Hepatitis C Virus Infection Screening Within Community Health Centers

Methods

Results

In a CHC population of 60,772 eligible patients, 5033 (8.3%) had an HCV infection screen. Of 5033 patients, 2450 women (48.7%) and 2583 men (51.3%) were screened (Table 1; 6.5% vs 11.1%, respectively; P≤.01). Between both sexes, patients categorized as Caribbean Islanders or Haitian or other had a significantly lower predicted probability of being screened (Table 2; P<.01). Conversely, black Hispanics, white non-Hispanics, and black non-Hispanics had the highest predicted probability of being screened (P<.01). Results from the final model also indicate that as a patient’s age increased by 1 year, the probability of being screened decreased by 4.2% (95% CI, 3.9-5.2). Model parameter estimates (Table 3) indicated that black Hispanic patients were 1.73 times more likely to be screened than white Hispanic patients (95% CI, 1.26-2.20) and that men were 1.79 times more likely to be screened than women (95% CI, 1.30-2.47). The probability of screening was found to differ by age, race/ethnicity, and sex.

Discussion

To our knowledge, the present study is the first large-scale multistate study assessing the gap in HCV infection screening among a CHC patient population in accordance with current USPSTF birth cohort screening guidelines for HCV infection, in addition to identifying screening gaps by demographic characteristics. Overall, the low screening rates suggest that less than 9% of all patients were screened. This finding is important because it highlights the need to improve HCV infection screening among patients receiving care in CHCs, the nation’s primary care safety net. In addition, the present study highlights that some populations, including blacks and men, are more likely to be screened than other race/ethnic groups or women. These populations are more likely to be screened possibly because of provider bias in terms of offering the screening test or the unwillingness of certain races/ethnicities or sexes to be screened.⁹ Other reasons may include knowledge regarding HCV infection screening (eg, use of a USPSTF-recommended HCV antibody test vs other laboratory tests) and the cost of screening.

Fostering discussions on how to improve HCV infection screening rates, particularly among underserved populations, is important for future cost savings^11-13 and optimal patient care. Early identification of infected patients allows for earlier treatment, thereby potentially reducing costly health care expenses associated with advanced disease.¹⁴

Numerous opportunities exist for increasing HCV infection screening in primary care. Educating health care professionals on the new USPSTF birth cohort screening guidelines is vital to support adherence of screening practices. Education regarding new treatment options and referrals to appropriate health care for patients with HCV infection is also necessary to ensure that the overall screening program is cost-effective and will contribute to decreasing disease prevalence. New opportunities for integrating point-of-care reminders supported by EHR implementations have also shown promise in improving screening rates.¹⁵ Similarly, incorporating HCV infection screening into national policies and accreditation requirements that are designed to improve patient health outcomes, such as the Healthcare Effectiveness Data and Information Set and meaningful use, can also help to establish clinical practice guidelines for early detection and treatment.¹⁶

Limitations

A number of reasons exist for low screening rates that are suggested in the literature but were not assessed directly in this study.

Limited awareness of USPSTF birth cohort screening guidelines for HCV infection, prioritization of birth cohort HCV infection screening vs screening on the basis of specific risk factors such as injection drug use, communication barriers, and limited treatment options for low-income patients are some of the limiting factors.¹³ Other limitations of this study include possible misclassification bias of patients who received screening outside the CHC that was either not reported in their CHC EHR or was captured in the EHR in a field not extracted for this study (eg, using a free-text note), which would result in higher screening rates among the population than reported in the current study.

The CHCs included in this study were all early adopters of EHR systems. Although EHRs have been shown to be a valuable tool for conducting surveillance among underserved populations and hold promise for ongoing study among underserved patients who are typically underrepresented in research, data quality is an ongoing improvement initiative.¹⁷ Misclassification bias may have been introduced by patients who were classified as not having been screened but who received screening before the 3-year “look-back” period used in the current study or among patients with previous diagnosis of and treatment for HCV infection. Although initiatives to improve interoperability of EHR data are still in their infancy, health care professionals can help to reduce misclassification bias and support understanding of HCV infection screening and the effectiveness of treatment modalities in future studies.

Another limitation of the current study is that it sought to determine HCV infection screening among all patients who had a primary care visit from January 1, 2013, to December 31, 2013, according to the new USPSTF birth cohort screening guidelines for HCV infection, which were released in June 2013. Before the USPSTF guidelines, high-risk populations were eligible for screening. Therefore, most patients included in the current study who were seen before June 2013 were not recommended for screening according to the USPSTF guidelines in place at that time. Although changes in screening practices may have been notable after the release of the USPSTF birth cohort screening guidelines, we could not assess HCV infection screening rates separately before and after the USPSTF guidelines change because of the timeframe of the study. Future studies should take this point into consideration and, in addition to understanding the screening gap, should assess the change in screening practices as a result of the 2013 USPSTF birth cohort screening guidelines.

Conclusion

The present study demonstrated that opportunities exist to promote implementation of the current USPSTF birth cohort screening guidelines and improve overall HCV infection screening rates across the CHC population. Strategies are needed to improve screening and treatment, particularly for underserved patients. Further research should include identifying and assessing testing strategies to improve screening in primary care, as well as understanding barriers to implementation of USPSTF birth cohort screening guidelines for HCV infection. As CHCs are the frontline of primary care for populations that may be at increased risk of HCV infection, improving screening rates in CHCs can support earlier treatment for patients with HCV infection, which can contribute to reducing the burden of morbidity and mortality caused by the disease.