Hepatitis C Testing and Linkage to Care:

An Urban Hospital’s Approach to Address

and Manage a Community Epidemic
Elise Mann, PharmD
PGY1 Pharmacy Resident
Eskenazi Health, Indianapolis, IN
April 29, 2022

The presenter has no actual or potential conflicts of interest in relation to this presentation
Background
 Epidemiology

“Viral Hepatitis Multimedia Resources.” Centers for Disease Control and Prevention. 2020. Retrieved from https://www.cdc.gov/nchhstp/newsroom/multimedia-resources/vh-multimedia-resources.html
 Pathophysiology

May lead to:

• Cirrhosis
• Liver failure
• Hepatocellular
carcinoma

HCC= hepatocellular carcinoma

ESLD= end stage liver disease
“Viral Hepatitis and Liver Disease.” US Department of Veterans Affairs. 2020. Retrieved from https://www.hepatitis.va.gov/hcv/background/natural-history.asp
 Diagnosis

Non-
HCV Reactive
Antibody Not
Test HCV RNA Detected
Reactive
Test Link to
Detected
Care

“Recommended Testing Sequence for Identifying Current HCV Infection.” Centers for Disease Control and Prevention. 2013.
 Self-Assessment #1
Patients with which of the following positive lab tests
should have a referral for HCV treatment?

a. HCV DNA test

b. HCV antibody test
c. HCV RNA test
d. HCV antigen test
Literature Review
 HCV Testing Challenges
Objective • Describe the results of an ED HCV testing program that
integrated birth cohort screening and screening of
patients with a history of IVDU

Intervention • HCV antibody positive patients referred to primary care

• Assisted linking to HCV clinic once RNA confirmed
• Later linked directly to HCV clinic if HCV antibody positive

Results • N= 126 HCV RNA+

• Follow-up appointments were arranged for 45% of
patients with confirmed positive results
• 24% overall follow-up appointment attendance rate

Conclusion • Challenges included result disclosure, confirmatory

testing, and linkage to care

White D, Anderson E, et al. Ann Emerg Med. 2015: 67 (1).

 HCV Continuum of Care
Objective Evaluate the HCV continuum of care for patients identified
with HCV in the ED

Intervention • Screened patients in birth cohort and those with current

or historical injection drug use

Results • N= 302 HCV RNA+

• 97 (32.2%) attended their follow-up appointment
• 19 (19.6%) were treated and achieved an SVR

Conclusions • ED patients have a high prevalence of undiagnosed HCV

infection
• ED often acts as a safety net for patients without a
primary care provider

Anderson E, Galbraith J, et al. Clinical Infectious Diseases. 2017: 1540-1546.

 LTC Failure Predictors
Objective Identify predictors of linkage to care (LTC) outcomes for
patients with newly diagnosed HCV identified through non-
targeted ED screening program

Intervention • Linkage to care coordinator (LCC) delivered HCV

confirmatory test results via telephone
• LCC sought to coordinate follow-up either with HCV
specialty clinics or with a PCP

Results • N= 1674 HCV RNA+

• 355 (21.2%) were successfully linked to care

Conclusion • Predictors of LTC failure included: younger age, white race,

homelessness, documented substance use, and comorbid
psychiatric illness

Blackwell JA, Rodgers JB, et al. Am J Emerg Med. 2020: Jul; 38(7): 1396-1401.
 Self-Assessment #2
Which of the following has not been well described in the
current literature regarding linkage to care for HCV treatment
after diagnosis in the ED?

a. Predictors of linkage to care failure

b. Lack of established primary care for patients presenting to
the ED
c. Linkage to care coordinator roles
d. Pharmacist involvement in HCV clinics
 Eskenazi Health

• 333-bed safety net hospital with 10 Federally Qualified Health Centers in Indianapolis, IN
• Annual ED census >100,000 patient visits
 HCV Screening in the ED

EMR alert-driven HCV testing in the

EMR alert criteria expands
ED begins

July 2019 February 2021

May 2019 January 2021

Indiana Medicaid removes fibrosis Indiana removes prior authorization

score minimum requirement
 Improved Care Coordination

EMR alert-driven HCV Case Manager

testing in the ED Pharmacist added EMR alert criteria granted ability to
begins with CDTM protocol expands schedule follow-up
appointments

July 2019 August 2020 February 2021 October 2021

May 2019 July 2020 January 2021 April 2021

Indiana removes Indiana removes

Public Health Medical Pharmacist CDTM
Medicaid fibrosis prior authorization
Case Manager hired expanded
score minimum requirement

CDTM= Collaborative Drug Therapy Management

 To determine if the efforts
in improved care
coordination increased
Objective linkage to care rates of
patients identified as
having HCV through testing
in the ED
 Methods
• Single-center, retrospective, cohort study
• Inclusion: ≥ 18 years old, positive HCV antibody test in the
ED and positive confirmatory RNA test
• Exclusion: already engaged in HCV specific care

Pre-Intervention Improved Care Post- Intervention

Coordination

• September 2019– • July 2020 – • October 2021–

December 2019 October 2021 January 2022
 Endpoints

Primary
• Proportion of patients linked to care to a primary care provider or
to an HCV treating provider

Secondary
• Time to linkage to care
• Proportion of patients who initiated treatment
• Time to treatment initiation
• Proportion of patients who completed treatment
• Proportion of patients who achieved SVR
• Type of initial follow-up appointment attended
 Statistical Analysis
Sample Size & Normality
• Convenience sample
• Anderson-Darling test for normality

Demographic Statistics
• Nominal: Chi-square (χ2) test or Fisher’s exact test
• Continuous, non-parametric: Mann-Whitney U test

Primary & Secondary Outcome Statistics

• Categorical Variables: Chi-square (χ2) test or Fisher’s exact test
• Continuous, non-parametric: Mann-Whitney U test
• Continuous, parametric: Two-sampled T-test
• Significance level (alpha) predetermined to be ≤ 0.05
Preliminary Results
 RNA+ Patient Demographics
Demographic Pre-Intervention Cohort Post-Intervention Cohort P-value
(N=247) (n=109) (n=136)

Sex, male 71 (65%) 91 (67%) 0.771

Born 1945-1965 (%) 86 (52%) 40 (29%) <0.001

Born before or after (%) 23 (14%) 96 (71%)

Black or African American 50 (46%) 28 (21%) <0.001

White 56 (51%) 103 (76%)

Other Race/Declined 3 (3%) 5 (4%)

Hispanic 0 (0%) 1 (1%) 1.000

Non-Hispanic 109 (99%) 135 (99%)
Preliminary Results
Pre-Intervention Post-Intervention
Patients Tested
N=1561 N=3876

Positive HCV RNA Test

109/1561 (7%) 136/3876 (3.5%)

Linked to Care*
37/109 (34%) 31/136 (23%)

Linked to Care with a Treating Provider*

10/109 (9.2%) 21/136 (15.4%)
*p > 0.05
Preliminary Results (cont).
Pre-Intervention Post-Intervention
Initiated Treatment*

6/109 (5.5%) 16/136 (11.8%)

Completed Treatment

3/109 (2.8%) TBD

Achieved SVR

3/109 (2.8%) TBD

*p = 0.076
 Preliminary Results (cont.)

Pre-Intervention Post-Intervention p-value

Time to Treating Provider 73 days [49, 90] 57 days [38, 66] 0.176
(median [IQR])

Time to Treatment Initiation 219 days +/- 115 89 days +/- 32 0.042
(mean +/- SD)

Initial Follow-Up with PCP 36/37 (97.3%) 15/29 (51.7%)

<0.001

Initial Follow-Up with HCV 1/37 (2.7%) 14/29 (48.3%)

Treating Provider
 Strengths and Limitations

Retrospective chart review, Inclusive testing and reflex

single-center study labs

Site specific restrictions for Comparable to historical

Hepatitis C treatment literature

Potential confounding Novel demonstration of

Therevariables
is a needduring study linkage pharmacist
to improve to care to animpact
HCV on HCV
timeframe
treating linkage
provider following diagnosis in thetoED
care
 Conclusions
A low number of HCV positive patients were successfully
linked to treating providers prior to improved care
coordination

Efforts in improved care coordination have resulted in an

increased rate of patients initially seen by a treating provider
following identification of HCV in the ED

These efforts have also resulted in decreased time to

treatment initiation following identification of HCV in the ED
 Acknowledgements
Kerri Degenkolb, PharmD, BCPS
Todd Walroth, PharmD, BCPS, BCCCP, FCCM
Molly Howell, PharmD, BCPS, BCCCP
Kristopher Posthuma, MSW
Brittany Wynn, MSW
Nancy Olmstead, MSW, LSW
Tyler Stepsis, MD
 Hepatitis C Testing and Linkage to Care:
An Urban Hospital’s Approach to Address
and Manage a Community Epidemic
Elise Mann, PharmD
PGY1 Pharmacy Resident
Eskenazi Health, Indianapolis, IN
April 29, 2022