Real-world clinical effectiveness and sustainability of universal bloodborne virus testing in an urban emergency department in the UK

Abstract

Innovative testing approaches and care pathways are required to meet HIV, hepatitis B (HBV) and hepatitis C (HCV) elimination goals. Routine testing for blood-borne viruses (BBVs) within emergency departments (EDs) is suggested by the European Centre for Disease Prevention and Control but there is a paucity of supporting evidence. We evaluated the introduction of routine BBV testing in EDs at a large teaching hospital in northern England. In October 2018, we modified the electronic laboratory ordering system to reflex opt-out HIV, HBV and HCV testing for all ED attendees aged 16–65 years who had a routine blood test for urea and electrolytes (U&Es). Linkage to care (LTC) was attempted for newly diagnosed patients, those never referred and those who had previously disengaged from care. The project operated for 18 months, here we present evaluation of the initial nine months (2 October 2018–1 July 2019). We analysed testing uptake, BBV seropositivity, LTC and treatment initiation within six months post-diagnosis. Over 9 months, 17,026/28,178 (60.4%) ED attendees who had U&Es performed were tested for ≥ 1 BBV. 299 active BBV infections were identified: 70 HIV Ab/Ag-positive (0.4% seroprevalence), 73 HBsAg-positive (0.4%) and 156 HCV RNA-positive (1.0%). Only 24.3% (17/70) HIV Ab/Ag-positive individuals required LTC, compared to 94.9% (148/156) HCV RNA-positive and 53.4% (39/73) HBsAg-positive individuals. LTC was successful in 94.1% (16/17) HIV Ab/Ag-positive and 69.3% (27/39) HBsAg-positive individuals. However, at 6 months LTC was just 39.2% (58/148) for HCV RNA-positive individuals, with 64% (37/58) of these commencing treatment. Universal opt-out ED BBV testing proved feasible and effective in identifying active BBV infections, especially among marginalised populations with reduced healthcare access. Our integrated approach achieved good LTC rates although further service development is necessary, particularly for HCV RNA-positive people who inject drugs.

Universal testing for hepatitis B and hepatitis C in the emergency department: a cost-effectiveness and budget impact analysis of two urban hospitals in the United Kingdom

“…The analysis evaluated the cost-effectiveness of ED testing in two locations; Leeds Teaching Hospitals NHS Trust (LTHT), and Guys and St. Thomas' NHS Foundation Trust (GSTT) in London [13,14]. In both EDs, the electronic patient record systems were modified to include a HBV and HCV test for adults, unless they opt-out.…”

“…Patients requiring linkage to care in both EDs were contacted by various means, including phone calls, text messages, and letters to their home and registered GP. Full details are available in the original testing publications [13,14]. Specialist outreach nurses or teams working with the homeless were also informed of those requiring linkage to care.…”

“…A budget impact analysis was performed to estimate the costs associated with HBV and HCV testing and linkage to care. The analysis assumes testing is performed over a one year period (at the same testing rate as the 2 studies, since both studies were performed for less than a year) [13,14]. For both HBV and HCV, the budget impact estimated the costs of the intervention, including all tests, contacting positive patients, and healthcare visits for those engaging with care (Table 2).…”

“…We have used data from two long-term testing studies in two different cities in the UK, with a higher uptake of testing compared to the previous studies. This is likely to be reflective of the impact of real-world universal opt-out ED testing using electronic patient record based testing [13,14]. We also provide a budget impact analysis for decision makers who are considering the cost of implementing ED based testing.…”

Feasibility of a selective targeted strategy of HIV testing in emergency departments: a before-after study

“…Patient autonomy would be maintained by using systems that allow individuals to opt out of implicit consent [26]. A recent experience in England showed that the introduction of routine bloodborne virus (BBV) testing in the ED, modifying the electronic laboratory ordering system to reflect opt-out for testing for all ED attendees aged 16-65 years who had a routine blood test, proved feasible and effective in identifying active BBV infections, and showed a seroprevalence of 0.4% for HIV infection [27]. Another important barrier may be the fact that HIV care in the ED today does not routinely occur for AIDS-indicative illnesses [28][29][30], which may lead the physician not to perceive HIV as an important problem.…”