The hospitalist’s role in improving hepatitis C screening in baby boomers

Hepatitis C screening became a practical hospital medicine issue when evidence showed that many people infected with hepatitis C virus (HCV) had no symptoms and did not know they carried it. The baby boomer cohort, generally defined as people born between 1946 and 1964, includes adults who may have encountered blood products, medical procedures or other exposures before modern infection-control and testing systems were established. The Hospitalist’s Role in Improving Hepatitis C Screening in Baby Boomers: HM17 Call to Action framed case finding as part of safer, more complete inpatient care.

The 2017 Society of Hospital Medicine meeting at Mandalay Bay Resort and Casino in Las Vegas placed this work within a wider discussion of quality improvement, clinical research and continuing medical education. The event’s learning materials remain useful for understanding how hospitalists can turn an overlooked preventive task into a reliable workflow. The HM17 conference resources also reflect the broader professional setting in which screening, discharge planning and care coordination were discussed.

For Australian clinicians, the issue has a distinctive local context. Hepatitis C is now curable for most people with direct-acting antiviral medicines, which are subsidised through the Pharmaceutical Benefits Scheme, yet diagnosis remains uneven. A patient admitted to a Melbourne or Brisbane hospital may have had a transfusion before Australia introduced routine blood donor screening for HCV in 1990, or may have acquired infection through injecting equipment, an unregulated tattoo or another blood-to-blood exposure.

Hospital admission can provide a valuable opportunity because patients are already connected to pathology, medication review and follow-up services. It can also expose gaps: a busy ward team may focus on the immediate diagnosis, while an abnormal liver result or a remote risk factor disappears from the discharge summary. A considered screening pathway helps hospitalists identify infection without making assumptions based on age, appearance, occupation or perceived lifestyle.

Why the baby boomer cohort needs attention

HCV infection is often clinically silent for years. Some patients have mildly abnormal alanine transaminase levels, fatty liver or thrombocytopenia, but routine blood results may be normal even when chronic infection is present. Untreated infection can progress to fibrosis, cirrhosis, liver cancer and complications that become visible only after substantial liver damage has occurred.

People born from 1946 to 1964 form a useful population group for case finding because some were exposed during periods when HCV was not yet identified and blood supplies were not routinely screened for it. In Australia, a historical transfusion, surgery or hospital treatment before 1990 may be relevant. The same applies to people who received care overseas, had unsafe medical injections or used shared injecting equipment, though risk-based assessment must be handled sensitively.

The hospitalist’s role is not to label every older inpatient as infected. It is to recognise that age cohort, previous healthcare exposure and liver-related findings can justify a brief, respectful conversation. Screening should sit alongside—not replace—ongoing attention to people who inject drugs, people in correctional settings, Aboriginal and Torres Strait Islander communities, migrants from regions with higher HCV prevalence and anyone with a known blood-borne virus exposure.

Turning an admission into a screening opportunity

A workable pathway begins with a prompt in the admission history or electronic medical record. The clinician can record birth year, previous HCV testing, a history of transfusion or major surgery, injecting drug use, tattoos or piercings performed outside regulated settings, and prior treatment for hepatitis. Questions should be private, neutral and focused on clinical relevance rather than moral judgement.

The initial test is usually an HCV antibody test. A reactive result indicates previous exposure, not necessarily current infection, so it must be followed by HCV RNA testing to identify active viraemia. Where laboratory systems allow, reflex RNA testing can prevent the common failure in which a patient leaves hospital with a positive antibody result but no confirmatory test. Results should be explained clearly, with attention to confidentiality and the possibility of stigma.

Hospitalists can also use the admission to check vaccination and liver health needs. There is no vaccine for hepatitis C, but people with chronic infection may benefit from protection against hepatitis A and hepatitis B, depending on their immune status and clinical history. Medication reconciliation, alcohol assessment and review of hepatotoxic medicines add value while the team arranges follow-up.

Building a reliable pathway across Australian services

Screening is effective only when a positive result leads to care. Australian hospitals should define who reviews pending results, contacts the patient after discharge and arranges confirmatory testing or treatment. Depending on the setting, this may involve a general practitioner, infectious diseases or gastroenterology clinic, a sexual health service, an alcohol and other drug service, or a specialist nurse-led pathway.

The process should work for patients who live far from tertiary hospitals. Someone admitted in regional New South Wales may return home hundreds of kilometres away, while a patient treated in Perth or Darwin may have limited access to specialist appointments. Telehealth, local pathology collection, Aboriginal Community Controlled Health Services and clear written communication can reduce the chance that care stops at discharge.

The conference’s wider attention to coordinated inpatient care is relevant here. Work on preoperative optimisation evidence illustrates a general principle: hospital medicine improves when teams identify risks early, assign responsibility and communicate a plan across transitions. HCV screening requires the same discipline, even though the intervention may be a single test rather than a procedure.

Addressing stigma, consent and equity

Many patients associate hepatitis C with injecting drug use and may fear judgement, disclosure or discrimination. A hospitalist can reduce this burden by presenting screening as routine, evidence-based care for a defined age group and relevant clinical circumstances. “This is a common blood test that can identify a curable infection” is more constructive than implying that a patient must disclose a particular lifestyle before testing is considered.

Consent and privacy remain important. Patients should understand what is being tested and what a positive result means. In shared rooms or busy emergency departments, sensitive questions should not be asked where visitors or other patients can hear. Results should be communicated through secure channels, with records limited to staff who need the information for care.

Equity also means adapting the pathway. Aboriginal and Torres Strait Islander patients may prefer care through an Aboriginal Community Controlled Health Service, while people who speak limited English may need a professional interpreter rather than a family member. Patients experiencing homelessness, unstable housing or substance dependence may need flexible follow-up, peer support and same-day referral instead of an appointment several weeks later.

Measuring whether screening improves care

A hospital cannot judge success by counting antibody tests alone. Useful measures include the proportion of eligible admissions offered testing, the percentage of reactive antibody results receiving RNA confirmation, the time from diagnosis to treatment assessment, and the number of patients with documented follow-up after discharge. These measures identify where the pathway breaks.

A small audit can provide a practical starting point. Review several months of admissions, compare screening rates between wards, and examine whether missed opportunities were linked to absent prompts, unclear responsibility or laboratory limitations. Feedback should be shared with medical, nursing, pharmacy, pathology and health information teams rather than assigning the problem to individual clinicians.

The patient experience should be measured as well. A pathway that increases testing but makes people feel exposed or judged is poorly designed. Short interviews, consumer representatives and feedback from Aboriginal health services can show whether the language, consent process and referral arrangements are acceptable. Quality improvement should focus on dependable systems, not a single enthusiastic clinician.

Practical recommendations for hospital teams

A hospitalist-led programme can begin modestly and expand as the service learns. The following actions are suitable for a ward, emergency department or hospital-wide pilot:

• Add birth year, previous HCV testing and key blood exposure questions to the admission or medication history.
• Use reflex HCV RNA testing where pathology systems support it, and assign a named clinician or service to review pending results.
• Give patients a plain-language explanation that distinguishes a reactive antibody result from current infection.
• Build discharge instructions that include the GP, relevant specialist or community service, expected follow-up and contact details.
• Monitor testing, RNA confirmation, treatment linkage and patient feedback by ward and priority population.

A local protocol should also state how clinicians manage results for patients who are transferred, leave against medical advice or cannot be contacted. The Australian Commission on Safety and Quality in Health Care principles of partnering with consumers and communicating at transitions are particularly relevant, even when the screening pathway is developed at hospital level.

The most effective approach treats HCV case finding as ordinary clinical work rather than an optional research activity. It connects screening with liver assessment, medication safety, culturally safe communication and access to curative therapy. For an older inpatient in Sydney, Adelaide or Hobart, a well-timed conversation and a correctly completed test may prevent years of undiagnosed infection.

A practical takeaway is simple: identify eligible patients, order the right confirmatory pathway, document responsibility for results and ensure every positive diagnosis has a clear route to treatment.