Providers May Be Overlooking Average-Risk Patients for HCV Screening

Monica Kasting, PhD

Credit: Purdue University

Although the US Preventive Services Task Force recommends universal hepatitis C virus (HCV) screening for all individuals 18-79 years of age, findings from a recent study suggest providers may still be basing their recommendations on patient risk factors and overlooking screening in patients perceived to be at average-risk of infection.¹

In the cross-sectional survey of 284 primary care providers in Indiana, 42.4% reported strongly recommending HCV screening to patients who did not present risk factors compared to 70.4% for high-risk patients, also showing the strength, frequency, and timeliness of screening recommendations were lower for average-risk patients compared to their high-risk counterparts.¹

“A strong recommendation from healthcare providers is one of the strongest predictors of preventive services uptake,” Monica Kasting, PhD, assistant professor in the department of public health at Purdue University, and colleagues wrote.¹ “Unfortunately, providers tend to recommend HCV screening on an individual, case-by-case basis rather than adopting universal screening consistently.”

Globally, an estimated 58 million people have chronic hepatitis C virus infection. Many cases often go undiagnosed because patients remain asymptomatic until symptoms eventually develop secondary to serious liver damage – to account for these individuals, in 2020, the US Preventive Services Task Force updated their screening recommendations to include those who did not display high-risk behaviors or medical conditions. However, many providers continue to make risk-based screening recommendations, potentially overlooking asymptomatic individuals who are not considered to be high-risk but could still have HCV.^2,3

To examine differences in providers’ HCV screening recommendations between high-risk and average-risk patients, investigators recruited primary care providers from August - November 2020 and invited them to participate in the 94-item cross-sectional survey. Physicians, nurse practitioners, or physician assistants practicing in internal medicine or adult family medicine in Indiana were eligible for inclusion.¹

The final sample included 284 providers, 49.6% (n = 130) of whom were female with an average age of 47.3 (Standard deviation, 10.9) years. The majority of participants were non-Hispanic White (75.2%), specialized in family medicine (60.2%), were physicians (69.7%), and practiced in private practices (55.3%) in suburban areas (46.6%).¹

Investigators assessed provider characteristics, HCV screening recommendation practices, self-efficacy, and barriers to recommending HCV screening. Regarding screening recommendations, they examined provider-reported strength, presentation, frequency, and timeliness. Strength and frequency were measured on 4- and 5-point Likert scales, respectively, whereas presentation and timeliness were measured based on set response options. A recommendation was considered high-quality if it was strong, routine, frequent, and timely.¹

Investigators examined providers’ self-efficacy based on responses to 8 items regarding their ability to provide various aspects of HCV screening and care, rated on a 5-point Likert scale from no proficiency to expert proficiency. A further 11 survey items examined barriers to HCV screening at both the provider and patient level, again rated on a 5-point Likert scale.¹

High-risk patients were defined as those who may be engaging in behaviors that put them at risk of HCV infection, such as intravenous drug use, while average-risk patients included any adults 18–75 years of age. Upon analysis, there was a statistically significant difference in screening recommendations for high-risk versus average-risk patients that were strong (70.4% vs 42.4%), routine (61.9% vs 55.6%), frequent (37.7% vs 28.0%), and timely (74.2% vs. 54.9%) (P <.001).¹

Compared to average-risk patients, providers with high-risk patients were less likely to give a strong recommendation if they were nurse practitioners (Prevalence ratio [PR] = .49). Additionally, providers who practiced in a public health setting also reported a higher percentage of strong recommendations for average-risk patients compared to high-risk patients (PR = .57).¹

Further analysis revealed the odds of giving a strong recommendation for average-risk patients were significantly greater among providers with a predominantly Non-Hispanic Black patient population (adjusted odds ratio [aOR], 7.34; 95 % CI, 1.73–31.20) and for providers who had greater self-efficacy (aOR, 2.13; 95% CI, 1.08–4.21), whereas the odds of giving a strong recommendation were lower among physician assistants (aOR, 0.15; 95% CI, 0.04–0.63) and for providers who reported more barriers (aOR, 0.41; 95% CI, 0.23–0.72).¹

For high-risk patients, investigators noted the odds of giving a strong recommendation were significantly increased among providers with HCV screening training after residency (aOR, 5.01; 95% CI, 1.89–13.31) while higher barriers (aOR, 0.19; 95% CI, 0.09–0.39) and internal medicine specialty (aOR, 0.22; 95% CI, 0.08–0.57) were associated with lower odds of giving a strong recommendation.¹

“Most [primary care providers] are continuing to follow out-of-date guidance of risk-based HCV screening. Because provider recommendation is one of the strongest predictors of preventive service uptake, universally providing strong recommendation of HCV screening to patients, regardless of risk status, is crucial in improving HCV screening rates,” investigators concluded.¹

References:

1. ^{Laily A, Duncan R, Gabhart KM, et al. Differences in Provider Hepatitis C Virus Screening Recommendations by Patient Risk Status. Prev Med Rep. 2024;38:102602. doi:10.1016/j.pmedr.2024.102602}
2. ^{World Health Organization. Hepatitis C. Newsroom. July 18, 2023. Accessed February 26, 2024. https://www.who.int/news-room/fact-sheets/detail/hepatitis-c}
3. ^{US Preventive Services Task Force. Hepatitis C Virus Infection in Adolescents and Adults: Screening. March 2, 2020. Accessed February 26, 2024. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/hepatitis-c-screening}