Researchers Look at Optimal Communication Method for HCV Screenings

A large proportion of HCV patients remain undiagnosed, particularly in the older population.

It remains challenging and important for high-risk individuals to be screened for hepatitis C virus (HCV) infections.

A team, led by Shivan J. Mehta, assistant professor of Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, evaluated whether opt out framing, messaging incorporating behavioral science concepts or electronic communication increases the prevalence of HCV screening for patients born between 1945-1965.

"We think that sending the lab order with outreach was so successful because it framed screening as the default,” Mehta said in a statement. "However, this strategy was also successful because it reduced effort and the number of steps to screen by both the patient and clinician."

Hepatitis C is one of the leading causes of liver transplants and hepatocellular carcinoma in the US. While the advent of direct acting antivirals (DAA) has improved care, there are still a high rate of undiagnosed patients in the older populations.

The Different Communication Methods

In the randomized controlled trial, the investigators examined data of 21,303 patients from 43 primary care practices from an academic health system in Philadelphia between April 2019 and May 2020.

Each patient was born between 1945-1965 and had no history of screening and at least 2 primary care visits in the 2 years prior to enrolling in the study.

The study was divided into 2 different cohorts—a substudy (A) that included 1656 patients of 17 primary care clinicians who were randomized to receive either a mailed letter about HCV screening or a similar letter with a laboratory order for HCV screening and a substudy (B) that included 19,837 patients followed by 417 clinicians.

In addition, active electronic patient portal users were randomized at a 1:5 ratio to receive either a mailed letter about HCV screening or an electronic patient portal message with similar content. Inactive patient portal individuals were also mailed a letter.

Participants in substudy B were also randomized equally to receive standard content or content based on the principles of social norming, anticipated regret, reciprocity, and commitment.

The investigators sought main outcomes of the proportion of patients who completed HCV testing within 4 months.

Surprising Results

In the final analysis, the researchers found 19.2% of patients in substudy A (95% CI, 16.5-21.9%) completed screening in the letter only cohort and 43.1% (95% CI, 39.7-46.4%) in the letter and order arm completed screening (P <0.001).

In substudy B, 14.6% (95% CI, 13.9-15.3%) of the usual care content patients and 13.6% (95% CI, 13.0-14.3%) of the behavioral science group completed screening (P = 0.06).

For the active patient portal participants, 17.8% (95% CI, 16.0-19.5%) completed screening after they received a letter, compared to 13.8% (95% CI, 13.1-14.5%) of the group that received a patient portal message completed screening (P <0.001).

"This was the biggest surprise for us. Many presume that most people are moving digital towards email, but for some populations, traditional letters might be best," Mehta said. "Additionally, the user experience of the secure messages also may have had to do with the lower response rate. Patients need to click on a link and remember their password, which may pose challenges."

The study, “Behavioral interventions to improve population health outreach for hepatitis C screening: randomized clinical trial,” was published online in BMJ.