One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk

Percentage of patients aged 18 years and older with one or more of the following: a history of injection drug use, receipt of a blood transfusion prior to 1992, receiving maintenance hemodialysis, OR birthdate in the years 1945-1965 who received one-time screening for hepatitis C virus (HCV) infection

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Of the estimated 3.5 million people living in the United States with the hepatitis C virus infection (HCV), only 50% have been tested for HCV and are aware of their status. Reported cases of HCV have increased (approximately 20% per year) between 2010-2016 which is partially due to improved case detection and more likely due to rising rates of injection drug use. Additionally, only one third have been referred for HCV care and only 5.6% receive recommended treatment. Studies indicate that even among high-risk patients for whom screening is recommended, only 49-75% are aware of their infection status. In a recent analysis of data from a national health survey, 67.9% of persons ever infected with HCV reported an exposure risk, (e.g., injection drug use, having sexual contact with suspected/confirmed hepatitis C patient), 2 weeks to 6 months prior to symptom onset, and the remaining 32.1% reported no known exposure risk. Current risk-based testing strategies have had limited success, as evidenced by the substantial number of HCV-infected persons who remain unaware of their infection. As a result, many do not receive needed care (e.g., education, counseling, and medical monitoring), and are not evaluated for treatment. HCV causes acute infection, which can be characterized by mild to severe illness but is usually asymptomatic. In approximately 75%-85% of persons, HCV persists as a chronic infection, placing infected persons at risk for liver cirrhosis, hepatocellular carcinoma (HCC), and extrahepatic complications that develop over the decades following onset of infection. HCV testing is the first step toward improving health outcomes for persons infected with HCV.

In addition to testing adults of all ages at risk for HCV infection, CDC recommends that:
-- Adults born during 1945-1965 should receive one-time testing for HCV without prior ascertainment of HCV risk (Strong Recommendation, Moderate Quality of Evidence), and
-- All persons identified with HCV infection should receive a brief alcohol screening and intervention as clinically indicated, followed by referral to appropriate care and treatment services for HCV infection and related conditions  (Strong Recommendation, Moderate Quality of Evidence).

Providers and patients can discuss HCV testing as part of an individual's preventive health care. For persons identified with HCV infection, CDC recommends that they receive appropriate care, including HCV-directed clinical preventive services (eg, screening for alcohol use, hepatitis A and hepatitis B vaccination as appropriate, and medical monitoring of disease). Recommendations are available to guide treatment decisions. Treatment decisions should be made by the patient and provider after several factors are considered, including stage of disease, hepatitis C genotype, comorbidities, therapy-related adverse events, and benefits of treatment. (CDC, 2012)

The USPSTF recommends screening for hepatitis C virus (HCV) infection in persons at high risk for infection. The USPSTF also recommends offering 1-time screening for HCV infection to adults born between 1945 and 1965.
(Grade B recommendation) (USPSTF, 2013)

Assessment of Risk
The most important risk factor for HCV infection is past or current injection drug use. Another established risk factor for HCV infection is receipt of a blood transfusion before 1992. Because of the implementation of screening programs for donated blood, blood transfusions are no longer an important source of HCV infection. In contrast, 60% of new HCV infections occur in persons who report injection drug use within the past 6 months. Additional risk factors include long-term hemodialysis, being born to an HCV-infected mother, incarceration, intranasal drug use, getting an unregulated tattoo, and other percutaneous exposures (such as in health care workers or from having surgery before the implementation of universal precautions). Evidence on tattoos and other percutaneous exposures as risk factors for HCV infection is limited. The relative importance of these additional risk factors may differ on the basis of geographic location and other factors. (USPSTF, 2013)

Verbatim from AASLD and IDSA Recommendations for Testing, Managing, and Treating Hepatitis C, February 2016:

One-time HCV testing is recommended for persons born between 1945 and 1965* without prior ascertainment of risk. (Rating: Class I, Level B) (AASLD/IDSA, 2016)

Other persons should be screened for risk factors for HCV infection, and one-time testing should be performed for all persons with behaviors, exposures, and conditions associated with an increased risk of HCV infection.

1. Risk behaviors
     a. Injection drug use (current or ever, including those who injected once)
     b. Intranasal illicit drug use
2. Risk exposures
     a. Long-term hemodialysis (ever)
     b. Getting a tattoo in an unregulated setting
     c. Healthcare, emergency medical, and public safety workers after needle sticks, sharps, or mucosal exposures 
         to HCV-infected blood
     d. Children born to HCV-infected women
     e. Prior recipients of transfusions or organ transplants, including persons who:
         i. Were notified that they received blood from a donor who later tested positive for HCV infection
         ii. Received a transfusion of blood or blood components, or underwent an organ transplant before July 1992
         iii. Received clotting factor concentrates produced before 1987
     f. Persons who were ever incarcerated
3. Other
     a. HIV infection
     b. Unexplained chronic liver disease and/or chronic hepatitis including elevated alanine aminotransferase levels
     c. Solid organ donors (deceased and living)
*Regardless of country of birth (Rating: Class I, Level B) (AASLD/IDSA, 2016)

Higher score indicates better quality

Centers for Disease Control and Prevention. Surveillance for viral hepatitis the United States, 2016. Available at:
https://www.cdc.gov/hepatitis/statistics/2016surveillance/index.htm

Zibbell JE, Asher AK, Patel RC, Kupronis B, Iqbal K, Ward JW, Holtzman D.  Increases in acute hepatitis C related infection related to a growing opioid epidemic and associated injection drug use, 2004-2014.  Amer J Pub Health. 2018 Feb; 108(2):175-81.

Holmberg SD, Spradling PR, Moorman AC, Denniston MM. Hepatitis C in the United States. N Engl J Med. 2013; 368:1859-1861. doi: 10.1056/NEJMp1302973

Colvin HM, Mitchell AE. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C. 2010. Available at: http://www.nap.edu/catalog/12793.html.

Coffin PO, Reynolds A. Ending hepatitis C in the United States: the role of screening. Hepat Med. 2014:6 79 - 87. 

Hagan H, Campbell J, Thiede H, et al. Self-reported hepatitis C virus antibody status and risk behavior in young injectors. Public Health Rep 2006;121:710–9.

Alter MJ, Margolis HS, Krawczynski K, Judson, FN, Mares A, Alexander WJ, et al. The natural history of community-acquired hepatitis C in the United States. N Engl J Med 1992;327:1899–1905

Centers for Disease Control and Prevention (CDC). Recommendations for the Identification of Chronic Hepatitis C Virus Infection Among Persons Born During 1945–1965. MMWR 2012;61(No. RR-4): 1-36. Accessed February 20, 2019. Available at: http://www.cdc.gov/hepatitis/hcv/guidelinesc.htm

Moyer VA, on behalf of the U.S. Preventive Services Task Force. Screening for hepatitis C virus infection in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2013 Jun 25.

AASLD-IDSA. Recommendations for testing, managing, and treating hepatitis C.  http://www.hcvguidelines.org. Accessed February 20, 2019.

Screening for HCV Infection includes current or prior receipt of:
1)  HCV antibody test
2)  HCV RNA test
3)  Recombinant immunoblot assay (RIBA) test (if performed at any time in the past)

This measure evaluates the proportion of at-risk patients who have received a one-time screening for Hepatitis C Virus (HCV). In order to meet the measure, the reporting provider must have the laboratory test result present in the patient's medical record. On occasion, providers will view HCV screening results that were performed elsewhere and therefore the results are not present in the EHR in a structured format. To allow such tests to be applied to this measure, they should be entered into the EHR as a laboratory test in a manner consistent with the EHR in use. If the specific LOINC code of the test is not known, the entry should use the more generic LOINC Panel code which is included in the HCV test value sets as outlined below:

If the provider does not know the exact HCV RNA test performed elsewhere, report the generic LOINC HCV RNA Panel code 75888-8, found in the value set titled, "HCV RNA Test".

If the provider does not know the exact HCV Antibody test performed elsewhere, report the generic LOINC HCV Ab Panel code, 75886-2, found in the value set titled, "HCV Antibody Test".

If the provider does not know the exact HCV RIBA test performed elsewhere, report the generic LOINC HCV RIBA Panel code, 75887-0, found in the value set, "HCV RIBA Test".

The following screening tests are included as allowable screening tests for HCV: HCV antibody test, HCV RNA test or RIBA test. The RIBA test qualifies as "one-time screening" if it was performed at some time in the past.  Because RIBA is not a screening method currently used in clinical practice, it is not included as an option in the numerator logic for a screening that occurred during the measurement period.

The start datetime stamp associated with the data element "Diagnosis: History of Blood Transfusion" should be the datetime of the transfusion event, and not a datetime stamp associated with the documentation action in order to satisfy the logic clause.

TBD

All patients aged 18 years and older who were seen twice for any visit or who had at least one preventive visit within the 12-month reporting period

Equals Initial Population with one or more of the following: a history of injection drug use, receipt of a blood transfusion prior to 1992, receiving maintenance hemodialysis, OR birthdate in the years 1945-1965

Patients with a diagnosis of chronic hepatitis C

Patients who received one-time screening for HCV infection

Not Applicable

Documentation of medical reason(s) for not receiving one-time screening for HCV infection (e.g., decompensated cirrhosis indicating advanced disease [i.e., ascites, esophageal variceal bleeding, hepatic encephalopathy], hepatocellular carcinoma, waitlist for organ transplant, limited life expectancy, other medical reasons)

Documentation of patient reason(s) for not receiving one-time screening for HCV infection (e.g., patient declined, other patient reasons)

For every patient evaluated by this measure also identify payer, race, ethnicity and sex