Sex, Drugs, Hepatitis C, and an Urban Emergency Department

Editor’s Capsule Summary for White et al:1White D.A.E. Anderson E.S. Pfeil S.K. et al.Results of a rapid hepatitis C virus screening and diagnostic testing program in an urban emergency department.Ann Emerg Med. 2016; 67: 119-128Abstract Full Text Full Text PDF PubMed Scopus (57) Google ScholarWhat is already known on this topic: The Centers for Disease Control and Prevention recommends hepatitis C screening for intravenous drug users and individuals born between 1945 and 1965, but few emergency departments (EDs) currently do so.What question this study addressed: Hepatitis C antibody results were retrospectively studied at a busy urban ED after initiation of a triage-based screening program. Barriers to screening, result disclosure, and follow-up are discussed.What this study adds to our knowledge: Among 26,639 visits during 6 months, 2,581 antibody tests were performed; 267 (10.3%) were positive. Of 180 ribonucleic acid tests for active infection, 126 were positive, and 30 patients (1.2% of all tested) attended an appointment in the hepatitis C clinic.How this is relevant to clinical practice: Urban EDs may find a high prevalence of hepatitis C but will likely encounter similar challenges to implementing screening and linking patients to follow-up. Editor’s Capsule Summary for White et al:1White D.A.E. Anderson E.S. Pfeil S.K. et al.Results of a rapid hepatitis C virus screening and diagnostic testing program in an urban emergency department.Ann Emerg Med. 2016; 67: 119-128Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar What is already known on this topic: The Centers for Disease Control and Prevention recommends hepatitis C screening for intravenous drug users and individuals born between 1945 and 1965, but few emergency departments (EDs) currently do so. What question this study addressed: Hepatitis C antibody results were retrospectively studied at a busy urban ED after initiation of a triage-based screening program. Barriers to screening, result disclosure, and follow-up are discussed. What this study adds to our knowledge: Among 26,639 visits during 6 months, 2,581 antibody tests were performed; 267 (10.3%) were positive. Of 180 ribonucleic acid tests for active infection, 126 were positive, and 30 patients (1.2% of all tested) attended an appointment in the hepatitis C clinic. How this is relevant to clinical practice: Urban EDs may find a high prevalence of hepatitis C but will likely encounter similar challenges to implementing screening and linking patients to follow-up. 1.White et al1White D.A.E. Anderson E.S. Pfeil S.K. et al.Results of a rapid hepatitis C virus screening and diagnostic testing program in an urban emergency department.Ann Emerg Med. 2016; 67: 119-128Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar described an emergency department (ED)–based screening program for hepatitis C virus (HCV) infection. They conducted a retrospective cohort study, with the primary outcome being prevalence of HCV among tested patients. Targeted screening was performed among 2 patient groups at triage: those with a history of injection drug use (IDU) and those born between 1945 and 1965 (“baby boomers” birth cohort). They showed that 267 patients (10.3%) screened positive for HCV antibody in a 6-month period.AAccording to an analysis of 2003 to 2010 National Health and Nutrition Examination Survey (NHANES) data, 1% of the US population has chronic HCV. Approximately 3% to 4% of baby boomers in the United States have chronic HCV.2Denniston M.M. Jiles R.B. Drobeniuc J. et al.Chronic hepatitis C virus infection in the United States. National Health and Nutrition Examination Survey 2003 to 2010.Ann Intern Med. 2014; 4: 293-300Google Scholar Why do you think baby boomers have a much higher prevalence of chronic HCV? How does the change in prevalence of the disease affect the sensitivity and specificity of a diagnostic test? How does prevalence affect positive and negative predictive value?BWhite et al1White D.A.E. Anderson E.S. Pfeil S.K. et al.Results of a rapid hepatitis C virus screening and diagnostic testing program in an urban emergency department.Ann Emerg Med. 2016; 67: 119-128Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar use a confirmatory ribonucleic acid (RNA) test on all patients with a positive HCV antibody test result. What is the purpose of the confirmatory RNA test in the diagnosis and management of HCV? What does it mean if a patient has a positive anti-HCV antibody and negative results for HCV by RNA testing?CNot all diseases are amenable to screening programs, whether in primary care or ED settings. Describe the epidemiologic and clinical characteristics of a disease that make it appropriate for screening. Describe new advances in treatment of HCV that may make screening for HCV more desirable.DGiven your answer to 1A, are baby boomers the ideal target population for HCV screening? Imagine that a large, multicenter, randomized, controlled trial was performed to evaluate the clinical efficacy of ED screening for HCV on HCV mortality. Discuss the concept of length-time bias and how it relates to the screening of baby boomers for HCV.2.White et al1White D.A.E. Anderson E.S. Pfeil S.K. et al.Results of a rapid hepatitis C virus screening and diagnostic testing program in an urban emergency department.Ann Emerg Med. 2016; 67: 119-128Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar used 2 testing approaches in their study: screening and diagnostic. In the screening approach, nurses targeted baby boomers according to a predefined screening protocol. In the diagnostic approach, physicians tested patients at their clinical discretion. The primary outcome was the proportion of HCV-tested patients with positive results.AWhite et al1White D.A.E. Anderson E.S. Pfeil S.K. et al.Results of a rapid hepatitis C virus screening and diagnostic testing program in an urban emergency department.Ann Emerg Med. 2016; 67: 119-128Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar stated that the intention of their study was to provide a descriptive analysis of ED-based HCV screening. Without using the word “describe,” explain what information descriptive statistics report? How do descriptive statistics differ from inferential statistics?BWhat is the general goal of disease screening (eg, breast cancer, colon cancer, HIV, HCV)? What are your views about screening for HCV in the ED? As of January 2016, does Medicare pay for screening for HCV in the ED?CWhite et al1White D.A.E. Anderson E.S. Pfeil S.K. et al.Results of a rapid hepatitis C virus screening and diagnostic testing program in an urban emergency department.Ann Emerg Med. 2016; 67: 119-128Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar concluded that “we believe our findings highlight the burden of HCV infection among patients receiving care in an urban ED.” In accordance with information presented in their article, do you agree with this statement? What are some of the strengths of the article? What are the major limitations mentioned by the authors that affect their conclusions? Might there be additional limitations that are not addressed? How might you address these limitations if you were to repeat this study at your institution?DIn their methods, White et al1White D.A.E. Anderson E.S. Pfeil S.K. et al.Results of a rapid hepatitis C virus screening and diagnostic testing program in an urban emergency department.Ann Emerg Med. 2016; 67: 119-128Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar specified that patients with a known HCV diagnosis were not eligible for screening. However, they also reported that 64 of the 267 HCV-positive patients were previously known to be HCV positive. How do you reconcile these results with the reported screening methods? Do you believe that no patients with previously known HCV were screened? How do these results affect your interpretation of overall study detection rates in the screening and diagnostically tested groups?3.White et al1White D.A.E. Anderson E.S. Pfeil S.K. et al.Results of a rapid hepatitis C virus screening and diagnostic testing program in an urban emergency department.Ann Emerg Med. 2016; 67: 119-128Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar performed logistic regression to determine whether demographic and clinical characteristics were predictive of HCV status. Covariates for the logistic regression were based on theory and the results of bivariate analyses. These covariates included birth cohort (before 1945, 1945 to 1965, and after 1965), past or current IDU, sex, race, homelessness, and reason for testing (screening versus diagnostic). Results are reported as adjusted odds ratios (ORs).AExplain why patients who had diagnostic testing had higher odds of having HCV antibody reactivity compared with those who had screening tests.BORs are often confused with risk ratios. In this cohort study, using the information in Table 2, calculate the unadjusted risk ratio and risk difference of having HCV of someone with IDU compared with someone without a history of IDU. Could you do this if this were a case control study?CParticipants were eligible to be offered HCV screening if they were born between 1945 and 1965 or if they ever used injection drugs. However, the authors stated that more than 2,000 patients outside the birth cohort and whose injection status was unknown were included. Do you think that these 2,000 patients were offered screening because someone believed they had increased risk of having chronic HCV? According to your previous answer, do you think the unadjusted OR of risk of HCV screening positive for those born in the 1945 to 1965 cohort compared with those born after 1965 represents an unbiased estimate?DOf the 2,581 patients who were offered testing, 585 (22.6%) of them had unknown IDU status. How did the authors deal with missing variables in their logistic regression model? Might this bias their results? Did the authors provide any evidence that this missing variable may not bias the results significantly? If the authors did not address this potential confounder, examine Table 1 in the article by White et al1White D.A.E. Anderson E.S. Pfeil S.K. et al.Results of a rapid hepatitis C virus screening and diagnostic testing program in an urban emergency department.Ann Emerg Med. 2016; 67: 119-128Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar to identify whether the missing data might have biased the results.4.Let’s imagine that the authors did not have any protocol violations and they enrolled only patients born in the 1945 to 1965 birth cohort or those with an IDU history. Additionally, they had perfect recordings of IDU status (ie, no missing data).AWhat are the risk factors for HCV? What percentage of individuals with chronic HCV do not have classic risk factors?BIn this imaginary cohort, what do you think the adjusted OR of being born in 1945 to 1965 versus after 1965 would be compared with that of the current study? Please explain your answer.CWhat is the risk of transmission of HCV if you were to sustain a needlestick from an infected person? How does this compare with that for HIV and hepatitis B? Results of a Rapid Hepatitis C Virus Screening and Diagnostic Testing Program in an Urban Emergency DepartmentAnnals of Emergency MedicineVol. 67Issue 1PreviewWe describe the results of an emergency department (ED) hepatitis C virus testing program that integrated birth cohort screening and screening of patients with a history of injection drug use, as well as physician diagnostic testing, according to national guidelines. Full-Text PDF