Impact of a hepatitis C elimination program at a large academic health system

We appreciate the article by Ezzat and colleagues and present an elimination program, specifically at the institutional level.1 In the United States, 2.4 million people are infected with chronic hepatitis C virus (HCV) but only 40% are aware of their disease.2 Due to state requirements that limit Medicaid access to HCV therapies, Illinois in particular, received a grade ‘F’ per the Hepatitis C: State of Medicaid Access Report Card.3 In light of these restrictions, we summarize our initiatives that improved HCV screening and care at Northwestern Medicine, the largest academic health system in Illinois. We developed an institution-specific clinical guideline to standardize the evaluation and management of HCV across the health system and to encourage new treaters by assisting with medical decision-making. All treating providers were linked to a clinical pharmacist who selected treatment, obtained prior authorization/financial assistance approval, counselled patients and assisted with treatment monitoring. In addition, we provided education to primary care, gastroenterology and infectious disease providers about updates to HCV screening recommendations and to raise disease awareness. Education flyers were displayed in outpatient gastroenterology/hepatology consult rooms and distributed to patients at check-in. Within the electronic health record (EHR), we implemented a best practice alert (BPA) for universal screening in all ambulatory adults ≥18 years and annual screening in high-risk populations: injection/intranasal illicit drug users, men who have sex with men who have HIV or are taking PrEP, long-term sexual partners of individuals with hepatitis, and those on maintenance haemodialysis. BPA usage was expanded to all primary care, gastroenterology, hepatology, infectious disease, transplant and obstetrics/gynaecology providers. Furthermore, to ensure efficient evaluation of patients with active HCV, we created an EHR smartset that included pertinent lab, fibrosis assessment and specialist referral orders required for HCV treatment prior authorization approval. We chose to align the smartset with Illinois Medicaid criteria as it is the strictest among insurance providers in our region. Monthly reports were pulled to ensure patients with positive screening tests were linked to care. Though default orders in the hospital admission smartset have been shown to improve screening rates, we were unable to implement these at our institution. Nonetheless, HCV screening increased by 173%, from 76 086 HCV antibody tests ordered pre-implementation to 207 695 ordered post-implementation, especially among women and younger individuals, whom we know to have increasing rates of HCV (Table 1). The next steps include automated screening reminders through patient portals and community outreach. We hope these efforts will encourage other institutions to implement similar strategies for HCV elimination. Sonalie Patel led, Ryan Tang, and Ryan Tang assisted with the study concept and design. Sonalie Patel completed data acquisition. Sonalie Patel, Ryan Tang, and Ryan Tang contributed to the analysis and interpretation of data. Sonalie Patel led the initial drafting of the manuscript. All authors provided critical revision of the manuscript for important intellectual content, gave final approval of data and are accountable for the work. SP serves on the speakers' bureau for AbbVie and Gilead and has also served on their advisory boards. Data sharing is not applicable to this article as no data sets were generated or analysed during the current study.