Linkage to specialty care in the hepatitis C care cascade

Abstract

Quality gaps exist in the hepatitis C virus (HCV) care process from diagnosis to cure. To better understand current gaps and to identify targets for quality improvement, we constructed an HCV care cascade in a patient-centered medical home (PCMH) with an emphasis on the specialty referral process. We performed a retrospective study of HCV-infected patients in a PCMH using electronic health record (EPIC) data. Patients with a first positive HCV RNA between 2012 and 2019 were included. With an adaptation to analyze linkage to specialty care, we created an HCV care cascade that included the following: (1) a positive HCV RNA, (2) referral to a specialty provider, (3) a scheduled specialty appointment, (4) attendance at a specialty visit, (5) prescription for HCV therapy, and (6) evidence of sustained virological response (SVR). Patient and referring clinician characteristics were analyzed at each step of the care pathway, and the proportion of patients completing each step was calculated. Of the 256 HCV RNA-positive patients, 229 (89.5%) received a specialty referral; 215 (84.0%) had an appointment scheduled; 178 (69.5%) attended the specialty appointment; 116 (45.3%) were prescribed antiviral therapy; and 87 (34.1%) had documented SVR during the study period. Of the 178 patients attending a specialty visit, 62 (34.8%) did not receive a prescription, and the barrier most often noted was the desire for further workup (40.3%). Gaps occur at all stages of the HCV care continuum, with drop-offs in care occurring both before and after linkage to specialty care.