV RNA Admission order sets Patient education Subjects Baby boomer HCV screening Majority Hispanic Population 498 bed safety- net academic affiliated hospital South Texas 2 year implementation ( ) Interventions Opt-out consent (admission packet flyers and posters) HCV counselor for positive results Community health worker arranged linkage to care

19 Hospital Based Results 4 Mean age 56.4 years 4.2% of all eligible patients were chronically infected with HCV

20 Hospital Based Primary Care 2 Pre-intervention-baseline measurements Prospective interventional study Maintenance phase Mount Sinai Hospital Internal Medicine primary care practice November

21 Hospital Based Primary Care 2 Results: HCV positive-3.3% Screening increased- 55% to 75% Percentage of patients linked to care and attended first appointment -77%

22 Primary Care Screening 13 Developed Best Practice Advisory (BPA) in EHR to prompt for screening among baby boomers Subsequent workflow for care management of newly diagnosed patients Baseline screening consisted of 3 years prior to BPA This study did NOT have reflex HCV RNA testing Subjects All baby boomers who had one visit during prior 3 years in PCP clinic 13 clinics within 30 miles of Ann Arbor, Michigan 3 month period

23 Primary Care Screening 13 Results Increased screening by 5-fold Successful linkage to care and curative treatment EHR design eliminated work flow burden placed on PCPs to remember recommendation during visit and locate previous testing

24 HCV positive-what next? 8 Provide info on HCV infection Evaluate support- behavioral health services Counsel Patients about reducing risk of transmission Do not donate blood, body organs, other tissue, or semen Do not share personal items that might have small amounts of blood (toothbrushes, razors, nailgrooming equipment, needles) and cover cuts and wounds HCV is not spread by hugging, kissing, food or water, sharing utensils, or casual contact If in short term or multiple relationships, use latex condoms. No condom use is recommended for longterm monogamous couples (risk of transmission is very low)

25 HCV positive-what next? 8 Brief alcohol usage screen and intervention Goal is reducing or discontinuing alcohol consumption Alcohol increased the development of cirrhosis in those with HCV with an odds ration of Abstinence from substances

26 HCV positive-what next? 8 Referral to specialist- Infectious Disease/Gastroenterology Coordination, labs and imaging prior to referral Insurance Coverage or financial assistance

27 HCV positive-what next? 8 Weight management Consider weight management or losing weight Counsel on following a healthy diet and staying physically active. Those with obesity and metabolic syndrome who have underlying insulin resistance are more prone to nonalcoholic fatty liver disease which can accelerate fibrosis progression in HCV.

28 HCV positive-what next? 8 Vaccination Test for HIV antibody and Hepatitis B Co-infection with Hepatitis B virus or HIV is associated with poorer prognosis Hepatitis A and B vaccine Twinrix vaccine- 3 injections If Cirrhosis: Pneumovax and flu vaccine Screening for HCC every 6 months with liver ultrasound

29 Screening and linkage to care 11 One-time testing is estimated to: identify 800,000 infections with linkage to care and treatment, avert more than 120,000 HCV-related deaths save $1.5 $7.1 billion in liver disease related costs

30 Treatment All patients with chronic HCV should be treated Goal is to reduce all cause mortality and liver associated complications

31 When and Whom to treat 16 All HCV infected individuals Best initiated early in course of disease Immediate benefit to those at highest risk of liver-related complications Accurate assessment of liver fibrosis helps to predict progression

32 Strategies to improve screening

33 Family Health Center Baby Boomer Screening N= % N=3290 baby boomers Screened

34 Family Health Center N= % N=482 Total Screened Chronic HCV

35 What populations are we currently screening? IV drug users Hx blood transfusion HIV + Long term hemodialysis Incarceration Everyone Other

36 Barriers to discussing screening N=73 Not important No prompt in EMR Unclear on current recommendations Not applicable Time constraints Never really think about it

37 Increasing screening HCV informational posters around the clinic HCV handouts available in clinic Provider education Recall letters with CDC fact sheet Cerner implementation Behavioral Health Support

38 Family Health Center screening Conducted Grand Rounds presentation regarding screening and interventions Recall letters sent to eligible non-screened patients on physician panel Physician panel pilot statistically significantly increased screening from 21% to 48% (p<.05) Electronic medical record transition did impede data requisition and monthly interval data collection.

39 FHC screening

40 Screening Recommendations Annual Testing: persons who inject drugs HIV-seropositive men who have unprotected sex with men Once obtained SVR: Without fibrosis-require no additional follow up Advanced fibrosis-hcc screening twice yearly Assessment for reoccurrence only with ongoing risk, HCV RNA

41 Resources for providers and patients

42

43 Hepatitis C Commercial

44 Conclusion HCV recognition is important It is imperative that we feel confident in counseling regarding HCV We have resources available to assist in guiding patients and ourselves through the diagnosis

45 References 1. Easterbrook PJ, Who to test and how to test for chronic hepatitis c infection WHO testing gyidance for low and middle income countries. Journal of hepatology. 2016; 65 (1) S46-S Goel A, Sanchez J, Paulino L, et al. A systemic model improves hepatitis C virus birth cohort screening in hospital based primary care. J Viral Hepatitis. 2017; Rein DB, Smith BD, Wittenborn JS, et. Al, The Cost-Effectiveness of Birth-Cohort Screening for Hepatitis C Antibody in U.S. Primary Care Settings. 4. Turner BJ, Taylor BS, Hanson JT, et al. Implementing hospital based baby boomer hepatitis c virus screening and linkage to care: strategies, results and costs. Journal of Hospital Medicine. 2015; 10 (8) Wilkins T, Akhtar M, Gititu E. Diagnosis and management of hepatitis C. American Family Physician. 2015; 91(12): Graham CS. National virus hepatitis roundtable HCV baby boomer screening and linkage to care program Ly KN, Xing J, Klevens M et al. The increasing burden of mortality from viral hepatitis in the United Statses between 1999 and Ann Intern Med. 2012; 156: (get this article through library) 8. Centers for Disease Control and Prevention MMWR. Recommendations for the identification of chronic Hepatitis C Virus infection among persons born between 1945 and Huffman MM, Mounsey AL. Hepatitis C for primary care physicians. JABFM. 2014;27 (2): Cantab AC-GBAH. Hepatitis C (HCV) testing for baby boomers: an interview with Dr. Donald Jensen, Director, Center for Liver Diseases, University of Chicago. News-Medical.net. Published August 3, Accessed November 5, Coffin PO, Reynolds A. Ending hepatitis C in the United States: the role of screening. Hepatic Medicine. 2014; 6: Morgan RL, Baack B, Smith BD, et al. Eradication of hepatitis C virus infection and the development of hepatocellular carcinoma. Annals of Internal Medicine. 2013; 158 (5): Konerman MA, Thomson M, Gray K, et al. Impact of an Electronic Health Record Alert in Primary Care on Increasing Hepatitis C Screening and Curative Treatment for Baby Boomers. Hepatology. 2017;00(00): Recommendations for the Identification of Chronic Hepatitis C Virus Infection Among Persons Born During (2012, August 17). Retrieved November 05, 2017, from Andrade LJ, D'Oliveira A, Melo RC, et al. Association Between Hepatitis C and Hepatocellular Carcinoma. Retrieved from (2009). 16. Chung, R. T., Davis, G. L., Jensen, et al (2015), Hepatitis C guidance: AASLD IDSA recommendations for testing, managing, and treating adults infected with hepatitis C virus. Hepatology, 62: doi: /hep.27950

46 Questions? Comments?