Predictive Factors for not Undergoing RNA Testing in Patients Found to Have Hepatitis C Serology and Impact of an Automatic Alert

Dalia Morales-Arraez; Ana Alonso-Larruga; Felicitas Diaz-Flores; Jose A. García Dopico; Antonia de Vera; Enrique Quintero; Manuel Hernández-Guerra


J Viral Hepat. 2019;26(9):1117-1123. 

In This Article

Abstract and Introduction


The process of diagnosis and linkage to care in cases of hepatitis C virus (HCV) infection remains an obstacle to disease control. The aims of this study were to evaluate predictive factors for not undergoing RNA testing among patients with positive HCV serology and impact of incorporating an automated electronic alert with recommendations in clinical practice. We collected HCV antibody tests requested from October 2011 to September 2014 to evaluate the rate of RNA testing and predictive factors for not undergoing RNA testing. Since October 2014, an automated alert notification has been implemented to remind physicians for testing RNA after a positive HCV test and referral to specialist care. 41 403 HCV antibody tests were requested from 34 073 patients. 870 (2.55%) patients tested positive. After a median of follow-up of 57.0 months (range 45.6-82.1), 37.6% did not have RNA testing. The independent predictors for not undergoing RNA testing were primary care serology requests (P < 0.001), no history of drug use (P = 0.005) and a lack of social support (P = 0.015). The intervention impact was evaluated in a pre-alert cohort (October 2011-September 2014) and a post-alert cohort (October 2014-September 2015). After the incorporation of the alert, the rate of RNA testing increased from 62.4% to 77.7% (P < 0.001). Incomplete assessment of HCV infection is a challenge in primary care. The implementation of an automated alert for recommending RNA testing after a positive HCV antibody test is feasible in clinical practice and increases the rate of patients with RNA testing.


Hepatitis C virus (HCV) infection is a significant global problem for public health.[1] Chronic HCV infection is associated with the development of liver cirrhosis, hepatocellular carcinoma, liver failure, and death.[2] Although a decline in the incidence and prevalence of the infection is expected in the next decades, complication rates are expected to increase in the near future.[3] The World Health Organization's staged goal of global elimination of HCV by 2030 may be jeopardized by the fact that many patients remain unaware of their infection and without treatment,[4–7] despite the availability of extremely effective antiviral regimens.[8,9]

There are well-known barriers at different levels of the HCV cascade,[10–13] which mainly occur in the process of diagnosis and referral to care. Chronic HCV infection is usually asymptomatic and thus difficult to diagnose.[14] Once the treatment issue has been resolved, recent efforts have focused on identifying undiagnosed asymptomatic subjects by different testing strategies.[15] Another important challenge to address is linking care to patients with a previous positive HCV antibody test but without full assessment and proper follow-up. There are low adherence rates to the clinical guidelines which recommend HCV RNA evaluation after positive HCV antibody tests.[16,17] This is relevant to determining the impacts of active HCV infection on decisions about potential treatment prescriptions, reducing the risks of HCV transmission and the adoption of measures to reduce liver damage, such as avoiding obesity or alcohol intake.[8]

There is lack of information about patient characteristics and predictive factors in not undergoing RNA testing, which may help to identify target populations for full assessment. In addition, effective measures are necessary to ensure adequate diagnosis and referral to specialist care. Automatic alert systems have proven to be effective increasing adherence to gastroenterology guidelines such as in the prescription of gastroprotection with the use of nonsteroidal anti-inflammatory drugs,[18] preventing the recurrence of hepatitis B virus infection with biologic agents[19] and more recently to improve HCV screening among baby boomers.[20,21]

The aims of this study were to evaluate the prevalence and characteristics of patients with a positive HCV antibody test without RNA testing and to identify predictive factors for not undergoing RNA testing. Additionally, we assessed the impact of incorporating an automated alert message into actual clinical practice on the rates of not receiving RNA testing and linkage to specialty care.