Joshua T. Hanson, MD, MPH

INTRODUCTION

The baby boomer generation, born from 1945 to 1965, accounts for 75% of the estimated 2.7 to 3.9 million persons with chronic hepatitis C virus (HCV) infection in the US.[1, 2, 3] Most HCV‐infected baby boomers do not know that they are infected.[4] With the advent of better‐tolerated, more‐effective therapies to treat chronic HCV infection,[5] and to reduce rates of complications such as cirrhosis, liver failure, and hepatocellular carcinoma,[6] universal 1‐time screening of baby boomers has been endorsed by the Centers for Disease Control and Prevention (CDC) and the United States Preventive Services Task Force.[1, 7] Hospitalized baby boomers may offer an important target for HCV screening. Our group conducted an anonymous HCV seroprevalence study of nearly 800 patients on general medicine and trauma services of 2 Philadelphia hospitals, and found that 8% had undiagnosed HCV infection, and 8% had diagnosed HCV. [8]

Little is known about barriers and facilitators to implementation of universal HCV screening of baby boomers. Lessons from implementing HIV screening offer a useful guide.[9] First, limited clinician knowledge and confusion about screening guidelines necessitated convenient, well‐designed educational programs.[10] Second, burdensome consent procedures were reduced by opt‐out consent for screening supplemented by patient education.[9] Third, electronic medical record (EMR) algorithms minimized burdens on staff by efficiently identifying and flagging eligible persons for screening.[11] Fourth, ancillary staff support for patient education and linkage to follow‐up care increased screening rates compared with usual care by physicians/staff.[11] Finally, routine human immunodeficiency virus (HIV) testing of inpatients increased rates of diagnosis, especially compared with physician referral systems.[12]

This article describes how HIV screening strategies informed the development in a baby boomer HCV screening and linkage to a care program in a safety‐net hospital serving a majority Hispanic population. We report results of the first 14 months of the screening program and linkage to care for chronically HCV‐infected persons after a minimum 10 months follow‐up. We also estimate costs for program implementation and maintenance to inform hospital administrators, healthcare policymakers, and clinicians about resources that may be required to effectively screen hospitalized baby boomers for HCV.

METHODS

RESULTS

Within 14 months, 6410 unique baby boomers were admitted with a mean age 56.4 years (standard deviation [SD] 5.7), 55.9% men, 59.1% Hispanic, 8.2% nonwhite, and 46.7% uninsured (Table 1). Among admitted patients, 729 (11.4%) had a previous HCV diagnosis and 1904 (29.7%) had been tested for HCV (Figure 1). Anti‐HCV antibody testing was completed for 3168 (49.4% of all admitted patients and 83.9% of never‐tested patients). After exclusions such as significant comorbidity or psychiatric admission, 95% of eligible persons were tested. Of screened patients, 240 (7.6%) were positive; these patients were significantly younger (P<0.0001) and more likely to be men (P<0.0001) and uninsured (P=0.002) (Table 1). Notably, 10% of men were anti‐HCV positive versus 4% of women. In this predominantly Hispanic cohort, no significant difference appeared by race‐ethnicity, but African Americans had a higher prevalence (10.4%) than other groups.

Figure 1

HCV RNA testing was completed for 214 (89.2%) anti‐HCVpositive patients, of whom 134 (62.6%) had detectable RNA, indicating chronic HCV infection (Figure 1). Overall, 4.2% of all eligible patients tested for HCV were chronically infected. No characteristics were significantly associated with chronic HCV, but persons with chronic infection tended to be younger, uninsured, and African American (Table 2).

Among patients with chronic HCV infection, 129 (96.3%) were counseled and follow‐up plans developed (Figure 2). By December 10, 2014, 108 (80.6%) patients had received follow‐up primary care, and 52 (38.8%) had care from a hepatologist. Five had initiated HCV‐specific treatment, but many others were awaiting approval for compassionate drug programs offering direct‐acting antivirals. Barriers to care included 82 (61.2%) uninsured, 45 (34%) problem drinkers, 22 (16%) homeless, and 25 (18.6%) incarcerated (not shown). The promotora addressed these issues by visiting homes or homeless shelters, assistance with obtaining county‐based or other types of insurance, offering alcohol risk‐reduction counseling, linking patients to alcohol‐treatment programs, and communicating with the county jail about follow‐up care.

Figure 2

Most of the developmental costs for the program were dedicated to developing EMR programs (Table 3). An optional cost was for the development of the tablet educational program about HCV. In regard to maintenance costs for the first 14 months, the majority was to support the program faculty, counseling/case management, and a nurse practitioner who helped with ordering tests. We also estimated costs for testing uninsured patients (45% of HCV antibody tested, 57% of HCV PCR tested, per Tables 1 and 2, respectively), as they must be borne by the hospital.

DISCUSSION

Implementation of universal HCV screening and linkage to care for hospitalized baby boomers utilizes a multicomponent infrastructure that reflects lessons learned from similar HIV programs. Use of an EMR algorithm to identify eligible patients and programs to automatically order HCV screening was a linchpin of our high testing rate and averted testing those who did not require screening. Of all 6410 baby boomers admitted to our safety‐net hospital, the EMR screen identified over 40% as ineligible due to prior diagnosis of HCV infection or prior HCV tests. Most of the additional 609 patients who were not tested were excluded due to comorbidities or admission to psychiatry. Overall, the EMR programs, tests ordered by the team, and opt‐out screening with education resulted in screening 95% of eligible patients. However, this program carries substantial costs, nearly $300,000 for the first 2 years, for unreimbursed services in this safety‐net hospital. The new guidelines for HCV screening[1, 2] are not accompanied by financial support either for program implementation or for screening and linkage to care for the uninsured, creating significant financial hurdles to achieve guideline compliance within already overtaxed public healthcare systems.

The infrastructure implemented in this hospital succeeded in achieving a higher rate of HCV screening of baby boomers than reported by other programs. In an emergency department in Birmingham, Alabama, a screening program for baby boomers tested 66% of 2325 persons who were HCV‐unaware.[17] In an outpatient clinic for men who have sex with men, only 54% of 1329 patients were screened for HCV.[18]

Among 3168 screened patients in our cohort, 7.6% were anti‐HCV antibody positive, which is over twice the prevalence of 3.5% (95% confidence interval: 2.2%‐4.8%) for anti‐HCVpositive tests in baby boomers based on National Health and Nutrition Examination Survey (NHANES) data from 2001 to 2010.[19] However, the Alabama emergency department study found that 11% of tested patients were anti‐HCV positive.[17] Although that study lacked race‐ethnicity data for half of the subjects, among those with this information, 13% of black and 7% of white subjects tested anti‐HCV positive. Compared with the Alabama study, the anti‐HCV prevalence in our cohort was somewhat lower for blacks (10.4%) but higher for non‐Hispanic whites (8.3%). Hispanics in our cohort had the lowest anti‐HCV prevalence (7.2%), whereas the Alabama study did not report this figure. National studies also find that the prevalence of anti‐HCVpositive results is twice as high for blacks compared with non‐Hispanic whites and Hispanics, and nearly twice as high for men compared with women.[19] In our cohort, the proportion of men with anti‐HCVpositive results was nearly 3 times that for women.

Diagnosis of chronic HCV infection requires 2 tests, similar to performing a Western blot test after a positive enzyme‐linked immunoassay for HIV. In a Veterans Affairs study, only 64% of patients with a positive anti‐HCV antibody test had a HCV RNA performed when reflex testing was not performed, and patients had to come in for a second test versus >90% of patients in sites that offer reflex testing.[20] At a somewhat increased price due to using more expensive PPTs ($96/100 PPT tubes vs $6.50/100 for serum red top tubes), both tests were performed on the same blood sample, resulting in 89% of anti‐HCV antibody‐positive patients being tested for HCV RNA.

Overall, 62% of patients in our cohort with a positive anti‐HCV antibody test had HCV RNA detected (viremic) compared with 71% of persons aged 20 years in an NHANES study from 2003 to 2010.[21] Several factors may contribute to this lower rate of chronic infection. In a study of HCV seropositive blood donors, Hispanics and non‐Hispanic whites were significantly more likely to have spontaneously cleared HCV infection than Asians and non‐Hispanic blacks.[22] Spontaneous clearance of HCV has also been associated with younger age at infection and HCV genotype 1.[23] Poorly understood genetic factors may also play a role.[24] The high rate of HCV clearance in our cohort reinforces the need to perform HCV RNA testing.

Overall, 4.2% of our cohort had chronic HCV infection. According to CDC estimates from 1999 to 2008 NHANES data, 2.74 million (3.25%) of 84.2 million US baby boomers have been infected with HCV, and 2.04 million (2.4%) have chronic infection.[1] Therefore, our safety‐net cohort of never‐tested baby boomers had over twice the prevalence of chronic HCV infection than the national estimate for this age group. This high proportion of chronic HCV may reflect our predominantly low‐income patient population. An analysis conducted by Milliman, Inc. using 2010 data estimated that half of all persons with undiagnosed HCV infection are uninsured.[25] This finding reinforces the need to conduct HCV screening in acute‐care settings such as hospitals, because the uninsured have poor access to ambulatory care.

Our chronic HCV‐infected cohort had many barriers to follow‐up care because most were uninsured and 15% were homeless. Our counselors addressed socioeconomic barriers to care[26] and concerns about the disease.[27] Many patients also had problem drinking based on either self‐report or documented in the medical record. Even moderate alcohol use may increase the risk of overall and liver‐related mortality from chronic HCV infection,[28] so our team offered brief alcohol counseling and partnered with healthcare providers and local Alcoholics Anonymous programs to offer support.

We linked 80% of newly diagnosed patients to primary care or hepatology providers, aided by a county‐level financial assistance program for healthcare services for uninsured residents, but it still required patients to pay out of pocket for care. Access to newer, highly effective, all‐oral therapy treatment[5] was slowed while awaiting US Food and Drug Administration approval in the first year of this project, then treatment provided only after lengthy applications to drug company assistance programs with priority given to persons with compensated cirrhosis.

Our project raises serious concerns for policymakers and payers. Should universal baby boomer HCV testing be undertaken without taking into account the financial and personnel resources required to implement this screening program or the substantial expenditures necessary to treat chronically infected persons? Although the Centers for Medicaid and Medicare Services pay for HCV screening costs,[29] our hospital had to cover costs for uninsured persons. Admittedly, Texas has the highest proportion of residents who are uninsured in the nation, but even in other states, Medicaid and other insurance programs are wrestling with how to deal with the high cost of HCV therapy.[30]

We acknowledge several limitations of this project. First, it was undertaken in only 1 hospital. Yet, our challenges and solutions are likely to be applicable to other hospitals nationally, especially those serving vulnerable populations. Second, patients in our cohort were usually admitted for comorbidities that needed to be managed before HCV infection could be addressed. However, persons with a poor prognosis, such as metastatic cancer, were excluded. We did not attempt to exclude other persons with serious comorbidities such as congestive heart failure, because the guidelines do not currently recommend this, and there may be benefits for patients, their families, and providers from knowing that an individual is chronically HCV infected even if they are not eligible to be treated. Third, the cost of the program was supported in part by a grant and would otherwise have to be borne by the hospital. Fourth, the EMR used by our hospital allows hundreds of admission order sets to be created and made automated order entry hard to implement. This is unlikely to be the situation in other hospitals using different types of EMRs.

It remains to be seen whether safety‐net hospitals with populations at greater risk of HCV infection can afford to support HCV testing and linkage to care. In view of several cost‐effectiveness studies that find screening and treating chronic HCV‐infected baby boomers cost‐effective within standard thresholds,[31, 32, 33] it may be important for policymakers and payers to consider lessons from HIV programs. Because HIV‐infected persons could not afford life‐saving medication, vigorous advocacy efforts led to legislation approving the Ryan White program in 1990 to fill gaps in HIV care that were not covered by other sources of support.[34] HCV infection is the most common blood‐borne infection in the nation, with potentially devastating consequences if ignored, but the underlying premise that universal HCV testing will save lives is in question if most of the individuals who are diagnosed with chronic HCV are low income, uninsured, or underinsured with limited access to curative medications. A rigorous public policy debate regarding both the merits of screening and the availability of treatment to those who are diagnosed is essential to the success of these programs.

INTRODUCTION

The baby boomer generation, born from 1945 to 1965, accounts for 75% of the estimated 2.7 to 3.9 million persons with chronic hepatitis C virus (HCV) infection in the US.[1, 2, 3] Most HCV‐infected baby boomers do not know that they are infected.[4] With the advent of better‐tolerated, more‐effective therapies to treat chronic HCV infection,[5] and to reduce rates of complications such as cirrhosis, liver failure, and hepatocellular carcinoma,[6] universal 1‐time screening of baby boomers has been endorsed by the Centers for Disease Control and Prevention (CDC) and the United States Preventive Services Task Force.[1, 7] Hospitalized baby boomers may offer an important target for HCV screening. Our group conducted an anonymous HCV seroprevalence study of nearly 800 patients on general medicine and trauma services of 2 Philadelphia hospitals, and found that 8% had undiagnosed HCV infection, and 8% had diagnosed HCV. [8]

Little is known about barriers and facilitators to implementation of universal HCV screening of baby boomers. Lessons from implementing HIV screening offer a useful guide.[9] First, limited clinician knowledge and confusion about screening guidelines necessitated convenient, well‐designed educational programs.[10] Second, burdensome consent procedures were reduced by opt‐out consent for screening supplemented by patient education.[9] Third, electronic medical record (EMR) algorithms minimized burdens on staff by efficiently identifying and flagging eligible persons for screening.[11] Fourth, ancillary staff support for patient education and linkage to follow‐up care increased screening rates compared with usual care by physicians/staff.[11] Finally, routine human immunodeficiency virus (HIV) testing of inpatients increased rates of diagnosis, especially compared with physician referral systems.[12]

This article describes how HIV screening strategies informed the development in a baby boomer HCV screening and linkage to a care program in a safety‐net hospital serving a majority Hispanic population. We report results of the first 14 months of the screening program and linkage to care for chronically HCV‐infected persons after a minimum 10 months follow‐up. We also estimate costs for program implementation and maintenance to inform hospital administrators, healthcare policymakers, and clinicians about resources that may be required to effectively screen hospitalized baby boomers for HCV.

METHODS

RESULTS

Within 14 months, 6410 unique baby boomers were admitted with a mean age 56.4 years (standard deviation [SD] 5.7), 55.9% men, 59.1% Hispanic, 8.2% nonwhite, and 46.7% uninsured (Table 1). Among admitted patients, 729 (11.4%) had a previous HCV diagnosis and 1904 (29.7%) had been tested for HCV (Figure 1). Anti‐HCV antibody testing was completed for 3168 (49.4% of all admitted patients and 83.9% of never‐tested patients). After exclusions such as significant comorbidity or psychiatric admission, 95% of eligible persons were tested. Of screened patients, 240 (7.6%) were positive; these patients were significantly younger (P<0.0001) and more likely to be men (P<0.0001) and uninsured (P=0.002) (Table 1). Notably, 10% of men were anti‐HCV positive versus 4% of women. In this predominantly Hispanic cohort, no significant difference appeared by race‐ethnicity, but African Americans had a higher prevalence (10.4%) than other groups.

Figure 1

HCV RNA testing was completed for 214 (89.2%) anti‐HCVpositive patients, of whom 134 (62.6%) had detectable RNA, indicating chronic HCV infection (Figure 1). Overall, 4.2% of all eligible patients tested for HCV were chronically infected. No characteristics were significantly associated with chronic HCV, but persons with chronic infection tended to be younger, uninsured, and African American (Table 2).

Among patients with chronic HCV infection, 129 (96.3%) were counseled and follow‐up plans developed (Figure 2). By December 10, 2014, 108 (80.6%) patients had received follow‐up primary care, and 52 (38.8%) had care from a hepatologist. Five had initiated HCV‐specific treatment, but many others were awaiting approval for compassionate drug programs offering direct‐acting antivirals. Barriers to care included 82 (61.2%) uninsured, 45 (34%) problem drinkers, 22 (16%) homeless, and 25 (18.6%) incarcerated (not shown). The promotora addressed these issues by visiting homes or homeless shelters, assistance with obtaining county‐based or other types of insurance, offering alcohol risk‐reduction counseling, linking patients to alcohol‐treatment programs, and communicating with the county jail about follow‐up care.

Figure 2

Most of the developmental costs for the program were dedicated to developing EMR programs (Table 3). An optional cost was for the development of the tablet educational program about HCV. In regard to maintenance costs for the first 14 months, the majority was to support the program faculty, counseling/case management, and a nurse practitioner who helped with ordering tests. We also estimated costs for testing uninsured patients (45% of HCV antibody tested, 57% of HCV PCR tested, per Tables 1 and 2, respectively), as they must be borne by the hospital.

DISCUSSION

Implementation of universal HCV screening and linkage to care for hospitalized baby boomers utilizes a multicomponent infrastructure that reflects lessons learned from similar HIV programs. Use of an EMR algorithm to identify eligible patients and programs to automatically order HCV screening was a linchpin of our high testing rate and averted testing those who did not require screening. Of all 6410 baby boomers admitted to our safety‐net hospital, the EMR screen identified over 40% as ineligible due to prior diagnosis of HCV infection or prior HCV tests. Most of the additional 609 patients who were not tested were excluded due to comorbidities or admission to psychiatry. Overall, the EMR programs, tests ordered by the team, and opt‐out screening with education resulted in screening 95% of eligible patients. However, this program carries substantial costs, nearly $300,000 for the first 2 years, for unreimbursed services in this safety‐net hospital. The new guidelines for HCV screening[1, 2] are not accompanied by financial support either for program implementation or for screening and linkage to care for the uninsured, creating significant financial hurdles to achieve guideline compliance within already overtaxed public healthcare systems.

The infrastructure implemented in this hospital succeeded in achieving a higher rate of HCV screening of baby boomers than reported by other programs. In an emergency department in Birmingham, Alabama, a screening program for baby boomers tested 66% of 2325 persons who were HCV‐unaware.[17] In an outpatient clinic for men who have sex with men, only 54% of 1329 patients were screened for HCV.[18]

Among 3168 screened patients in our cohort, 7.6% were anti‐HCV antibody positive, which is over twice the prevalence of 3.5% (95% confidence interval: 2.2%‐4.8%) for anti‐HCVpositive tests in baby boomers based on National Health and Nutrition Examination Survey (NHANES) data from 2001 to 2010.[19] However, the Alabama emergency department study found that 11% of tested patients were anti‐HCV positive.[17] Although that study lacked race‐ethnicity data for half of the subjects, among those with this information, 13% of black and 7% of white subjects tested anti‐HCV positive. Compared with the Alabama study, the anti‐HCV prevalence in our cohort was somewhat lower for blacks (10.4%) but higher for non‐Hispanic whites (8.3%). Hispanics in our cohort had the lowest anti‐HCV prevalence (7.2%), whereas the Alabama study did not report this figure. National studies also find that the prevalence of anti‐HCVpositive results is twice as high for blacks compared with non‐Hispanic whites and Hispanics, and nearly twice as high for men compared with women.[19] In our cohort, the proportion of men with anti‐HCVpositive results was nearly 3 times that for women.

Diagnosis of chronic HCV infection requires 2 tests, similar to performing a Western blot test after a positive enzyme‐linked immunoassay for HIV. In a Veterans Affairs study, only 64% of patients with a positive anti‐HCV antibody test had a HCV RNA performed when reflex testing was not performed, and patients had to come in for a second test versus >90% of patients in sites that offer reflex testing.[20] At a somewhat increased price due to using more expensive PPTs ($96/100 PPT tubes vs $6.50/100 for serum red top tubes), both tests were performed on the same blood sample, resulting in 89% of anti‐HCV antibody‐positive patients being tested for HCV RNA.

Overall, 62% of patients in our cohort with a positive anti‐HCV antibody test had HCV RNA detected (viremic) compared with 71% of persons aged 20 years in an NHANES study from 2003 to 2010.[21] Several factors may contribute to this lower rate of chronic infection. In a study of HCV seropositive blood donors, Hispanics and non‐Hispanic whites were significantly more likely to have spontaneously cleared HCV infection than Asians and non‐Hispanic blacks.[22] Spontaneous clearance of HCV has also been associated with younger age at infection and HCV genotype 1.[23] Poorly understood genetic factors may also play a role.[24] The high rate of HCV clearance in our cohort reinforces the need to perform HCV RNA testing.

Overall, 4.2% of our cohort had chronic HCV infection. According to CDC estimates from 1999 to 2008 NHANES data, 2.74 million (3.25%) of 84.2 million US baby boomers have been infected with HCV, and 2.04 million (2.4%) have chronic infection.[1] Therefore, our safety‐net cohort of never‐tested baby boomers had over twice the prevalence of chronic HCV infection than the national estimate for this age group. This high proportion of chronic HCV may reflect our predominantly low‐income patient population. An analysis conducted by Milliman, Inc. using 2010 data estimated that half of all persons with undiagnosed HCV infection are uninsured.[25] This finding reinforces the need to conduct HCV screening in acute‐care settings such as hospitals, because the uninsured have poor access to ambulatory care.

Our chronic HCV‐infected cohort had many barriers to follow‐up care because most were uninsured and 15% were homeless. Our counselors addressed socioeconomic barriers to care[26] and concerns about the disease.[27] Many patients also had problem drinking based on either self‐report or documented in the medical record. Even moderate alcohol use may increase the risk of overall and liver‐related mortality from chronic HCV infection,[28] so our team offered brief alcohol counseling and partnered with healthcare providers and local Alcoholics Anonymous programs to offer support.

We linked 80% of newly diagnosed patients to primary care or hepatology providers, aided by a county‐level financial assistance program for healthcare services for uninsured residents, but it still required patients to pay out of pocket for care. Access to newer, highly effective, all‐oral therapy treatment[5] was slowed while awaiting US Food and Drug Administration approval in the first year of this project, then treatment provided only after lengthy applications to drug company assistance programs with priority given to persons with compensated cirrhosis.

Our project raises serious concerns for policymakers and payers. Should universal baby boomer HCV testing be undertaken without taking into account the financial and personnel resources required to implement this screening program or the substantial expenditures necessary to treat chronically infected persons? Although the Centers for Medicaid and Medicare Services pay for HCV screening costs,[29] our hospital had to cover costs for uninsured persons. Admittedly, Texas has the highest proportion of residents who are uninsured in the nation, but even in other states, Medicaid and other insurance programs are wrestling with how to deal with the high cost of HCV therapy.[30]

We acknowledge several limitations of this project. First, it was undertaken in only 1 hospital. Yet, our challenges and solutions are likely to be applicable to other hospitals nationally, especially those serving vulnerable populations. Second, patients in our cohort were usually admitted for comorbidities that needed to be managed before HCV infection could be addressed. However, persons with a poor prognosis, such as metastatic cancer, were excluded. We did not attempt to exclude other persons with serious comorbidities such as congestive heart failure, because the guidelines do not currently recommend this, and there may be benefits for patients, their families, and providers from knowing that an individual is chronically HCV infected even if they are not eligible to be treated. Third, the cost of the program was supported in part by a grant and would otherwise have to be borne by the hospital. Fourth, the EMR used by our hospital allows hundreds of admission order sets to be created and made automated order entry hard to implement. This is unlikely to be the situation in other hospitals using different types of EMRs.

It remains to be seen whether safety‐net hospitals with populations at greater risk of HCV infection can afford to support HCV testing and linkage to care. In view of several cost‐effectiveness studies that find screening and treating chronic HCV‐infected baby boomers cost‐effective within standard thresholds,[31, 32, 33] it may be important for policymakers and payers to consider lessons from HIV programs. Because HIV‐infected persons could not afford life‐saving medication, vigorous advocacy efforts led to legislation approving the Ryan White program in 1990 to fill gaps in HIV care that were not covered by other sources of support.[34] HCV infection is the most common blood‐borne infection in the nation, with potentially devastating consequences if ignored, but the underlying premise that universal HCV testing will save lives is in question if most of the individuals who are diagnosed with chronic HCV are low income, uninsured, or underinsured with limited access to curative medications. A rigorous public policy debate regarding both the merits of screening and the availability of treatment to those who are diagnosed is essential to the success of these programs.

INTRODUCTION

The baby boomer generation, born from 1945 to 1965, accounts for 75% of the estimated 2.7 to 3.9 million persons with chronic hepatitis C virus (HCV) infection in the US.[1, 2, 3] Most HCV‐infected baby boomers do not know that they are infected.[4] With the advent of better‐tolerated, more‐effective therapies to treat chronic HCV infection,[5] and to reduce rates of complications such as cirrhosis, liver failure, and hepatocellular carcinoma,[6] universal 1‐time screening of baby boomers has been endorsed by the Centers for Disease Control and Prevention (CDC) and the United States Preventive Services Task Force.[1, 7] Hospitalized baby boomers may offer an important target for HCV screening. Our group conducted an anonymous HCV seroprevalence study of nearly 800 patients on general medicine and trauma services of 2 Philadelphia hospitals, and found that 8% had undiagnosed HCV infection, and 8% had diagnosed HCV. [8]

Little is known about barriers and facilitators to implementation of universal HCV screening of baby boomers. Lessons from implementing HIV screening offer a useful guide.[9] First, limited clinician knowledge and confusion about screening guidelines necessitated convenient, well‐designed educational programs.[10] Second, burdensome consent procedures were reduced by opt‐out consent for screening supplemented by patient education.[9] Third, electronic medical record (EMR) algorithms minimized burdens on staff by efficiently identifying and flagging eligible persons for screening.[11] Fourth, ancillary staff support for patient education and linkage to follow‐up care increased screening rates compared with usual care by physicians/staff.[11] Finally, routine human immunodeficiency virus (HIV) testing of inpatients increased rates of diagnosis, especially compared with physician referral systems.[12]

This article describes how HIV screening strategies informed the development in a baby boomer HCV screening and linkage to a care program in a safety‐net hospital serving a majority Hispanic population. We report results of the first 14 months of the screening program and linkage to care for chronically HCV‐infected persons after a minimum 10 months follow‐up. We also estimate costs for program implementation and maintenance to inform hospital administrators, healthcare policymakers, and clinicians about resources that may be required to effectively screen hospitalized baby boomers for HCV.

METHODS

RESULTS

Within 14 months, 6410 unique baby boomers were admitted with a mean age 56.4 years (standard deviation [SD] 5.7), 55.9% men, 59.1% Hispanic, 8.2% nonwhite, and 46.7% uninsured (Table 1). Among admitted patients, 729 (11.4%) had a previous HCV diagnosis and 1904 (29.7%) had been tested for HCV (Figure 1). Anti‐HCV antibody testing was completed for 3168 (49.4% of all admitted patients and 83.9% of never‐tested patients). After exclusions such as significant comorbidity or psychiatric admission, 95% of eligible persons were tested. Of screened patients, 240 (7.6%) were positive; these patients were significantly younger (P<0.0001) and more likely to be men (P<0.0001) and uninsured (P=0.002) (Table 1). Notably, 10% of men were anti‐HCV positive versus 4% of women. In this predominantly Hispanic cohort, no significant difference appeared by race‐ethnicity, but African Americans had a higher prevalence (10.4%) than other groups.

Figure 1

HCV RNA testing was completed for 214 (89.2%) anti‐HCVpositive patients, of whom 134 (62.6%) had detectable RNA, indicating chronic HCV infection (Figure 1). Overall, 4.2% of all eligible patients tested for HCV were chronically infected. No characteristics were significantly associated with chronic HCV, but persons with chronic infection tended to be younger, uninsured, and African American (Table 2).

Among patients with chronic HCV infection, 129 (96.3%) were counseled and follow‐up plans developed (Figure 2). By December 10, 2014, 108 (80.6%) patients had received follow‐up primary care, and 52 (38.8%) had care from a hepatologist. Five had initiated HCV‐specific treatment, but many others were awaiting approval for compassionate drug programs offering direct‐acting antivirals. Barriers to care included 82 (61.2%) uninsured, 45 (34%) problem drinkers, 22 (16%) homeless, and 25 (18.6%) incarcerated (not shown). The promotora addressed these issues by visiting homes or homeless shelters, assistance with obtaining county‐based or other types of insurance, offering alcohol risk‐reduction counseling, linking patients to alcohol‐treatment programs, and communicating with the county jail about follow‐up care.

Figure 2

Most of the developmental costs for the program were dedicated to developing EMR programs (Table 3). An optional cost was for the development of the tablet educational program about HCV. In regard to maintenance costs for the first 14 months, the majority was to support the program faculty, counseling/case management, and a nurse practitioner who helped with ordering tests. We also estimated costs for testing uninsured patients (45% of HCV antibody tested, 57% of HCV PCR tested, per Tables 1 and 2, respectively), as they must be borne by the hospital.

DISCUSSION

Implementation of universal HCV screening and linkage to care for hospitalized baby boomers utilizes a multicomponent infrastructure that reflects lessons learned from similar HIV programs. Use of an EMR algorithm to identify eligible patients and programs to automatically order HCV screening was a linchpin of our high testing rate and averted testing those who did not require screening. Of all 6410 baby boomers admitted to our safety‐net hospital, the EMR screen identified over 40% as ineligible due to prior diagnosis of HCV infection or prior HCV tests. Most of the additional 609 patients who were not tested were excluded due to comorbidities or admission to psychiatry. Overall, the EMR programs, tests ordered by the team, and opt‐out screening with education resulted in screening 95% of eligible patients. However, this program carries substantial costs, nearly $300,000 for the first 2 years, for unreimbursed services in this safety‐net hospital. The new guidelines for HCV screening[1, 2] are not accompanied by financial support either for program implementation or for screening and linkage to care for the uninsured, creating significant financial hurdles to achieve guideline compliance within already overtaxed public healthcare systems.

The infrastructure implemented in this hospital succeeded in achieving a higher rate of HCV screening of baby boomers than reported by other programs. In an emergency department in Birmingham, Alabama, a screening program for baby boomers tested 66% of 2325 persons who were HCV‐unaware.[17] In an outpatient clinic for men who have sex with men, only 54% of 1329 patients were screened for HCV.[18]

Among 3168 screened patients in our cohort, 7.6% were anti‐HCV antibody positive, which is over twice the prevalence of 3.5% (95% confidence interval: 2.2%‐4.8%) for anti‐HCVpositive tests in baby boomers based on National Health and Nutrition Examination Survey (NHANES) data from 2001 to 2010.[19] However, the Alabama emergency department study found that 11% of tested patients were anti‐HCV positive.[17] Although that study lacked race‐ethnicity data for half of the subjects, among those with this information, 13% of black and 7% of white subjects tested anti‐HCV positive. Compared with the Alabama study, the anti‐HCV prevalence in our cohort was somewhat lower for blacks (10.4%) but higher for non‐Hispanic whites (8.3%). Hispanics in our cohort had the lowest anti‐HCV prevalence (7.2%), whereas the Alabama study did not report this figure. National studies also find that the prevalence of anti‐HCVpositive results is twice as high for blacks compared with non‐Hispanic whites and Hispanics, and nearly twice as high for men compared with women.[19] In our cohort, the proportion of men with anti‐HCVpositive results was nearly 3 times that for women.

Diagnosis of chronic HCV infection requires 2 tests, similar to performing a Western blot test after a positive enzyme‐linked immunoassay for HIV. In a Veterans Affairs study, only 64% of patients with a positive anti‐HCV antibody test had a HCV RNA performed when reflex testing was not performed, and patients had to come in for a second test versus >90% of patients in sites that offer reflex testing.[20] At a somewhat increased price due to using more expensive PPTs ($96/100 PPT tubes vs $6.50/100 for serum red top tubes), both tests were performed on the same blood sample, resulting in 89% of anti‐HCV antibody‐positive patients being tested for HCV RNA.

Overall, 62% of patients in our cohort with a positive anti‐HCV antibody test had HCV RNA detected (viremic) compared with 71% of persons aged 20 years in an NHANES study from 2003 to 2010.[21] Several factors may contribute to this lower rate of chronic infection. In a study of HCV seropositive blood donors, Hispanics and non‐Hispanic whites were significantly more likely to have spontaneously cleared HCV infection than Asians and non‐Hispanic blacks.[22] Spontaneous clearance of HCV has also been associated with younger age at infection and HCV genotype 1.[23] Poorly understood genetic factors may also play a role.[24] The high rate of HCV clearance in our cohort reinforces the need to perform HCV RNA testing.

Overall, 4.2% of our cohort had chronic HCV infection. According to CDC estimates from 1999 to 2008 NHANES data, 2.74 million (3.25%) of 84.2 million US baby boomers have been infected with HCV, and 2.04 million (2.4%) have chronic infection.[1] Therefore, our safety‐net cohort of never‐tested baby boomers had over twice the prevalence of chronic HCV infection than the national estimate for this age group. This high proportion of chronic HCV may reflect our predominantly low‐income patient population. An analysis conducted by Milliman, Inc. using 2010 data estimated that half of all persons with undiagnosed HCV infection are uninsured.[25] This finding reinforces the need to conduct HCV screening in acute‐care settings such as hospitals, because the uninsured have poor access to ambulatory care.

Our chronic HCV‐infected cohort had many barriers to follow‐up care because most were uninsured and 15% were homeless. Our counselors addressed socioeconomic barriers to care[26] and concerns about the disease.[27] Many patients also had problem drinking based on either self‐report or documented in the medical record. Even moderate alcohol use may increase the risk of overall and liver‐related mortality from chronic HCV infection,[28] so our team offered brief alcohol counseling and partnered with healthcare providers and local Alcoholics Anonymous programs to offer support.

We linked 80% of newly diagnosed patients to primary care or hepatology providers, aided by a county‐level financial assistance program for healthcare services for uninsured residents, but it still required patients to pay out of pocket for care. Access to newer, highly effective, all‐oral therapy treatment[5] was slowed while awaiting US Food and Drug Administration approval in the first year of this project, then treatment provided only after lengthy applications to drug company assistance programs with priority given to persons with compensated cirrhosis.

Our project raises serious concerns for policymakers and payers. Should universal baby boomer HCV testing be undertaken without taking into account the financial and personnel resources required to implement this screening program or the substantial expenditures necessary to treat chronically infected persons? Although the Centers for Medicaid and Medicare Services pay for HCV screening costs,[29] our hospital had to cover costs for uninsured persons. Admittedly, Texas has the highest proportion of residents who are uninsured in the nation, but even in other states, Medicaid and other insurance programs are wrestling with how to deal with the high cost of HCV therapy.[30]

We acknowledge several limitations of this project. First, it was undertaken in only 1 hospital. Yet, our challenges and solutions are likely to be applicable to other hospitals nationally, especially those serving vulnerable populations. Second, patients in our cohort were usually admitted for comorbidities that needed to be managed before HCV infection could be addressed. However, persons with a poor prognosis, such as metastatic cancer, were excluded. We did not attempt to exclude other persons with serious comorbidities such as congestive heart failure, because the guidelines do not currently recommend this, and there may be benefits for patients, their families, and providers from knowing that an individual is chronically HCV infected even if they are not eligible to be treated. Third, the cost of the program was supported in part by a grant and would otherwise have to be borne by the hospital. Fourth, the EMR used by our hospital allows hundreds of admission order sets to be created and made automated order entry hard to implement. This is unlikely to be the situation in other hospitals using different types of EMRs.

It remains to be seen whether safety‐net hospitals with populations at greater risk of HCV infection can afford to support HCV testing and linkage to care. In view of several cost‐effectiveness studies that find screening and treating chronic HCV‐infected baby boomers cost‐effective within standard thresholds,[31, 32, 33] it may be important for policymakers and payers to consider lessons from HIV programs. Because HIV‐infected persons could not afford life‐saving medication, vigorous advocacy efforts led to legislation approving the Ryan White program in 1990 to fill gaps in HIV care that were not covered by other sources of support.[34] HCV infection is the most common blood‐borne infection in the nation, with potentially devastating consequences if ignored, but the underlying premise that universal HCV testing will save lives is in question if most of the individuals who are diagnosed with chronic HCV are low income, uninsured, or underinsured with limited access to curative medications. A rigorous public policy debate regarding both the merits of screening and the availability of treatment to those who are diagnosed is essential to the success of these programs.

For hospitalized patients, restrictions on resident duty hours and the hospitalist movement have led to fragmentation in care.[1] After 2003 duty‐hour regulations were implemented, one study estimated an increase of 11% in care transfers for a given patient, whereas another study reported that an individual intern participated in 40% more handoffs.[2, 3] Although these changes have represented an improvement in safety with reduced provider fatigue and increased expertise in inpatient care, tradeoffs in safety may occur. Communication breakdown during care transfers has been implicated in many medical errors,[4, 5, 6] and the ability to safely transfer a patient's care has been identified as a necessary clinical skill.[7] The Accreditation Council on Graduate Medical Education has mandated that training programs include education to ensure effective handoff processes.[8] The Joint Commission has developed a toolset for improving handoffs.[9] Taking cues from the military and other industries that operate continuously, approaches designed to standardize handoffs have been developed.[3, 10, 11, 12]

The use of handoff tools has been reported to reduce the time required to transfer care from one provider to another,[13] but evidence that these handoff tools improve quality of care is limited.[14, 15] Concern that patients have poorer outcomes in care transitions remains, particularly at night when many patients are cared for by covering or night float providers.[6] Studies regarding the outcomes of patients at night have had mixed results.[16, 17, 18] Uncertainty is inherent in the trajectories of individual patients and in the systems in which they receive care.[19] The recognition of uncertainty reframes care transitions from a problem of improving information transfer to a problem of navigating uncertainty, or making sense. Sensemaking is an activity through which providers come to understand what is happening with a patient, in a way that allows them to take action.[20]

We sought to better understand how to support providers' ability to make sense and act in uncertain situations, focusing on night float resident physicians. We hoped to better understand overnight encounters and the information needed to navigate them. We approached the issue in two ways: first, through assessing resident attitudes and perceptions of handoffs using survey methodology, and second, through assessing actual calls night float residents receive and strategies they use to navigate these scenarios. We focused on handoffs between the primary team and covering nighttime providers. Our goal was to use this information to understand what approaches could better support care transitions and handoff practices.

METHODS

RESULTS

DISCUSSION

Our goal was to understand how to better support care transitions and handoff processes. Our residents report that current approaches to care transitions are safe and useful. Although this perception is reassuring, it is difficult to know whether this reflects the actual delivery of safe care. A minority of residents report giving and receiving do not do lists, which are important aspects of care when giving guidance to a covering physician. Also, we find discrepancies between our survey results and nighttime call collection data in important areas. Although residents report that the written sign‐out is useful, it was deemed useful for resolving a clinical issue only 27% of the time. Previous reports have found variable and conflicting rates of written sign‐out utilization, as well as variable quality of a written sign‐out,[21, 22, 23] and our data support infrequent usage. Residents were much more likely to access the electronic medical record than they were to use the handoff tool. Additionally, although residents report documentation, very little actual documentation occurred. The high rates of calls for routine and pain‐related notifications are notable and should be examined further for areas of potential improvement. Preemptive orders for routine, common, and benign conditions are often not employed as strategy and their omission can lead to higher workloads for nighttime physicians. Additionally, education and training may be necessary to help housestaff understand how such a strategy is safely implemented, such as a specific regimen for mild pain, and why it is helpful beyond reducing nighttime workload, such as a proactive approach to clinical care.

Several important insights emerge from our results. First, the electronic health record is accessible, and providers use it frequently. This raises the question of the need for a handoff tool for information transfer. When data can be easily accessed, their presence in a physical tool may be less important. Because electronic health records can easily be leveraged to populate handoff tools, having a brief tool that minimizes information transfer but better supports clinical reasoning may be more effective.

Second, our data highlight the need to focus on the handback, or providing information back to the returning day team. Our experience and previous studies support that this process is not adequately developed.[24, 25] There is little opportunity for communication between the covering and primary providers, and there is little documentation. In our observations, 3.8% of calls resulted in documentation, whereas the majority of respondents to the survey state it is performed frequently or always. The reason for this discrepancy is unclear, but fostering more of a mentality that considers all of the providers involved in patient care to be part of the same team may help address this issue.

Third, clinical services assume providers have what they need to provide care in the form of the handoff instrument. In fact, providers have handoff instruments, but whether they need them is unclear. Based on these observations, overnight physicians are able to provide care in the vast majority of cases without the use of the handoff tool.

Fourth, our data demonstrate the social or relational nature of providing clinical coverage. The single most frequent action taken by covering residents was speaking to the nurse. This may not be surprising; however, when we reframe transitions of care and handoffs as a relational issue, we are forced to reframe potential strategies to improve these transitions. The problem we need to address is not only of information transfer; it is also of making sense of what is happening.

How do we make handoff tools more effective sensemaking tools? More focus on contingency statements might be an approach. These have the dual benefit of helping the covering provider to make sense using the primary team's reasoning, as well as improving the primary team's reasoning by making the potential complications more explicit. Another approach could be to reinforce relational actions, through providing guidance on who to call if there is a change in the status of the patient. We found that the night intern rarely discussed care with supervising physicians, indicating weak integration of the night team. The handoff tool could thus strengthen the network of providers caring for the patient. A tool that emphasizes sensemaking may be a tool that captures the nonroutine aspects of care that are not already documented in the health record.

Our data are limited in that they were collected in a single institution over few nights with few interns. Our processes may not be representative, and our expectations for provider communication may not be the norm. Although a night float system of coverage is not the only model of providing care, it is common, and our handoff tool is similar to those reported in the literature. One area of concern is that our handback expectations may be less robust than other institutions. Despite this limitation, the larger issues of information transfer and sensemaking are generally applicable. Although we collected data over only 18 nights, we did obtain information on almost 300 calls, giving us a robust sample of actual issues that residents were called to resolve. Interns are the most involved in actually providing night coverage. Their response rate was 55%, slightly below our overall response rate of 59.6%, but representing the majority of interns. A 2‐step process of sign‐out may have ramifications on care transitions; however, these data were collected at night. Because the handoff tool information is the day team's responsibility, the process may have less impact on these results.

Coverage and care transfers are part of the inpatient landscape, and it may be unreasonable to expect care to be delivered by a group of providers who know the patient with the same level of depth at all hours of the day. By understanding that fostering effective care for patients requires providers to pay attention to not only how they transfer information, but also how they collectively make sense of what is happening, we will enable safer care.

Disclosures: The research reported here was supported by the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service (CDA 07‐022). Investigator salary support was provided through this funding, and through the South Texas Veterans Health Care System. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. Parts of these data were presented at the 2013 SGIM National Meeting in Denver, Colorado. The authors report no conflicts of interest.

For hospitalized patients, restrictions on resident duty hours and the hospitalist movement have led to fragmentation in care.[1] After 2003 duty‐hour regulations were implemented, one study estimated an increase of 11% in care transfers for a given patient, whereas another study reported that an individual intern participated in 40% more handoffs.[2, 3] Although these changes have represented an improvement in safety with reduced provider fatigue and increased expertise in inpatient care, tradeoffs in safety may occur. Communication breakdown during care transfers has been implicated in many medical errors,[4, 5, 6] and the ability to safely transfer a patient's care has been identified as a necessary clinical skill.[7] The Accreditation Council on Graduate Medical Education has mandated that training programs include education to ensure effective handoff processes.[8] The Joint Commission has developed a toolset for improving handoffs.[9] Taking cues from the military and other industries that operate continuously, approaches designed to standardize handoffs have been developed.[3, 10, 11, 12]

The use of handoff tools has been reported to reduce the time required to transfer care from one provider to another,[13] but evidence that these handoff tools improve quality of care is limited.[14, 15] Concern that patients have poorer outcomes in care transitions remains, particularly at night when many patients are cared for by covering or night float providers.[6] Studies regarding the outcomes of patients at night have had mixed results.[16, 17, 18] Uncertainty is inherent in the trajectories of individual patients and in the systems in which they receive care.[19] The recognition of uncertainty reframes care transitions from a problem of improving information transfer to a problem of navigating uncertainty, or making sense. Sensemaking is an activity through which providers come to understand what is happening with a patient, in a way that allows them to take action.[20]

We sought to better understand how to support providers' ability to make sense and act in uncertain situations, focusing on night float resident physicians. We hoped to better understand overnight encounters and the information needed to navigate them. We approached the issue in two ways: first, through assessing resident attitudes and perceptions of handoffs using survey methodology, and second, through assessing actual calls night float residents receive and strategies they use to navigate these scenarios. We focused on handoffs between the primary team and covering nighttime providers. Our goal was to use this information to understand what approaches could better support care transitions and handoff practices.

METHODS

RESULTS

DISCUSSION

Our goal was to understand how to better support care transitions and handoff processes. Our residents report that current approaches to care transitions are safe and useful. Although this perception is reassuring, it is difficult to know whether this reflects the actual delivery of safe care. A minority of residents report giving and receiving do not do lists, which are important aspects of care when giving guidance to a covering physician. Also, we find discrepancies between our survey results and nighttime call collection data in important areas. Although residents report that the written sign‐out is useful, it was deemed useful for resolving a clinical issue only 27% of the time. Previous reports have found variable and conflicting rates of written sign‐out utilization, as well as variable quality of a written sign‐out,[21, 22, 23] and our data support infrequent usage. Residents were much more likely to access the electronic medical record than they were to use the handoff tool. Additionally, although residents report documentation, very little actual documentation occurred. The high rates of calls for routine and pain‐related notifications are notable and should be examined further for areas of potential improvement. Preemptive orders for routine, common, and benign conditions are often not employed as strategy and their omission can lead to higher workloads for nighttime physicians. Additionally, education and training may be necessary to help housestaff understand how such a strategy is safely implemented, such as a specific regimen for mild pain, and why it is helpful beyond reducing nighttime workload, such as a proactive approach to clinical care.

Several important insights emerge from our results. First, the electronic health record is accessible, and providers use it frequently. This raises the question of the need for a handoff tool for information transfer. When data can be easily accessed, their presence in a physical tool may be less important. Because electronic health records can easily be leveraged to populate handoff tools, having a brief tool that minimizes information transfer but better supports clinical reasoning may be more effective.

Second, our data highlight the need to focus on the handback, or providing information back to the returning day team. Our experience and previous studies support that this process is not adequately developed.[24, 25] There is little opportunity for communication between the covering and primary providers, and there is little documentation. In our observations, 3.8% of calls resulted in documentation, whereas the majority of respondents to the survey state it is performed frequently or always. The reason for this discrepancy is unclear, but fostering more of a mentality that considers all of the providers involved in patient care to be part of the same team may help address this issue.

Third, clinical services assume providers have what they need to provide care in the form of the handoff instrument. In fact, providers have handoff instruments, but whether they need them is unclear. Based on these observations, overnight physicians are able to provide care in the vast majority of cases without the use of the handoff tool.

Fourth, our data demonstrate the social or relational nature of providing clinical coverage. The single most frequent action taken by covering residents was speaking to the nurse. This may not be surprising; however, when we reframe transitions of care and handoffs as a relational issue, we are forced to reframe potential strategies to improve these transitions. The problem we need to address is not only of information transfer; it is also of making sense of what is happening.

How do we make handoff tools more effective sensemaking tools? More focus on contingency statements might be an approach. These have the dual benefit of helping the covering provider to make sense using the primary team's reasoning, as well as improving the primary team's reasoning by making the potential complications more explicit. Another approach could be to reinforce relational actions, through providing guidance on who to call if there is a change in the status of the patient. We found that the night intern rarely discussed care with supervising physicians, indicating weak integration of the night team. The handoff tool could thus strengthen the network of providers caring for the patient. A tool that emphasizes sensemaking may be a tool that captures the nonroutine aspects of care that are not already documented in the health record.

Our data are limited in that they were collected in a single institution over few nights with few interns. Our processes may not be representative, and our expectations for provider communication may not be the norm. Although a night float system of coverage is not the only model of providing care, it is common, and our handoff tool is similar to those reported in the literature. One area of concern is that our handback expectations may be less robust than other institutions. Despite this limitation, the larger issues of information transfer and sensemaking are generally applicable. Although we collected data over only 18 nights, we did obtain information on almost 300 calls, giving us a robust sample of actual issues that residents were called to resolve. Interns are the most involved in actually providing night coverage. Their response rate was 55%, slightly below our overall response rate of 59.6%, but representing the majority of interns. A 2‐step process of sign‐out may have ramifications on care transitions; however, these data were collected at night. Because the handoff tool information is the day team's responsibility, the process may have less impact on these results.

Coverage and care transfers are part of the inpatient landscape, and it may be unreasonable to expect care to be delivered by a group of providers who know the patient with the same level of depth at all hours of the day. By understanding that fostering effective care for patients requires providers to pay attention to not only how they transfer information, but also how they collectively make sense of what is happening, we will enable safer care.

Disclosures: The research reported here was supported by the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service (CDA 07‐022). Investigator salary support was provided through this funding, and through the South Texas Veterans Health Care System. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. Parts of these data were presented at the 2013 SGIM National Meeting in Denver, Colorado. The authors report no conflicts of interest.

For hospitalized patients, restrictions on resident duty hours and the hospitalist movement have led to fragmentation in care.[1] After 2003 duty‐hour regulations were implemented, one study estimated an increase of 11% in care transfers for a given patient, whereas another study reported that an individual intern participated in 40% more handoffs.[2, 3] Although these changes have represented an improvement in safety with reduced provider fatigue and increased expertise in inpatient care, tradeoffs in safety may occur. Communication breakdown during care transfers has been implicated in many medical errors,[4, 5, 6] and the ability to safely transfer a patient's care has been identified as a necessary clinical skill.[7] The Accreditation Council on Graduate Medical Education has mandated that training programs include education to ensure effective handoff processes.[8] The Joint Commission has developed a toolset for improving handoffs.[9] Taking cues from the military and other industries that operate continuously, approaches designed to standardize handoffs have been developed.[3, 10, 11, 12]

The use of handoff tools has been reported to reduce the time required to transfer care from one provider to another,[13] but evidence that these handoff tools improve quality of care is limited.[14, 15] Concern that patients have poorer outcomes in care transitions remains, particularly at night when many patients are cared for by covering or night float providers.[6] Studies regarding the outcomes of patients at night have had mixed results.[16, 17, 18] Uncertainty is inherent in the trajectories of individual patients and in the systems in which they receive care.[19] The recognition of uncertainty reframes care transitions from a problem of improving information transfer to a problem of navigating uncertainty, or making sense. Sensemaking is an activity through which providers come to understand what is happening with a patient, in a way that allows them to take action.[20]

We sought to better understand how to support providers' ability to make sense and act in uncertain situations, focusing on night float resident physicians. We hoped to better understand overnight encounters and the information needed to navigate them. We approached the issue in two ways: first, through assessing resident attitudes and perceptions of handoffs using survey methodology, and second, through assessing actual calls night float residents receive and strategies they use to navigate these scenarios. We focused on handoffs between the primary team and covering nighttime providers. Our goal was to use this information to understand what approaches could better support care transitions and handoff practices.

METHODS

RESULTS

DISCUSSION

Our goal was to understand how to better support care transitions and handoff processes. Our residents report that current approaches to care transitions are safe and useful. Although this perception is reassuring, it is difficult to know whether this reflects the actual delivery of safe care. A minority of residents report giving and receiving do not do lists, which are important aspects of care when giving guidance to a covering physician. Also, we find discrepancies between our survey results and nighttime call collection data in important areas. Although residents report that the written sign‐out is useful, it was deemed useful for resolving a clinical issue only 27% of the time. Previous reports have found variable and conflicting rates of written sign‐out utilization, as well as variable quality of a written sign‐out,[21, 22, 23] and our data support infrequent usage. Residents were much more likely to access the electronic medical record than they were to use the handoff tool. Additionally, although residents report documentation, very little actual documentation occurred. The high rates of calls for routine and pain‐related notifications are notable and should be examined further for areas of potential improvement. Preemptive orders for routine, common, and benign conditions are often not employed as strategy and their omission can lead to higher workloads for nighttime physicians. Additionally, education and training may be necessary to help housestaff understand how such a strategy is safely implemented, such as a specific regimen for mild pain, and why it is helpful beyond reducing nighttime workload, such as a proactive approach to clinical care.

Several important insights emerge from our results. First, the electronic health record is accessible, and providers use it frequently. This raises the question of the need for a handoff tool for information transfer. When data can be easily accessed, their presence in a physical tool may be less important. Because electronic health records can easily be leveraged to populate handoff tools, having a brief tool that minimizes information transfer but better supports clinical reasoning may be more effective.

Second, our data highlight the need to focus on the handback, or providing information back to the returning day team. Our experience and previous studies support that this process is not adequately developed.[24, 25] There is little opportunity for communication between the covering and primary providers, and there is little documentation. In our observations, 3.8% of calls resulted in documentation, whereas the majority of respondents to the survey state it is performed frequently or always. The reason for this discrepancy is unclear, but fostering more of a mentality that considers all of the providers involved in patient care to be part of the same team may help address this issue.

Third, clinical services assume providers have what they need to provide care in the form of the handoff instrument. In fact, providers have handoff instruments, but whether they need them is unclear. Based on these observations, overnight physicians are able to provide care in the vast majority of cases without the use of the handoff tool.

Fourth, our data demonstrate the social or relational nature of providing clinical coverage. The single most frequent action taken by covering residents was speaking to the nurse. This may not be surprising; however, when we reframe transitions of care and handoffs as a relational issue, we are forced to reframe potential strategies to improve these transitions. The problem we need to address is not only of information transfer; it is also of making sense of what is happening.

How do we make handoff tools more effective sensemaking tools? More focus on contingency statements might be an approach. These have the dual benefit of helping the covering provider to make sense using the primary team's reasoning, as well as improving the primary team's reasoning by making the potential complications more explicit. Another approach could be to reinforce relational actions, through providing guidance on who to call if there is a change in the status of the patient. We found that the night intern rarely discussed care with supervising physicians, indicating weak integration of the night team. The handoff tool could thus strengthen the network of providers caring for the patient. A tool that emphasizes sensemaking may be a tool that captures the nonroutine aspects of care that are not already documented in the health record.

Our data are limited in that they were collected in a single institution over few nights with few interns. Our processes may not be representative, and our expectations for provider communication may not be the norm. Although a night float system of coverage is not the only model of providing care, it is common, and our handoff tool is similar to those reported in the literature. One area of concern is that our handback expectations may be less robust than other institutions. Despite this limitation, the larger issues of information transfer and sensemaking are generally applicable. Although we collected data over only 18 nights, we did obtain information on almost 300 calls, giving us a robust sample of actual issues that residents were called to resolve. Interns are the most involved in actually providing night coverage. Their response rate was 55%, slightly below our overall response rate of 59.6%, but representing the majority of interns. A 2‐step process of sign‐out may have ramifications on care transitions; however, these data were collected at night. Because the handoff tool information is the day team's responsibility, the process may have less impact on these results.

Coverage and care transfers are part of the inpatient landscape, and it may be unreasonable to expect care to be delivered by a group of providers who know the patient with the same level of depth at all hours of the day. By understanding that fostering effective care for patients requires providers to pay attention to not only how they transfer information, but also how they collectively make sense of what is happening, we will enable safer care.

Disclosures: The research reported here was supported by the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service (CDA 07‐022). Investigator salary support was provided through this funding, and through the South Texas Veterans Health Care System. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. Parts of these data were presented at the 2013 SGIM National Meeting in Denver, Colorado. The authors report no conflicts of interest.