ED-based screening programs for hepatitis C (HCV) highlight significant opportunity to identify patients, prevent downstream costs/complications
January 1, 2014
Reprints
ED-based screening programs for hepatitis C (HCV) highlight significant opportunity to identify patients, prevent downstream costs/complications
Pilot study data show uninsured, underinsured adversely impacted by HCV
Executive Summary
New data suggest there is a huge opportunity for EDs to identify patients with the hepatitis C virus (HCV) and link them into care before downstream complications lead to higher medical costs and adverse outcomes. Early results from a pilot study at the University of Alabama Medical Center in Birmingham show that at least 12% of the targeted baby boomer population being screened for HCV in the ED is testing positive for HCV, with confirmatory tests showing that about 9% of the screened population is infected with the disease.
• Both the Centers for Disease Control in Atlanta and the US Preventive Services Task Force recommend one-time HCV screening for patients who were born between 1945 and 1965.
• Public health experts say 75% of HCV infections occur in patients born during the baby boomer years, and that roughly half of them are unaware of their HCV status.
• Researchers at UAB report that so many patients are testing positive for HCV that demand for care can quickly overwhelm the health system if new primary care/specialty resources are not identified.
• Administrators of ED-based HCV screening programs in both Birmingham and Houston note that EDs with existing screening programs for HIV should have the easiest time implementing HCV screening. They also stress that patients are more accepting of HCV screening, and that the counseling process is easier.
There is provocative new evidence that EDs could play a crucial role in identifying patients with the hepatitis C virus (HCV) and connecting these individuals with needed care. In just the first few weeks of a new pilot study that is testing the impact of ED-based screening for HCV among baby boomers who are unaware of their HCV status, researchers at the University of Alabama Medical Center in Birmingham (UAB) have found that at least 12% of the population being screened in the ED at UAB are testing positive for HCV antibodies, and confirmatory tests are showing that about 9% of the patients population is, indeed, infected with the disease.
Both the Centers for Disease Control and Prevention (CDC)1 and the U.S. Preventive Services Task Force2 have called for routine screening among patients at high risk for HCV, and one-time screening for patients born between 1945 and 1965, a cohort found to be disproportionately impacted by the disease. Public health experts report that 75% of HCV infections occur in patients within this birth cohort, and roughly half of those infected in this group are not aware of their infection status.
While only a handful of EDs have begun to provide some level of screening for HCV, the early results from the pilot study at UAB show that there can be no denying the potential yield from these efforts. In fact, researchers at UAB were initially stunned by the results.
"We had seven or eight patients test positive for HCV on the first day of testing, and I thought there must be something wrong with the machine. It must be calibrated wrong. And then the next day came and we saw the same thing," explains James Galbraith, MD, an associate professor of emergency medicine at UAB and the lead investigator on the pilot. "So then we waited for the confirmatory PCR [polymerase chain reaction] tests to be done, and we couldn’t believe it."
Even 10 weeks into the testing program, the results are pretty consistent with the first days of screening, says Galbraith. "The number of antibody positives that we have in a given day just goes along with our volume. If we test 40 people, we are going to see four or five people test positive. If we test 100, we will have 12 test positive," he explains.
Patients accept HCV screening
Armed with a grant from the CDC Foundation, launching the HCV screening program was not a heavy lift for Galbraith because he was able to leverage the infrastructure already in place in the ED at UAB to conduct HIV screening. In fact, he notes that it is definitely easier to get patients to go along with the HCV tests. "We are getting to about 75% of our baby boomer population," he says, noting that roughly one-quarter of the baby boomers are too sick when they come in to the ED to be even offered the HCV screening. "Of those patients who are offered screening and are unaware of their HCV status, we have a 91% acceptance rate of the test offering, so we are testing a majority of the baby boomers who are coming through."
There is much less of a stigma associated with HCV than HIV, observes Galbraith. As a result, patient counseling around the test is easier to deliver. And the patients have thus far proven to be much more proactive in pursuing care. "One thing I have noticed is that these patients call us. Unlike with HIV, where sometimes we are telling patients results and we can never find them again the vast majority of these patients have really taken ownership of their [HCV] results, and they are calling us to ask us what we can do to help them," he explains. "It is not something that they are just going home to ignore."
Patients who test positive for HCV are linked with a care coordinator who will be in touch with them by phone within a week of their diagnosis. "We help them link to a primary care provider if they don’t already have one, and then they are linked to our liver disease clinic with our hepatitis specialists," explains Galbraith.
Early concerns that patients might panic upon hearing that they have HCV, possibly leading to a long, drawn-out process of counseling in the ED, have evaporated, given the ease with which patients have accepted and responded to the health information. "We have found that it has been relatively simple," says Galbraith.
The only complaint is that there are so many patients who require counseling that staff stay very busy and engaged with the HCV screening. "Assuming that you spend 10 minutes with a patient — giving them the linkage information, giving them post-test counseling, explaining what [the positive test results] mean, and what the next steps are — that is a lot of time that is taken away [from other tasks] in the ED," acknowledges Galbraith.
Linkage to primary care is critical
What Galbraith has determined thus far is that uninsured and under-insured patients are much more likely to receive positive test results than patients who come in with private insurance. "If you look at the privately insured patients in our department, you will see an overall 4.4% prevalence rate of being HCV positive. When you look at the uninsured or Medicaid recipients, that prevalence goes up to between 16% and 17%," explains Galbraith. "Many of these patients have had risk factors [for HCV]. They just have never had a physician to go to [in order to] have these tests done before."
The data illustrate precisely why ED-based screening can be such a powerful tool in reaching the patients most at risk for HCV. However, the opportunity goes hand-in-hand with the challenge of connecting the large number of patients identified through the HCV screening program with primary care providers. "Every month we have another 100 patients who need to be followed, so clinics can become quickly overwhelmed," explains Galbraith. "Right now, our hospital has been opening up new clinics for patients identified through our department, so we have been fortunate."
There are drugs in the development pipeline that could drastically reduce the treatment time required for patients diagnosed with HCV, but ongoing primary care is critical, explains Galbraith. "Getting someone treated for HCV requires that they’ve got their blood pressure under control and their diabetes under control. You certainly don’t want to put them through all the risks and treatments for hepatitis C only to find out that they have breast cancer or some other health issue," he says. "We won’t be successful at prolonging someone’s life if all we do is treat them for HCV because these patients certainly have other conditions. And lack of primary care is a common thing that we have seen, particularly among baby boomers."
HCV screening begins in Houston ED
The UAB program is the only ED-based HCV screening program that has been funded through the CDC thus far, but a few other medical centers are beginning to offer HCV screening as well. For instance, with funding from Gilead Sciences, a Foster City, CA-based biotechnology company, the ED at Memorial Hermann Hospital in Houston, TX, began offering HCV screening in March of 2013, according to Pamela Green, RN, BSN, the HIV project coordinator and an emergency department nurse at Memorial Hermann.
Through the program, patients who present to the ED with risk factors for HCV — such as prior IV drug abuse, a blood transfusion prior to 1992, or a large number of tattoos — will be offered HCV screening, as well as all baby boomers who are unaware of their HCV status. Memorial Hermann has a nurse-driven HIV screening program in the ED, but rather than place more responsibilities on the nurses, administrators have elected to have residents take charge of the HCV testing. However, results from the HCV screening program are similar to what UAB is experiencing.
"Overall, we are seeing the same high numbers that [Galbraith] has seen," explains Green, citing a positive screening rate of about 10%. Some of these patients have tested positive for HCV in the past, but they were either never connected into care for the disease at that time or they underwent treatment for HCV, but because of knowledge deficits, didn’t realize that their antibodies would always test positive for the disease, observes Green.
As with UAB’s program, Green has found patients to be very accepting of the testing. And there is a process in place to notify patients when their tests come back positive. "We have a letter we send out informing them that they have been found to be antibody positive for hepatitis C," explains Green. "We provide a phone number for them to call, and if we haven’t heard from them, we go ahead and print out their demographics and we get in touch with them."
Staff then take steps to determine how the patients may have acquired the disease, and they provide them with several options for further testing and care. "We then find out what choices the patients have made — where they want to go for follow-up," adds Green.
While the HCV screening hasn’t been in place for long at Memorial Hermann, Green has a few lessons to pass along to ED colleagues interested in setting up a program in their own settings. First, she advises ED administrators to incorporate HCV testing into their electronic medical records (EMR). "Then you won’t have to worry about someone forgetting that they should have tested a particular patient for hepatitis C because the patient was 50 years old," she says. "If you have it built into your EMR, it is an automatic firing of the order process and an automatic questioning process will appear."
Green also emphasizes that at least for the first year of testing, it doesn’t make that much difference whether you identify known HCV patients or new diagnosis patients; it is just important to come up with a baseline for your institution. "In most cities, hepatitis C is not something that is on the surveillance radar. It hasn’t been monitored by health departments," she says. "Right now, the recommendation from the CDC is that people within the [baby boomer] birth cohort be tested once, so it is irrelevant if you have a known hepatitis C patient. At least it is documented that they have indeed been tested, and you can follow-up afterward with what other health care needs that they have."
Learn from ED-based HIV screening programs
There is much to learn from the ED-based screening efforts for HIV, stresses Green. "If you look back at [the experiences] with HIV, the CDC put out recommendations that essentially went ignored for two years before any of the EDs started implementation," she observes. "It would be nice if we could learn from those efforts and build something that is truly a strong program from our experiences and our HIV work. I think [if we do that] we will be better off down the road."
Given the clear opportunity to identify high numbers of patients with HCV and connect them into potentially life-saving care, Galbraith, too, would like to see more EDs step up to the plate. "I am hopeful that this [pilot study data at UAB] will be a call for other EDs to obtain funding to launch similar programs because they really need to validate our results outside of what we are seeing in our department," he explains.
In particular, Galbraith observes that EDs that already have screening programs in place for HIV should have the easiest time implementing screening for HCV. "If you have been successful with HIV, you absolutely can be successful with doing a similar screening program for hepatitis C. I don’t think this would be difficult to add on, other than the cost."
While Galbraith has obtained funding to cover the costs of his HCV screening program, he says the expenses associated with all the staffing, information systems, management, and testing amount to about $250,000 to screen 8,000 people in a year. "That includes assistance with linking patients to care and a lot of things that you might not need if everyone was insured," he says, noting that health care reform could offset at least some of these costs. "There is a large population that is out there that has been silently carrying this disease, and no one has really been aware of it. It has been suspected, but it is more real now as we expand screening."
References
- Centers for Disease Control and Prevention (CDC). Recommendations for the identification of chronic hepatitis C virus infection among persons born during 1945-1965. MMWR Morb Mortal Wkly Rep. 2012;61(4):1-32.
- Moyer, V. Screening for hepatitis C virus infection in adults: US Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2013;159:349-357.
Sources
- James Galbraith, MD, Associate Professor, Emergency Medicine, University of Alabama, Birmingham, AL. E-mail: [email protected].
- Pamela Green, RN, BSN, HIV Project Coordinator, Emergency Room Nurse, Memorial Hermann Hospital, Houston, TX. E-mail: [email protected].
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.