studies

HEPATOLOGY, VOLUME 62, NUMBER 1 (SUPPL) AASLD ABSTRACTS 1081A
1791
Ability of EMR-based fibrosis scores to identify HCV-infected
patients with cirrhosis
Mohammad Qasim Khan 3 , Vijay Anand 3 , Ammar Hassan 3 , Alya
Assan 3 , Amnon Sonnenberg 2 , Claus J. Fimmel 1 ; 1 Gastroenterology,
Northshore University Health System, Evanston, IL; 2 Gastroenterology,
Oregon Health Sciences University, Portland, OR;
3 Internal Medicine, NorthShore University Health System, Evanston,
IL
Background: With the advent of fixed-dose treatment regimens
for chronic HCV (CHC) infection and the updated, population-based
screening guidelines, clinicians are faced with the
challenge of assessing the degree of liver fibrosis in large
patient populations. We asked whether it would be possible
to predict cirrhosis in HCV-infected patients using fibrosis algorithms
that are entirely based on simple laboratory and demographic
features extractable from the electronic medical record
system (EMR). Objective: To compare a set of seven EMR-derived
fibrosis scores with liver imaging studies in a cohort of
CHC patients. Methods: Patients with CHC (n=869) were identified
by searching the EPIC-derived patient data warehouse. A
total of 566 patients had undergone a liver imaging study, and
had no confounding medical conditions affecting the fibrosis
scores. Cirrhosis was defined as the presence of a nodular
liver or portal collaterals on ultrasound, CT, or MRI imaging.
Demographic and laboratory data were extracted from the
EMR, matched with the date of the imaging studies, and used
to calculate the following previously established fibrosis scores:
APRI, Fib4, Fibrosis Index, Forns, GUCI, Lok Index, and Vira-
HepC. Areas under the receiver operating curves (AUROC),
optimum cut-offs, positive and negative predictive values were
calculated for each score. Results: The seven algorithms performed
similarly well in predicting cirrhosis (Table). No single
test was superior as all of their AUROC confidence intervals
overlapped. Sensitivites ranged from 0.65 to 1.00, specificities
from 0.67 to 0.90, positive predictive values from 0.33
to 0.38, and negative predictive values from 0.93 to 1.00.
Summary: EMR-based algorithms performed well in ruling out
radiologic cirrhosis, whereas their ability to predict the presence
of cirrhosis was modest. Conclusions: Simple, EMR-based
scoring systems can be used to rule out advanced cirrhosis in
CHC patients with high reliability. They are less accurate in
identifying patients with advanced cirrhosis, suggesting that
positive scores would need to be confirmed by secondary testing.
Table
1792
Characteristics of Patients Tested for Hepatitis C and
Intervention Costs in the BEST-C Study
Joanne E. Brady 1 , Danielle Liffmann 1 , Anthony K. Yartel 2 , Natalie
B. Kil 3 , Alex D. Federman 3 , Cynthia E. Jordan 4 , Omar I. Massoud 4 ,
David R. Nerenz 5 , Kimberly Ann Brown 5 , Bryce Smith 6 , Claudia
Vellozzi 2 , David B. Rein 1 ; 1 Public Health, NORC at the University
of Chicago, Bethesda, MD; 2 Division of Viral Hepatitis, U.S. Centers
for Disease Control and Prevention, Atlanta, GA; 3 Division
of General Internal Medicine, Mount Sinai School of Medicine,
New York, NY; 4 Department of Medicine, University of Alabama
at Birmingham, Birmingham, AL; 5 Department of Medicine, Henry
Ford Hospital, Detroit, MI; 6 Division of Diabetes Translation, U.S.
Centers for Disease Control and Prevention, Atlanta, GA
Given that 80% of Hepatitis C virus (HCV)-infected Americans
were born during the years 1945-1965, the Centers for Disease
Control and Prevention (CDC) and the U.S Preventive
Services Task Force recommended a one-time HCV antibody
test for adults born in the 1945-1965 birth cohort (BC). CDC’s
Birth-cohort Evaluation to Advance Screening and Testing for
Hepatitis C was designed to assess the impact of testing interventions
on the probability of HCV testing in primary care
(PC) among BC patients as compared to usual care and the
incremental costs per person tested and per case identified
at each site. From December 2012-March 2014, 3 health
systems implemented independent testing interventions using
randomized designs to compare intervention testing and identification
rates to usual care. Site 1 mailed paid lab test orders
and repeated reminders to a randomly selected list of active
patients compared to a second list who received no mailings.
Site 2 created an electronic health record best practice alert
(BPA) implemented or not implemented based on cluster randomized
design. Site 3 directly solicited patients following a
scheduled PC visit and used a cluster randomized crossover
design. Multilevel multivariable regression was used to estimate
the risk ratio for HCV testing; activity-based costing was used
to estimate costs. HCV testing was significantly more common
for all interventions compared to controls; adjusted risk ratio
(aRR) 19.2, (95% CI, 9.7–38.2), 13.2 (95% CI, 3.6–48.6),
and 32.9 (95% CI 19.3–56.1) for sites 1, 2, and 3, respectively.
The BPA intervention had the lowest incremental cost
per person tested ($25 with fixed startup costs, $3 without
startup costs). The incremental cost per new case identified
under usual care ranged from $3,771-$6207 across sites. All
interventions increased HCV testing among the BC compared
to usual care, but also increased the costs. The cost per case
identified excluding startup costs was lowest for the BPA intervention
($1,691), suggesting that integrating BC testing into
usual care is likely to be more cost-effective than instituting an
intervention in addition to usual care, e.g., repeated-mailings
and patient-solicitation.
n=number of patients, AUROC=area under the receiver operating
curve, CI=confidence interval
Disclosures:
The following authors have nothing to disclose: Mohammad Qasim Khan, Vijay
Anand, Ammar Hassan, Alya Assan, Amnon Sonnenberg, Claus J. Fimmel
Costs measured in dollars