• HEPATITIS
• Diagnostic Screening Programs
• Epidemiology
• HEALTH SERVICES RESEARCH

The US Viral Hepatitis National Strategic Plan centres on every person knowing their status; to achieve this, the Department of Health and Human Services (HHS) calls for improved surveillance data and expanded hepatitis screening in a broad range of clinical environments, including the emergency department (ED).1 Although a growing amount of all care—including preventive care—is provided in ED settings, little is known about how often EDs screen for viral hepatitis or about ED-specific barriers to implementing preventive health services like routine hepatitis screening.1–3 We recently completed an updated assessment on the availability of a subset of preventive health services in a sampling of US EDs; this included characterising ED directors’ perceived barriers to implementing these services.4 We found that nearly all US EDs offer at least one preventive health service, many offer multiple and the number of services offered has increased over time; however, among the services studied, we also found that hepatitis was one of the least commonly offered.4 The primary goals of this work were to characterise US EDs by whether they do (or do not) screen for hepatitis and to explore factors associated with screening.

This study was a planned secondary analysis of a larger cross-sectional survey of preventive health services being offered in US EDs.4 As described elsewhere, the National Emergency Department Inventory-USA was used to obtain a random sampling of all US EDs.4 5 From this 5.4% random sampling, ED directors were surveyed to characterise the availability of, and their preference for, a subset of 11 preventive health services.4 Given current recommendations for viral hepatitis screening, this included determining whether they offer any form of hepatitis screening, excluding employee needlestick-based screening.6 7 The survey also obtained information on ED social worker availability, ED-level and patient-level characteristics, and ED directors’ perceptions about barriers to implementing preventive health services like hepatitis screening. Data were summarised as counts (proportions) and medians (IQRs) and comparisons were made with χ2 and Wilcoxon rank-sum tests, respectively. Multivariable logistic regression was then used to explore factors associated with offering hepatitis screening. Consistent with prior model, results are presented with relative risk (RR) ratios and 95% CIs.3 4 Analyses were completed in Stata V.15.1 (Stata Corp, College Station, Texas, USA) and R Studio (https://www.R-project.org). This study followed the Strengthening the Reporting of Observational studies in Epidemiology guidelines for observational studies.8

Among the EDs included (n=290), 58 (20%) reported offering routine hepatitis screening. As demonstrated in the online supplemental table, EDs that do not routinely screen for hepatitis were similar to those that do. This included similar median visit volumes, measures of crowding, and a similar geographical and urban/rural distribution. However, EDs that do not routinely screen had less 24-hour social work coverage and had a higher number of directors express strong worry about the costs associated with implementing preventive health services (p<0.05 for both). In multivariable regression modelling, only ED directors’ strong worry about costs of implementing preventive health services remained significant (0.33 RR (95% CI 0.13 to 0.82)) (table 1).

Overall, most of the EDs studied do not offer routine hepatitis screening and among the variables analysed, ED directors’ strong worry about costs was the only factor significantly associated with a reduced rate of screening. These findings are in the context of worsening boarding and crowding in ED settings, EDs being tasked with how to best allocate finite resources and the increasingly complex landscape of providing care in the ED.9 Although EDs routinely provide care to some of the most vulnerable communities in the USA, there will likely need to be external resources allocated into ED settings before rates of hepatitis screening increase.10 The strong worry of ‘cost’ by ED directors supports new economic analyses on the cost-effectiveness of viral hepatitis screening in ED settings.

This study has several limitations. First, this is an observational, cross-sectional exploration of associations. Second, as described in the parent study, we can only comment on the availability of hepatitis screening along with ED-level and population-level characteristics; we cannot comment on the comprehensiveness, effectiveness or specificity (eg, screening limited to just hepatitis B or C compared with routine co-screening) of any individual programme. Although these aspects are important and merit future attention, these are beyond the stated goals of the current work. Despite these limitations, our findings represent the most current assessment of how often hepatitis screening occurs in US EDs. Given HHS’s ongoing efforts, it also represents a benchmark against which future implementation efforts can be compared.