HCV linkage-to-care for baby boomers in the ED

Posted on April 8, 2015

Recent study highlights the necessity of providing HCV screening and linkage-to-care to baby boomer patients in the emergency department

HCV-infected individuals are more likely to use the emergency department (ED) for care than any other healthcare venue. HCV antibody prevalence appears to be between 4-18% in the general ED population. Frequent users of the care provided by EDs including minorities, Medicaid recipients, and uninsured/underinsured individuals, are known to be disproportionately affected by HCV infection. Unfortunately, there have been no systematic efforts to screen ED Baby Boomer patients for HCV. The expansion of illicit drug use and contaminated transfusions in the 1970s and 1980s has resulted in a high prevalence of HCV infection in the Baby Boomer population (those born between 1945 and 1965). Approximately 3.3% of Baby Boomers are HCV-antibody positive, and this birth cohort accounts for up to 75% of all US HCV infections. Unfortunately, 43-85% of baby boomers are unaware of their HCV infection status.

James W. Galbraith and colleagues, recently published the results of an integrated, opt-out pilot HCV screening and linkage to care program of baby boomers presenting to the ED of University of Alabama at Birmingham (UAB) Hospital, Birmingham, Alabama, from September through November 2013 (Galbraith JW et al. Hepatology. 2015 Mar;61(3):776-82). UAB Hospital is an urban academic 1,000-bed tertiary care center serving the greater Alabama region. The UAB Hospital Emergency Department is a Level I trauma center and provides care for approximately 65,000 visits per year, including approximately 12,500 unique baby boomers. A high proportion of individuals served by UAB represent racial and ethnic minorities and the uninsured, similar to many US urban academic EDs.

Opt-out screening was offered to consecutive patients born between the years of 1945 and 1965 presenting to the UAB ED for care, including prisoners and non-English speaking individuals. ED nurses were trained to perform HCV screening by using a questionnaire embedded within the primary assessment section of the ED electronic health record system (EHR). The mean elapsed time for HCV antibody assay results during the study period was 82 minutes. No pre-test counseling was performed and ED physicians informed individuals of HCV-antibody results. HCV-positive cases were provided with an informational packet containing HCV education and detailed instructions on the linkage to care process. From September 3 to November 19, 2013, there were 4,117 unique ED visits by individuals born between 1945 and 1965. Among 3,170 (77.0%) eligible for pre-screening, 2,323 were unaware of their HCV-status.

  • Of the 1,988 receiving automated HCV testing orders, 1,529 ultimately received HCV screening
  • Among 1,529 tests, 170 were seropositive for HCV (11.1%; 95% CI 9.6-12.8)
  • HCV-positive test rates were higher among individuals with public insurance or Medicaid (16.8% vs. 5.0%; OR 3.81, 95% CI 2.19-6.64) and the uninsured (16.9% vs. 5.0%; OR 3.83, 95% CI 2.22-6.61)
  • Compared with females, males had higher HCV-positive test rates (14.7% vs. 7.4%; OR 2.17, 95% CI 1.55-3.05)
  • African Americans were more likely than whites to be HCV-antibody positive (13.3% vs. 8.8%; OR 1.59, 95% CI 1.14-2.21).
  • Among the 170 HCV-antibody positive results, confirmatory PCR RNA testing results were available for 150 (88.2%). HCV viremia was confirmed in 102 of 150 (68.0%; 95% CI 59.9-75.4).

While HCV detection is important, linkage-to-definitive care is also an essential component of an HCV screening program.

  • 54 (54%) RNA-positive individuals were successfully contacted by phone within five call back attempts.
  • Among those successfully contacted, 38 (70.4%) received a confirmed an appointment with a liver specialist.
  • Among those with a confirmed appointment, 21 (55.3%) attended their initial appointment and three (7.9%) are awaiting an upcoming scheduled appointment.
  • Call back success was greater for persons with private insurance or Medicare compared to persons with Medicaid, public insurance, or uninsured (67.6% vs. 46.0%, P = 0.04)

Based upon eleven weeks of screening, unrecognized HCV antibody reactivity was identified in one out of nine baby boomers presenting to the UAB ED. These results substantiate the CDC and US Prevention Services Task Force HCV screening recommendations, and highlight the ED as an important and feasible target for focused HCV screening. An important question is whether this HCV screening and linkage to care program can be generalized to other EDs, without specialized funding, personnel or equipment.

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