Evidence
Alert

Testing for hepatitis in A&E departments is likely to be cost-effective in many areas of the UK

Accident and Emergency (A&E) departments may be a cost-effective location for testing for hepatitis, new research has found.

Rates of hepatitis are higher among A&E patients than in the general population. This is because hepatitis is more common among marginalised communities - including people who are homeless or who inject drugs - and they attend A&E more often. Further, almost two in five patients in A&E have blood test as a routine part of their care, which could provide a valuable opportunity for testing for hepatitis.

Hepatitis B and C are inflammatory liver conditions, caused by different strains of the hepatitis virus. They are transmitted through body fluids and infection is confirmed by a blood test.

Symptoms include fatigue, weight loss and yellow skin and eyes. They may develop slowly and may not be immediately obvious. However, infection can lead to severe illness or liver failure unless treated with antiviral medication.

The new research suggests that testing for hepatitis in A&E departments may be more cost-effective than in other settings.

What’s the issue?

Within the UK, it is estimated that 210,000 people have hepatitis C, and 440,000 have hepatitis B.

Prevalence of hepatitis is higher among the 25.6 million people per year who attend A&E, than in the general population. In London and some other areas, up to 2% of those arriving in A&E have hepatitis B, and up to 2.9% have hepatitis C.

Most are in the early stage of the condition and are not showing symptoms. If the condition is diagnosed early enough, it can be treated before it causes serious liver damage and potentially death.

NICE guidelines currently recommend HIV testing in A&Es for areas where more than 0.2% population is infected. Yet there is currently no equivalent UK guidance for hepatitis testing in A&E, partly due to a lack of cost-effectiveness evidence. This study endeavours to plug that knowledge gap.

What’s new?

The researchers believe their study is the first economic evaluation of testing for hepatitis B and C in UK A&E departments.

The study included data from two London hospitals which piloted hepatitis testing in A&E. Researchers used an economic model to estimate the benefit to people who are diagnosed and treated for hepatitis, and also the additional costs associated with providing testing.

The researchers estimated the gain in quality adjusted life years (QALY) associated with testing. NICE defines this as a measure of a person’s health in which benefits in terms of length of life, are adjusted to reflect the quality of life. One QALY is equal to one year of life in perfect health.

The researchers also calculated the costs with and without hospital testing, taking into account factors such as the cost of testing and treatment at diagnosis, and the reduction in costs associated with liver disease.

The analysis found that A&E testing for hepatitis B and C is highly likely to be cost effective. It showed that, in these two London hospitals:

  • for hepatitis B, the cost was £9,858 per QALY
  • for hepatitis C, it was £8,019 per QALY
  • by age, testing was highly cost-effective for those aged 16-69, and most cost-effective in those aged 30-69
  • hepatitis C testing was 99.1% likely to be cost-effective, and hepatitis B testing 98.4% at the NICE cut-off level for cost-effectiveness.

This means that A&E testing for hepatitis is not only cost-effective in London, where infection rates are high. It is likely also to be cost-effective where as few as one in 200 (0.5%) of those arriving at A&E have hepatitis B or C.

The researchers also suggest it could be cost-effective in areas where as few as one in 400 (0.25%) are infected. This is much lower than the prevalence of hepatitis B (one in 120) and hepatitis C (one in 80) found in the two pilot studies.

Why is this important?

Hepatitis can cause severe liver damage if left untreated. It can be fatal. But, as with many conditions, early diagnosis and treatment can result in a good recovery.

With many sufferers unaware that they have early stage hepatitis, the opportunity to pick it up from routine blood tests in A&E departments could be crucial in helping identify sufferers.

In turn, this will reduce the risk of the disease becoming more severe and requiring more expensive treatments. This will enable patients to lead a normal healthy life. It will also reduce the risk of a carrier transmitting hepatitis to others.

NHS England has adopted the World Health Organization commitment to eliminate hepatitis B and hepatitis C as a major public health threat by 2030. This study offers guidance about the spending necessary to achieve that goal.

What’s next?

HIV testing is already recommended in A&E departments. Researchers say it is a natural step to extend testing to cover hepatitis and for NICE guidelines to recommend testing for hepatitis.

This was an initial, pilot study in London.  Further studies are currently underway in A&E departments across the UK, with evaluations of cost in different geographical areas. The ongoing work aims to reduce uncertainties in the first analysis and evaluate the budget impact of testing for hospitals.

The cost-effectiveness of testing those aged 70 and over remains uncertain. People in this group are less likely to be infected and have lower life expectancy from the point of diagnosis. The researchers say further analyses are required to assess this in more detail.

This study will help with decision-making and healthcare planning at local level. It demonstrates that A&E screening for hepatitis can be cost-effective and supports the extension of existing guidelines to include hepatitis.

You may be interested to read

The full paper: Williams J, and others. An Economic Evaluation of the Cost-Effectiveness of Opt-Out Hepatitis B and Hepatitis C Testing in an Emergency Department Setting in the United Kingdom. Value Health. 2020; 23:1003–1011

World Health Organisation (WHO) Global hepatitis report, 2017, which details the call to eliminate viral hepatitis by 2030, and presents data to help monitor progress and measure the impact of interventions

NHS England plans to be first in the world to eliminate Hepatitis C, 2018

A previous study looking at hepatitis testing in an A&E department: Evans H, and others. An innovative approach to increase viral hepatitis diagnoses and linkage to care using opt-out testing and an integrated care pathway in a London Emergency Department. PLoS One. 2018;13:e0198520

Previous results showing high (but variable) prevalence in across the UK: Hopkins MJ, and others. Consistent high prevalence of undiagnosed blood‐borne virus infection in patients attending large urban emergency departments in England. J Viral Hepat. 2020;27:88–91

 

Funding: The research was funded by the NIHR Health Protection Research Unit in Blood Borne and Sexually Transmitted Infections at UCL in partnership with Public Health England, the London School of Hygiene & Tropical Medicine and the University of Bristol. The University of Bristol has received funding from Gilead to perform this independent economic analysis.

Conflicts of Interest: Several study authors have received fees and funding from various pharmaceutical companies.

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

Commentaries

Study author

The initial results are encouraging, and show that testing in emergency departments is likely to be cost-effective in many areas. However, more research needs to be performed to ensure that these results are robust. The key questions that we will seek to answer are: is testing still cost-effective when provided at full scale (rather than just in small pilot studies); and what other factors might influence the cost-effectiveness across geographical regions, since patient characteristics, costs, and levels of cases already diagnosed are likely to differ from region to region.

We hope that emergency departments will introduce hepatitis testing and collect data on the outcomes of testing. We also hope that NICE will update hepatitis testing guidelines, and consider our economic evidence for testing in emergency departments.

Jack Williams, Research Fellow in Health Economics, London School of Hygiene & Tropical Medicine

Researcher

The findings from the study are robust, with appropriate economic modelling performed, different thresholds applied and sensitivity analyses. The proposed screening for hepatitis B and C in emergency departments should be evaluated further. Laboratory capacity, available staffing, the time required to conduct the screening test, and its acceptability among the general public, all need to be assessed for the proposed measures to be taken forward.

Despite the uncertainty around the prevalence of hepatitis B and C in the general population, this study demonstrates that screening for these diseases in emergency departments could be cost-effective for the NHS, even if the infections are rare.

Bruna Rubbo, Senior Research Assistant, Health Workforce Research, University of Southampton

Member of the public

These findings are particularly important because they provide good evidence for changing practice, with the potential benefit of earlier interventions for individual patients, and implications for reducing onward transmission. As the ‘cost’ to society and healthcare of onward transmission is not included, the benefit of screening is likely to be higher than demonstrated in the paper. If this screening is implemented as an opt-out test for patients in ED (emergency departments), these patients should be informed of the intended test, its potential benefits for them and others, and possible consequences if they choose to opt out.

Toto Anne Gronlund, Llanrwst, Conwy, North Wales