By Permanente Medical Staff
Spread through contaminated blood, the hepatitis C virus (HCV) is most commonly associated with intravenous drug abuse, and the incidence among young people has been increasing along with the opioid epidemic. Also, an increasing mode of transmission is among men who have sex with men having unprotected sex.
However, the largest burden falls on Baby Boomers. Many people are surprised to learn that 75 percent of people infected with HCV are people born between 1945 and 1965. Many of these individuals may have become infected through contaminated blood or blood products prior to 1992 when tests to screen the blood supply were developed, through medical equipment or procedures used at that time (before infection control practices were put in place), or through other means. Many people don’t know how they were infected.
So, when the CDC in 2012 and the U.S. Preventive Services Task Force in 2013 both came out with recommendations that all Baby Boomers have a one-time screening for the virus, scientists at Kaiser Permanente’s Mid-Atlantic Permanente Research Institute (MAPRI) joined physicians and leaders at the Mid-Atlantic Permanente Medical Group (MAPMG) to create a new Hepatitis C (HCV) Care Pathway to make sure infected patients didn’t fall through the cracks.
“There were a number of reasons it made especially good sense to do this at the time,” says M. Cabell Jonas, PhD, who as Executive Consultant of Strategic Program Design and Implementation for MAPMG has taken a lead in coordinating and implementing the new pathway.
First was the availability of new treatments. MAPRI epidemiologist Carla Rodriguez, PhD, whose research focus is infectious disease and who led the evaluation of the HCV care pathway, explains that “an exciting new generation of drugs was replacing older treatments that had many side effects, had to be taken over a long period of time, usually as injections, and were effective only about half the time. The new drugs have an amazing 95 percent cure rate and are much easier to take. Most patients are cured in 12 weeks.”
Plus, there was a great new diagnostic tool. “New technology simplified how liver damage is assessed,” Dr. Jonas says. “If blood tests indicate that you have an active HCV infection, the next step is to examine the liver for damage. Before, the main way to check for liver damage was by doing a liver biopsy, an invasive procedure that uses a large needle to collect a sample of liver tissue. Now we have the Fibroscan® (hepatic transient elastography), a non-invasive test that uses a small external probe to assesses your liver health (specifically liver stiffness) in about 15 minutes. Patients love it. So, we were very eager to get patients screened and diagnosed.”
As part of Kaiser Permanente’s integrated and data-driven health system, MAPRI’s scientists research and refine treatments and techniques to better help today’s patients recover and manage their health in the future. A new HCV care pathway fit this mission perfectly.
“One of our great strengths here at Kaiser Permanente is that we’ve been longtime adopters of the electronic health record, so we have a goldmine of information that we leverage to conduct research and program evaluation that informs best practices to improve patient health,” Dr. Rodriguez says.
The team launched the new care pathway to address the screening issue in 2014, and it has been extraordinarily successful. Overall HCV screening has doubled since the implementation of the pathway and increased almost seven-fold in Baby Boomers. The pathway has been named a best practice for hepatitis care by the World Health Organization. It includes:
- Automated alerts using a computer algorithm that searches MAPMG’s electronic health record and reminds physicians that their Baby Boomer patients are candidates for screening.
- A streamlined blood testing process. Patients no longer need to return for a second blood draw to confirm a HCV diagnosis. Patients provide two samples at the time of initial HCV screening. If the antibody screen is positive, the lab automatically runs a confirmatory HCV RNA test on the remaining sample, as well as ancillary screening for HIV and the hepatitis B virus.
- Use of the noninvasive Fibroscan by trained technicians to check for liver damage.
- Trained patient coordinators with extensive experience with the virus who call patients to inform them of their status, take time to reassure them and answer questions, schedule appointments, connect them with appropriate physicians, and remind them of follow-up testing and treatment.
“One of the most interesting issues we had, and it’s a testament to the quality of our doctors, is that they were very reluctant, at first, to delegate responsibility to the coordinators,” says Dr. Jonas. “But once each doctor had a couple of patients go through the process and saw how well the coordinators were doing their jobs, they loved it. It optimizes the time our doctors have with their patients.”
The care pathway has been so successful in terms of patient screening, patient compliance with all the necessary follow-up testing, and patient satisfaction, that Dr. Jonas, Dr. Rodriguez, and other team members are looking forward to expanding this streamlined and automated approach to treatment. They also plan to expand the existing pathway to include other HCV risk groups and hope to apply it to other underdiagnosed diseases. They have already launched a similar pathway for hepatitis B and liver cancer surveillance.
“It’s important that we stop the spread of disease,” Dr. Jonas says. “This pathway model can be used for many different diseases to improve care for many populations – ensuring patients get the care they need.”
Find out more about the work of the Mid-Atlantic Permanente Research Institute by visiting the MAPRI website.