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Linkage to specialty care in the hepatitis C care cascade
  1. Dena P Blanding1,
  2. William P Moran1,
  3. John Bian1,
  4. Jingwen Zhang2,
  5. Justin Marsden1,
  6. Patrick D Mauldin2,
  7. Don C Rockey2,
  8. Andrew D Schreiner1
  1. 1 Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
  2. 2 Internal Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
  1. Correspondence to Dr Andrew D Schreiner, Medicine, Medical University of South Carolina, Charleston, SC 29425, USA; schrein{at}


Quality gaps exist in the hepatitis C virus (HCV) care process from diagnosis to cure. To better understand current gaps and to identify targets for quality improvement, we constructed an HCV care cascade in a patient-centered medical home (PCMH) with an emphasis on the specialty referral process. We performed a retrospective study of HCV-infected patients in a PCMH using electronic health record (EPIC) data. Patients with a first positive HCV RNA between 2012 and 2019 were included. With an adaptation to analyze linkage to specialty care, we created an HCV care cascade that included the following: (1) a positive HCV RNA, (2) referral to a specialty provider, (3) a scheduled specialty appointment, (4) attendance at a specialty visit, (5) prescription for HCV therapy, and (6) evidence of sustained virological response (SVR). Patient and referring clinician characteristics were analyzed at each step of the care pathway, and the proportion of patients completing each step was calculated. Of the 256 HCV RNA-positive patients, 229 (89.5%) received a specialty referral; 215 (84.0%) had an appointment scheduled; 178 (69.5%) attended the specialty appointment; 116 (45.3%) were prescribed antiviral therapy; and 87 (34.1%) had documented SVR during the study period. Of the 178 patients attending a specialty visit, 62 (34.8%) did not receive a prescription, and the barrier most often noted was the desire for further workup (40.3%). Gaps occur at all stages of the HCV care continuum, with drop-offs in care occurring both before and after linkage to specialty care.

  • primary health care
  • hepatitis C

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  • Contributors All authors made significant contributions to the conception of the work. DB, AS, JZ, and JM were responsible for the acquisition of data, and all authors contributed to the analysis and interpretation of data for the work. DB and AS drafted the original manuscript, but all authors significantly contributed to critical revisions and intellectual content. All authors gave final approval of the version to be published, and all authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

  • Funding Dr Schreiner is supported by a career development award (K23) from the National Institute of Health and National Institute of Diabetes and Digestive and Kidney Diseases (1K23DK118200 (principal investigator: AS).

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval This study was approved by the institutional review board at the Medical University of South Carolina.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information. Data for this study are deidentified, securely stored in an encrypted server, and used as permitted by the institutional review board at the Medical University of South Carolina.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.