Trinh Jane, Turner Nicholas
Internal Medicine, Duke University Health System, Durham, North Carolina, USA.
Pediatrics, Duke University Health System, Durham, North Carolina, USA.
BMJ Open Qual. 2018 May 26;7(2):e000108. doi: 10.1136/bmjoq-2017-000108. eCollection 2018.
Hepatitis C (HCV) is a viral liver disease that can result in cirrhosis, hepatocellular carcinoma, liver transplantation or death. The Centers for Disease Control (CDC) estimates that 2.7-3.9 million Americans are living with HCV, yet the majority are unaware. Starting in 2013, both CDC and US Preventative Services Task Force guidelines agreed in recommending HCV screening for all those born between 1945 and 1965 yet many clinics have been slow to adopt screening.
We designed a quality improvement project seeking to improve HCV screening rates among patients seen for new or annual visits to ≥90% over a 3-year period in an academic primary care clinic.
Screening rates were assessed through repeated review of charts (50 per cycle or 300 charts total, roughly 35% of eligible visits) as a series of interventions were executed. Sustainability was assessed by repeating an additional 50-chart analysis 1 year after completion of the study interventions. At the conclusion of the study, a post hoc analysis of socioeconomic factors was undertaken to determine whether gender, income or ethnicity might affect screening rates.
Over 6 cycles of interventions, screening rates improved from 24% to ≥90%. Screening rates remained at 88% 1 year after completion of the interventions. The most effective interventions used reminders built into our electronic medical record and informed providers of their personal HCV screening rates relative to the clinic as a whole. Our post hoc analysis found that lower socioeconomic standing and white race were associated with reduced likelihood of screening.
Provider adoption of new HCV screening guidelines can be markedly and sustainably increased with electronic medical record prompts as well as directed feedback informing providers of their personal screening rates compared with colleagues.
丙型肝炎（HCV）是一种病毒性肝病，可导致肝硬化、肝细胞癌、肝移植或死亡。疾病控制中心（CDC）估计，有270万至390万美国人感染了HCV，但大多数人并不知晓。从2013年开始，CDC和美国预防服务工作组的指南都一致建议对所有1945年至1965年出生的人进行HCV筛查，但许多诊所采用筛查的速度一直很慢。
我们设计了一个质量改进项目，旨在使一所学术性初级保健诊所中因初次就诊或年度就诊前来的患者的HCV筛查率在3年内提高到90%以上。
在实施一系列干预措施时，通过反复查阅病历（每个周期50份或总共300份病历，约占符合条件就诊的35%）来评估筛查率。在研究干预措施完成1年后，通过再次进行50份病历的分析来评估可持续性。在研究结束时，对社会经济因素进行事后分析，以确定性别、收入或种族是否可能影响筛查率。
经过6个周期的干预，筛查率从24%提高到了90%以上。干预措施完成1年后，筛查率仍保持在88%。最有效的干预措施是利用电子病历中的提醒功能，并告知医生其个人HCV筛查率相对于整个诊所的情况。我们的事后分析发现，社会经济地位较低和白人种族与筛查可能性降低有关。
与同事相比，通过电子病历提示以及告知医生其个人筛查率的定向反馈，可以显著且可持续地提高医生对新HCV筛查指南的采用率。
