Patient and Provider-level Barriers to Hepatitis C Screening and Linkage to Care

A Mixed-methods Evaluation

Robin T. Higashi; Mamta K. Jain; Lisa Quirk; Nicole E. Rich; Akbar K. Waljee; Barbara J. Turner; Simon Craddock Lee; Amit G. Singal


J Viral Hepat. 2020;27(7):680-689. 

In This Article


Changes in recommendations for guideline-based care are common in the current era of rapidly changing scientific discovery. However, achieving practice change in response to shifting guidelines can be arduous, particularly in large, integrated healthcare systems.[1] In 2013, the US Preventive Services Task Force recommended one-time screening for hepatitis C (HCV) infection for all adults born between 1945 and 1965, thereby simplifying screening from a risk-based approach to a population-based strategy in this age group.[2] This recommendation coincided with the advent of direct-acting antiviral (DAA) treatment that substantially increased treatment eligibility, tolerability and effectiveness. Although a shift from risk-based to population-based screening may seem straightforward, it can be difficult to achieve because it requires providers to move from a paradigm of screening and treating a few patients to screening and treating many.

In response to the change in guidelines, Parkland Health and Hospital System (Parkland), Dallas County's safety-net health system, developed a multi-level HCV screening process intervention to promote HCV screening and linkage to care (hereafter referred to as 'the HCV intervention'). The HCV intervention comprised three parts. First, system-level changes included creation of an HCV registry within the Epic electronic health record (EHR) with a best practice alert (BPA) highlighting the need for HCV screening among patients born between 1945 and 1965 who are HCV screen-naïve, a streamlined referral process, and expansion of the HCV Treatment Clinic that increased capacity fivefold. Second, hepatology and infectious disease specialists performed provider-level education through in-clinic forums for primary care providers (PCPs) and staff. Finally, we conducted patient-level telephone outreach and navigation for linkage-to-treatment evaluation.[3] The intervention was developed following stakeholder engagement with the Medical Directors of the adult ambulatory care, primary care and hepatology clinics, in consultation with the Parkland Chief Executive Officer and Chief Medical Officer.

The purpose of this paper was to describe a mixed-method, multi-modal evaluation of the evidence-based HCV intervention. We have previously reported both screening and linkage-to-care significantly increased after the HCV intervention was implemented; however, over two-thirds of patients still failed to undergo HCV screening and one-third with confirmed HCV infection were not linked to treatment evaluation, suggesting continued barriers to guideline implementation in clinical practice.[3] Herein, we sought patient and provider experiences to identify ongoing barriers to adoption and implementation processes at the system-, provider- and patient-level across the HCV screening and treatment evaluation continuum.