The Viral Hepatitis Action Plan spells out the importance of identifying persons infected with viral hepatitis early in the course of their disease as an important component of national efforts to improve diagnosis, care and treatment to prevent liver disease and liver cancer. As awareness of viral hepatitis increases and treatment options become more effective and better tolerated, it is vital that we implement best practices to improve the frequency, availability, and acceptability of viral hepatitis testing.
To inform and advance these efforts, my office hosted a day-long consultation last month. Sharing their perspectives with us were representatives from state and local health departments, community health centers, drug treatment and correctional health programs, local and national advocacy organizations, the American Association for the Study of Liver Disease, the National Medical Association and other partners. Also participating in the discussion were experts from various federal agencies including the Centers for Disease Control, Agency for Healthcare Research and Quality, Centers for Medicaid and Medicare Services, HRSA’s Bureau of Primary Health Care and HIV/AIDS Bureau, Indian Health Service, National Institutes of Health, Office of Minority Health, and Substance Abuse and Mental Health Services Administration, as well as Federal Bureau of Prisons and the Department of Veterans Affairs.
Among the many examples of promising practices shared from diverse settings were:
- Targeting patient education and outreach – Tamara Brickham, M.P.H., Houston Department of Health and Human Services, shared details of a successful community partnership model the agency used to increase hepatitis B awareness, screening, testing and vaccination among Asian Americans. To more effectively reach the communities with a higher prevalence of HBV infection, the health department partnered with numerous community-based organizations already working with the Vietnamese, Chinese, Korean, and Asian Indian communities. Ms. Brickham noted that this enabled the health department to take the education, screening, vaccination and testing activities directly to higher risk adults in community settings rather than waiting for them to come to the health department or a healthcare provider. As a result of the first year of this population-specific outreach, more than 1,000 people were screened. Three percent were identified as having chronic HBV infection and were referred for care. One-third of those screened were vaccinated.
- Using rapid testing – Several participants highlighted the challenge of getting those who do ultimately get tested to return for their results. Colleen Flanigan, R.N., M.S., Director of the Viral Hepatitis Section at the New York State Department of Health, discussed how a 12-site state-supported demonstration project will use rapid HCV testing to overcome this hurdle. The demonstration project will target higher risk populations and use rapid HCV tests to eliminate the need for clients to return for a second visit for test results. Clients with a reactive test result will receive a written referral to a provider that can perform a confirmatory PCR test. Through the demonstration project, they will study how this approach improves diagnosis and linkage to care for chronic HCV.
- Adapting systems to support viral hepatitis testing – A number of participants noted that inadequate fiscal resources are an impediment in many settings but that even when resources are available, improving viral hepatitis screening and testing requires the development of processes and systems that make it easier for providers to implement the recommended protocols. Kenneth Tai, M.D., discussed the efforts he led at North East Medical Services (NEMS) in San Francisco to address high rates of HBV among its patient population who are primarily people of Asian heritage. NEMS started by setting a goal to increase HBV testing and vaccination among patients from 60% to 70% in one year. In addition to enhancing patient education, the community health center undertook critical systems changes including: adding an HBV module to the electronic health record (EHR) used at the clinic, improving the workflow in the clinic to make testing and vaccination more efficient, and mining EHR data to generate a list of patients being seen each day who need an HBV test. Finally, the health center also added HBV testing as a measure to its physician report card. Janet Durfee, R.N., M.S.N, A.P.R.N., Deputy Chief Consultant, Clinical Public Health at the Department of Veterans Affairs (VA) noted that systems changes have also helped the VA health system to improve and enhance their HCV screening efforts. Among the changes implemented in recent years has been adding a clinical reminder to the electronic health record prompting healthcare providers to screen and test if indicated. VA has distributed responsibility for screening among nurses and other personnel, so this does not fall to physicians alone. To address both provider and patient discomfort with discussing risks, VA revised its approach so that providers ask the patient whether he/she has any of a list of risks, thereby avoiding the need to admit to any particular stigmatizing risk factor and increasing the likelihood of candid responses.
“The promising practices shared by consultation participants and the lively discussion that followed underscored that it is possible to improve the frequency, availability, and acceptability of viral hepatitis testing in a variety settings, in some cases by only making minor changes to processes, in others through partnerships and coordination of services,” observed my colleague Corinna Dan, R.N., M.P.H., Viral Hepatitis Policy Advisor, Office of HIV/AIDS and Infectious Disease Policy, who organized the consultation.
As Corinna notes, the consultation clearly illustrated that numerous successful approaches to improving viral hepatitis testing exist in very diverse settings. A key to our success in scaling up these efforts will be better documenting, disseminating and encouraging the adoption of these model programs.