DISCUSSION
HCV-infected, HCV microelimination, liver disease
ADVERSE EFFECTS
In this randomized clinical trial, we investigated the effectiveness and efficiency of 2 different strategies for reengagement in specialist care for HCV patients lost to follow-up. In our setting, both the strategies were feasible and similar in terms of effectiveness; meanwhile, the mail letter strategy seemed to be more efficient, except if only 1 call attempt was considered, in which case, the phone call was superior. Prior specialist’s evaluation and being tested for HCV in the pre-DAA era were the factors associated with not showing up for the appointment. Both strategies were similar in costs. Patients with suboptimal diagnosis, that is, with a positive HCV antibody with unknown RNA, and those with active infection lost to follow-up, were considered a priority group to be linked to care in the microelimination plansThe first reengagement attempt implemented to rescue patients lost to follow-up using laboratory records was conducted in the Netherlands, where patients were invited to participate by a mailed letter.In our study, the number of patients contacted by mail was 34% higher than that by phone calls. However, in the phone call strategy, half of the patients were successfully contacted and scheduled for an appointment, a rate similar to that in the REACH study considering the mail strategy. However, in terms of contacting potential cases, both the strategies are insufficient and far from perfect if patient reengagement is the main objective.The high number of eligible patients for reengagement that were excluded from the study because of the change in residency or no contact data available since the HCV diagnostic test date recorded (overall 64%) was the main limiting factor in the development of successful reengagement strategies. In this regard, automatic electronic alerts addressed to the primary care physician for a referral to specialist cases with HCV antibodies could be a better way to contact this group of difficult-to-reach patients.Our findings support that the mail strategy is more efficient than the phone call strategy with a 3.1 ratio of contact attempts, except when only 1 call attempt is considered in the analysis, which then favors the phone call strategy. In our study, to improve the chances of contact, up to 3 different attempts at different times were planned. The use of answering machines could increase efficiency. Nevertheless, because of confidentiality reasons, their use was not permitted.The phone call strategy nearly doubled the percentage of patients who attended the appointment after contact was successfully established (PP analysis 52.7% vs. 33.7%). Therefore, phone calls were more effective than letters when contact was established; however, in the ITT analysis among randomized patients, there were no differences (26.5% vs. 28.5%). It is still unclear whether mobile text messages would be more effective than phone calls, as there is evidence suggesting that mobile messages and phone calls have similar efficacy in promoting attendance at health care appointments.One recent study has demonstrated that reengagement is cost saving for the public health system because of the estimated reductions in liver disease complications and mortality, being able to link to care 26% of the candidate patients, which is quite similar to our global results (27.4%).With both the strategies, patients could perceive a medical confidentiality breach. However, the basic principles of medical ethics were considered,The factors associated with unsuccessful reengagement were previous evaluation by any specialist and HCV-antibody detection in the pre-DAA era. None of the reengaged patients were previously treated, so it is tempting to speculate that patients who were lost to follow-up after being evaluated by a specialist, keep in mind the complexity and adverse effects of previous treatment regimens or the lack of compliance perceived by the physicians. In this regard, news media information about DAAs is relevant and could improve linkage to care, as shown in this study and by our group.Imprison and homeless population are usually excluded from reengagement plansIn conclusion, the phone call and mail strategies are feasible for the reengagement of HCV patients lost to follow-up. Both the strategies were similar in effectiveness and costs, whereas the mail strategy was more efficient, except when only 1 phone call attempt was considered. This pragmatic study may guide other institutions to implement a systematic strategy to reengage care for HCV-infected patients and may contribute to achieving HCV microelimination and get us closer to meeting the World Health Organization elimination goals.