Nontargeted ED Screening Offers Best Value in Hepatitis C Care

Offering hepatitis C virus (HCV) tests to every adult in the emergency department (ED), rather than only to those flagged as high risk, provided the greatest health benefit at a cost far below common value thresholds, according to an economic evaluation recently published in JAMA Internal Medicine.¹

How EDs Fit Into HCV Elimination Efforts

The CDC recommends 1-time HCV screening for all adults as part of broader efforts to eliminate HCV by 2030, a goal shared with the World Health Organization. EDs can help reach that goal because they serve 2 high-priority groups who are hard to reach in ambulatory care: people without regular access to preventive services and those who use drugs. However, limited time, space, and staffing have historically made ED screening difficult to implement.¹

The Determining Effective Testing in Emergency Departments and Care Coordination on Treatment Outcomes for Hepatitis C Screening (DETECT Hep C) trial found in 2025 that nontargeted screening identified significantly more new HCV diagnoses than targeted, risk-based screening (relative risk, 1.34; 95% CI, 1.05-1.70).² However, few patients diagnosed with HCV went on to achieve a cure.

The challenge is not new. In 2015, The American Journal of Managed Care^® reported that an ED program in Oakland, California, screened fewer than 10% of adults, and many patients scheduled for follow-up did not attend.³

To estimate the long-term value of targeted and nontargeted HCV screening, investigators used the Hepatitis C Cost-Effectiveness microsimulation model, informed by data from 147,498 ED visits at Denver Health Medical Center, Johns Hopkins Hospital, and the University of Mississippi Medical Center.¹ They simulated a cohort of 500 million individuals with a mean (SD) age of 46.3 (17.2) years under 3 strategies: no ED screening, targeted screening, and nontargeted screening.

The analysis used a health sector perspective over a lifetime horizon, expressed costs in 2024 US dollars, applied a 3% annual discount rate, and considered strategies cost-effective at less than $100,000 per quality-adjusted life-year (QALY) gained.

What the Model Showed About Costs and Cures

Nontargeted screening produced the best clinical results, curing 65.89% of HCV infections with a discounted quality-adjusted life expectancy of 15.8723 QALYs, a discounted lifetime cost of $214,465, and an incremental cost-effectiveness ratio (ICER) of $12,820 per QALY gained. Staff time was the main cost driver, with personnel accounting for $380.26 of the $445.84 cost per RNA test in the nontargeted arm.

Targeted screening resulted in a cure rate of 65.88%, with a discounted quality-adjusted life expectancy of 15.8721 QALYs and a discounted lifetime cost of $214,462. No ED screening was the least favorable option, as it cured the fewest infections (65.60%) while generating fewer QALYs (15.8717) at a slightly higher cost ($214,467). Compared with no ED screening, nontargeted screening reduced the share of infections progressing to cirrhosis (4.81% vs 4.94%) and liver-related deaths (1.75% vs 1.81%).

The investigators noted that these absolute differences appeared small because more than 90% of people screened did not have HCV. When they modeled a cohort in which every individual was infected, nontargeted screening was both the most effective and least costly strategy, adding approximately 0.0428 discounted QALYs compared with no ED screening.

Where the Model Falls Short

At the same time, the researchers acknowledged several limitations, one being that it was not possible to eliminate all stochastic variation, limiting their ability to quantify remaining uncertainty. In addition, the DETECT Hep C trial was conducted in 3 urban EDs and may not be generalizable to other settings in the US.

Despite these limitations, the researchers emphasized that their results suggest that nontargeted HCV screening provided greater benefits than both no ED HCV screening and targeted HCV screening.

“Embedding nontargeted HCV screening within routine ED workflows may promise meaningful and cost-effective gains in patient and population health, representing a key strategy in the goal of HCV elimination,” they concluded.

References

1. Czoty LMW, Munroe S, Stewart E, et al; DETECT Hep C Trial Investigators. Cost-effectiveness of HCV screening in emergency departments using DETECT Hep C trial results. JAMA Intern Med. Published online October 19, 2026. doi:10.1001/jamainternmed.2026.5163
2. Haukoos J, Rothman RE, Galbraith JW, et al; DETECT Hep C Screening Trial Investigators. Hepatitis C screening in emergency departments: the DETECT Hep C randomized clinical trial. JAMA. 2025;334(6):497-507. doi:10.1001/jama.2025.10563
3. Dangi-Garimella S. Urban emergency departments play a critical role in identifying undiagnosed HCV patients. AJMC^®. August 7, 2015. Accessed November 5, 2026. https://www.ajmc.com/newsroom/urban-emergency-departments-play-a-critical-role-in-identifying-undiagnosed-hcv-patients