HCV Emergency Department Screening: Nontargeted Approach More Effective

DETECT Hep C trial reveals superior results with broad screening.

New research suggests that a nontargeted approach to hepatitis C virus (HCV) screening in emergency departments (EDs) identifies more new infections than targeted methods. However, linking patients to follow-up care remains a challenge.

Landmark Trial Findings

The DETECT Hep C Trial, the largest pragmatic clinical trial of HCV screening in EDs to date, compared targeted and nontargeted screening strategies. The study, conducted across three high-volume EDs, found that nontargeted screening led to significantly more new HCV diagnoses. Jason Haukoos, MD, MSc, a professor at the University of Colorado Anschutz Medical Campus, and colleagues highlighted the importance of real-world evaluations of HCV screening approaches in emergency care.

Global Impact of Hepatitis C

The World Health Organization (WHO) estimates that 50 million people globally have chronic HCV infection, with approximately 1 million new infections annually. The WHO recommends simplified service delivery for testing and treatment, emphasizing decentralization and integration, particularly in primary care and harm reduction services. As EDs serve large numbers of at-risk patients who may not access healthcare elsewhere, they have become a focal point for screening efforts.

Study Design and Methodology

The multicenter, prospective, randomized clinical trial enrolled patients aged 18 years and older who consented and had no prior HCV diagnosis. Participants were assigned to nontargeted screening (testing offered regardless of risk) or targeted screening based on factors such as birth year (1945-1965), injection drug use, or tattoos in unregulated settings. Randomization occurred from November 2019 through August 2022, integrated into each institution’s electronic health record (EHR) system.

Key Results

The trial randomized 147,498 patient visits. In the nontargeted group, 13.4% were tested for HCV, resulting in 154 new diagnoses. In the targeted group, 31.8% were identified as having risk factors, with 6.3% tested and 115 new diagnoses. Nontargeted screening was associated with a significantly greater number of new HCV diagnoses (relative risk, 1.34; 95% CI, 1.05-1.70; P = .02).

Gaps in Follow-Up Care

Despite the success of nontargeted screening in identifying more HCV infections, a relatively small proportion of patients in both groups were linked to follow-up care, initiated treatment, completed treatment, or achieved sustained virologic response at 12 weeks (SVR12). For instance, follow-up care was 19.5% in the non-targeted group compared to 24.3% in the targeted group.

Call to Action

“This multicenter randomized clinical trial determined a nontargeted screening approach was superior to targeted screening for identifying new HCV infections among patients seen in 3 urban EDs,” investigators concluded. They emphasized that the substantial decrease in patients progressing from diagnosis to SVR12 highlights an urgent need for innovative models of HCV treatment. According to the CDC, in 2022, only 33% of people aware of their HCV status received treatment (CDC), showcasing the importance of improving access to care and treatment.

New Guidelines Address Chronic Venous Disease

SCAI releases recommendations for personalized treatment approaches.

The Society for Cardiovascular Angiography and Interventions (SCAI) has recently released its inaugural clinical practice guidelines focused on the treatment of chronic venous disease (CVD), offering a roadmap for clinicians and patients alike.

Key Development

These guidelines, comprised of nine formal recommendations addressing eight clinical scenarios, provide recommendations on options such as compression therapy, wound care, ablation, sclerotherapy, phlebectomy, and deep vein stenting. According to Robert Attaran, MD, MBBS, chair of the guideline writing committee, the recommendations aim to offer clinicians and patients a “roadmap for personalized, evidence-informed care.”

The guidelines help determine which patients might initially benefit from conservative treatments versus when to consider more invasive procedures.

In-Depth Analysis

The SCAI’s technical review involved an extensive search for published systematic reviews and included three de novo systematic reviews focusing on ablation therapy, sclerotherapy, and phlebectomy.

Initial screening of 3648 titles and abstracts resulted in 19 being selected to inform the technical review. Individual recommendations were classified as either “strong” or “conditional,” taking into account the certainty of the evidence and other contextual factors.

The guidelines introduce treatment algorithms for symptomatic varicose veins and for venous ulcer disease.

Limitations and Future Research

The SCAI acknowledges the uncertainty of evidence for certain treatments including perforator vein ablation, venoplasty, and stenting for iliocaval obstruction. Similarly, pooling data was challenging due to dissimilar underlying studies.

According to the National Institutes of Health, CVD affects as many as 40% of adults in the United States (NIH, 2022).

Acknowledging these limitations, the SCAI panel advocates for further research, particularly regarding specific ablation modalities for C2-C4 disease and treatment of perforator and accessory reflux.

SCAI’s Commitment

“These guidelines reflect SCAI’s commitment to bringing high-quality, evidence-based standards to areas where our members are increasingly practicing,” said SCAI president Srihari Naidu, MD. As interventional cardiologists become more involved in managing CVD, these recommendations seek to standardize and personalize patient care.

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