Treating Hepatitis C Virus Reinfection With 8 Weeks of Ledipasvir/Sofosbuvir Achieves Sustained Virologic Response.

Three patients reinfected with hepatitis C virus after a sustained virologic response were considered treatment naïve and treated with a short-course direct acting antiviral regimen.

Evaluating a hepatitis c quality gap: missed opportunities for HCV-related cares.

OBJECTIVES: Diagnosis of chronic hepatitis C virus (HCV) is a 2-step process involving hepatitis C antibody (HCVab) testing followed by viral ribonucleic acid (RNA) testing. The HCV status of those with a positive HCVab without viral testing cannot be determined. This study sought to describe the HCV-related care provided to patients in this care gap. STUDY DESIGN: Retrospective cohort study of active patients with a positive HCVab test who did not complete viral testing. METHODS: Electronic medical records (EMRs) were reviewed to determine if each subject's first positive HCVab result was acknowledged by a provider. For results acknowledged, we described provider actions in response to the result. When providers performed specific clinical actions within 1 year of the positive HCVab test, we captured the type of action taken. When the unsubstantiated diagnosis was documented in the EMR, we determined if the diagnosis was mentioned by subsequent providers. RESULTS: Positive HCVab results were not acknowledged in 31% of subjects. In 35%, providers added chronic HCV to the problem list in the EMR, resulting in a higher likelihood of subsequent providers mentioning the diagnosis in their EMR documentation. In 143 subjects whose providers recommended HCV-related clinical actions within 1 year of the positive result, 45% were educated about HCV and 42% had their liver enzymes monitored. CONCLUSIONS: With more widespread testing anticipated and more effective treatments available, health systems should ensure the HCV diagnostic process results in the delivery of an accurate and timely HCV diagnosis, to reduce the risk of harm to patients.

Implementation and evaluation of a multicomponent quality improvement intervention to improve efficiency of hepatitis C screening and diagnosis.

BACKGROUND: Given recent advances in hepatitis C virus (HCV) treatment, health systems must ensure that patients with a positive HCV antibody receive timely determination of their HCV status through viral testing. At the Louis Stokes Cleveland Department of Veterans Affairs Medical Center, viral testing was completed within six months of the first instance of a positive HCV antibody test for only 45% of patients. Beginning in 2008, three sequential improvements were implemented to close this care gap. METHODS: The three sequential improvements phases were as follows: (1) improving patient-centeredness of screening process in ambulatory patients, (2) local implementation of the Department of Veterans Affairs national HCV reflex testing policy, and (3) local evaluation of the efficiency and effectiveness of local implementation of reflex testing. RESULTS: From 2005 through 2013, 40 to 150 unique patients/quarter required viral testing following a positive antibody test. The firsts and second-phase improvements resulted in a 68% and 96% completion rate for timely viral testing during respective improvement phases. In the third improvement phase, remaining process problems related to the reflex testing process were identified using a locally developed electronic HCV population management application, resulting in a sustained rate of 100% completion of timely viral testing. Interrupted time series analysis revealed that the implementation of HCV reflex testing had the largest impact on the ability to complete timely viral testing. CONCLUSIONS: A continuous quality improvement approach, supported by an HCV population management application, achieved the complete closure of an important HCV care gap. Reflex testing should be initiated at facilities that have yet to adopt this approach.

Effective antimicrobial stewardship in a long-term care facility through an infectious disease consultation service: keeping a LID on antibiotic use.

DESIGN: We introduced a long-term care facility (LTCF) infectious disease (ID) consultation service (LID service) that provides on-site consultations to residents of a Veterans Affairs (VA) LTCF. We determined the impact of the LID service on antimicrobial use and Clostridium difficile infections at the LTCF. SETTING: A 160-bed VA LTCF. METHODS: Systemic antimicrobial use and positive C. difficile tests at the LTCF were compared for the 36 months before and the 18 months after the initiation of the ID consultation service through segmented regression analysis of an interrupted time series. RESULTS: Relative to that in the preintervention period, total systemic antibiotic administration decreased by 30% (P<.001), with significant reductions in both oral (32%; P<.001) and intravenous (25%; P=.008) agents. The greatest reductions were seen for tetracyclines (64%; P<.001), clindamycin (61%; P<.001), sulfamethoxazole/trimethoprim (38%; P<.001), fluoroquinolones (38%; P<.001), and ß-lactam/ß-lactamase inhibitor combinations (28%; P<.001). The rate of positive C. difficile tests at the LTCF declined in the postintervention period relative to preintervention rates (P=.04). CONCLUSIONS: Implementation of an LTCF ID service led to a significant reduction in total antimicrobial use. Bringing providers with ID expertise to the LTCF represents a new and effective means to achieve antimicrobial stewardship.

Pilot study to assess subjective and objective reporting of potential adverse drug reactions in older versus younger HIV-infected patients using antiretroviral therapy.

Limited data exist on tolerability of antiretroviral therapy (ART) in older HIV-infected patients compared to their younger counterparts. There is also concern for overlap of ART toxicities with concomitant conditions potentially leading to an increased burden of ART-related adverse drug reactions (ADRs). A prospective, descriptive-comparative study was conducted to compare incidence and severity of ADRs secondary to ART in older (≥ 50 years) versus younger (<50 years) HIV-infected patients. No differences were found in the presence or severity of subjective or objective ADRs between groups. The burden of intolerance appeared to be high for certain ADRs in both age groups. Regardless of age, subjects with certain concomitant illnesses had higher rates of potential ADRs. Providers need to be aware of patient characteristics that lead to increased rates of ART intolerance; for patients with an increased comorbidity burden, providers need to be attentive to the potential impact on ART tolerability.