Barbara J Turner MD, MSED, MA, MACP Senior Advisor, Gehr Family Center for Health Systems Science Professor of Clinical Medicine Keck School of Medicine, USC

HCV Guidelines Difficult to Implement in Low Income Populations Without Enhanced Infrastructure and Funding

MedicalResearch.com Interview with:

Barbara J Turner MD, MSED, MA, MACP Senior Advisor, Gehr Family Center for Health Systems Science Professor of Clinical Medicine Keck School of Medicine, USC

Dr. Turner

Barbara J Turner MD, MSED, MA, MACP
Senior Advisor, Gehr Family Center for Health Systems Science
Professor of Clinical Medicine
Keck School of Medicine, USC 

MedicalResearch.com: What is the background for this study?

Response: Chronic hepatitis C (HCV) infection affects millions of persons in the United States but especially minorities and persons from low income communities. Current national guidelines recommend testing all baby boomers (born 1945 – 65) for HCV with the aim of ultimately curing those with chronic HCV infection with a short course of highly effective medication.  However implementation of these guidelines faces many hurdles in “safety net” practices serving vulnerable populations.

MedicalResearch.com: What are the main findings? 

Response: This study demonstrates significant variation across safety net primary care practices in conducting HCV screening and management of chronic HCV infection despite our team offering an extensive infrastructure to support practices through this process. Some practices had limited adoption of this infrastructure due to barriers both within the practice and outside of practice control whereas others with greater infrastructure support were able to achieve much more satisfactory outcomes. This study offers evidence regarding the difficulty of operationalizing national guidelines without substantial public policy and payment systems that support the full continuum of care for low income and even uninsured patients.

MedicalResearch.com: What should readers take away from your report?

Response: The United States Preventive Services Task Force is now considering updating their HCV screening guideline to test all adults 18 to 79.  Given our research and others that have shown implementation of baby boomer HCV screening guidelines has been limited at best, especially in practices that serve the higher risk populations, it will be an even more significant challenge to implement these recommendations. One of the saving graces of the baby boomer screening guidelines is that many baby boomers are eligible for Medicare that will cover testing and treatment for most. In many states, Medicaid has highly restrictive guidelines regarding which patients with chronic HCV can receive medication to treat the HCV infection.  In states with large proportions of low income residents who are uninsured due to the states’ refusal to participate in the Affordable Care Act, these patients will not have testing covered, which can total hundreds of dollars for the patients to pay.  Fortunately, uninsured low income patients can access treatment for HCV through pharmaceutical assistance programs. Nonetheless this is a fragile infrastructure that is unlikely to achieve the goals of diagnosing and treating chronic HCV infection in all adults even though we know that HCV is increasingly being spread among younger age groups

Safety net practices as well as other primary care practices that serve low income populations need to have extensive infrastructure support such modification of the electronic medical record to support screening and follow-up, as laboratories that offer an reflex test for HCV RNA, coverage for community health workers educate patients with chronic HCV and to help navigate through the healthcare, and primary care clinician access to specialists who can remotely advise about managing and treating chronic HCV on site.

One option is to have practices receive incentive payments to develop a system for HCV screening and management as well as incentives for subsequent high performance of screening and cure of chronic HCV infection.  A special fund could be set aside such that uninsured individuals can be tested and managed if they have chronic HCV infection.

Without these measures, the opioid epidemic has shown that HCV can again be transmitted readily in the population after years of declining prevalence. In addition to guidelines for screening, we need to focus on developing the infrastructure to eradicate this treatable infection that causes many thousands of deaths annually in the United States through chronic liver disease and its complications.

No disclosures

Citation:

3 DECEMBER 2019

Hepatitis C Virus Screening and Care: Complexity of Implementation in Primary Care Practices Serving Disadvantaged Populations

Barbara J. Turner, MD, MSEd; Andrea Rochat, MFA; Sarah Lill, MAM; Raudel Bobadilla, BS; Ludivina Hernandez; Aro Choi, MS; Juan A. Guerrero, MD
Published:Ann Intern Med. 2019.

DOI:10.7326/M18-3573

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Last Modified: Dec 4, 2019 @ 1:59 pm 

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