scholarly journals 908. Dismantling Barriers to Hepatitis Elimination: Automated Hepatitis C Screening with Care and Cure by a Primary Care Based Team

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S545-S546
Author(s):  
Binghong Xu ◽  
Ruth P Brogden ◽  
Ammie J Patel ◽  
Alyssa Gallipani ◽  
Jaymie Yango ◽  
...  
Keyword(s):  
Primary Care ◽  
Viral Hepatitis ◽  
Scale Up ◽  
Financial Assistance ◽  
Hcv Rna ◽  
Team Approach ◽  
Prior Authorization ◽  
Research Support ◽  
Hcv Screening ◽  
The Cost

Abstract Background Liver cancer rates are rising in the US, viral hepatitis accounting for more than 65% of the cases. Yet more than half of viral hepatitis infections remain undiagnosed. In response to the rise in HCV due to the opioid epidemic, the Centers for Disease Control and Prevention began recommending a one-time HCV test for all adults in 2020. Screening, linkage to care (LTC) and access to HCV curative therapy must be scaled up to reach the WHO goal of eliminating hepatitis by 2030. Methods In 2018, automated HCV screening utilizing electronic medical record protocols began in the emergency department (ED) based on the date of birth. Drug testing and peer recovery consults were added as eligibility criteria. Screening became universal and expanded to the inpatient units in 2020. Patient navigators (PN) received alerts of positive results and worked with patients to arrange LTC, one site being a primary care-based practice (PCP) where internists provided HCV care and support from ambulatory care clinical pharmacists. Results From Mar 2018 to Mar 2021, 50,873 people were screened for HCV, with 977 (1.9%) testing HCV Ab+, and 259 (0.5%) had confirmed infection by reflex HCV RNA. LTC 86.6% of patients, and 128 (49.4%) were newly diagnosed. Universal screening led to 35,482 testings from Jan 2020-Mar 2021. People born out of the 1945-65 birth cohort made up 75.8% of the screened and 39.1% of the infected. The PCP evaluated 47 HCV patients, initiated therapy in 38; 36 required prior authorization and 15 needed financial assistance. Treatment breakdown was: 29 (76.3%) glecaprevir/pibrentasvir, 6 (15.8%) sofosbuvir/velpatasvir & 3 (7.9%) ledipasvir/sofosbuvir. Pharmacist intervention with prior authorizations and financial assistance significantly reduced the cost (table 1). Thus far, 35 achieved cure with undetectable HCV RNA at 12 weeks. Table 1. The Cost of Treatment before and after Pharmacist Assistance Conclusion Automated universal testing was an effective and seamless way to scale up HCV screening. Warm handoffs from a PN were important for engaging patients in care. A team approach assisted with removing barriers in therapy access, including prior authorization, specialist requirements, and financial assistance. Novel strategies utilizing ED and hospitals for testing with coordination to PCP are needed to find the missing millions and achieve hepatitis elimination. Disclosures Su Wang, MD MPH, Gilead Sciences (Grant/Research Support)Gilead Sciences (Grant/Research Support)

Finding the missing millions: Integrating automated viral hepatitis screening in a hospital with care and treatment in a primary care setting.

2021 ◽  
Vol 39 (15_suppl) ◽  
pp. 108-108
Author(s):  
Ruth Brogden ◽  
Su Wang ◽  
Binghong Xu
Keyword(s):  
Primary Care ◽  
Liver Cancer ◽  
Viral Hepatitis ◽  
Scale Up ◽  
Cancer Center ◽  
Patient Navigator ◽  
Care Practice ◽  
Hcv Rna ◽  
Inpatient Setting ◽  
Hospital System

108 Background: Rates of hepatocellular carcinoma (HCC) are rising in the US. Patients at Saint Barnabas Medical Cancer Center (SBMC) present with late-stage HCC at higher rates (29%) compared to the national (16%). Chronic Hepatitis C (HCV) and Hepatitis B (HBV) are major drivers of liver cancer, yet screening rates are low. Finding these missing millions is important to reducing rates of HCC. An automated emergency department (ED) viral hepatitis (VH) screening program was initiated in 2018 at SBMC. In January 2020, it was expanded to the inpatient setting and HCV screening was modified from cohort screening (those born in 1945-65) to a one time test for anybody 18 years or over, per updated Centers for Disease Control (CDC) and USPSTF (US Preventive Services Taskforce) recommendations. Methods: The electronic medical record (EMR) was modified to automate screening. HBV testing is triggered by a patient’s country of birth or race, and HCV testing is triggered by age over 18 and no previous testing. The automated HCV (HCV Ab with reflex to HCV RNA) or HBV (HBsAg) lab orders lead to an EMR notification to the nurses of patient eligibility and education is provided to patients. Alerts of positive results are sent to nursing staff, physicians, and the patient navigator (PN). The PN is sent a real-time secure text message and works individually with patients to arrange linkage-to-care (LTC) for evaluation and treatment. Results: From March 2018 - December 2020, 44,002 patients were screened for HCV and 884 (2.0%) were HCVAb+ and 242 (0.55%) HCV RNA+. For HBV, 21,328 patients were screened and 212 (0.99%) were HBsAg+. The expanded screenings accounted for 8,716 (19.8%) of the total HCV screenings. Individuals born outside the 1945-65 birth cohort (younger and older) made up 76.2% of those screened and 41% of the infected. The top 3 countries for HBV screenings were Haiti, Jamaica, and Ecuador. LTC rates, defined as attending first medical appointment or already in care, were 86.8% for HCV and 85.4% for HBV. Of those linked to care, 43 HCV+ patients were seen at a outpatient primary care practice part of SBMC, and of those, 39 initiated HCV cure therapy and 33 were cured (confirmed sustained virologic response at 12 weeks), and 35 HBV+ patients were seen and 6 initiated treatment. Conclusions: This automated program for VH has led to a significant scale up of screening with successful LTC and treatment of patients. Expansion to universal screening of all adults and to the inpatient setting found additional viral hepatitis patients who would have otherwise been missed. In addition to the automated screening, a multidisciplinary team including internists, pharmacists, and patient navigators were part of creating a primary care based program. Integration of viral hepatitis screening and care in a hospital system can be initial steps towards establishing liver cancer prevention program.

High prevalence of hepatitis C (HCV) in the emergency department (ED) of a London hospital: should we be screening for HCV in ED attendees?

2015 ◽  
Vol 143 (13) ◽  
pp. 2837-2840 ◽  
Author(s):  
C. ORKIN ◽  
E. LEACH ◽  
S. FLANAGAN ◽  
E. WALLIS ◽  
M. RUF ◽  
...  
Keyword(s):  
Emergency Department ◽  
Hepatitis C ◽  
Cost Benefit ◽  
Hcv Rna ◽  
London Hospital ◽  
High Prevalence ◽  
Cost Benefit Ratio ◽  
Hcv Antibody ◽  
Hcv Screening ◽  
The Cost

SUMMARYAn unlinked anonymous study was conducted to estimate the prevalence of hepatitis C virus (HCV) infection in emergency department (ED) attendees at a London Hospital. Nine hundred and ninety-seven samples collected over a 12-day period were tested for HCV antibody (Ab) and reactive samples were further tested for HCV RNA. The HCV seroprevalence was 2·6% (26/997) with 1·2% (12/997) HCV RNA positive. A peak HCV RNA-positive prevalence of 4·8% (3/63) was found in males aged 35–44 years, this was compared to 0% (0/136) in males aged <35 years (P = 0·0614) and 1·4% (4/278) in males aged ⩾45 years (P = 0·2415). Assuming the cost for HCV Ab is £6 and HCV RNA is £40 per test, screening ED attendees aged 25–54 years would cost £360 per viraemic infection and identify 82% of those who were HCV RNA positive, yielding the most favourable cost/benefit ratio. HCV screening of ED attendees aged 25–54 years in this population could be an effective way of identifying patients and limit onward transmission.

scholarly journals The Practicability of the Xpert HCV Viral Load Fingerstick Point-of-Care Assay in Primary Care Settings

Viruses ◽  
2021 ◽  
Vol 13 (11) ◽  
pp. 2327
Author(s):  
David Petroff ◽  
Olaf Bätz ◽  
Katrin Jedrysiak ◽  
Jan Kramer ◽  
Thomas Berg ◽  
...  
Keyword(s):  
Primary Care ◽  
Viral Load ◽  
Primary Care Physicians ◽  
Point Of Care ◽  
Linkage To Care ◽  
Hcv Rna ◽  
Primary Care Settings ◽  
Hcv Screening ◽  
The Individual ◽  
Point Of Care Assay

Linkage to care presents one obstacle toward eliminating HCV, and the current two-step pathway (anti-HCV, followed by HCV-RNA testing) results in the loss of patients. HCV screening was tested in the primary care setting with the fingerstick Xpert HCV viral load point-of-care assay to analyze the practicability of immediate diagnosis. Anti-HCV (Cobas) and HCV-RNA (Cobas Amplicor version 2.0, only performed if anti-HCV was positive) were analyzed centrally as the gold standard. The Xpert assay was performed by 10 primary care private practices. In total, 622 patients were recruited. Five individuals (0.8%) were anti-HCV positive, and one was HCV-RNA positive. The Xpert test was valid in 546/622 (87.8%) patients. It was negative in 544 and positive in 2 cases, both of whom were anti-HCV negative. The HCV-RNA PCR and the Xpert test were both negative in 4/5 anti-HCV-positive cases, and the individual with HCV-RNA 4.5 × 106 IU/mL was not detected by the Xpert test. Primary care physicians rated the Xpert test practicability as bad, satisfactory, or good in 6%, 13%, and 81%, respectively, though 14/29 (48%) bad test ratings were assigned by a single practice. Despite adequate acceptance, interpretability and diagnostic performance in primary care settings should be further evaluated before its use in HCV screening can be recommended.

scholarly journals From Screening to Therapy: Anti-HCV Screening and Linkage to Care in a Network of General Practitioners and a Private Gastroenterology Practice

Pathogens ◽  
2021 ◽  
Vol 10 (12) ◽  
pp. 1570
Author(s):  
David Petroff ◽  
Olaf Bätz ◽  
Katrin Jedrysiak ◽  
Anja Lüllau ◽  
Jan Kramer ◽  
...  
Keyword(s):  
Primary Care ◽  
Hepatitis C ◽  
Secondary Care ◽  
Primary Care Physicians ◽  
Linkage To Care ◽  
Drop Out ◽  
Hcv Rna ◽  
Care Practices ◽  
Hcv Screening ◽  
Primary Care Practices

(1) Background: Low rates of hepatitis C virus (HCV) diagnosis and sub-optimal linkage to care constitute barriers toward eliminating the infection. In 2012/2013, we showed that HCV screening in primary care detects unknown cases. However, hepatitis C patients may not receive further diagnostics and therapy because they drop out during the referral pathway to secondary care. Thus, we used an existing network of primary care physicians and a practice of gastroenterology to investigate the pathway from screening to therapy. (2) Methods: HCV screening was prospectively included in a routine check-up of primary care physicians who cooperated regularly with a private gastroenterology practice. Anti-HCV-positive patients were referred for further specialized diagnostics and treatment if indicated. (3) Results: Seventeen primary care practices screened 1875 patients. Twelve individuals were anti-HCV-positive (0.6%), six of them reported previous antiviral HCV therapy, and one untreated patient was HCV-RNA-positive (0.05% of the population). None of the 12 anti-HCV-positive cases showed up at the private gastroenterology practice. Further clinical details of the pathway from screening to therapy could not be analyzed. (4) Conclusions: The linkage between primary and secondary care appears to be problematic in the HCV setting even among cooperating partners, but robust conclusions require larger datasets.

scholarly journals Challenging the status quo: results of an acceptability and feasibility study of hypertensive disorders of pregnancy (HDP) management pathways in Indonesian primary care

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Fitriana Murriya Ekawati ◽  
Ova Emilia ◽  
Jane Gunn ◽  
Sharon Licqurish ◽  
Phyllis Lau
Keyword(s):  
Primary Care ◽  
Health Care Professionals ◽  
Primary Care Practice ◽  
Scale Up ◽  
Primary Care Providers ◽  
Care Practice ◽  
Local Health ◽  
Care Providers ◽  
Hypertensive Disorders Of Pregnancy ◽  
Hypertensive Disorders

Abstract Background Hypertensive disorders of pregnancy (HDP) are the leading cause of maternal mortality in Indonesia. Focused HDP management pathways for Indonesian primary care practice have been developed from a consensus development process. However, the acceptability and feasibility of the pathways in practice have not been explored. This study reports on the implementation process of the pathways to determine their acceptability and feasibility in Indonesian practice. Methods The pathways were implemented in three public primary care clinics (Puskesmas) in Yogyakarta province for a month, guided by implementation science frameworks of Medical Research Council (MRC) and the Practical Robust Implementation and Sustainability Model (PRISM). The participating providers (general practitioners (GPs), midwives, and nurses) were asked to use recommendations in the pathways for a month. The pathway implementation evaluations were then conducted using clinical audits and a triangulation of observations, focus groups (FGs), and interviews with all of the participants. Clinical audit data were analysed descriptively, and qualitative data were analysed using a mix of the inductive-deductive approach of thematic analysis. Results A total of 50 primary care providers, four obstetricians, a maternal division officer in the local health office and 61 patients agreed to participate, and 48 of the recruited participants participated in evaluation FGs or interviews. All of the providers in the Puskesmas attempted to apply recommendations from the pathways to various degrees, mainly adopting preeclampsia risk factor screenings and HDP monitoring. The participants expressed that the recommendations empowered their practice when it came to HDP management. However, their practices were challenged by professional boundaries and hierarchical barriers among health care professionals, limited clinical resources, and regulations from the local health office. Suggestions for future scale-up studies were also mentioned, such as involving champion obstetricians and providing more patient education toolkits. Conclusion The HDP management pathways are acceptable and feasible in Indonesian primary care. A further scale-up study is desired and can be initiated with investigations to minimise the implementation challenges and enhance the pathways’ value in primary care practice.

scholarly journals Analysis of Annual Costs of Mobile Clinics in the Southern United States

2020 ◽  
Vol 11 ◽  
pp. 215013272098062
Author(s):  
Sharon Attipoe-Dorcoo ◽  
Rigoberto Delgado ◽  
Dejian Lai ◽  
Aditi Gupta ◽  
Stephen Linder
Keyword(s):  
Primary Care ◽  
Healthcare Services ◽  
Medicare Beneficiaries ◽  
Mobile Clinic ◽  
Efficient Manner ◽  
Healthcare Facilities ◽  
Capital Costs ◽  
At Risk Populations ◽  
Mobile Clinics ◽  
The Cost

Introduction Mobile clinics provide an efficient manner for delivering healthcare services to at-risk populations, and there is a need to understand their economics. This study analyzes the costs of operating selected mobile clinic programs representing service categories in dental, dental/preventive, preventive care, primary care/preventive, and mammography/primary care/preventive. Methods The methodology included a self-reported survey of 96 mobile clinic programs operating in Texas, North Carolina, Georgia, and Florida; these states did not expand Medicaid and have a large proportion of uninsured individuals. Data were collected over an 8-month period from November 2016 to July 2017. The cost analyses were conducted in 2018, and were analyzed from the provider perspective. The average annual estimated costs; as well the costs per patient in each mobile clinic program within different service delivery types were assessed. Costs reported in the study survey were classified into recurrent direct costs and capital costs. Results Results indicate that mean operating costs range from about $300 000 to $2.5 million with costs increasing from mammography/primary care/preventive delivery to dental/preventive. The majority of mobile clinics provided dental care followed by dental/preventive. The cost per patient visit for all mobile clinic service types ranged from $65 to $529, and appears to be considerably less than those reported in the literature for fixed clinic services. Conclusion The overall costs of all delivery types in mobile clinics were lower than the costs of providing care to Medicare beneficiaries in federally funded health centers, making mobile clinics a sound economic complement to stationary healthcare facilities.

Estimating the cost of primary care training in ambulatory settings

2000 ◽  
Vol 9 (8) ◽  
pp. 715-726 ◽  
Author(s):  
Andrew J. Hogan ◽  
Luisa Franzini ◽  
James R. Boex
Keyword(s):  
Primary Care ◽  
Primary Care Training ◽  
Care Training ◽  
The Cost

scholarly journals The financial burden of PARP inhibitors on patients, payors, and financial assistance programs: Who bears the cost?

2021 ◽  
Author(s):  
Whitney N. Goldsberry ◽  
Sarah S. Summerlin ◽  
Allison Guyton ◽  
Brittani Caddell ◽  
Warner K. Huh ◽  
...  
Keyword(s):  
Financial Burden ◽  
Parp Inhibitors ◽  
Financial Assistance ◽  
Assistance Programs ◽  
The Cost

scholarly journals Implementation support for contingency management: preferences of opioid treatment program leaders and staff

2021 ◽  
Vol 2 (1) ◽  
Author(s):  
Kelli Scott ◽  
Shelly Jarman ◽  
Samantha Moul ◽  
Cara M. Murphy ◽  
Kimberly Yap ◽  
...  
Keyword(s):  
Performance Feedback ◽  
Contingency Management ◽  
Scale Up ◽  
Team Approach ◽  
Evidence Based ◽  
Implementation Support ◽  
Training Performance ◽  
Opioid Treatment ◽  
Treatment Providers ◽  
External Facilitation

Abstract Background Contingency management (CM), a behavioral intervention that provides incentives for achieving treatment goals, is an evidence-based adjunct to medication to treat opioid use disorder. Unfortunately, many front-line treatment providers do not utilize CM, likely due to contextual barriers that limit effective training and ongoing support for evidence-based practices. This study applied user-informed approaches to adapt a multi-level implementation strategy called the Science to Service Laboratory (SSL) to support CM implementation. Methods Leaders and treatment providers working in community-based opioid treatment programs (OTPs; N = 43) completed qualitative interviews inquiring about their preferences for training and support implementation strategies (didactic training, performance feedback, and external facilitation). Our team coded interviews using a reflexive team approach to identify common a priori and emergent themes. Results Leaders and providers expressed a preference for brief training that included case examples and research data, along with experiential learning strategies. They reported a desire for performance feedback from internal supervisors, patients, and clinical experts. Providers and leaders had mixed feelings about audio-recording sessions but were open to the use of rating sheets to evaluate CM performance. Finally, participants desired both on-call and regularly scheduled external facilitation to support their continued use of CM. Conclusions This study provides an exemplar of a user-informed approach to adapt the SSL implementation support strategies for CM scale-up in community OTPs. Study findings highlight the need for user-informed approaches to training, performance feedback, and facilitation to support sustained CM use in this setting.

scholarly journals POS0059-PARE DELAY TO DIAGNOSIS IN AXIAL SPONDYLOARTHRITIS – TIME FOR A GOLD STANDARD APPROACH

2021 ◽  
Vol 80 (Suppl 1) ◽  
pp. 235.3-236
Author(s):  
D. Webb ◽  
K. Gaffney ◽  
R. Sengupta ◽  
S. S. Zhao ◽  
L. Swingler
Keyword(s):  
Primary Care ◽  
Gold Standard ◽  
Axial Spondyloarthritis ◽  
Public Awareness ◽  
Delayed Diagnosis ◽  
Research Support ◽  
Professional Societies ◽  
Standard Time ◽  
Time To Diagnosis ◽  
The Uk

Background:In the UK, the average time to diagnosis of axial SpA is 8.5 years (1). There is little evidence this has improved, despite the acceptance of MRI use in diagnosis (2). A recent review identified significant clinical, economic and humanistic burden from delayed diagnosis (3). Urgent action is needed to ensure delayed diagnosis is not normalized.Objectives:We created a proposal for a Gold Standard time to diagnosis for axial SpA and a national implementation plan (4) through consensus development with patients, healthcare professionals and professional bodies.Methods:A.A scoping literature review identifying where delays occur, from first symptom onset to diagnosis by a rheumatologist, and potential solutions. From this, a summary report / draft plan was produced for consultationB.A national consultation survey to elicit views on the proposals from clinicians, healthcare professionals, professional societies and patientsC.Structured feedback to written proposals via e-consultation with clinicians and patientsD.A consensus development workshop to finalise the Gold Standard and implementation plan.Results:The literature review identified four delays:1. People do not know axial SpA may be a cause of their chronic back pain2. Primary care practitioners may not recognise features of axial SpA3. People may be referred to non-rheumatologists who may not recognise axial SpA promptly4. Rheumatology and radiology teams may not optimally request or interpret investigations.202 participants responded to the summary report (74% patients, 21% healthcare professsionals, 5% professional societies). All supported the principles behind the gold standard time to diagnosis. Qualitive analysis confirmed agreement with the proposed solutions, underscoring the importance of education and visibility for axial SpA within primary care and increased public awareness. Additional proposals were suggested, including a tool in primary care to run audits on IT systems.40 clinicians contributed to the e-consultation and 55 clinicians, policy makers, social marketing experts, health journalists and patients attended the consensus workshop. Consensus was reached on a gold standard time to diagnosis of one year, and the principles, key components and phasing of the implemention plan. This included: public awareness about axial SpA symptoms; a primary care clinical champions programme; creating a referral pathway from primary care direct to rheumatology; a secondary care service educational programme.Conclusion:There is consensus from UK axial SpA clinicians, patients and professional societies on the need for a Gold Standard time to diagnosis of axial SpA of one year, so that patients can live happy, healthy and productive lives.References:[1]Hamilton L, Gilbert A, Skerett J, et al. Services for people with ankylosing spondylitis in the UK - a survey of rheumatologists and patients. Rheumatology 2011:50:1991[2]Sykes MP, Doll H, R Sengupta, Gaffney, K. Delay to diagnosis in axial spondyloarthritis: are we improving in the UK? Rheumatology, July 2015[3]Yi E, Ahuja A, Rajput T, et al. Clinical, Economic, and Humanistic Burden Associated With Delayed Diagnosis of Axial Spondyloarthritis: A Systematic Review. Rheumatol Ther. 2020 Mar;7(1):65–87.[4]Webb D, Zhao S, Whalley S, et al. Gold Standard Time to Diagnosis in axial Spondyloarthritis: Consultation Document. 2020, NASS.Disclosure of Interests:Dale Webb Speakers bureau: Janssen, Novartis, Grant/research support from: NASS receives grants from AbbVie, Biogen, Eli Lilly, Novartis and UCB, Karl Gaffney Speakers bureau: Abbvie, Lilly, Novartis, UCB, Consultant of: Abbvie, Celltrion, Lilly, Grant/research support from: Abbvie, Pfizer, Lilly, UCB, Raj Sengupta Speakers bureau: Abbvie, Biogen, Celgene, Novartis, Roche, UCB, Consultant of: Advisory boards for Abbvie, Biogen, Novartis, UCB, Grant/research support from: Abbvie, Celgene, Novartis, Sizheng Steven Zhao: None declared, Lisa Swingler Grant/research support from: NASS receives grants from AbbVie, Biogen, Eli Lilly, Novartis and UCB.

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