From the Journals

Targeted strategies better for birth cohort HCV testing



Targeted birth cohort testing for the hepatitis C virus is effective at identifying infections in primary care, particularly if a strategy of repeated mailings is used to reach out to patients about testing, according to new research.

Writing in the Sept. 23 online edition of Hepatology, researchers reported the results of three independent, randomized, controlled trials in three large academic primary care medical centers, each of which compared a different method of testing the 1945-1965 birth cohort – as recommended by the Centers for Disease Control and Prevention and U.S. Preventive Services Task Force – with usual care (2017. doi: 10.1002/hep.29548).

The first center randomized 9,000 patients, who were born during 1945-1965 and had no record of prior hepatitis C virus (HCV) testing or diagnosis, to receive either repeated-mailing invitations for a one-time hepatitis C testing or the routine testing practice that has been in place around the release of the birth cohort testing guidelines.

The results revealed a significant, eightfold greater likelihood of diagnosing hepatitis C in the intervention arm, compared with the control arm, with a 0.27% adjusted probability of a positive test in the intervention arm, compared with a 0.03% probability in the control arm.

The second center investigated a strategy of electronic medical record–integrated “Best Practice Alerts” that first targeted the medical assistant and then automatically implemented an order for testing to be included in the physician’s list of orders, including information about birth cohort testing recommendations.

“Targeting the medical assistant with the BPA first was designed to address alert fatigue commonly reported in studies of EMR-embedded alerts,” wrote Anthony K. Yartel, MPH, from the Centers for Disease Control and Prevention and his coauthors in their report about these studies.

This cluster-randomized trial, which included 14,475 eligible patients, found the intervention was 2.6 times more likely to identify patients with anti-HCV antibodies, compared with a control approach of usual care (95% confidence interval, 1.1-6.4). The adjusted probability of picking up a positive infection was 0.29% in the intervention arm compared to 0.11% in the usual care arm.

In the third center, 8,873 patients across four clinics participated in a cluster-randomized, cluster-crossover trial that compared a strategy of direct solicitation of eligible patients after an outpatient visit with a control strategy of usual care.

This approach achieved a fivefold higher rate of hepatitis C diagnoses than the control arm (95% CI, 2.3-12.3). The adjusted probability of a diagnosis was 0.68% in the intervention arm and 0.13% in the usual care arm.

“A key rationale for BC [birth cohort] testing is the premise that usual care is ineffective in identifying HCV infections since nearly half of adults (including those born in 1945-1965) do not report exposure to risk factors,” the authors wrote. “Our results are consistent with this rationale and bolster current public health recommendations for targeted HCV testing among persons born during 1945-1965.”

This study was funded by the CDC Foundation. No conflicts of interest were declared.

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