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

Disclosures

J Viral Hepat. 2020;27(7):680-689. 

In This Article

Discussion

Our evaluation provides insight into guideline implementation in large healthcare systems, even as guidelines ostensibly simplify recommendations and processes of care. Despite engagement with institutional leadership that resulted in fivefold increases in screening and treatment capacity,[3] clinic providers and patients identified continued barriers to HCV screening and linkage to care in clinical practice. For example, provider interviews revealed ongoing need for education to inform providers about coverage for HCV treatment cost during conversations with patients about HCV screening. Patient survey data demonstrated knowledge increases as patients progressed through the screening continuum and suboptimal knowledge may play a larger role in HCV screening than linkage to care and treatment uptake. However, interview data suggested a continued need to address persistent misconceptions about HCV treatment cost and efficacy in all patient groups.

Additionally, while our survey data did not indicate statistically significant differences across patient cohorts, our patient interview data suggest that stigma may still play a role in deterring individuals from being screened or treated. Thus, while shifting HCV screening from risk-based profiling to a population health approach based on birth cohort may decrease disease-associated stigma, some interviewed patients still associated HCV with risk-taking groups, such as intravenous drug users. If future screening guidelines recommend extending HCV screening to all adults, not just 'baby boomers', it is possible that the influence of HCV-related stigma may diminish over time. Alternatively, it is possible stigma may increase in the future with increasing attention being paid to the opioid epidemic and associated increase in acute HCV infections.

Our evaluation builds on prior studies examining HCV screening and linkage-to-care interventions. Like other highly successful interventions, our intervention effectively integrated screening into routine primary care practice[10] and utilized a multi-component programmatic approach that included clinician and staff education, EHR algorithms for eligibility and order entry to serve a hard-to-reach safety-net population.[11] Prior literature suggests that more modest designs that emphasize EHR-based tools can also achieve remarkable increases in screening and linkage to care.[12–14] However, additional evidence-based interventions such as reflex RNA testing among patients with positive antibody results, patient navigation[15] and case management[16] may further enhance HCV screening and linkage to care.

Our empirical findings reinforce a recently published roundtable outlining directions for future HCV intervention enhancements.[17] For example, patients need greater assurance that currently available treatments have dramatically increased the likelihood of being cured. Additional support for emotional and social challenges need to be provided such as assisting low-income older adults with more comorbidities and/or barriers in access to care.[16] Similarly, continued knowledge gaps among patients, particularly those earlier in the screening process, highlight an opportunity for better patient education when interfacing with primary care providers. It is possible that lowering barriers to HCV clinic referral may have had the unintended consequence of lowering primary care provider education of patients, instead deferring this responsibility to HCV clinic providers. Thus, our findings offer insights to inform improved performance from diagnosis to cure.

Recent changes in hepatitis C screening and therapy have created a paradigm shift in healthcare delivery. Instead of focusing on limitations of biomedical barriers, such as treatment eligibility, efforts to enhance care have shifted towards service delivery barriers, including underuse of screening to identify infected individuals. This shift requires health systems to optimize screening-to-treatment workflows, which can be particularly challenging for resource-limited systems that serve high-prevalence, but complex, difficult-to-reach patient populations. Limited clinician time for preventive care amid more urgent competing clinical demands requires additional strategies to facilitate systematic screening. For example, outreach invitations have been used in colon cancer and hepatocellular cancer screening but have yet to be evaluated for HCV screening and linkage to care.[18,19] Based on our evaluation findings, we are adopting the following new strategies to enhance effectiveness of the original intervention: (a) use of mailed outreach strategies to identify and better educate at-risk patients who have not undergone HCV screening and refer them for screening; (b) posting flyers and other print materials emphasizing availability of low- or no-cost HCV treatment options, including tolerability and high likelihood of cure; and (c) enlisting nurses in primary care clinics to pend orders during intake for patients with incomplete HCV screening results (eg antibody-reactive result with no confirmatory HCV test). We have initiated additional studies to evaluate effectiveness of these strategies.

Our results must be considered within the context of the limitations of our study design. We evaluated an HCV intervention in a single integrated system; however, our multi-modal approach is likely to be relevant to other care settings undertaking screening and treatment evaluation, especially those seeking to care for underserved patient populations. In addition, with respect to our findings, we acknowledge the association between knowledge and screening completion may be driven by reverse causation; in other words, patients who attended Hepatology Clinic likely received additional education at that time. Our recruitment of physician and staff subjects relied on volunteer participation for interviews, and thus results may be biased by those who may have had stronger feelings about the intervention. Finally, we had a limited number of interview participants, although our sample size is typical for qualitative studies and the consistency of participants' comments indicated thematic saturation.

In conclusion, we identified important opportunities for quality improvement to enhance the implementation of a multi-level practice change initiative to improve HCV screening and linkage to care. Patients and providers in our evaluation identified several persistent barriers despite our having implemented a multi-component intervention to advance HCV screening and treatment. Clinicians still struggled with addressing screening in the context of competing clinical concerns and highlighted opportunities for further education and/or audit-and-feedback interventions.[20] Identifying these barriers informed new strategies to enhance the effectiveness of our HCV intervention in the future. Our study highlights the importance of systematic stakeholder engagement and iterative intervention refinement to optimize adoption and change in clinical practice.

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