Handling HCV in the hospital

Background

During residency and then a fellowship in infectious disease, Madeline McCrary, MD, observed that the typical hospital protocols for HCV testing just didn't make sense. “We were universally screening patients admitted for injection-related infections for hepatitis C, and then effectively not doing anything about it,” she said. Patients who tested positive were given referrals to infectious disease or hepatology at discharge or told to follow up with their primary care physicians. “In reality, that just never happened,” she said.

Some of these patients with serious infections were in the hospital so long they could have completed the full HCV medication regimen. “We would have patients in the hospital for six weeks for things like endocarditis and osteomyelitis. … They're there for potentially an entire treatment course,” said Dr. McCrary. She and fellow infectious disease (ID) specialists at UNC got together with the addiction consult team and decided to do something about these missed opportunities for treatment.

How it works

Initially, the collaboration involved an ID fellow and attending and an addiction medicine social worker getting patients fully prepared for outpatient treatment of HCV. The social workers would talk to patients who tested positive about treatment and then set up an e-consult, in which an ID physician reviewed labs, imaging, and medications; assessed the patients' eligibility for treatment; and recommended testing and vaccinations. The patients didn't actually start the medications until a postdischarge visit, which could be completed via telehealth.

That last step proved to be a barrier. “We were noticing that even though we started this e-consult model, we were having a big dropoff in being able to get people started in the outpatient setting, and it was very challenging to get medications actually in hand,” said Dr. McCrary, who is now an assistant professor in the division of infectious diseases at Washington University School of Medicine in St. Louis.

To find a solution, the team talked to other hospital clinicians who prescribed expensive specialty medications to inpatients. “If you do it for one population, you should be able to do it for another,” said Dr. McCrary. Based on these conversations, the team integrated an outpatient specialty pharmacy into their process and also began handling the logistics of getting drugs covered by manufacturers' assistance programs for uninsured patients.

Results

In the first year of the program, 28 patients with HCV were enrolled. All of them expressed interest in treatment and received e-consults. Eleven then started medication for HCV during their inpatient stay, and eight began treatment as outpatients; nine patients were lost to follow-up or transferred care. Overall, 13 patients completed their treatment regimen and 12 were found to have sustained virologic response (SVR), according to results published by the Journal of General Internal Medicine on Aug. 31.

“We were really impressed,” said Dr. McCrary. “We didn't anticipate keeping people in care long enough to get SVR 12, which is 12 weeks after finishing treatment—the accepted, formal hepatitis C cure.”

Anecdotally, hepatitis C treatment seemed to provide other health benefits, she added. “There's a bond that forms,” Dr. McCrary said. “Patients just continued to stay engaged in care, and we feel that helps prevent future infections.”

Challenges

Seven patients were lost to follow-up before starting treatment, and another four were lost after they began treatment. More than half of the lost patients did not have phones. “Lack of cellphones or the lack of reliable cellphone access … if we weren't able to get the full course in hand by the time they left the hospital, that was a major challenge in getting people their medication,” said Dr. McCrary. “Something that we didn't achieve was getting dedicated care navigation for patients.”

Next steps

More care navigation and expansion to other services are two potential areas of growth for the program. All of the initial patients were those seen by the addiction medicine consult service, but the model can be applied elsewhere, including on hospital medicine services. “I was working a lot with a hospitalist at the time, and there are also hospitalist patients that have hepatitis C … getting tested and not really linked to care,” said Dr. McCrary. UNC expanded the e-consult model to hospital medicine patients, although she noted that they are less likely to get all the way to HCV treatment initiation as inpatients.

“People on the hospitalist side tend to have much shorter lengths of stay,” Dr. McCrary said. “But they're also more likely, at least in our state, to be insured, so that was something that was a little bit easier than expected.” Other populations to target for inpatient HCV care could include trauma and burn patients. “There's other populations that could potentially benefit from this type of intervention, if we knew where those higher-incidence populations were,” said Dr. McCrary.

Lessons learned

The project shows that when you're trying to fix a problem in the hospital, it's worth looking around for existing models that can potentially be adapted. “When I presented this at ID Week, a lot of people were surprised that we could get patients started on these drugs in the hospital, and we didn't think that it was possible either until we saw that it was done with other medications and other patients,” she said. “It's just a matter of talking to the right people, making those connections, and figuring out how to do it.”

Words of wisdom

“Hepatitis C is an easily curable infection,” said Dr. McCrary. “We really should be thinking about it as an inpatient problem, especially if we're going to be testing people for it. … A lot of folks that don't have their hepatitis C treated right now, it's because they don't have access to treatment on the outpatient side, so reframing hep C as an inpatient problem could really help us address and meet the [World Health Organization] 2030 target of hep C elimination.”