To identify baby boomers with HCV, target them in primary care settings

Targeting baby boomers in primary care settings is up to eight times more effective than usual care for identifying adults with undetected hepatitis C virus (HCV) infections, according to results of a recent study published in Hepatology.

Sending invitations by mail for HCV testing was the most effective targeting strategy, researchers found.

Baby boomers—born between 1945 and 1965—are four times as likely to be infected with HCV compared to other adult Americans. This age group accounts for 67%–76% of adult HCV infections, and up to 75% of deaths among HCV patients, according to prior studies.

To increase HCV testing and identification in this birth cohort, the Centers for Disease Control and Prevention (CDC) and the US Preventive Services Task Force recommend that everyone born during 1945–1965 receive a one-time HCV antibody test without the need for additional HCV risk assessment.

But, an estimated 50% to 80% of people with HCV aren’t aware they’re infected, so they don’t typically seek out testing or treatment.

To that end, the researchers of this study investigated whether strategies targeting baby boomers could better identify undiagnosed HCV infections in primary care settings. They studied three targeted HCV-testing strategies in different academic medical centers, including:

• Repeated mailings: The first intervention strategy included 8,992 patients born during 1945-1965 with no record of prior HCV testing or diagnosis. Patients were randomly assigned to receive repeated invitations by mail for a one-time HCV test or to receive no outreach (control arm).

The researchers found that the repeated mailing strategy was eight times as likely to identify HCV-infected patients compared with no outreach.

• Provider best-practice alert: The second strategy used a best-practice alert (BPA) for HCV antibody testing sent via electronic medical records (EMR). The BPA was first triggered when the medical assistant entered the eligible patient’s vital signs at the beginning of a primary care visit, and then automatically populated into the physician’s list of orders with a link to the appropriate HCV test order.

“Targeting the medical assistant with the BPA first was designed to address alert fatigue commonly reported in studies of EMR-embedded alerts,” wrote lead researcher and epidemiologist Anthony K. Yartel, MPH, of CDC’s Center for Global Health, Atlanta, GA, and colleagues.

This BPA strategy was tested at 10 primary care clinics and involved 14,475 eligible patients. Researchers found that the intervention was 2.6 times more likely to identify infected HCV patients than the control strategy of usual care.

• Direct patient solicitation: The third strategy involved four internal medicine clinics where 8,873 eligible patients were either invited by trained recruiters for HCV antibody testing immediately after outpatient visits or were given usual care (control arm).

This intervention was five times as likely to identify HCV-positive patients compared with usual care, the researchers reported.

“The findings from these trials demonstrate that, overall, targeted birth cohort testing was 2.6 to 8 times as effective in identifying persons with previous or current HCV infection compared with usual care,” wrote Yartel and colleagues.

“The findings also demonstrate that [birth cohort] testing in primary care is feasible and amenable to a variety of implementation strategies, although implementation costs would likely vary by strategy and need to be considered,” they concluded.

Of the three strategies, “the BPA trial was arguably the most pragmatic trial—in that BC testing was fully integrated into routine care,” the authors noted.