Testing for hepatitis C virus (HCV) is critical for baby boomers who account for nearly 70% of all HCV cases in the US. However, screening rates remain low for this birth cohort, despite guidelines from the CDC and the US Preventive Services Task Force that recommend testing for all individuals in this age group.
To address this problem, a quality improvement program was implemented in a Durham, North Carolina-based internal medicine/pediatrics practice. Thanks to the program, screening rates improved from 24% to greater than 90%. How did they do it? They implemented a sequence of interventions (6 cycles) including screening remiders built in to electronic medical records, and providing feedback to clinicians on how their screening rates compared to others.
Check out the slide set above for more details on how exactly the program worked.
Using QI to Improve HCV Screening Rates. Baby boomers, born between 1945-1965, harbor 67% of all HCV cases and while universal screening is recommended, many clinics have been slow to adopt it. The QI project was designed to combat this issue and improve HCV screening rates in a Durham-based academic combined internal medicine/pediatrics practice that included 27 physicians.
Using QI to Improve HCV Screening Rates. The goal of the QI project was to improve HCV screening rates to over 90% over a 3-year period. HCV screening rates were assessed every 6 months over a 3-year period with a review of charts (50 charts per interval or 300 total, 35% of eligible visits).
Step 1: Baseline Survey of Provider Knowledge. Clinic providers were surveyed on HCV screening knowledge, skills, and attitude. Chart data was recollected post-survey and evaluated for HCV screening status in baby boomers. Only 24% of patients had HCV results in the EMR, but there was a small increase (4%) in documentation of HCV testing discussion with patient.
Step 2: Guidance on How to Discuss HCV Screening with Patients. The EMR script was used to facilitate counseling on the need for testing and outlined reasons for new recommendations. Results showed screening rates essentially did not improve and it was clear that discussion assistance tools were not enough. Subsequent interventions need to directly target provider's decision to screen.
Step 3: Add EMR Prompt to Annual Visit Template. During this step, the provider prompts in the note template were used by the clinic for annual and new patient visits. HCV screening rates remained at 30%, but documented discussions of HCV screening increased to 36%. In a follow-up survey, 67% said they relied on the EMR health maintenance section, suggesting that clinician guidance placed here may represent the best approach to improving screening rates.
Step 4: Update EMR Prompt with Age-Specific Information. An automatic, age-specific prompt was placed in the health maintenance section with an additional line added to the annual clinic visit template listing HCV screening for baby boomers with choices of "not indicated," "declined," or "complete." Screening rates slightly improved to 38% and documentation rate increased to 40%.
Step 5: Incorporate HCV Screening in Health Maintenance Section. During this step, authors successfully petitioned EMR management board to add modified EMR prompt which "forced" response to screening. The screening rate improved to 60% and documentation rate to 64%. Patients who declined testing accounted for 3% of missed screening opportunities.
Step 6: Provider HCV Screening Audit and Reward System. First intervention consisted of providers individually notified via email of their HCV screening rate vs the clinic's overall rate. Providers with a lower reate were given a reminder to update clinic templates. The screening rates improved to 74% and documentation rates increased to 84%.
Step 6: Provider HCV Screening Audit and Reward System. The second intervention offered rewards for the highest screening rates in the clinic including copies of Sanford Guides and AAP Redbooks. The incentive program was announced via email and at one residency program meeting. Screening rates finally reached 90% and documentation rates increased to 96%.
QI to Improve HCV Screening Rates: How Did it Work? One year after completion of the 6 cycles, screening rates remained high at 88% and documentation rates at 80%. Barriers to screening in post-hoc analysis included white race and lower socioeconomic standing.
QI interventions dramatically and sustainably improved HCV screening rates in an academic primary care clinic.
Efforts to improve knowledge alone helped raise awareness of the screening recommendation, but had no impact on screening rates.
EMR prompts and individualized provider feedback were among particularly effective in improving screening rates.