mamta k. jain, md,mph91% vs. 87% , p=0.15 ... mamta k. jain created date: 10/20/2020 10:03:20 am

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