Factors predicting staging and treatment initiation for patients with chronic hepatitis C infection: insurance a key predictor.

BACKGROUND: Chronic hepatitis C (HCV) infection affects over 2.4 million Americans and accounts for 18 000 deaths per year. Treatment initiation in this population continues to be low even after introduction of highly effective and shorter duration direct-acting antivirals. This study assesses factors that influence key milestones in the HCV care continuum. METHODS: Retrospective time-to-event analyses were performed to assess factors influencing liver fibrosis staging and treatment initiation among individuals confirmed with chronic HCV infection at University of Illinois Hospital and Health Sciences System between 1 August 2015 and 24 October 2016 and followed through 28 January 2018. Cox regression models were utilized for multivariable analyses. RESULTS: Individuals tested at the liver clinic (hazard ratio [HR] = 2.03; 95% confidence interval [CI]: 1.19-3.46) and at the federally qualified health center (HR = 3.51; 95% CI: 2.19-5.64) had higher instantaneous probability of being staged compared with individuals tested at the emergency department (ED) or inpatient setting. And probability of treatment initiation increased with advancing liver fibrosis especially for Medicaid beneficiaries (HR = 1.64; 95% CI: 1.35-1.99). CONCLUSIONS: The study demonstrates a need for improving access for patients with early stages of the disease in order to reduce HCV-related morbidity and mortality, especially those tested at nontraditional care locations such as the ED or the inpatient setting.

Patient and System Factors Related to Missed Opportunities for Screening in an Electronic Medical Record-driven, Opt-out HIV Screening Program in the Emergency Department.

OBJECTIVE: Emergency departments (EDs) have implemented HIV screening using a variety of strategies. This study investigates how specific patient and health system factors in the ED impact who is and is not screened in a combined targeted and nontargeted, electronic medical record (EMR)-driven, opt-out, HIV screening program. METHODS: This was a retrospective, cross-sectional study of ED visits where patients were determined eligible for HIV screening by an EMR algorithm between November 18, 2014, and July 15, 2015. The HIV screening workflow included three sequential events, all of which were required to get screened for HIV at the ED visit. The events were having a blood draw, being informed of the HIV screening policy by an ED nurse at the point of blood draw, and the patient consenting to the HIV test. Each event represented a dichotomous outcome and its association with six patient factors (age, sex, race/ethnicity, marital status, preferred language, and Emergency Severity Index [ESI]) and two health system factors (ED crowding and program phase) was investigated using multivariable modeling. RESULTS: A total of 15,918 ED visits were analyzed. Blood was drawn in 8,388 of 15,918 visits (53%). Of 8,388 visits where blood was drawn, there were 5,947 (71%) visits where ED nurses documented informing patients of the HIV screening policy. Of those visits, patient consent to the HIV test was documented at 3,815 (64%) visits. Patients between 13 and 19 years of age were significantly less likely to have blood drawn, to be informed of the screening policy, and to consent to the HIV test compared to other age groups. Both ED crowding and a patient's ESI were associated with decreased odds of having a blood draw and being informed of HIV screening by an ED nurse, but showed no association with patients consenting to the HIV test. CONCLUSION: Many patients, particularly adolescents and young adults, are missed in ED HIV screening programs that require blood draw and depend on providers to obtain consent for testing. To ensure that these patients are reached, future ED screening programs should strive to develop innovative workflows that allow for blood draws for HIV screening only and streamline the processes of obtaining informed consent and ordering tests for all eligible patients.

Assessment of Nurse Perspectives on an Emergency Department-Based Routine Opt-Out HIV Screening Program.

Routine opt-out HIV screening is recommended for everyone between 13 and 64 years of age. An urban, academic emergency department implemented a nurse-driven routine opt-out HIV screening program. The aim of our study was to assess program uptake and opportunities to improve the program from the perspectives of emergency nurses. Emergency nurses completed a brief prediscussion questionnaire and then participated in a focus group or semi-structured one-on-one interview to elicit feedback on the routine opt-out HIV screening program. All 16 participants felt adequately prepared for the screening program. Several themes emerged from the discussions, including challenges of specific patient characteristics and overall nurse and patient support for the program. One thread across themes was the importance of good language and communication skills in such programs. While there are opportunities to improve nurse-driven routine opt-out HIV testing programs in emergency settings, this program was found to be accepted by emergency nurses.

Harnessing the Power of the Electronic Medical Record to Facilitate an Opt-Out HIV Screening Program in an Urban Academic Emergency Department.

Emergency Departments (EDs) are important settings for routine HIV screening because they are safety nets for populations with limited access to primary care and high risk for HIV infection. However, EDs rarely perform routine HIV screening due to logistical barriers. An electronic medical record (EMR)-driven routine opt-out HIV screening program was implemented in an urban academic ED and led to rapid scale-up of screening volume and detection of unknown HIV infection. The streamlined tool, requiring 4 mouse clicks, automates screening for eligibility, facilitates documentation of consent and orders the HIV test. HIV screening increased to a monthly average of 550 tests compared to an average of 7 tests prior to program implementation. Similar EMR innovations can be leveraged in a variety of other clinical settings and for testing of other diseases to improve clinical flow and outcomes.