A contactless cure: Leveraging telehealth to improve hepatitis C treatment at a safety-net hospital.

Hepatitis C virus (HCV) causes significant mortality worldwide. HCV is highly curable but access to care is limited for many patients. The Grady Liver Clinic (GLC), a primary care-based HCV clinic, utilizes a multidisciplinary team to provide comprehensive care for a medically underserved patient population in Atlanta, Georgia. The GLC added a telehealth option for HCV treatment at the start of the COVID-19 pandemic. We describe the outcomes of utilizing telehealth in this population. We performed a retrospective chart review of patients who initiated HCV treatment from March 2019 to February 2020 (pre-pandemic) and March 2020 to February 2021 (pandemic). Charts were abstracted for patient demographics and characteristics, treatment regimen, and treatment outcomes. Our primary outcome was HCV cure rate of the pre-pandemic compared to the pandemic cohorts and within the different pandemic cohort visit types. We performed an intention-to-treat (ITT) analysis for all patients who took at least one dose of a direct-acting antiviral (DAA) regardless of therapy completion, and a per-protocol (PP) analysis of those who completed treatment and were tested for HCV cure. SVR12 rates were >95% on ITT analysis, with no significant difference between pre-pandemic and pandemic cohorts. There was also no significant difference within the pandemic group when treatment was provided traditionally, via telehealth, or via a hybrid of these. Our findings support the use of telehealth as a tool to expand access to HCV treatment in a medically underserved patient population.

Impact of Clinical Decision Support on Azithromycin Prescribing in Primary Care Clinics.

BACKGROUND: Inappropriate use of antibiotics in the outpatient setting is a common problem, yet literature evaluating best practices for stewardship interventions in this setting is sparse. OBJECTIVE: To evaluate the impact of clinical decision support (CDS) order panels for azithromycin prescribing on the percentage of inappropriate azithromycin prescriptions in primary care clinics. DESIGN: Single-center, retrospective analysis of azithromycin prescribing within nine primary care clinics. Pre-intervention and post-intervention data included azithromycin prescriptions from November 2016 to April 2017 and February 2019 to July 2019, respectively. Key exclusion criteria included prescriptions for the treatment of a sexually transmitted infection or for prophylaxis against Mycobacterium avium complex. INTERVENTION: The azithromycin CDS panel was created to provide point-of-care information on appropriate use of azithromycin along with recommended alternatives based on indications. CDS panels were implemented on January 10, 2019. MAIN MEASURES: The primary composite outcome was the change in the percentage of inappropriate azithromycin prescribing before and after implementation of CDS panels. The composite outcome included prescriptions with inappropriate indications for azithromycin, unnecessary prescriptions, inappropriate treatment durations, and/or inappropriate dose. KEY RESULTS: There were 306 and 263 prescriptions for azithromycin prescriptions included for analysis in the pre- and post-intervention periods, respectively. Inappropriate prescriptions decreased by 12.6% from the pre- to post-intervention period (81.4% vs. 68.8%; P < 0.001). In both the pre- and post-intervention period, bronchitis and unspecified upper respiratory tract infections (URI) were the two most common indications where azithromycin was prescribed inappropriately. CONCLUSIONS: Implementation of CDS order panels resulted in a reduction in inappropriate azithromycin prescribing. However, additional improvement in azithromycin prescribing is needed especially for the indications of bronchitis and unspecified URI.

Large-Scale, Primary Care-Based Hepatitis C Treatment in an Urban, Medically Underserved Patient Population.

Hepatitis C virus (HCV) infection is a critical public health concern in the United States. HCV is highly curable, but access to care is limited for many patients. Primary care models can expand access to HCV care. The Grady Liver Clinic (GLC) is a primary care-based HCV clinic founded in 2002. During 20 years, using a multidisciplinary team, the GLC expanded its operations in response to advances in HCV screening and treatment. We describe the clinic model, patient population, and treatment outcomes of the clinic from 2015 through 2019. During this period, 2689 patients were seen in the GLC, and 77% (n = 2083) initiated treatment. Eighty-five percent (1779 of 2083) of patients who started treatment completed treatment and were tested for cure, and 1723 (83% of the total treated cohort, 97% of those tested for cure) were cured. Building on a successful primary care-based treatment model, the GLC dynamically responded to the changes in HCV screening and treatment guidelines, continually increasing access to HCV care. The GLC serves as a model of primary care-based HCV care that aims to achieve HCV microelimination in a safety-net health system. Our findings support the notion that for the United States to achieve elimination of HCV by 2030, generalists can and should provide HCV care, particularly in medically underserved patient populations.

Incorporation and Impact of a Clinical Pharmacist in a Hospital-Based Neurology Clinic Treating Patients with Multiple Sclerosis.

BACKGROUND: Clinical pharmacists are uniquely positioned to assist with the complexities of medication management for patients with multiple sclerosis (MS). The objective was to describe clinical pharmacy services provided, as well as provider satisfaction with and perceived impact of incorporating a clinical pharmacist in MS patient care. METHODS: The study consisted of a retrospective medical record review and a provider survey conducted in an outpatient neurology clinic at an academic medical center. Between April 2017 and June 2018, electronic medical records of patients with documented interventions by a pharmacist were reviewed to describe clinical pharmacy services provided to patients with MS. A voluntary, anonymous survey was distributed to neurology providers to evaluate provider satisfaction with and perceived impact of clinical pharmacist involvement in MS patient care. RESULTS: There were 64 patients identified with 378 documented interventions made by clinical pharmacists. Pharmacist interventions were mostly related to facilitating medication access (n = 208), pretreatment screening (n = 57), patient counseling (n = 51), and providing drug information (n = 43). All nine providers surveyed indicated that facilitating medication access, counseling patients, and managing drug interactions were moderately or very important clinical pharmacy services. Furthermore, all providers surveyed strongly agreed that pharmacist involvement decreased time to therapy initiation and provider time spent on medication management. CONCLUSIONS: Clinical pharmacists play an integral role in MS patient care, particularly with facilitating medication access. Prospective studies are needed to further evaluate the contribution of clinical pharmacists in MS patient care.

Evaluation of Human Papillomavirus Vaccination After Pharmacist-Led Intervention: A Pilot Project in an Ambulatory Clinic at a Large Academic Urban Medical Center.

OBJECTIVES: Despite the safety and efficacy of the human papillomavirus (HPV) vaccine, many persons are still not receiving it. The purpose of this pilot project was to evaluate the number of first doses of the 9-valent HPV (9vHPV) vaccination administered after a pharmacist-led intervention in the Adult Family Planning Clinic at Grady Health System (GHS), a large academic urban medical center in Atlanta, Georgia. METHODS: The pilot project had 3 phases: pre-intervention (November 15, 2016, through March 31, 2017), active intervention (November 15, 2017, through December 29, 2017), and post-intervention (December 30, 2017, through March 31, 2018). The pre-intervention phase was used as a historical control. The active intervention phase consisted of pharmacist interventions in the clinic and patient and health care provider education. The post-intervention phase evaluated the durability of pharmacist-led interventions performed and education provided during the active phase. RESULTS: Eighty-nine first-dose 9vHPV vaccines (of the 3-dose series) were administered to young adults aged 18-26 during the project period (November 15, 2017, through March 31, 2018); none were administered during the pre-intervention phase. Of 89 patients who received a first 9vHPV vaccine dose, 20 patients also received a second 9vHPV vaccine dose. During the project period, 166 doses of 9vHPV vaccine (first, second, or third doses) were administered. CONCLUSION: This pharmacist-led intervention led to an increase in the number of young adult patients receiving their first dose of the 9vHPV vaccination series. With the support of other health care providers, pharmacist-led initiatives can expand vaccine-related health literacy and facilitate access to immunization services.

Improved Hepatitis C Cure Cascade Outcomes Among Urban Baby Boomers in the Direct-Acting Antiviral Era.

OBJECTIVES: We compared outcomes of the hepatitis C virus (HCV) cure cascade (ie, the path a patient follows from diagnosis to cure), including antiviral treatment outcomes, from 2 HCV screening programs. Our objective was to assess whether treatment uptake and HCV cure rates improved in the cohort screened after the release of all-oral HCV direct-acting antiviral therapies. METHODS: We retrospectively compared outcomes of the HCV cure cascade from a cohort of newly diagnosed patients screened during 2012-2014 (period 1) with outcomes from a cohort of newly diagnosed patients screened during 2015-2016 (period 2) at Grady Health System in Atlanta, Georgia. Cure cascade outcomes included HCV antibody (anti-HCV) and RNA testing, linkage to care, antiviral treatment, and sustained virologic response. RESULTS: During period 1, 412 of 5274 (7.8%) persons screened were anti-HCV positive, and 264 (69.3%) of those tested were RNA positive. During period 2, 462 of 7137 (6.5%) persons screened were anti-HCV positive, and 240 (59.3%) of those tested were RNA positive (P = .003). The percentage of newly diagnosed patients who were treated during period 2 (64.0%) was 3 times that of newly diagnosed patients treated during period 1 (21.2%; P < .001). Both cohorts had similarly high levels of linkage to care (95.8% during period 1, 95.4% during period 2) and cure (92.6% during period 1, 95.5% during period 2). CONCLUSIONS: Over time, the prevalence of anti-HCV and HCV RNA positivity declined substantially, and linkage-to-care and cure rates remained high. Treatment uptake increased significantly after the introduction of all-oral direct-acting antiviral therapy. These findings suggest that combining large-scale screening initiatives with treatment programs can speed progress toward HCV elimination.

High-Yield Birth-Cohort Hepatitis C Virus Screening and Linkage to Care Among Underserved African Americans, Atlanta, Georgia, 2012-2013.

OBJECTIVE: Hepatitis C virus (HCV) infection disproportionately affects certain populations, including those born between 1945 and 1965 (i.e., baby boomers) and African Americans. As part of the Hepatitis Testing and Linkage to Care initiative, which promoted hepatitis B and hepatitis C screening, posttest counseling, and linkage to care at 34 U.S. sites, we conducted routine HCV screening to identify previously undiagnosed, primarily African American baby boomers with chronic hepatitis C infection and link them to care. METHODS: We launched the Internal Medicine Trainees Identifying and Linking to Treatment for Hepatitis C (TILT-C) initiative at the Grady Memorial Hospital Primary Care Center and Grady Liver Clinic in Atlanta, Georgia, in October 2012, and present results from the first year. TILT-C faculty implemented an electronic medical record prompt and conducted educational sessions to boost HCV screening. A project coordinator tracked testing outcomes and linked HCV-positive patients to care. RESULTS: Of 2,894 patients tested for anti-HCV, 201 (6.9%) tested positive. Men had a significantly higher (p<0.001) prevalence of HCV infection than women, with 106 of 1,091 (9.7%) men compared with 95 of 1,803 (5.3%) women testing anti-HCV positive. A total of 174 of 201 (86.6%) anti-HCV-positive patients received HCV ribonucleic acid (RNA) testing. Of 124 patients with a positive HCV RNA test, 122 were referred to care and 120 attended the first appointment. CONCLUSION: The TILT-C screening program was feasible and effective in detecting previously undiagnosed HCV infection and linking patients to care. The unexpectedly high prevalence of HCV infection in this primarily African American, baby boomer population underscores the need for aggressive HCV screening efforts in similar populations.