Health Policy and Health Services Research
Background: Hepatitis C virus (HCV), the most common chronic blood-borne illness in the U.S., is responsible for more deaths annually than HIV, tuberculosis, and 58 other nationally reportable infectious diseases combined. In 2013, we pioneered a targeted, opt-out HCV screening and linkage-to-care (LTC) program for baby boomers presenting to the emergency department (ED). In 2015, ED screening was expanded to nontargeted, opt-out (universal) testing. Data on screening yield, LTC outcomes, and predictors of LTC using a nontargeted screening strategy is limited.
Methods: The study was conducted at an urban tertiary care academic ED with 73,000 annual patient visits. All patients were offered an HCV antibody screening test, and confirmatory HCV RNA testing was performed for patients who screened positive. A coordinator facilitated LTC for confirmed cases and followed patients until they were successfully linked (attended an HCV clinic visit) or lost to follow-up. Multiple logistic regression was used to measure the adjusted association between potential predictors and the primary outcome of LTC. Covariates included previously reported LTC barriers, sociodemographic factors, and clinical factors. Deceased patients were excluded from the analysis.
Results: From August 2015 to June 2018, 48,947 patients were screened for HCV, yielding 4,026 (8%) positive screening tests and 1,798 (4%) RNA-confirmed HCV cases. Deceased patients (147) were excluded, leaving 1,651 patients for the multivariate analysis. By July 2018, 884 patients (54%) were linked to care. Odds of LTC were increased for baby boomers (odds ratio [OR] 1.6, 95%CI 1.1-2.2), patients with HBV co-infection (OR 2.8, 95%CI 1.1-7.1), mental health disorders (OR 3.6, 95%CI 2.7-4.8), active substance abuse (OR 1.54, 95%CI 1.1-2.1), or competing comorbidities (OR 3.2, 95%CI 2.1-4.8). Odds of LTC were decreased for those who were uninsured (OR 0.51, 95%CI 0.26-0.99), publicly insured (OR 0.5, 95%CI 0.2-0.9), or medically ineligible for HCV treatment (OR 0.05, 95%CI 0.02-0.14).
Conclusion: The HCV positivity rate in an ED cohort identified through nontargeted screening was 4%, with a 54% LTC rate over a three-year period. Patients who were uninsured, publicly insured, or medically ineligible for HCV treatment were less likely to be linked to care. Targeted interventions to optimize LTC efforts are urgently needed.