Racial-Ethnic Disparities in Uptake of New Hepatitis C Drugs in Medicare

Racial Disparities in Treatment and Outcomes of Patients With Hepatitis C Undergoing Elective Total Joint Arthroplasty

BACKGROUND

African Americans have the highest prevalence of chronic Hepatitis C virus (HCV) infection. Racial disparities in outcome are observed after elective total hip arthroplasty (THA) and total knee arthroplasty (TKA). This study sought to identify if disparities in treatments and outcomes exist between Black and White patients who have HCV prior to elective THA and TKA.

METHODS

Patient demographics, comorbidities, HCV characteristics, perioperative variables, in-hospital outcomes, and postoperative complications at 1-year follow-up were collected and compared between the 2 races. Patients who have preoperative positive viral load (PVL) and undetectable viral load were identified. Chi-square and Fisher's exact tests were used to compare categorical variables, while 2-tailed Student's Kruskal-Wallis t-tests were used for continuous variables. A P value of less than .05 was statistically significant.

RESULTS

The liver function parameters, including aspartate aminotransferase and model for end-stage liver disease scores, were all higher preoperatively in Black patients undergoing THA (P = .01; P < .001) and TKA (P = .03; P = .003), respectively. Black patients were more likely to undergo THA (65.8% versus 35.6%; P = .002) and TKA (72.1% versus 37.3%; 0.009) without receiving prior treatment for HCV. Consequently, Black patients had higher rates of preoperative PVL compared to White patients in both THA (66% versus 38%, P = .006) and TKA (72% versus 37%, P < .001) groups. Black patients had a longer length of stay for both THA (3.7 versus 3.3; P = .008) and TKA (4.1 versus 3.0; P = .02).

CONCLUSIONS

The HCV treatment prior to THA and TKA with undetectable viral load has been shown to be a key factor in mitigating postoperative complications, including joint infection. We noted that Black patients were more likely to undergo joint arthroplasty who did not receive treatment and with a PVL. While PVL rates decreased over time for both races, a significant gap persists for Black patients.

REPRESENTATION AND EXTRAPOLATION: EVIDENCE FROM CLINICAL TRIALS. THE QUARTERLY JOURNAL OF ECONOMICS 2024;139:575-635. [PMID: 38859982 PMCID: PMC11164133 DOI: 10.1093/qje/qjad036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

This article examines the consequences and causes of low enrollment of Black patients in clinical trials. We develop a simple model of similarity-based extrapolation that predicts that evidence is more relevant for decision-making by physicians and patients when it is more representative of the group being treated. This generates the key result that the perceived benefit of a medicine for a group depends not only on the average benefit from a trial but also on the share of patients from that group who were enrolled in the trial. In survey experiments, we find that physicians who care for Black patients are more willing to prescribe drugs tested in representative samples, an effect substantial enough to close observed gaps in the prescribing rates of new medicines. Black patients update more on drug efficacy when the sample that the drug is tested on is more representative, reducing Black-white patient gaps in beliefs about whether the drug will work as described. Despite these benefits of representative data, our framework and evidence suggest that those who have benefited more from past medical breakthroughs are less costly to enroll in the present, leading to persistence in who is represented in the evidence base.

Hepatitis C Treatment Initiation Among US Medicaid Enrollees

Importance

Direct-acting antiviral (DAA) treatment for hepatitis C virus (HCV) infection is highly effective but remains underused. Understanding disparities in the delivery of DAAs is important for HCV elimination planning and designing interventions to promote equitable treatment.

Objective

To examine variations in the receipt of DAA in the 6 months following a new HCV diagnosis.

Design, Setting, and Participants

This retrospective cohort study used national Medicaid claims from 2017 to 2019 from 50 states, Washington DC, and Puerto Rico. Individuals aged 18 to 64 years with a new diagnosis of HCV in 2018 were included. A new diagnosis was defined as a claim for an HCV RNA test followed by an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) diagnosis code, after a 1-year lookback period.

Main Outcomes and Measures

Outcome was receipt of a DAA prescription within 6 months of diagnosis. Logistic regression was used to examine demographic factors and ICD-10-identified comorbidities associated with treatment initiation.

Results

Among 87 652 individuals, 43 078 (49%) were females, 12 355 (14%) were age 18 to 29 years, 35 181 (40%) age 30 to 49, 51 282 (46%) were non-Hispanic White, and 48 840 (49%) had an injection drug use diagnosis. Of these individuals, 17 927 (20%) received DAAs within 6 months of their first HCV diagnosis. In the regression analyses, male sex was associated with increased treatment initiation (OR, 1.24; 95% CI, 1.16-1.33). Being age 18 to 29 years (OR, 0.65; 95% CI, 0.50-0.85) and injection drug use (OR, 0.84; 95% CI, 0.75-0.94) were associated with decreased treatment initiation. After adjustment for state fixed effects, Asian race (OR, 0.50; 95% CI, 0.40-0.64), American Indian or Alaska Native race (OR, 0.68; 95% CI, 0.55-0.84), and Hispanic ethnicity (OR, 0.81; 95% CI, 0.71-0.93) were associated with decreased treatment initiation. Adjustment for state Medicaid policy did not attenuate the racial or ethnic disparities.

Conclusions

In this retrospective cohort study, HCV treatment initiation was low among Medicaid beneficiaries and varied by demographic characteristics and comorbidities. Interventions are needed to increase HCV treatment uptake among Medicaid beneficiaries and to address disparities in treatment among key populations, including younger individuals, females, individuals from minoritized racial and ethnic groups, and people who inject drugs.

Actionable Solutions to Achieve Health Equity in Chronic Liver Disease

There are well-described racial and ethnic disparities in the burden of chronic liver diseases. Hispanic persons are at highest risk for developing nonalcoholic fatty liver disease, the fastest growing cause of liver disease. Hepatitis B disproportionately affects persons of Asian or African descent. The highest rates of hepatitis C occur in American Indian and Alaskan Native populations. In addition to disparities in disease burden, there are also marked racial and ethnic disparities in access to treatments, including liver transplantation. Disparities also exist by gender and geography, especially in alcohol-related liver disease. To achieve health equity, we must address the root causes that drive these inequities. Understanding the role that social determinants of health play in the disparate health outcomes that are currently observed is critically important. We must forge and/or strengthen collaborations between patients, community members, other key stakeholders, health care providers, health care institutions, professional societies, and legislative bodies. Herein, we provide a high-level review of current disparities in chronic liver disease and describe actionable strategies that have potential to bridge gaps, improve quality, and promote equity in liver care.

Factors Associated With Asthma Biologic Prescribing and Primary Adherence Among Adults in a Large Health System

BACKGROUND

The availability of asthma biologics may not benefit all patients equally.

OBJECTIVE

We sought to identify patient characteristics associated with asthma biologic prescribing, primary adherence, and effectiveness.

METHODS

A retrospective, observational cohort study of 9,147 adults with asthma who established care with a Penn Medicine asthma subspecialist was conducted using Electronic Health Record data from January 1, 2016, to October 18, 2021. Multivariable regression models were used to identify factors associated with (1) receipt of a new biologic prescription; (2) primary adherence, defined as receiving a dose in the year after receiving the prescription, and (3) oral corticosteroid (OCS) bursts in the year after the prescription.

RESULTS

Factors associated with a new prescription, which was received by 335 patients, included being a woman (odds ratio [OR] 0.66; P = .002), smoking currently (OR 0.50; P = .04), having an asthma hospitalization in the prior year (OR 2.91; P < .001), and having 4+ OCS bursts in the prior year (OR 3.01; P < .001). Reduced primary adherence was associated with Black race (incidence rate ratio 0.85; P < .001) and Medicaid insurance (incidence rate ratio 0.86; P < .001), although most in these groups, 77.6% and 74.3%, respectively, still received a dose. Nonadherence was associated with patient-level barriers in 72.2% of cases and health insurance denial in 22.2%. Having more OCS bursts after receiving a biologic prescription was associated with Medicaid insurance (OR 2.69; P = .047) and biologic days covered (OR 0.32 for 300-364 d vs 14-56 d; P = .03).

CONCLUSIONS

In a large health system, primary adherence to asthma biologics varied by race and insurance type, whereas nonadherence was primarily explained by patient-level barriers.

Racial Inequities in Asthma Care

Racial inequities in asthma care are evolving as a recognized factor in long-standing inequities in asthma outcomes (e.g., hospitalization and mortality). Little research has been conducted regarding the presence or absence of racial inequities among patients seen in asthma specialist settings, this is an important area of future research given that asthma specialist care is recommended for patients experiencing the poor asthma outcomes disproportionately experienced by Black and Hispanic patients. This study provides a systematic review of racial asthma care inequities in asthma epidemiology, clinical assessment, medication prescription, and asthma specialist referral practices.

Changes in proportionate cardiovascular mortality in patients with chronic infectious and inflammatory conditions in the United States, 1999-2018

Treatment options for several chronic infectious and inflammatory conditions have expanded in recent years. This may have implications for evolving competing risks for chronic inflammation-associated comorbidities, including cardiovascular diseases (CVDs). Yet sparse data exist on patterns over time in cardiovascular mortality for chronic infectious and inflammatory conditions. We used data from the Centers for Disease Control and Prevention 1999–2018 Multiple Causes of Death database to investigate patterns in CVD mortality from January 1, 1999 to December 31, 2018 in several infectious and inflammatory conditions. Specifically, we determined age-adjusted proportionate CVD mortality separately for patients with the following conditions (as well as the general population): hepatitis C virus (HCV), human immunodeficiency virus (HIV), inflammatory bowel diseases (IBD), psoriasis (PSO), rheumatoid arthritis (RA), and systemic lupus erythematosus (SLE). Proportionate CVD mortality differed significantly in 1999 and 2018 for each condition compared with the general population (p < 0.0001). Proportionate CVD mortality decreased steadily in the general population (40.9 to 30.6%) but increased for patients with HCV (7.0 to 10.2%) and HIV (1.9 to 6.7%). For IBD, PSO, RA, and SLE, proportionate CVD mortality initially decreased followed by plateauing or increasing rates. Underlying disease-specific pathophysiologies, changes in natural history, and competing risks of chronic end-organ diseases contributing to these differences merit further study.

Second-Line Therapy for Type 2 Diabetes Management: The Treatment/Benefit Paradox of Cardiovascular and Kidney Comorbidities

OBJECTIVE

To examine whether glucagon-like peptide 1 receptor agonists (GLP-1RA) and sodium-glucose cotransporter 2 inhibitors (SGLT2i) are preferentially initiated among patients with cardiovascular disease, heart failure (HF), or nephropathy, where these drug classes have established benefit, compared with dipeptidyl peptidase 4 inhibitors (DPP-4i), for which corresponding benefits have not been demonstrated.

RESEARCH DESIGN AND METHODS

We retrospectively analyzed claims of adults with type 2 diabetes included in OptumLabs Data Warehouse, a deidentified database of commercially insured and Medicare Advantage beneficiaries, who first started GLP-1RA, SGLT2i, or DPP-4i therapy between 2016 and 2019. Using multinomial logistic regression, we examined the relative risk ratios (RRR) of starting GLP-1RA and SGLT2i compared with DPP-4i for those with a history of myocardial infarction (MI), cerebrovascular disease, HF, and nephropathy after adjusting for demographic and other clinical factors.

RESULTS

We identified 75,395 patients who started GLP-1RA, 58,234 who started SGLT2i, and 91,884 who started DPP-4i. Patients with prior MI, cerebrovascular disease, or nephropathy were less likely to start GLP-1RA rather than DPP-4i compared with patients without these conditions (RRR 0.83 [95% CI 0.78-0.88] for MI, RRR 0.77 [0.74-0.81] for cerebrovascular disease, and RRR 0.87 [0.84-0.91] for nephropathy). Patients with HF or nephropathy were less likely to start SGLT2i (RRR 0.83 [0.80-0.87] for HF and RRR 0.57 [0.55-0.60] for nephropathy). Both medication classes were less likely to be started by non-White and older patients.

CONCLUSIONS

Patients with cardiovascular disease, HF, and nephropathy, for whom evidence suggests a greater likelihood of benefiting from GLP-1RA and/or SGLT2i therapy, were less likely to start these drugs. Addressing this treatment/benefit paradox, which was most pronounced in non-White and older patients, may help reduce the morbidity associated with these conditions.

Lower Use of Biologics for the Treatment of Asthma in Publicly Insured Individuals

BACKGROUND

Despite bearing a disproportionate burden of poorly controlled asthma, publicly insured individuals are less likely to receive biologics.

OBJECTIVE

To assess biologic use by payer among individuals with asthma.

METHODS

We used IQVIA's National Disease and Therapeutic Index, a nationally representative, all-payer audit of ambulatory care in the United States, to describe the patterns of use by payer.

RESULTS

Asthma treatment visits in which a biologic product was reported increased from approximately 0.1% of asthma-related visits in 2003 to 1% in 2015 and doubled to 2% by 2019. Omalizumab use initially increased from 2003 to 2006 and plateaued till 2015 when its use declined modestly, coinciding with the release of additional biologic products. In 2019, omalizumab accounted for 37% of biologic treatment visits, mepolizumab 21%, benralizumab 27%, dupilumab 15%, and reslizumab <1%. Biologic treatment visits were higher for privately insured individuals (28.3 per 1000 visits) compared with publicly insured individuals (16.3 per 1000 visits). This difference persisted after accounting for age, sex, and race using nationally representative estimates. Whites accounted for a disproportionate amount of biologic treatment visits among the publicly insured (80%) despite accounting for only 60% of publicly insured asthma treatment visits. No biologic treatment visits were observed for individuals who were uninsured. Half of dupilumab visits were for publicly insured patients, compared with 22% of mepolizumab/benralizumab and 27% of omalizumab visits.

CONCLUSION

Biologics were uncommonly used among patients with asthma, and the basis for disproportionately lower use of biologics among the publicly insured, where the burden of uncontrolled asthma is greatest, merits further investigation.

Comparison of Diabetes Medications Used by Adults With Commercial Insurance vs Medicare Advantage, 2016 to 2019

IMPORTANCE

Glucagonlike peptide-1 receptor agonists (GLP-1RA), sodium-glucose cotransporter-2 inhibitors (SGLT2i), and dipeptidyl peptidase-4 inhibitors (DPP-4i) are associated with low rates of hypoglycemia, and postmarketing trials of GLP-1RA and SGLT2i demonstrated that these medications improved cardiovascular and kidney outcomes.

OBJECTIVE

To compare trends in initiation of treatment with GLP-1RA, SGLT2i, and DPP-4i by older adults with type 2 diabetes insured by Medicare Advantage vs commercial health plans.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used administrative claims data from a deidentified database of commercially insured and Medicare Advantage beneficiaries. Adults aged 58 to 66 years with type 2 diabetes who filled any medication prescription to lower glucose levels from January 1, 2016, to December 31, 2019, were compared between groups.

EXPOSURE

Enrollment in a Medicare Advantage or commercial health insurance plan.

MAIN OUTCOMES AND MEASURES

The odds of initiating GLP-1RA, SGLT2i, and DPP-4i treatment were examined for Medicare Advantage vs commercial insurance beneficiaries using 3 separate logistic regression models adjusted for year and demographic and clinical factors. These models were used to calculate adjusted annual rates of medication initiation by health plan.

RESULTS

A total of 382 574 adults with pharmacologically treated type 2 diabetes (52.9% men; mean [SD] age, 62.4 [2.7] years) were identified, including 172 180 Medicare Advantage and 210 394 commercial beneficiaries. From 2016 to 2019, adjusted rates of initiation of GLP-1RA, SGLT2i, and DPP-4i treatment increased among all beneficiaries, from 2.14% to 20.02% for GLP-1RA among commercial insurance beneficiaries and from 1.50% to 11.44% among Medicare Advantage beneficiaries; from 2.74% to 18.15% for SGLT2i among commercial insurance beneficiaries and from 1.57% to 8.51% among Medicare Advantage beneficiaries; and from 3.30% to 11.71% for DPP-4i among commercial insurance beneficiaries and from 2.44% to 7.68% among Medicare Advantage beneficiaries. Initiation rates for all 3 drug classes were consistently lower among Medicare Advantage than among commercial insurance beneficiaries. Within each calendar year, the odds of initiating GLP-1RA treatment ranged from 0.28 (95% CI, 0.26-0.29) to 0.70 (95% CI, 0.65-0.75) for Medicare Advantage and commercial insurance beneficiaries, respectively; SGLT2i, from 0.21 (95% CI, 0.20-0.22) to 0.57 (95% CI, 0.53-0.61), respectively; and DPP-4i, from 0.37 (95% CI, 0.34-0.39) to 0.73 (95% CI, 0.69-0.78), respectively (P < .001 for all). The odds of starting GLP-1RA and SGLT2i increased with income; for an income of $200 000 and higher vs less than $40 000, the odds ratio for GLP-1RA was 1.23 (95% CI, 1.15-1.32) and for SGLT2i was 1.16 (95% CI, 1.09-1.24).

CONCLUSIONS AND RELEVANCE

These findings suggest that Medicare Advantage beneficiaries may be less likely than commercially insured beneficiaries to be treated with newer medications to lower glucose levels, with greater disparities among lower-income patients. Better understanding of nonclinical factors contributing to treatment decisions and efforts to promote greater equity in diabetes management appear to be needed.

Racial/Ethnic and Socioeconomic Disparities in Use of Direct-Acting Antivirals Among Medicare Beneficiaries with Chronic Hepatitis C, 2014-2016

BACKGROUND

New hepatitis C virus (HCV) drugs-direct-acting antivirals (DAAs)-are highly effective but costly, which raises a concern about limited access to DAAs by vulnerable populations. Previous studies of disparities in DAA use across patient groups showed mixed results, but their generalizability was limited due to using data from commercial insurers or from 2014 only-the first year DAAs were available. Disparities in DAA use in a national cohort in the years when more DAAs were available is unknown.

OBJECTIVE

To examine whether disparities in DAA use by patient race/ethnicity and socioeconomic status in Medicare changed between 2014 and 2016.

METHODS

The study population was made up of chronic hepatitis C patients in fee-for-service Medicare with Part D between 2014 and 2016. We used multinomial logistic regression to estimate adjusted odds ratios (aOR) of using DAAs by patient race/ethnicity and socioeconomic status. We estimated the model separately for 2014 and 2014-2016.

RESULTS

Of 281,810 Medicare patients who were followed to the end of 2016, a total of 90,419 (32.1%) filled prescriptions for DAAs. In the 2014 analysis, blacks were less likely to use DAAs than whites (aOR = 0.95; 95% CI = 0.91-0.99). However, in the 2014-2016 analysis, blacks had higher odds of using DAAs than whites (aOR = 1.24; 95% CI = 1.22-1.27). No significant Hispanic-white gap existed during the study period. Income was positively associated with DAA use in both periods. Between 2014 and 2016, patients who received a Part D low-income subsidy had lower odds of using DAAs than patients who did not (aOR = 0.90; 95% CI = 0.88-0.92), and patients in areas with the higher income tertiles were more likely to initiate DAAs than those in areas with the lowest income tertile.

CONCLUSIONS

DAA use among Medicare patients remained far below the level needed to eradicate HCV. The black-white gap in HCV treatment was closed by 2016, but disparities by patient socioeconomic status remained. DAA use also varied by patient age and health risk, as well as across geographic regions. Continued efforts to improve DAA uptake in all HCV patients are needed to eradicate HCV.

DISCLOSURES

This study was supported by the National Institute on Aging (1 R01 AG055636-01A1) and National Institute of Child Health & Human Development (R24 HD04025). The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Feldman owns stock in Gilead Sciences and Abbvie. No other potential competing interest exists.

Patterns of Hepatitis C-Related Inpatient Mortality in the United States in the Era of Direct-Acting Antivirals

BACKGROUND & AIMS

Direct-acting antivirals (DAA) have revolutionized the management of hepatitis C virus (HCV) infection. Data on national inpatient mortality in this new era are scarce. This study aimed to evaluate inpatient mortality among HCV-related hospital stays in the United States (US) during the years DAA were available.

METHODS

We conducted a cross-sectional analysis of the National Inpatient Sample (NIS) between 2012 and 2016. Using discharge weights, national estimates of HCV-related hospitalizations were calculated. Simple and multiple logistic regressions were performed to identify factors associated with inpatient mortality.

RESULTS

A total of 67,630 hospitalizations from NIS were HCV-related, accounting for an estimated 338,150 hospitalizations during 2012 - 2016. These hospitalizations have estimated average annual total charges of $4.6 billion, adjusted to 2020 US dollars. The rate of inpatient mortality declined modestly from 5.25% in 2012 to 4.75% in 2016 (P=0.07). Over the 5-year study period, the proportion of in-hospital deaths increased for black patients, Medicaid beneficiaries, and patients with substance-related disorders. Controlling for known predictors, the odds of inpatient mortality were significantly greater among black patients compared to white patients (OR= 1.27 [95% CI=1.16 - 1.39]).

CONCLUSIONS

The burden of HCV infection is substantial given the disease is now curable. Our findings indicate that major disparities in the HCV disease burden exist in the era of DAA.

Adoption of New Glucose-Lowering Medications in the U.S.-The Case of SGLT2 Inhibitors: Nationwide Cohort Study

Background: High-quality diabetes care is evidence-based, timely, and equitable. Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are the most recently approved class of glucose-lowering medications with additional cardio- and renal-protective benefits and low risk of hypoglycemia. Cardiovascular and kidney disease are among the most common chronic diabetes complications, whereas hypoglycemia is the most prevalent adverse effect of glucose-lowering therapy. We examine the sociodemographic and clinical factors associated with early SGLT2i initiation and appropriateness of use based on contemporaneous scientific evidence. Materials and Methods: Retrospective analysis of medical and pharmacy claims data from OptumLabs® Data Warehouse for commercially insured and Medicare Advantage adult beneficiaries with diabetes types 1 and 2, who filled any glucose-lowering medication between January 1, 2013 and December 31, 2016. Demographic (age, sex, race, income), clinical (comorbidities), and insurance-related factors affecting first prescription for a SGLT2i were examined using multivariable logistic regression. Results: Among 1,054,727 adults with pharmacologically treated diabetes, 7.2% (n = 75,500) initiated a SGLT2i. Patients with prior myocardial infarction (MI) (odds ratio [OR]: 0.94, 95% confidence interval [CI]: 0.91-0.96), heart failure (HF) (OR: 0.93, 95% CI: 0.91-0.94), kidney disease (OR: 0.80, 95% CI: 0.78-0.81), and severe hypoglycemia (OR: 0.96, 95% CI: 0.94-0.98) were all less likely to start a SGLT2i; P < 0.001 for all. SGLT2i were also less likely to be started by patients ≥75 years (OR: 0.57, 95% CI: 0.55-0.59, vs. 18-44 years), Black patients (OR: 0.93, 95% CI: 0.91-0.95, vs. White), and those with Medicare Advantage insurance (OR: 0.63, 95% CI: 0.62-0.64, vs. commercial). Conclusions: Younger, healthier, non-Black patients with commercial health insurance were most likely to start taking SGLT2i. Patients with MI, HF, kidney disease, and prior hypoglycemia were less likely to use SGLT2i, despite evidence supporting their preferential use in these patients. Efforts to address this treatment-risk paradox may help improve health outcomes among patients with type 2 diabetes.

Effect of Interferon-Free Regimens on Disparities in Hepatitis C Treatment of US Veterans

OBJECTIVES

To determine whether implementation of interferon-free treatment for hepatitis C virus (HCV) reached groups less likely to benefit from earlier therapies, including patients with genotype 1 virus or contraindications to interferon treatment, and groups that faced treatment disparities: African Americans, patients with HIV co-infection, and those with drug use disorder.

METHODS

Electronic medical records of the US Veterans Health Administration (VHA) were used to characterize patients with chronic HCV infection and the treatments they received. Initiation of treatment in 206,544 patients with chronic HCV characterized by viral genotype, demographic characteristics, and comorbid medical and mental illness was studied using a competing events Cox regression over 6 years.

RESULTS

With the advent of interferon-free regimens, the proportion treated increased from 2.4% in 2010 to 18.1% in 2015, an absolute increase of 15.7%. Patients with genotype 1 virus, poor response to previous treatment, and liver disease had the greatest increase. Large absolute increases in the proportion treated were observed in patients with HIV co-infection (18.6%), alcohol use disorder (11.9%), and drug use disorder (12.6%) and in African American (13.7%) and Hispanic (13.5%) patients, groups that were less likely to receive interferon-containing treatment. The VHA spent $962 million on interferon-free treatments in 2015, 1.5% of its operating budget.

CONCLUSIONS

The proportion of patients with HCV treated in VHA increased sevenfold. The VHA was successful in implementing interferon treatment in previously undertreated populations, and this may become the community standard of care.