mamta k. jain, md,mph91% vs. 87% , p=0.15 ... mamta k. jain created date: 10/20/2020 10:03:20 am
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Mamta K. Jain, MD,MPHUT Southwestern Medical Center TeCH Annual SymposiumOctober 17, 2020
Grant Funding Gilead Sciences, Janssen, Merck
Consultant/Advisory Board Gilead Sciences
Kanwal et al. Gastroenterology 2017; Ashahina et al., Hepatology 2010
Prevention:Curing HCV Reduces the Risk of HCC
Non-SVR
SVRNon-SVR
SVR
For patients with cirrhosis, continue screening even after cured
Where do you start?
US Preventive Services Task Force (USPSTF) Guidelines -2012
One time screening of all baby boomers (born 1945 through 1965) for HCV infection (USPSTF Rating: Class I, Level B)
USPSTF March, 2020 recommendation update to screen all adults 18-79 (Level B)
Rate of cure for each regimen varies depending on Genotype Presence of cirrhosis Prior treatment for HCV
Most of these have >90% cure rate
EMR Best Practice AlertBorn 1945-1965, seen in primary
care clinics with no prior HCV screening
ProviderEducation
and Feedback
Patient Navigation
and Education
Increased HCV clinic capacity
STOP-HCC (Screen Treat Or Prevent HCC) program (CPRIT PP150079)HCV is most common cause of HCC in U.S. and in TexasWe identified unscreened patients in the EMR and developed a multifaceted
intervention
Courtsey of Nicole E. Rich, MD
Provider Education
Patient Education
BPA will trigger for: Any person born between 1945-1965 with a primary clinic appointment who has not been
tested for HCV.
Patient Navigator Clinician Nurse Navigator
Medication Access Specialist/Pharmacist
Uninsured patients– medications obtained through Patient Assistance Program Insured patients– medications obtained through prior
authorization/appeal process
10.10
20.40
54.00
78.30
43.30
34.50
8.30
83.50
62.00
70.50
0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
80.00
90.00
Screened HCV Ab+ HCV RNA tested HCV RNA+ Linked to care
% Pre-Best PracticeAlert
Post- Best PracticeAlert
N=4,946 N=509
3.5 fold increase in screening rate
P<0.0001
N=1,007N=982 N=545 N=820 N=427N=11,780
Jain et al. Hepatology 2019; 70:40-50.
N=185 N=359
Predictors of SVR 12 Presence of decompensated
cirrhosis increased risk of treatment failure OR 0.37, 95% CI: 0.16-0.85
No differences in response by Race/ethnicity minorities vs. whites 91% vs. 87% , p=0.15
Insured vs. uninsured 90% vs. 90%, p=0.98
Drug and Alcohol Use 92% vs. 89%, p=0.34
HIV infection 90% vs. 87%, p=0.51
Mental health disorders 90% vs. 89%, p=0.57
90%
5%
1%1%
3%
SVR 12
SVR 12
lost to follow-up
death
Adverse events
Relapsse
N=512
Yek et al. BMC Medicine 2017
Implemented a patient navigation 1/1/2016.
Allowed 3 months after HCV RNA+ for usual care referral & if not done navigation started.
1393 (805 pre- & 588 post): 63% Black, 61% male, 61% uninsured.
No differences seen in proportion starting treatment of achieving SVR between the pre-intervention and post-intervention group
0%
10%
20%
30%
40%
50%
60%
70%
80%
Completed HCVevaluation within 6
months
Completed HCVevaluation anytime
Prop
orti
on c
omp
lete
d H
CV
eva
luat
ion
visi
t
Linkage to care
Pre-intervention :6/1/2013-5/31/2015
Post-Intervention:1/1/2016-12/31/2017
P<.0001
P<.0001
Jain et al. AASLD 2019
Train Primary Care providers Developed HCV slide sets Educated providers in FQHCs Re-trained as needed with new providers
Individual consultation with specialist to assist with treatment selection Survey with key HCV data completed by clinician Phone discussion on treatment
Navigators helped with follow-up Obtaining ultrasound Obtaining approval through patient assistance program
John Peter Smith has implemented a HCV alert under health maintenance and will be implementing navigation.
El Paso has implemented an HCV alert under health maintenance and will implement a link to order HCV Ab with reflex RNA testing.
We are using mobile van to screen patients in rural counties in North Texas through Moncrief Cancer Center
We will expand our services to include hepatitis B vaccination through partnership with DFW Hepatitis B Free student organization
JPS Fort Worth
Tenet Health El Paso
Community Outreach: Hepatitis B & C Testing
DFW Hepatitis B Free Organization
Dallas County
HCV Ab tested10825
HCV RNA tested1324
HCV RNA +696
HCV Ab+763
South Texas
HCV Ab tested3549
HCV RNA tested
101
HCV RNA +43
HCV Ab+119
Mobile Van For Cancer Screening
UT Southwestern UT Health San Antonio
Mamta K. Jain, MD, MPHNicole E. Rich, MDAmit G. Singal, MDDeyaun Villarrel, PhDLisk Quirk, MPH, MSPatrice Perryman, MPHJoanne Sanders, MSAnupama Vasudevan, BDS, MPH, PhDBrian Adamson, MSChul Ang, PhDJennifer McBryde, PA-CThuy Vu, DNPConnie RazakGrace Thompson, RNAmarachi Agada, MPHZamantha Magalis, BA
Bertha E. Flores, PhD, APRN, Barbara J. Turner, MD, MSEDRaudel Bobadilla BS, CHWAro Choi MSAdrian CebulaWHNPLudivina Hernandez CHWAriel Gomez BS, CHESSarah Lill MAMCharles Mathias PhDTrisha Melhado MPHJulie Parish Johnson, MS, LCDC, CRCLaura Tenner MDAndrea Rochat MFAJing Wang, PhDPaula Winkler MEd
Moncrief & JPS
Keith Argenbright, MDStephanie Lawerence, PA-CEmily Berry Sarah ZamarripaAurelio RodriguezLuAnn Snipes, RNRachel Stewart, PA-CMelissa AccostaRohit Ojha, PhD
