An innovative approach to increase viral hepatitis diagnoses and linkage to care using opt-out testing and an integrated care pathway in a London Emergency Department

Abstract

Therapies that halt progression of chronic hepatitis B virus (HBV) and achieve a cure for chronic hepatitis C virus (HCV) have encouraged development of innovative strategies to diagnose and link patients to care. We describe the prevalence and risk factors for HBV and HCV infections and use of an opt-out hepatitis testing and integrated linkage to care pathway in a London Emergency Department (ED). ED patients aged ≥16 years having routine blood tests from 15 February-28 March 2016 were tested for hepatitis, unless opted out. Hepatitis B surface antigen (HBsAg) and hepatitis C antibody tests (HCV-Ab, including a confirmatory hepatitis C antigen test (HCV-Ag)) were pre-selected on electronic blood test requests. Linkage to care (attending one clinic appointment) was offered to HBsAg and HCV-Ag patients (new or known-disengaged with care diagnoses). Weighted prevalence estimates and risk factors for seropositivity adjusted by demographics and survey weights were calculated using logistic regression. Hepatitis testing uptake was 56% (3,290/5,865). Overall, 26 HBsAg (10 new diagnoses) and 63 HCV-Ab patients were identified of which 32 were HCV-Ag positive (10 new diagnoses). Weighted seroprevalence of HBsAg was 0.50% (95% CI 0.3–0.8%); HCV-Ab 2.0% (95% CI 1.5–2.7%) and HCV-Ag 1.2% (95% CI 0.8–1.7%). Risk factors for infection were being male (HBsAg: aOR 4.1, 95% CI 1.5–11.3), of non-White British ethnicity (HBsAg: aOR>11) or being homeless (HCV-Ag: aOR 18.9, 95% CI 6.9–51.4). We achieved a high linkage to care uptake for HBsAg (93%) and HCV-Ag (78%) among patients who were contacted and required linkage. A pre-selected hepatitis testing ordering system facilitated a high testing uptake. New and disengaged with care diagnoses and a high HCV prevalence were identified demonstrating the potential to identify and link patients to care in this setting. Strategies connecting clinical care with community outreach services are key for improving patient linkage to care.

Seroprevalence and demographic factors associated with hepatitis B, hepatitis C and HIV infection from a hospital emergency department testing programme, London, United Kingdom, 2015 to 2016

“…Our elevated prevalence estimates may by partly due to a genuinely higher underlying HCV and HIV prevalence in the area served by the hospital, as compared to the rest of London; however, it is also highly unlikely that ED attendees, and the subset of them that require a FBC, represent the general population of either the hospital’s catchment area or the rest of London, in terms of risk factors for BBVs. With the exception of HCV-Ab prevalence estimated from an ED in Dublin (5.1%; 95% CI: 4.6–5.5) that was more than twice as high as we observed [23], there was, strong agreement between our crude estimates of infection-specific seroprevalence and those reported from previous urban ED testing campaigns in London (all BBVs) [17,18,35], Dublin (HIV and HBV) [23], Germany (HCV-Ab) [25], Switzerland (HCV-Ab) [24] and the Netherlands (HIV) [36].…”

The emergency department as a setting‐specific opportunity for population‐based hepatitis C screening: An economic evaluation

“…The modelled screening mechanism demonstrated the potential for the use of electronic health record information and dedicated screening personnel to facilitate the linkage to care for those who test positive. Additional strategies to overcome barriers in linkage to care have included adding alerts to patient records to inform healthcare professionals of their diagnosis and their need for further care, formation of teams dedicated to connecting community outreach services with clinical care and post‐test counselling programmes 34,35 …”

The testing of people with any risk factor for hepatitis C in community pharmacies is cost‐effective

“…Unfortunately, there remain numerous barriers to testing that need to be overcome . Attempts have been made to address these; in the UK, national action plans have encouraged an increase in HCV testing and this has prompted initiatives such as primary care record screening for people at risk of HCV, testing in emergency departments, and prisons and widespread testing in drug support centres . In addition to these initiatives, there is also growing evidence that targeted testing for HCV in community pharmacies may be an effective approach to identify undiagnosed cases of HCV …”

“…[11][12][13][14] Attempts have been made to address these; in the UK, national action plans have encouraged an increase in HCV testing and this has prompted initiatives such as primary care record screening for people at risk of HCV, testing in emergency departments, and prisons and widespread testing in drug support centres. [15][16][17][18] In addition to these initiatives, there is also growing evidence that targeted testing for HCV in community pharmacies may be an effective approach to identify undiagnosed cases of HCV. [19][20][21] However, treatment for HCV is expensive and when the costs of the directly acting antiviral drugs (DAAs) are assessed against potential benefits, they have been close to acceptable 'willingness to pay' thresholds in the USA, 22 UK 23 and Europe.…”