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Adding hepatitis C virus (HCV) screening as a default order within the electronic health record (EHR) led to more eligible patients receiving screening during hospitalization compared with a conventional interruptive alert, a stepped-wedge randomized trial found.

Among over 7,600 patients at two hospitals, 69.9% of those in the intervention group completed HCV screening compared with 38.1% of those in the control group (P<0.001), reported Shivan Mehta, MD, MBA, of the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, and colleagues.

"Because this was an EHR-based intervention, there was minimal incremental cost to clinicians or the health system after implementation, and it potentially saved clinician time by reducing clicks," the authors wrote in .

HCV can lead to cirrhosis, liver transplant, and cancer, but use of direct-acting antivirals can result in sustained virologic response in most treated patients. Pennsylvania, along with other states, has mandated HCV screening for all eligible inpatients, despite prior age-specific recommendations, Mehta's group noted.

"However, legislating mandated HCV screening for inpatients does not recognize the reality of how hospital medicine is practiced," wrote Jenny Jia, MD, MSc, and Jeffrey Linder, MD, MPH, both of Northwestern University Feinberg School of Medicine in Chicago, in an .

"Defaults can be great. However, defaults need to be carefully designed, implemented transparently, occur at the appropriate time and setting, and target the intended action," they added.

For this stepped-wedge trial, Mehta and colleagues enrolled 7,634 patients (mean age 65) at two hospitals from June 23, 2020 to April 10, 2021. About 56% were men, 60.6% were white, 28% were Black, and 51.7% had Medicare. Average BMI was 29 to 30, and average Charlson Comorbidity Index score was 2.

Each of the three wedges lasted 3 months:

• Wedge one: both hospitals used the conventional interruptive alert prompting a physician to screen for HCV
• Wedge two: hospital B (the intervention group) was randomized to the default order for HCV screening in the EHR
• Wedge three: the default order was implemented in both hospital A (the control group) and hospital B

The baseline HCV screening rates were 37.5% and 30.8% in wedge 1 compared with 72.1% and 71.1% in wedge 3, Mehta and team reported. During wedge 2, 66.2% of patients at hospital B completed screening compared with 42.6% of patients at hospital A.

Of all included patients, a positive HCV viral load was detected in 29 patients in the control group and 34 patients in the intervention group.

The majority of patients with positive viral loads were linked to care or approached for counseling. Overall, 16 received a direct-acting antiviral prescription for HCV.

Mehta and colleagues noted that screening rate increases were seen in the control hospital wedges over time, likely due to "other concurrent interventions or familiarity with the hepatitis linkage team program." Additionally, since this study was conducted in an academic environment, the findings may not be applicable to other settings or populations.

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