137EMF Effectiveness of Emergency Department Screening on Hepatitis C Treatment and Cure

Abstract

Emergency Department (ED) hepatitis C virus (HCV) screening programs are proliferating. The effectiveness of ED screening, compared to traditional clinic-based screening, at treating and curing HCV is unknown. The objective of this study is to evaluate treatment outcomes for patients identified HCV+ in the ED compared to those screened HCV+ in community clinics. A retrospective cohort study was performed including all patients found HCV seropositive (HCV+) at two urban medical centers in New Orleans, LA from March 2015 to August 2017. Those screened HCV+ in the ED were compared to patients screened HCV+ at one of seven neighboring community clinics. In both screening settings, all chronically infected patients were referred to the same infectious disease outpatient clinic for management of HCV infection. Study outcomes were: starting HCV therapy, completing HCV therapy, and achieving functional HCV cure (sustained virologic response at 12 weeks). Time from HCV antibody screening to each treatment outcome was measured. Analysis was performed using multivariable log-binomial regression, adjusting for insurance and history of intravenous drug use. A total of 3,929 patients (3,556 ED and 373 clinic) were screened HCV+, while 2,720 patients (2,562 ED and 158 clinic) were found chronically infected by persistent HCV RNA. HCV therapy was started in 9.8% of ED patients (median time=13.4 months) and 3.8% of clinic patients (median time=15.8 months). Compared to those screened in a clinic, patients testing HCV+ in the ED had significantly higher likelihood of starting therapy (adjusted relative risk [aRR]=2.82; 95% confidence interval [CI]=1.28-6.23; p=0.01). HCV therapy was completed in 7.8% of ED patients (median time=16.4 months) and 3.8% of clinic patients (median time=18.1 months). Compared to those screened in a clinic, patients testing HCV+ in the ED had significantly higher likelihood of completing therapy (aRR=2.28; 95% CI=1.03-5.05; p=0.04). Functional cure was achieved in 5.6% of ED patients (median time=19.0 months) and 1.9% of clinic patients (median time=23.7 months). Compared to those screened in a clinic, patients testing HCV+ in the ED had significantly higher likelihood of achieving cure (aRR=3.29, 95% CI=1.06-10.19; p=0.04). Patients diagnosed HCV+ in the emergency department were significantly more likely to initiate HCV therapy, complete HCV therapy, and achieve HCV cure, compared to patients screened in a community clinic. We believe the success of ED screening can be attributed to co-localization of follow-up HCV staging and treatment services in proximity to the ED. Furthermore, reflex ordering of viral RNA in the ED improved timeliness and confirmation of HCV chronic infection, likely increasing the momentum of ED patients to start treatment and achieve cure. Expanding ED-based HCV screening may serve as the most effective strategy to deliver HCV treatment and improve patient outcomes.