Q: Does your patient need a Hepatitis C (HCV) Viral load (VL) or genotype as an inpatient?
The Bottom Line: Do NOT routinely obtain HCV VL or genotype testing in inpatients with known chronic HCV.
Context: HCV is primarily transmitted through blood. 50-75% of acutely infected patients will go on to develop chronic infection. HCV antibody (Ab) testing is the recommended screening test for chronic HCV. A positive Ab implies exposure to HCV and doesn't distinguish between prior or chronic/active infection. To determine ongoing infection, a positive Ab test is followed by a HCV VL. A detectable VL >6 months after exposure or >6 months after positive Ab implies chronic infection. HCV VL is NOT a screening test for chronic HCV, nor does it correlate with disease progression or liver fibrosis. Monitoring of HCV VL in patients not on HCV treatment doesn't provide clinically relevant information.
HCV VL can be used to evaluate for acute HCV in patients with acute transaminase elevation of unclear etiology, as the Ab may take up to 6-8 weeks to develop. However, only 20-30% of patients with acute HCV will develop symptoms, and acute liver failure/severe hepatitis is uncommon. HCV VL is also used to monitor treatment response in patients on HCV treatment (the course of which is usually 12-24 weeks). As patients are usually treated as outpatients, monitoring in the inpatient setting is rare. If a patient on therapy is admitted, discuss VL testing with his/her outpatient provider prior to obtaining a VL.
The Data: In 2013 1,023 HCV VL tests were obtained in the inpatient setting at JHH. For each VL, JHH charges insurance companies $347, totaling $354,981 in 2014. However, Medicare reimburses approximately $58. In addition, JHH charges $737 for HCV genotypes, while Medicare reimburses approximately $351.
Multiple studies have found that serum HCV VL does not correlate with liver disease. Four studies (with sample sizes of 77, 187, 96 and 48 patients) measured HCV RNA levels in patients and then performed liver biopsies. In all of the studies, the level of viremia did not correlate with histological findings or liver disease.1-4 In another study, fibrosis progression was calculated using the Kaplan-Meier method for 2313 patients. The rate of fibrosis progression was assessed using the hazard function. There was no association between the degree of viremia and histological findings (p=.09).5
The only indication for HCV genotype testing is when planning HCV treatment, as different genotypes require different regimens. The HCV genotype does not provide other clinically relevant information. There are few indications for the initiation of inpatient treatment (such patients with fulminate liver failure due to HCV and specific scenarios in liver transplant patients who have HCV); these occurrences are rare and require specialist (Infectious Disease or Hepatology) consultation. Therefore, do not obtain an HCV genotype on inpatients unless requested by a viral hepatitis expert.
Conclusion: Indications for inpatient HCV VL ordering are:
- To evaluate for acute HCV in a patient with acute hepatitis of unclear etiology or suspicion of acute infection (exposure, etc.)
- To evaluate for chronic HCV infection in a patient with a positive Ab and no prior HCV VL testing. However, if the patient has a primary care provider outside the Hopkins health system, VL testing can be deferred to the outpatient setting. If you do obtain a HCV VL or HCV Ab for a patient with an outside provider, you must report the results to that provider.
- To monitor treatment response in a patient on HCV therapy, but ONLY if requested by his/her outpatient hepatitis provider
- HCV genotype testing is only necessary when choosing a regimen for HCV treatment. It is almost never indicated in the inpatient setting.
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Written by Natasha Chida, MD MSPH; Adena Greenbaum, MD MPH; Sue Tuddenham, MD MPH and Emily Kendall, MD from the Division of Infectious Diseases for the Department of Medicine High Value Care Committee