PRACTICE MANAGEMENT

New York American College of Emergency Physicians

Joseph Basile, MD MBA FACEP

Joseph Basile, MD MBA FACEP

Chair, Department of Emergency Medicine Medical Director, Clinical Operations Staten Island University Hospital

Elyse Lavine, MD FACEP

Elyse Lavine, MD FACEP

Medical Director, MSM ED Assistant Professor Department of Emergency Medicine Mount Sinai Morningside

Rajkumar S. Pammal, MD

Rajkumar S. Pammal, MD

Emegency Medicine Resident Mount Sinai Morningside/West

New York State (NYS) Hepatitis C Virus (HCV) Universal Screening: Implications for Emergency Departments

Beginning May 3, 2024, New York State (NYS) will require all persons 18 years and older and all persons under the age of 18 years with risk factors undergoing treatment in Emergency Departments (EDs) and other practice settings to be screened for Hepatitis C Virus (HCV).1 Hepatitis C is the most reported bloodborne infection in the United States and is responsible for approximately 15,000 deaths annually, making its death rate greater than that of HIV.2 In NYS alone, it is estimated that 116,000 New Yorkers are living with Hepatitis C.1As such, NYS in July 2018 announced the establishment of a Hepatitis C Elimination Task Force, aimed at furthering research, surveillance and cross-sector care models.3 This upcoming NYS Law presents an opportunity for discussion regarding the impetus for such measures, as well as its impact on EDs across the state.

As stated in the NYS Hepatitis C Elimination Plan, ensuring timely access to HCV screening, diagnosis and linkage to care/treat- ment is key to the elimination of HCV, making screening and surveillance the first step in addressing this public health issue.3 The goal is for NYS to screen approximately 10 million individuals to reach elimination goals by 2030.3 A major rationale for universal screening is that once individuals with HCV infection are identified, they can benefit from treatment with direct acting antiviral (DAA) therapy, with most of these patients being cured with 8 to 12 weeks of oral therapy. This treatment option is far more scalable and feasible now given recent lower costs of DAAs. Additionally, the use of HCV reflex testing enables simplified adoption of screening, as active hepatitis C infection can be confirmed with a single test order. Furthermore, it has been suggested that universal screening with opt-out testing is less stigmatizing for patients.4,5

In many ways, the ED is a suitable health care setting for HCV screening, however it does come at a cost to EDs. EDs serve as a safety net for persons at risk for HCV who may be living with the infection without knowing it. In a study at one large-volume New York City ED, prevalence of HCV infection was higher than previously reported state/national prevalence, and the proportion of undiagnosed HCV was nearly one-fifth of these cases.6 Additionally, it is well documented that injection drug use (IDU) is the most common risk factor in HCV cases and EDs already provide care for a large proportion of these patients (e.g., those with opioid use disorder).7

While the NYS HCV Testing Law specifies exceptions to universal screening in the ED such as instances of life-threatening emergency and when patients lack capacity to consent, there are still challenges to HCV screening in the ED. Firstly, HCV screening requires additional nursing/provider tasks such as drawing and sending blood samples. In situations in which patients otherwise would not be having lab work done, this may lengthen ED length of stay and further contribute to ongoing challenges with ED overcrowding. For patient presentations and workups that are unrelated to bloodborne infection, offering testing for such conditions may necessitate additional discussion and patient education, adding to provider burden. Also, such discussions and results reporting surrounding historically stigmatized conditions such as HCV and HIV infection ideally require privacy, which is often difficult given physical space within EDs. Lastly, follow-up is a concern with an integrated follow-up program needed to inform patients about results and provide appropriate linkage to treatment.5 All of these steps require additional resources without any financial assistance from the state.

Without treatment, however, active HCV infection progresses to chronic hepatitis C, liver cirrhosis and decompensation of these conditions results in increased ED visits, hospital admissions and mortality. The public health benefit of DAA treatment can only be realized through markedly increased screening and EDs are a reasonable healthcare setting to initiate such screening. Still, adding additional workflow steps and healthcare utilization via offering and ordering testing, drawing labs and following up results with reporting and treatment, to an already resource-constrained environment is not without challenge. Ultimately, though EDs in New York State will need to continually prepare for and adjust to incorporating opt-out HCV surveillance testing to their workflow, this public health measure represents a meaningful step in the goal of eliminating Hepatitis C from our population.

References