Inpatients Less Likely to Receive Linkage to Hepatitis C Care in Emergency Departments

Christine Roder, PhD

Credit: Barwon Health

Findings from a recent study are calling attention to notable deficits in hepatitis C virus (HCV) testing and linkage to care among hospitalized patients who inject drugs or are living with hepatitis C.¹

The retrospective study leveraged data for patients admitted to a regional hospital in Australia or seen in the emergency department and found missed opportunities for hepatitis C care among those with an indication for testing, especially for patients seen in the emergency department (ED).¹

“Using local health knowledge, targeted testing and treatment strategies can be developed that will overcome barriers to care experienced by the local population,” Christine Roder, PhD, an infectious disease and public health researcher at Barwon Health, and colleagues wrote.¹ “Understanding barriers and gaps in health service coverage is essential to develop targeted testing and treatment strategies.”

According to the World Health Organization (WHO), globally, an estimated 50 million people have chronic HCV infection, with about 1 million new infections occurring each year. Although direct-acting antivirals offer an effective cure for infected patients, access to diagnosis and treatment is low. The WHO recommends testing, care, and treatment can now be provided by trained non-specialist doctors and nurses, using simplified service delivery that includes decentralization, integration, and task shifting, but utilization of such approaches in real-world hospital settings is not well understood.²

To assess testing and engagement with care, investigators retrospectively analyzed data for adult hospital inpatients and ED attendees at University Hospital Geelong in Victoria, Australia from November 2018 to November 2021 with indications for intravenous drug use or hepatitis C on their discharge or summary. An inpatient admission or ED attendance was defined as an episode, and investigators categorized episodes by separation coding into 2 groups: persons with a history of injecting drug use and persons with hepatitis C.¹

Receipt of hepatitis C care was defined as documentation of HCV antibody or RNA test, provision of a script for DAAs, or dispensing of direct-acting antivirals (DAAs) from the hospital pharmacy. Hepatitis C care was further categorized as measured, defined as occurring during or following a patient’s first episode during the study period; historical, defined as occurring prior to their first episode; or inferred, defined as a subsequent step in the hepatitis C care cascade occurring during the study period.¹

Hepatitis C status was classified as HCV RNA positive, HCV RNA negative or HCV antibody negative, HCV antibody positive and RNA unknown, or unknown. A missed opportunity was defined as an episode in which a study inpatient did not receive hepatitis C care.¹

The primary study outcomes were the proportion of inpatients who inject drugs or have a history of injecting drug use that are engaged in hepatitis C testing and care in association with their hospital admission as well as predictors of receiving care.¹

Of 79,923 inpatients, 1892 (2.3%) had ≥ 1 relevant episode, including 628 (33.2%) with hepatitis C-coded episodes and 1345 (71.1%) with intravenous drug use-related coded episodes. The total number of episodes with intravenous drug use-related coding was 1643 (1.2 episodes per patient) with a median length of stay of 2.58 days (range, 1–88). The total number of episodes with hepatitis C coding was 1214 (1.9 episodes per patient), with a median length of stay of 4.6 days (range 1–124).¹

At the end of the study period, the hepatitis C status for inpatients with hepatitis C or intravenous drug use-related episodes was unknown for 82.9%; HCV antibody positive, RNA unknown for 4.7%; HCV antibody negative for 3.7%; HCV RNA not detected for 3.4%; and HCV RNA detected for 5.3%. Investigators noted 17.1% of patients received hepatitis C care.¹

Upon analysis, predictors of higher antibody testing rates were mental health unit admission (adjusted odds ratio [aOR], 2.12; 95% CI, 1.24–3.63); identifying as Aboriginal (aOR, 1.76; 95% CI, 1.09–2.84), male sex (OR, 1.59; 95% CI, 1.17–2.16); older age (for each increase in age by 1 year, OR increased 1.01; 95% CI, 1.00–1.02); and increased length of stay (for each increase in length of stay by 1 day, aOR increased 1.04; 95% CI, 1.02–1.06). Predictors of greater RNA testing rates were obstetrics and gynecology unit admission (aOR, 4.38; 95% CI, 1.55–12.37) and increased length of stay (for each increase in length of stay by 1 day, aOR increased 1.03; 95% CI, 1.01–1.05).¹

Predictors of hepatitis C care were mental health unit admission (aOR, 2.23; 95% CI, 1.36–3.66); identifying as Aboriginal (aOR, 1.64; 95% CI, 1.04–2.57); male sex (OR, 1.64; 95% CI, 1.24–2.17); older age (for each increase in age by 1 year, OR increased 1.01; 95% CI, 1.00–1.02); and increased length of stay (for each increase in length of stay by 1 day, aOR increased 1.04; 95% CI, 1.03–1.06). Of note, predictors of not receiving hepatitis C care were ED admissions (aOR, 3.29; 95% CI, 2.42–4.48) and episodes with an ICD-10 code of poisoning by drugs (aOR, 6.46; 95% CI, 4.79–8.71).¹

Investigators outlined potential limitations to these findings, including the fact that it was limited to inpatients with hepatitis C or IDU-related coding and did not include community-based testing and treatment, and did not account for risk factors for hepatitis C acquisition beyond injecting drug use. Additionally, investigators pointed out medical staff may not routinely ask or document if an inpatient has a history of injecting drug use, and if asked, an inpatient may not disclose such information.¹

“This study identified a scope to improve hepatitis C testing in hospital inpatients, particularly in EDs, working within medical priority and length of stay limitations,” investigators concluded.¹ “Increasing hepatitis C testing in at-risk populations enables those infected to realize the benefits of DAA treatment and contributes to micro-elimination in the region.”

References

1. ^{Roder C, Cosgrave C, Mackie K, et al. Missed Opportunities: A Retrospective Study of Hepatitis C Testing in Hospital Inpatients. Viruses. 2024; 16(6):979. https://doi.org/10.3390/v16060979}
2. ^{World Health Organization. Hepatitis C. Newsroom. April 9, 2024. Accessed July 3, 2024. https://www.who.int/news-room/fact-sheets/detail/hepatitis-c}