EXECUTIVE SUMMARY

Although the CDC recommends frontline providers use a targeted screening strategy for the hepatitis C virus (HCV), some EDs are finding that nontargeted approaches are more effective at uncovering new infections. Further, investigators note there is a new surge in HCV infections among younger people that is associated with the opioid epidemic. Such individuals often are reluctant to disclose their use of injectable drugs or other behaviors that put them at risk for HCV.

  • Data collected as part of a nontargeted screening program in the ED at Boston University Medical Center show that roughly half of the patients identified with HCV fall outside the baby boomer cohort recommended for testing by the CDC.
  • The ED at the University of Alabama at Birmingham Hospital moved from a targeted to a nontargeted screening approach for HCV in 2015, essentially doubling the number of infections identified.
  • Experts note that ED-based screening for HCV can be automated to the point where it does not place unacceptable burdens on emergency providers. Still, navigators are needed to link patients who test positive for HCV to appropriate care.

With new treatments offering greatly improved prospects for patients infected with the hepatitis C virus (HCV), more EDs have begun screening for the virus among high-risk groups, especially people born between 1945 and 1965, the group deemed at highest risk for HCV. The yield from such efforts has been impressive, although asking patients about high-risk behaviors has proven problematic.

However, there is evidence that ED-based screening efforts are considerably more effective at identifying HCV infections with routine testing, regardless of whether patients are baby boomers or report high-risk behaviors such as injection drug use.

The latest evidence comes from Boston University Medical Center (BUMC), which offers opt-out HCV testing to all emergency patients older than age 13 whose blood is drawn for any reason. Studying the three-month period between November 2016 and January 2017, investigators found that out of 3,808 tests performed, 504 of the initial tests for HCV were positive. Confirmatory tests were carried out in 497 of these cases, with active infections confirmed in 292 patients in the tested population.1

What is interesting about these results is that half the patients found to be infected with HCV did not fall within the baby boomer cohort recommended for testing by the CDC. (Editor’s Note: More information about the CDC recommendations are available at: https://bit.ly/2hxNkCb.) These results are not necessarily unique, as other EDs are finding similar results from broader HCV testing approaches. Prior to implementing the nontargeted HCV screening approach, emergency physicians at BUMC only tested for HCV when there was a clinical indication that a patient was infected, explains Elissa Perkins, MD, MPH, the study’s lead author and vice chair of emergency medicine research at BUMC.

“It was incredibly rare that [testing for HCV] would happen,” she says. “The year prior to our starting this intervention, we had approximately 15 tests per month performed. There really was no organized screening.”

Investigators hypothesized that a nontargeted screening program likely would identify a high number of active HCV infections because the area had been hit hard by the opioid epidemic.

“We had a suspicion ... that if we went only by the CDC screening guidelines [for HCV] that we would be missing a portion of patients,” Perkins explains. “There is a lot of stigma associated with injection drug use. Patients aren’t always honest about whether they are actively using drugs or have used drugs in the past. We decided that ... as long as we were developing a new program, we would be really broad in who could be potentially impacted.”

Investigators decided to begin HCV testing at age 13 because patients must be at least that age to receive the newer, breakthrough drugs for HCV.

“Whoever enters the blood draw order in the electronic medical record [EMR] ... that is what triggers a best practice advisory [BPA] ... indicating that the patient is eligible for HCV testing,” Perkins explains. “It prompts the provider to obtain the patient’s authorization for the test, and then it allows the provider to sign off on the BPA.”

Not only is the BPA a flag, Perkins says the BPA also is tied to an order entry so that once the provider accepts the BPA, it automatically generates an order for the HCV screen and prints labels for the blood tubes. The only instance when this will not occur is when a patient’s HCV status is documented in the EMR already. The system will check for this information automatically before generating the order for blood work.

“This approach was very intentionally designed to not be a heavy lift on the emergency physicians. We anticipated that if we were asking too much from them, they would not be interested in completing it,” Perkins says. As a result, emergency providers have been supportive of the program.

Are patients supportive? There are no hard data on what patients think about the screening, although most eligible patients have had orders placed for the test.

“In my own personal experience, I have only had one patient decline the HCV test in the two years we have been doing [the nontargeted screening],” Perkins reports. “Most patients, once they understand what it is, are very happy to have the screening.”

Employ Navigators

The preliminary HCV test determines whether a patient is antibody-positive or has been exposed to the virus. That is all that is required for patients who receive negative results. However, for patients who test positive on the antibody test, a second, confirmatory test is needed to show whether the patient is infected. Generally, Perkins says that the initial antibody test returns from the lab at BUMC within one or two hours. In most cases, patients still are in the ED at that point, and the provider can notify patients of the results.

When the antibody tests are positive, confirmatory tests are ordered, but they generally take a few days to complete.

“We have navigators who get a list of all the patients who have positive test results,” Perkins shares. “[Navigators] then contact all of those patients, inform them of their positive test, and work with them to link them to care.”

However, connecting with patients after they have left the ED is not always successful. In Perkins’s study, only about one-third of patients with active infections were scheduled for follow-up appointments. Of those, only 66 patients made it to the follow-up appointment. “There is a large number of patients we just have a lot of difficulty getting in contact with. To some extent, that is a product of this particular patient population,” Perkins laments. “A lot of the people we are diagnosing who we are unable to contact have injection drug use issues; many are homeless, and many have mental health issues.”

To improve follow-up for patients with active infections, program leaders have built capacity into the system so that patients who have been diagnosed with HCV will be flagged if they return to the ED for any reason.

“It is automated. The EMR will flag the navigator, and the navigator can then come down to the ED and talk to the patient and try to link him or her to care,” Perkins says.

Finding outpatient providers with the expertise to treat patients with HCV has not been a problem, as increasing numbers of primary care physicians have been trained in the treatment of HCV in recent years.

“We have been able to expand capacity in almost every outpatient provider arena,” Perkins says. “We are also working with our addiction providers to expand their capacity for treating HCV.”

Currently, much of the new HCV screening program at BUMC is funded through a pharmaceutical company that developed curative treatments for HCV. However, Perkins believes the program will endure beyond this grant funding.

“The institution’s [leaders] are showing they are very supportive of the program,” she says. “They recognize this is a need of our patients.”

Emergency medicine professionals interested in developing similar screening strategies should involve all key stakeholders early, Perkins advises.

“Figure out what the institutional priorities are and how you can work within those priorities to develop a program that is going to be supported,” she says. “Without this stakeholder buy-in and leadership ... such a program is going to be very difficult.”

Perkins adds that the results from BUMC strongly suggest that HCV screening should be expanded beyond what the CDC recommends.

“This is a bigger problem than what we recognized [earlier],” she says. “If we only screen the people recommended under the current guidelines, we will be missing a sizable portion of infections.”

Eliminate Stigma Barrier

James Galbraith, MD, vice chair of research in the department of emergency medicine at the University of Mississippi Medical Center, conducted some of the original investigative work showing that ED-based screening for HCV had great potential to identify a high number of infected patients. This work revealed an opportunity to prevent downstream medical complications/costs and further spread of the infection to other individuals.2,3

Further, Galbraith implemented the HCV screening program in place in the ED at the University of Alabama at Birmingham (UAB) Hospital. After initially screening in accordance with the CDC’s recommendations at UAB Hospital, Galbraith moved to universal screening criteria in 2015. “It is very easy to identify the risk factor of somebody’s date of birth. It is very hard to identify the other risk factors for acquiring HCV [outlined in the CDC guidelines]. A birth cohort-only screening strategy will be great at identifying baby boomers, but it is going to miss the growing number of individuals — especially those who are younger than baby boomers — who have acquired HCV even more recently through injection drug use,” he explains. “We have seen HCV surge in a second wave of this epidemic that coincides with the opioid epidemic.”

The difficulty of identifying risk factors for HCV in the ED has everything to do with stigma, Galbraith shares. “Patients feel stigmatized by their behavior. They are unwilling to share with providers because they feel like it will affect their rapport with them, and vice versa,” he says.

“Emergency providers are very challenged sometimes to ask the risk-based questions to every patient coming into the department, fearing that we will offend them, interfering with our rapport with the patient. A lot of HCV cases go undetected [with a targeted screening approach].”

With a universal screening strategy, providers no longer need to ask about risk factors. “We test people based on their awareness of their HCV status. If they are [unaware of] their HCV status or they haven’t been tested, we offer a test,” Galbraith reports. “We test approximately 22,000 people annually [in the UAB Medical Center ED] ... and we see an overall antibody-positive prevalence of 7.7%.”

Similar to the BUMC data, roughly half the individuals who test antibody-positive were born after 1965, putting them outside the baby boomer cohort targeted in the CDC screening guidelines.

“The most striking thing we identified at UAB Hospital is that our HCV antibody-positive prevalence for those born after 1965 overall is 6%. It is very high even in that younger group, but it is driven by a 13.7% prevalence amongst white individuals born after 1965 compared to a 2% prevalence for persons who are black,” he says. “It is a young, white problem. It fits exactly with what we are seeing going on in our local communities with the opioid epidemic and what is known also throughout Appalachia and nationally.”

When UAB Hospital moved to a universal testing strategy, it essentially doubled the number of HCV cases it was identifying, Galbraith explains.

“Part of the story here with HCV is that we do have this wave of baby boomers who still account for the majority of infections in the U.S. ... but there are more and more people transitioning and injecting opioids every day. We are failing to identify those individuals ... and that includes not just HCV testing, but also HIV testing.”

Address Concurrent Addiction

The HCV testing process in the ED at UAB Hospital begins when patients present to the front desk for any complaint.

“If they are older than age 18, the nurse asks them if they have ever been diagnosed with HCV. If the patient states no, then an opt-out test is offered,” Galbraith explains. “That nurse will then explain that [the ED] performs routine HCV testing, and that a test will be performed that day unless the patient wishes to decline.”

As long as the patient does not decline, an automated order for the HCV test will be issued; the patient will have blood drawn during the visit, and an HCV test will be conducted, Galbraith adds.

In the early days of the HCV testing program at UAB Hospital, finding outpatient providers to treat all patients who were testing positive was challenging. However, those capacity issues have eased considerably in recent years.

“Our linkage-to-care rate has improved and it has improved secondary to more providers coming on board to treat HCV,” Galbraith says. “Also, we have more treatment providers now in our surrounding Federally Qualified Health Centers, which have really allowed us to get patients into more stable medical homes.”

It has been very convenient to send patients who have otherwise uncomplicated HCV infections to primary care physicians, rather than subspecialists, to be treated, Galbraith notes. However, he says that new challenges have emerged: Many patients diagnosed with HCV also struggle with competing addiction problems.

“We have a new type of patient who has different needs than many of the baby boomers [with HCV] that we were seeing,” Galbraith says. “Many of the new, younger individuals we are identifying have problems with opioid addiction. We are really challenged to get them stabilized with their addictions.”

To address this problem, UAB Hospital will initiate buprenorphine prescribing in the ED.

“We are working on a lot of things in this area, and trying to build the resources needed because we want to treat individuals for HCV. We certainly can treat them, even while they have their addiction, but we are really not giving them the service they need if we are not getting them help for their addiction, which is actually potentially much more lethal.”

Galbraith intends to get both HCV and HIV testing off the ground at the University of Mississippi Medical Center ED and to work on opioid harm reduction interventions. Galbraith also recently assisted a colleague in starting an HCV testing program in the ED at the University of Kentucky HealthCare.

“Kentucky has perhaps the highest prevalence of HCV in the U.S., largely driven by the opioid epidemic,” Galbraith observes.

While the logistics of creating such a program in the ED are very feasible, funding remains an obstacle for many.

“There is just not enough financial support to screen. It is still not reimbursable,” Galbraith laments. “If you are going to test tens of thousands of patients annually, you are running budgets that are in the hundreds of thousands of dollars.” In addition to testing, funds are needed to support linkage-to-care components.

“It is a full-time job for multiple individuals to work on the navigation, and the cost of that navigation is expensive,” Galbraith acknowledges.

However, he stresses that the benefits of ED-based HCV screening are considerable.

“There are a lot of lessons we have learned from the HIV epidemic. One of the lessons was that testing was an important component of prevention,” Galbraith notes. “It gives people an opportunity to be treated. If they are treated, then they are not going to spread the virus anymore.”

REFERENCES

  1. Schechter-Perkins EM, Miller NS, Hall J, et al. Implementation and preliminary results of an emergency department nontargeted, opt-out hepatitis C virus screening program. Acad Emerg Med 2018 May 31. doi: 10.1111/acem.13484. [Epub ahead of print].
  2. Galbraith JW. Hepatitis C virus screening: An important public health opportunity for United States emergency departments. Ann Emerg Med 2016;67:129-130.
  3. Galbraith JW, Donnelly JP, Franco RA, et al. National estimates of healthcare utilization by individuals with hepatitis C virus infection in the United States. Clin Infect Dis 2014;59:755-764.

SOURCES

  • James Galbraith, MD, Vice Chair, Research, Department of Emergency Medicine, University of Mississippi Medical Center, Jackson, MS. Email: jwgalbraith@outlook.com.
  • Elissa Perkins, MD, MPH, Vice Chair, Emergency Medicine Research, Boston University Medical Center, Boston: Email: elissa.schechter@bmc.org.