Explore the Cs the Day poster

Hospitalization offers an opportunity to treat hepatitis C virus (HCV) among people unlikely to engage in outpatient care. Design: Two-hospital NYC quality improvement initiative, September 2024-August 2026, with a 12-month pre-implementation baseline. Eligibility: Adults with detectable HCV RNA, able to consent and not on direct-acting antiviral (DAA) treatment, identified through an Epic dashboard or HCV consult order. Exclusions: Decompensated cirrhosis, transplant, active malignancy, pregnancy/breastfeeding, discharge to law enforcement, limited life expectancy not improved by HCV treatment, or death during the encounter. Interventions: Phone or bedside assessment/counseling, DAA prescribing for select patients with inpatient or outpatient initiation, bedside delivery, low-barrier follow-up. Selection for DAA Treatment: Investigator made prescribing decisions based on anticipated feasibility of treatment completion, including the patient’s ability to take DAA reliably and maintain contact after discharge. Team: Infectious diseases attendings and one social worker.

Eligible encounters Characteristic Baseline Intervention (n=37) (n=87) Age, years, median (IQR)* 57 (45, 65) 44 (38, 51) Female 11 (29.7%) 20 (23.0%) Race* White 15 (40.5%) 63 (72.4%) Black 5 (13.5%) 12 (13.8%) Other 17 (45.9%) 12 (13.8%) Hispanic/Latinx ethnicity* 19 (51.4%) 23 (26.4%) Medicaid insurance* 22 (59.5%) 71 (81.6%) Unstably housed* 21 (56.8%) 71 (81.6%) Working telephone* 18 (48.6%) 16 (18.4%) Current injection drug use* 15 (40.5%) 73 (83.9%) HIV 6 (16.2%) 8 (9.2%) Compensated cirrhosis* 5 (13.5%) 2 (2.3%) Length of stay, days, median (IQR) 10 (7, 22) 10 (6.5, 24.5) Patient-directed discharge 8 (21.6%) 25 (28.7%) *p<0.05. IQR, interquartile range.

Baseline: 37 encounters. Intervention: 87 encounters. DAA prescribed: 3/37 versus 19/87. DAA started: 3/37 versus 17/87. Treatment completed: 2/37 versus 13/87. SVR4+: 1/37 versus 5/87. SVR4+: HCV RNA undetectable at least 4 weeks after treatment completion (sustained virologic response).

Eligible encounters: 87 Assessed by HCV team: 68 Immediate prescribing candidates*: 22 Interested in treatment: 20 DAA prescribed: 19 DAA started: 17 Treatment completed: 13 Undetectable RNA after discharge: 7 SVR4+: 5 *Assessed by the investigator as able to take medication reliably and maintain contact after discharge. 17 starts: 14 inpatient and 3 outpatient.

Candidates for immediate prescribing Characteristic Candidate Not candidate (n=22) (n=46) Age, years, median (IQR)* 49 (41, 62) 41 (37, 48) Medicaid insurance 16 (72.7%) 40 (87.0%) Unstably housed* 13 (59.1%) 42 (91.3%) Lack working telephone* 10 (45.5%) 44 (95.6%) Current injection drug use* 14 (63.6%) 43 (93.5%) Length of stay, days, median (IQR)* 31.5 (12, 50) 11 (7, 20) Patient-directed discharge 3 (13.6%) 13 (28.3%) *p<0.05

49 assessed encounters without a prescription. Telephone/contact barrier: 34 Patient-directed/early discharge: 5 Declined treatment: 5 Identity/insurance barrier: 3 Other medical issues took priority: 1 Preferred alternative care site: 1

Why treatment was not completed • Medication not collected from pharmacy (n=1). • Patient-directed discharge before bedside delivery (n=2). • Lost to follow-up after 2, 4, or 6 of 8 weeks (n=1 each).

Medication handoff near-misses One course was in transit when a patient left via patient-directed discharge. Another course was nearly lost during an intrahospital transfer.

Where treatment was completed (n=13). Patients 1–4: entirely inpatient. Patients 5–11: partly inpatient and partly after discharge. Patients 12–13: entirely after discharge. The original figure shows the proportion completed in each setting for each patient.

Qualitative evaluation 6 interviews: 4 providers, 1 patient, 1 caregiver All six interviewees rated the program acceptable and liked the program. Difficulty contacting patients after discharge limited patient interviews. Themes included: Bedside delivery reduced logistical barriers to treatment. “Starting treatment was very, very easy to do because of how it was provided. The medication was provided right away. I didn’t have to go pick it up anywhere.” - Caregiver Providers worried about care continuity after discharge. “… there’s always this fear of, I get them started on treatment, and then they vanish into the ether vs making sure they get safely established as an outpatient and then starting... sometimes I feel more comfortable with that.” - Provider Patients highlighted opportunities for family and community engagement. “… it would be amazing for you to have a program... that would be able to talk to family… and have them tested [for HCV] as well…” – Patient Providers identified a need for greater awareness of the program.

Conclusions • DAA prescribing, initiation, and completion were higher during the intervention despite greater housing instability, more injection drug use, and more limited telephone access in the intervention cohort. • Post-discharge contact and medication handoff remain barriers. No patients attended in-person follow-up visits. • Scale-up requires standardized feasibility criteria, reliable medication custody, greater program awareness, and a sustainable multidisciplinary workflow.