Curing hepatitis C virus (HCV) has become remarkably simple, but the drugs can only work their magic when patients with the infection are diagnosed. And that's where hospitalists come in.
“We have this unique ability to eliminate a virus. I think the whole world now knows how difficult that is with SARS-CoV-2. For HCV, we have oral medications with very few side effects,” said Jeffrey Lazarus, PhD, who researches health systems and infectious diseases. “Now we're in a situation where we really want to find everyone and treat and cure them, and hospitals would make an obvious place to eliminate hepatitis C.”
Dr. Lazarus, an associate professor at ISGlobal and the University of Barcelona, Spain, formalized this call to action in “Ten Steps to Eliminating Hepatitis C in Hospitals,” published by Nature Reviews Gastroenterology & Hepatology on June 23, 2022. He and his coauthors noted that only 12 high-income countries (the U.S. not among them) are on track to meet the World Health Organization's goal of eliminating HCV as a public health threat by 2030.
That's why gaining the participation of hospitals and hospitalists is so critical, according to experts. “It's not a question of ‘Why should we screen in inpatient environments?’ It's a question of ‘Where can we screen effectively?’” said Cody A. Chastain, MD, FACP, an infectious diseases subspecialist and assistant professor of medicine at Vanderbilt University Medical Center in Nashville, Tenn.
Dr. Chastain has studied the effects of screening patients for HCV in hospitals, EDs, and clinics in Southern Appalachia. Screening found antibodies to HCV in 8.5% of 195,152 patients in 2017 to 2019, according to results published in the Journal of the American College of Emergency Physicians Open in October 2022.
That adds up to a lot of candidates for treatment passing through hospitals' doors, even if HCV doesn't typically fall under hospitalists' purview.
“As a former hospitalist, I recognize that there are many, many acute medical issues that must be addressed in the inpatient environment. I also recognize that there are many medical conditions that are best cared for in the outpatient setting. That being said, making a diagnosis of hepatitis C can really dramatically change the arc of someone's long-term health,” said Dr. Chastain.
Populations to screen
The U.S. Preventive Services Task Force (USPSTF) expanded its recommendation on which people to screen for HCV in March 2020 (perhaps not the best time to gain hospitalists' attention). The Task Force newly recommended that every adult be screened at least once, in contrast to its 2013 guidance, which called for screening those born between 1945 and 1965 as well as anyone with a risk factor.
The new recommendation is supported by the trends on the front lines of care, according to Cara Varley, MD, MPH, an infectious diseases subspecialist and assistant professor at Oregon Health & Science University (OHSU) in Portland. “Most of the cases we're seeing now are occurring in those under 30 years,” she said.
These newly diagnosed young patients commonly have a history of injection drug use, which is a significant enough risk factor for HCV that her program aims for screening more than once a year in patients who use injection drugs, she noted.
Screening patients with risk factors is important, but it has not proven to be sufficient, the experts said. “Historically, risk factor-based screening has not performed adequately,” said Dr. Chastain. “Universal screening is effective, because it doesn't require a provider or a system to recall why a specific person may or may not qualify for screening.”
Universal screening in hospitals could also reach patients who are reluctant to discuss their HCV risk factors with clinicians. “There's really significant stigma, especially in health care settings, experienced by this population, which may reduce their likelihood of seeking health care. Often their only interaction with the health care system is when they're sick enough to be admitted,” said Dr. Varley.
Given these factors and the USPSTF's recommendation, some states have mandated that hospitals screen for HCV. For example, in 2016, Pennsylvania enacted a law requiring that anyone born between 1945 and 1965 be screened as part of inpatient or outpatient care.
In response, Penn Medicine in Philadelphia tried to implement screening, by adding an alert in its electronic health record (EHR) that recommended clinicians order an HCV test.
“We found there was limited uptake of this original best practice alert,” said Shivan J. Mehta, MD, MBA, MSHP, a gastroenterologist, an associate professor of medicine, and associate chief innovation officer at Penn Medicine. “We decided to shift it from an opt-in approach to an opt-out approach to ordering, because hepatitis C screening is a very inexpensive and easy-to-administer test.”
In 2020, two hospitals in the system had an order for HCV screening embedded within their admission order sets for all patients born from 1945 to 1965. (The study was designed before the USPSTF recommendation changed.) Once that was done, screening rates in this population rose from 38.1% to 69.9%, according to a study Dr. Mehta and colleagues published in JAMA Network Open on March 17, 2022.
“Most patients that are going into the hospital, especially at the beginning, are getting routine labs in the morning, and to just bundle this together so it was not even an extra lab draw made it very easy for the clinician and patient,” said Dr. Mehta.
“There are a lot of hospitals that are starting to do this,” said Dr. Varley. It can be helpful to put some notes in the EHR explaining the nuances of HCV testing for clinicians who are unfamiliar, she added.
Specifically, they need to know that antibody testing comes first, that if positive it's followed by testing for HCV RNA, and that the two are often combined under a protocol called reflex testing. (If a patient has been treated for HCV or cleared HCV on their own, the antibody will remain positive, thus those with ongoing risk for infection should undergo continued screening by RNA, Dr. Varley noted.)
“In the old days, which is just a few years ago, you would get another sample from the patient, and everything that entails—they give you blood again, you send it to the lab again, they test it again,” explained Dr. Lazarus. “Now, if it tests positive for the antibody, they can just test it right away for RNA. In the case of hepatitis C, it's incredibly simple to retest the blood.”
Another process issue for screening programs is determining when during a patient's stay to test. Hospitals that have integrated HCV screening into routine practice have typically made it part of admission or discharge, and the former usually works better, the experts said.
“Because discharge is often a process that requires efficiency and timeliness, most programs that have implemented hepatitis C screening effectively complete screening on the front end, which allows inpatient providers enough time to receive the results and to execute the most important part of the entire screening process, which is linkage to care,” said Dr. Chastain.
Next steps after diagnosis
Connecting patients with treatment for HCV is also often the most challenging part of the process.
“The inpatient environment is rarely where hepatitis C is going to be directly addressed,” said Dr. Chastain. “Linkage to care may differ quite a bit for different patient populations. It may differ based on payer status. It may differ based on where an individual is from.”
His study found that only about half of the patients diagnosed with HCV in a hospital were successfully connected to treatment: 44.1% of those with positive tests in the ED and 50.9% of those testing positive on inpatient units, compared to 67.6% of those who received their test in an outpatient clinic and 93.2% of those tested in a federally qualified health center, where treatment is typically provided on site.
Referral rates were even lower in a small study by Dr. Varley and colleagues that focused on screening patients with substance use disorders admitted for severe bacterial infections. Only 34.6% of patients who tested positive were referred for HCV treatment or follow-up, and most were advised to follow up with a primary care doctor (which they largely did not have), according to results published by Therapeutic Advances in Infectious Disease on Oct. 17, 2022.
The solution is to have a pre-established pathway that involves a team, according to Dr. Chastain. “That testing result can be routed back to the [hospitalist] for disclosure of the diagnosis, but the process can involve another individual, whether it be a nurse, a case manager, or another health care professional,” he said. “A lot of times, it is a nurse, case manager, or linkage coordinator that actually facilitates the connection between a patient and resources in the outpatient environment.”
Hospital medicine programs already successfully link patients to many other kinds of outpatient care, noted Dr. Mehta. “To say, ‘This is the clinic that you should go to [for] follow-up for hep C screening’ and to make sure that they can get an appointment isn't that different from all the other follow-up appointments patients need to have,” he said.
In some parts of Spain, patients diagnosed in the hospital can start treatment with a telemedicine visit after discharge, said Dr. Lazarus. “We don't even have to always see them in person. We just need to know that they have a positive confirmatory test, and we can prescribe the pills for them. There's very few side effects, very few contraindications.”
Another method that's being piloted in some places is to prescribe HCV medications to patients while they're still in the hospital. “When we ask them, ‘Hey, do you want your hepatitis C treated?’ there's very few that say no,” said Dr. Varley. “So we've been able to do this successfully a couple of times at OHSU. Our dedicated ID pharmacists have been critical to this success, but drug costs and prior authorizations remain a pretty big barrier.” A grant-funded pilot program has helped facilitate inpatient therapy and removed some structural barriers to HCV care, she noted.
Costs are a barrier to both screening and treatment for hospitals, despite the potential cost savings (and patient benefits) of preventing the complications of HCV, the experts said.
“Hepatitis C screening and treatment ultimately may save money for the health care system as a whole, but little revenue is generated for the inpatient environment,” said Dr. Chastain. “From my observation, the places that have been most successful in doing this are closed systems [where inpatient and outpatient care are provided by the same organization].”
But that doesn't mean you have to reorganize your health system before it's worth testing patients for HCV, he added. “A diagnosis of hepatitis C can still lead to dramatic behavioral changes now, as well as health care delivery in the future,” Dr. Chastain said. Even patients who don't immediately begin treatment might reduce their consumption of alcohol or drugs or take precautions to avoid spreading the virus.
“In addition, we also recognize that in the United States, whether someone can access health care depends on a variety of factors—age, pregnancy, employment. … Equipping patients with information about their health puts them in the best position to succeed in the future,” he said.