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Birth cohort-specific consideration in an Emergency Department Hepatitis C Testing Programme: A description of
Lauren A Walter1, Myles Prados2, Audrey Lloyd2
1Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA.
Insights
Younger generations, particularly Millennials, face significant barriers to hepatitis C virus (HCV) care linkage despite increasing prevalence. Emergency department testing highlights disparities, with older adults showing higher linkage success rates.
Area of Science:
- Public Health
- Epidemiology
- Health Systems Research
Background:
- Emergency departments (EDs) are crucial for public health, especially in hepatitis C virus (HCV) testing and care referral.
- HCV prevalence is shifting from older Baby Boomers to younger Millennials due to the opioid epidemic.
- Understanding demographic shifts in HCV is vital for targeted interventions.
Purpose of the Study:
- To examine the demographic shift in HCV infection within an ED testing program.
- To compare HCV testing and linkage success rates across different birth cohorts.
- To identify barriers to HCV care linkage in younger versus older generations.
Main Methods:
- Retrospective chart review of ED patients tested for HCV from August 2015 to December 2020.
- Analysis of HCV antibody (Ab) and RNA test positivity, linkage rates, and demographics.
- Disaggregation of data by birth cohort (Silent Generation, Baby Boomer, Gen X, Millennial, Gen Z) and evaluation of linkage barriers.
Main Results:
- Over 83,000 patients were tested; 7.4% were Ab-positive and 3.2% RNA-positive.
- RNA-positive individuals were predominantly white and male, with similar generational distribution across Baby Boomers, Gen X, and Millennials.
- Linkage to care was significantly lower in Millennials (17.8%) compared to Baby Boomers (38.1%), with over 90% experiencing barriers.
Conclusions:
- The ED population is a vulnerable cohort with high HCV prevalence and significant linkage barriers.
- Younger generations (Gen X, Millennials) face distinct barriers like substance use, lack of insurance, and incarceration, impeding care.
- Interventions must address these age-specific social determinants of health to improve HCV treatment outcomes.
Abstract:
The emergency department (ED) has increasingly become an important public health partner in non-targeted hepatitis C virus (HCV) testing and referral to care efforts. HCV has traditionally been an infection associated with the Baby Boomer generation; however, recent exacerbation of the opioid epidemic has resulted in a growing number of younger cohorts, namely Millennials, also impacted by HCV. Examination of this age-related demographic shift, including subsequent linkage success and linkage barriers, from the perspective of an ED-based testing and linkage programme may have implications for future population and health systems interventions. A retrospective descriptive chart review was performed, inclusive of data from August 2015 through December 2020. We compared the quantity of positive HCV screening antibody (Ab) and confirmatory (RNA) tests and further considered linkage rates and correlative demographics (e.g. gender, race). Patient barriers to HCV care linkage (e.g. substance misuse, lack of health insurance, homelessness) were also evaluated. The data set was disaggregated by birth cohort to include Silent Generation (SG) (1928-45), Baby Boomer (BB) (1946-64), Generation X (Gen X) (1965-80), Millennial (1981-96) and Generation Z (1997-2012). Descriptive statistics and chi-square analysis were performed. Overall, 83,817 patients were tested for HCV (50.6% of eligible); 6187 (7.4%) were HCV Ab positive, and 2665 were HCV RNA positive (3.2%). RNA-positive individuals were more likely to be white (70.4%) and male (67.7%); generational distribution was similar (BB 33.3%, Gen X 32.0% and Millennials 32.7%). Amongst Ab-positive patients, white (45.5%), male (47.2%) and Millennial (49.7%) individuals were most likely to be RNA-positive. Overall, 28.1% of the RNA-positive cohort successfully linked to care; linkage to care rates were significantly higher in older generations (38.1% in BB vs. 17.8% in Millennials) (p < .00001). Over 90% were identified as having at least one linkage to care barrier. Younger generations (Gen X and Millennials) were disproportionately impacted by linkage barriers, including incarceration, lack of health insurance, history of mental health and substance use disorders, as well as history of or active injection drug use (IDU) (p < .00001). Older generations (SG and BB) were more likely to be impacted by competing medical comorbidities (p < .00001). The ED population represents a particularly vulnerable, at-risk cohort with a high prevalence of HCV and linkage to care barriers. While past HCV-specific recommendations and interventions have focused on Baby Boomers, this data suggests that younger generations, including Gen X and Millennials, are increasingly affected by HCV and face disparate social risk and social need factors which impede definitive care linkage and treatment.
