Nontargeted Hepatitis C Screening Yields More ED Diagnoses

Key Takeaways

• Nontargeted screening was associated with more newly identified hepatitis C infections in this emergency department comparison.
• Targeted screening produced a higher proportion of new diagnoses among tested patients than nontargeted screening.
• Over 18 months, linkage, treatment start, treatment completion, and documented cure remained limited and were similar across screening strategies.

This pragmatic DETECT trial compared the two approaches in three high-volume urban emergency departments. The broader strategy found more previously unrecognized infections during routine care. Yet follow-up after diagnosis remained limited, leaving a gap between detection and treatment.

DETECT, short for Determining Effective Testing in Emergency Departments and Care Coordination on Treatment Outcomes for Hepatitis C, was conducted over nearly three years. A total of 147,498 adult patient visits were randomly assigned to nontargeted or targeted screening at Denver Health, Johns Hopkins Hospital, and the University of Mississippi Medical Center. Investigators described the study as a pragmatic clinical trial in three high-volume urban emergency departments. Screening was voluntary, and many patients opted out, so the two strategies were compared under routine participation conditions. Those conditions framed the difference between overall case finding and positivity among patients who accepted testing.

The broader screening approach produced the larger absolute diagnostic yield across the emergency departments. Among patients who underwent testing, however, targeted screening had the higher proportion of newly diagnosed infections, at 2.5% versus 1.6% with nontargeted screening. Risk-based selection concentrated more positives within the tested group. Even so, the wider approach uncovered more infections overall because it reached a larger pool of patients.

Researchers tracked patients for 18 months after diagnosis and found limited progress through follow-up care. About 20% linked with a hepatitis C specialist, about 16% started treatment, about 12% finished treatment, and 9% had a documented cure. Follow-up treatment rates were similar in both screening arms. Patients who disclosed recent injection drug use connected to care less often than others. The main shortfall after diagnosis involved linkage and treatment completion, not case finding alone.

Investigators noted that some smaller or rural emergency departments may still favor targeted screening because of cost and resource constraints. They also reported preliminary results from a subsequent trial showing advantages for patient navigators over standard emergency department referral without navigation.

A future study is being considered to explore treatment right in the emergency department. The comparison left a persistent tension in view: broader screening increased diagnoses, while linkage to care remained difficult.