Quality Improvement in IBD Care: The Influence of a QI Specific Conference for Fellows

Given the complexity of management of inflammatory bowel disease (IBD), medical societies such as the American Gastroenterological Association (AGA) and Crohn’s and Colitis Foundation of America (CCFA) have established measures aimed at defining quality of care. In 2011, the AGA proposed 10 quality metrics for IBD, eight of these measures relate to outpatient management and two focus on inpatient management. Our objective was to evaluate compliance with these measures in our own general GI practice and determine whether a GI conference discussing quality improvement (QI) in 2017 was effective

Critical Importance of Using FibroScan to Identify Patients with Cirrhosis in a Predominantly African American Patient Population

Introduction: Identifying patients with cirrhosis is complicated, but the availability of Transient Elastography by FibroScan for non-invasive assessment of fibrosis appears to have resolved this issue. The objective of our study was to use a Fibroscan database to identify patients with cirrhosis in our primarily African American Hepatitis C patients and to track outcome especially of patients with Hepatitis C (HCV). Methods: The electronic medical records of 79 out of the 332 individuals (24%) with a Fibroscan between 2014 and 2016 and a score of \u3e12.5 kPa laboratory values recorded, and etiology and outcomes evaluated. AST to Platelet Ratio Index (APRI) and Fibrosis-4 (FIB-4) scores were calculated. An APRI score \u3e0.7 and FIB-4 score \u3e3.25 was used for predicting advanced fibrosis. Results: Cirrhotic patients were 92% AA, 52% male, and the majority had Hepatitis C (92%). In patients who had FibroScan-defined cirrhosis, neither their APRI nor FIB-4 scores were as reliable as FibroScan for identifying cirrhosis. The lack of accuracy for APRI and FIB-4 was due to low serum-based scores in patients with early onset cirrhosis. Outcomes for patients with HCV who were treated or not treated were tracked using improvement in FibroScan scores, and development of decompensated cirrhosis. For patients who had a subsequent FibroScan performed after HCV eradication (SVR), there was a statistically significant improvement in fibrosis, as compared to the non-treated patients (p Conclusions: FibroScan is useful for evaluating for cirrhosis in a predominantly African American population, including regression of fibrosis after HCV eradication

Renal Safety and Racial Disparity in Patients on Antiviral Treatment for Chronic Hepatitis B

Background: Many African Americans (AA) are chronically infected with Hepatitis B (HBV). While antiviral therapy is highly effective, clinical trials suggest a treatment-related decline in kidney function is possible. Given that chronic HBV predominately affects Asians worldwide, most studies have contained few AA patients. We evaluated these treatment-related kidney function changes in our predominately AA patient population. Methods: From 225 HBV patients, we identified 42 patients who were not co-infected with HIV or HCV, had a recent visit, and at least one earlier visit (before Jan 2017). If on treatment with antivirals it must have been for at least 2 years. There were 27 AA (65%) and 15 non-AA (7 Asian, 6 Caucasian, 2 other). There were 24 patients on antiviral treatment and 18 patients not on treatment. Most patients were treated with tenofovir disoproxil fumarate (TDF; n= 19), with the remaining 5 treated with entecavir. Serum creatinine levels (mg/dL) and glomerular filtration rate (GFR; mL/min/1.73m2) were obtained from the earliest visit and the most recent visit. The average time between measurements was 7.4 years (range from 2-15; median 6.5). Results : The data in the figure below presents the average creatinine and GFR for all patients by race both before and after treatment. The p-value is for pairwise analysis of the change between the two visits. Patients treated with antivirals had nearly double the increase in serum creatinine as compared to untreated patients (treated: 0.091± 0.0439, p\u3c0.05; vs untreated: 0.047 ± 0.045, not significant). There was also a greater decrease in kidney function as defined by GFR for patients on treatment as compared to untreated patients (treated: -13.9 ± 5.0, p\u3c0.05; vs untreated: -11.3 ± 5.9, not significant). The creatinine increase was also significant in AA but not in non-AA (+0.76 for AA, p\u3c0.05; vs +0.11 for non-AA). Racial disparity for GFR was not as noticeable (-12.2/95.2= 13% decrease; p\u3c0.005 for AA, and -16.2/92.3= 18% decrease; p\u3c0.05 for non-AA). When limited to just TDF, the induced increase in creatinine (+0.10; p\u3c0.05) and the decline in GFR (-14; p\u3c0.005) were statistically significant. Conclusions: While few patients had a clinically relevant rise in creatinine and/or decrease in GFR to raise the issue of stopping medication, the value of continuing to monitor especially the AA patients on anti-viral treatment is revealed by our data. The data supports the counselling of AA patients that switching to the newer formulation of tenofovir alafenamide (TAF) which is associated with less renal toxicity than TDF should be strongly considered

FAILURE TO TREAT HCV IN PATIENTS SEEN IN A PREDOMINATELY AFRICAN AMERICAN SOCIOECONOMICALLY CHALLENGED POPULATION

The research objective of this proposal is to investigate the impediment with respect to moving a patient from initial antibody/PCR positive to successful completion of treatment. Secondary objectives include determining the most effective way for patients to progress from initial antibody/PCR positive to treatment and identifying the roadblocks for HCV antibody/PCR positive patients to be treated effectively. Data was collected from 2019 HCV patient EMR charts, including demographics, laboratory studies, and treatment history. Concerning treatment, we evaluated linkage to the care; we defined success as treatment within six months of the initial visit. Thus, data on treatment initiation was collected through the first six months of 2020

A Younger Demographic Defines Hepatitis C Patient Profiles in the Recent Direct-Acting Antiviral Era

A Younger Demographic Defines Hepatitis C Patient Profiles in the Recent Direct-Acting Antiviral Era Authors: Minawala, Ria1; Naylor, Paul H.2; Ehrinpreis, Murray N.2; Mutchnick, Milton G.2 Institutions: 1. Wayne State University School of Medicine, Detroit, MI, United States. 2. Wayne State University School of Medicine, Division of Gastroenterology, Detroit, MI, United States. Background: Highly effective and safe direct-acting antivirals (DAAs) against hepatitis C virus (HCV) combined with U.S. Preventive Services Task Force recommendation to screen for HCV in individuals born between 1945 and 1965 (age cohort; 54-79 years of age in 2019) was expected to reduce the number of actively infected patients via identification and treatment. Nevertheless, HCV infections remain a significant health concern. A study of HCV infected patients in our urban internal medicine practice, during the interferon era and prior to the introduction of DAAs, demonstrated a population within the age cohort. The objective of this study was to characterize the current patient population seen in the same practice with respect to age, race, and treatment status to determine the impact of DAA therapy on patient profiles and to test the hypothesis that there would be an increase in younger population among those infected. Methods: Using electronic medical records, we identified patients who presented to our urban GI practice in 2019. Data collected from patient charts included demographics, liver function tests, HCV genotype, viral load, imaging studies, and treatment history. Results: There were 601 patients with HCV seen in 2019 and the majority were African American (AA) (85%) and male (66%). Comparison of age alongside gender and race revealed that non-AA patients (51 years, SEM = 0.9) were significantly younger than AA patients (63 years, SEM = 0.4; p Conclusion: The primary shift in patient demographics as compared to the interferon era has been toward younger, non- AA females. In contrast, the predominant AA patients are still within the age cohort. The emergence of younger patients has important implications for screening, patient outreach, and treatment plans. A more intensive evaluation for risk factors and the role of COVID-19 in treatment is warranted. Many AA and non- AA patients were not started on any treatment in 2019, signifying a need for continued follow-up after initial visit to close the linkage to care gap

Effect of Treatment for HCV on the Development of HCC in a Predominately African American Medical Center Population

Introduction Direct Acting Antivirals (DAA) are effective in Hepatitis C (HCV) patients with cirrhosis, but viral elimination may occur in a setting where the HCC development pathway has already begun. Our objective was to determine whether achieving a sustained virologic response (SVR) prior to diagnosis of hepatocellular carcinoma (HCC) improved outcomes in our predominately African American population. Methods We reviewed the medical records of 96 HCV patients diagnosed with HCC between 2015 and 2019 Primary outcomes were defined as either alive, death/hospice, or transplant. Tumor size was measured as non-small (\u3e 5cm or multiple tumors) or small (\u3c 5cm). The study was approved by the WSU IRB and data analysis performed using the SAS-JMP statistical software. Results Of the 96 patients with HCV who developed HCC, only 17 (18%) were treated for their HCV prior to diagnosis. There was no significant difference in the gender, race, and age of treated or non-treated patients. Hospice/death rates were found to be lower in the treated group when compared to those who were not treated prior to diagnosis (47% compared to 81% p = 0.0078). However, there was no significant difference in tumor size between these two groups (29% compared to 25%, p = 0.7297). Conclusions Most patients with HCC in this study did not receive treatment for their HCV prior to HCC diagnosis, which is likely due to the recent development timeline of the highly effective DAAs. Prior treatment of HCV leads to better outcomes than with no treatment, although this was not due to a smaller tumor size at diagnosis. Therefore, this could be due to some other unknown mechanism which may benefit from further subsequent investigation. Indeed, as many of the patients treated for HCV with DAA have not yet developed HCC or have yet to otherwise have final outcomes, we will need to continue to monitor our patient population into the future for further analysis