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Jung J, Du P, Feldman R, Riley T. Discontinuation of new hepatitis C drugs among Medicare patients. AMERICAN JOURNAL OF MANAGED CARE 2021; 26:84-88. [PMID: 32059096 DOI: 10.37765/ajmc.2020.42397] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To examine factors associated with discontinuation of new hepatitis C drugs-second-generation direct-acting antivirals (DAAs)-among Medicare beneficiaries with chronic hepatitis C. STUDY DESIGN A retrospective analysis using 2014-2016 Medicare claims. METHODS The study population was patients with chronic hepatitis C in fee-for-service Medicare with Part D who initiated a DAA therapy between January 1, 2014, and September 1, 2016. We defined discontinuation of DAA therapy as filling prescriptions for fewer weeks than the expected duration of the DAA identified. We estimated adjusted odds ratios (aORs) of DAA discontinuation by patient characteristics using multivariable logistic regression. We estimated the model separately for patients with a Part D low-income subsidy (LIS) and those without an LIS. RESULTS Of 82,056 patients who initiated a DAA therapy during the study period, 5171 (6.3%) did not complete the therapy. Discontinuation rates varied across DAAs, ranging from 4.7% (elbasvir/grazoprevir) to 11.8% (ombitasvir/paritaprevir/ritonavir/dasabuvir). Women with an LIS were more likely to discontinue DAA therapy than men with an LIS (aOR, 1.16; 95% CI, 1.08-1.25; P <.01). Non-LIS black and Hispanic patients had higher odds of discontinuation than non-LIS white patients (black: aOR, 1.49; 95% CI, 1.28-1.73; P <.01; Hispanic: aOR, 1.56; 95% CI, 1.01-2.44; P <.05). High comorbidity index score increased the odds of DAA discontinuation among patients with an LIS. CONCLUSIONS Real-world discontinuation of DAA therapy was low, but it was 3 times more likely than in clinical trials and varied by patient characteristics. Efforts to increase DAA adherence would help lower patients' risk of developing resistance to future treatments and reduce potential waste of resources.
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Affiliation(s)
- Jeah Jung
- Department of Health Policy and Administration, College of Health and Human Development, The Pennsylvania State University, 601E Ford Bldg, University Park, PA 16801.
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Tran L, Jung J, Carlin C, Lee S, Zhao C, Feldman R. Use of Direct-Acting Antiviral Agents and Survival Among Medicare Beneficiaries with Dementia and Chronic Hepatitis C. J Alzheimers Dis 2021; 79:71-83. [PMID: 33216031 PMCID: PMC7855832 DOI: 10.3233/jad-200949] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Many patients with Alzheimer's disease and related dementia (ADRD) have chronic hepatitis C due to the high prevalence of both conditions among elderly populations. Direct-acting antivirals (DAAs) are effective in treating hepatitis C virus (HCV). However, the complexity of ADRD care may affect DAA use and outcomes among patients with HCV and ADRD. Little information exists on uptake of DAAs, factors associated with DAA use, and health benefits of DAAs among patients with HCV and ADRD. OBJECTIVE To examine use and survival benefits of DAAs in Medicare patients with HCV and ADRD. METHODS The study included Medicare patients with HCV between 2014 and 2017. We estimated Cox proportional hazards regressions to examine the association between having ADRD and DAA use, and the relation between DAA use and survival among patients with HCV and ADRD. RESULTS The adjusted hazard of initiating a DAA was 50% lower in patients with ADRD than those without ADRD (adjusted HR = 0.50, 95% CI: 0.46-0.54). The hazard of DAA use among ADRD patients with behavioral disturbances was 68% lower than non-ADRD patients (adjusted HR = 0.32, 95% CI: 0.28-0.37). DAA treatment was associated with a significant reduction in mortality among ADRD patients (adjusted HR = 0.52, 95% CI: 0.44-0.61). CONCLUSION The rate of DAA treatment in patients with HCV and ADRD was low, particularly among those with behavioral disturbance. The survival benefits of DAA treatment for patients with ADRD were substantial.
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Affiliation(s)
- Linh Tran
- Department of Health Policy and Administration, College of Health and Human Development, Pennsylvania State University, University Park, PA, USA
| | - Jeah Jung
- Department of Health Policy and Administration, College of Health and Human Development, Pennsylvania State University, University Park, PA, USA
| | - Caroline Carlin
- Department of Family Medicine and Community Health, School of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Sunmin Lee
- Department of Epidemiology, School of Medicine, University of California, Irvine, Irvine, CA, USA
| | - Chen Zhao
- Department of Neurology, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
- Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Roger Feldman
- Division of Health Policy and Management, School of Public Health, University of Minnesota, MN, USA
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Kalidindi Y, Jung J, Feldman R, Riley T. Association of Direct-Acting Antiviral Treatment With Mortality Among Medicare Beneficiaries With Hepatitis C. JAMA Netw Open 2020; 3:e2011055. [PMID: 32692371 PMCID: PMC7737657 DOI: 10.1001/jamanetworkopen.2020.11055] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Importance Direct-acting antiviral (DAA) drugs are highly effective in curing hepatitis C virus (HCV) infection. Previous simulations showed extended life as a key health advantage of DAA drugs, but real-world evidence on the association between DAA treatment and reduced mortality is limited. Objectives To examine the association of DAA treatment with mortality among Medicare beneficiaries with hepatitis C. Design, Setting, and Participants This cohort study used Medicare claims data of beneficiaries who sought hepatitis C care for the first time between January 1, 2014, and December 31, 2016, after at least a 1-year washout period. Medicare Part D files were used in identifying DAA therapy initiation and completion. Death dates, demographic data, and indicators of health risks were obtained from the Master Beneficiary Summary Files. Beneficiaries with hepatitis C were considered as patients with DAA treatment if they initiated DAA therapy during the study period. Beneficiaries with hepatitis C who did not initiate DAA therapy during the study period were considered as patients without DAA treatment. Patients without DAA treatment were selected using 1-to-1 propensity score matching. Data were analyzed between September 1, 2019, and March 31, 2020. Exposures Completion of DAA treatment. Main Outcomes and Measures Time to death from the index date of seeking hepatitis C care after at least a 1-year washout period. Cox proportional hazards regression models with time-varying exposure were used to compare mortality rates between propensity score-matched cohorts of patients with DAA treatment and those without DAA treatment. Separate analyses were performed for patients with or without cirrhosis. Heterogeneity in the association between DAA treatment and mortality by sex and dual-eligibility status was examined. Results A propensity score-matched sample of 51 478 Medicare beneficiaries with a mean (SD) age of 59.4 (11.1) years and 30 473 men (59.2%) was assessed. Of this total, 8240 patients (16.0%) had cirrhosis (5224 men [63.4%]; mean [SD] age, 62.3 [9.7] years) and 43 238 patients (84.0%) had no cirrhosis (25 249 men [58.4%]; mean [SD] age, 58.8 [11.3] years). The adjusted hazard ratio (HR) of dying between patients with DAA treatment and those without DAA treatment in the cirrhosis group was 0.51 (95% CI, 0.46-0.57). The association of DAA treatment with mortality did not differ by sex (women vs men: HR, 0.46 [95% CI, 0.38-0.56] vs HR, 0.53 [95% CI, 0.47-0.60]; P = .27) or dual-eligibility status (non-dual-eligible HR, 0.52 [95% CI, 0.43-0.63] vs dual-eligible HR, 0.50 [95% CI, 0.44-0.57]; P = .80) in the cirrhosis group. The adjusted HR of dying between patients with DAA treatment and those without DAA treatment among patients without cirrhosis was 0.54 (95% CI, 0.50-0.58). The association of DAA treatment with mortality did not differ by sex (women vs men: HR, 0.53 [95% CI, 0.46-0.60] vs HR, 0.55 [95% CI, 0.50-0.60]; P = .66) among patients without cirrhosis. However, the survival advantage associated with DAAs for non-dual-eligible beneficiaries was statistically significantly higher than for dual-eligible beneficiaries among patients without cirrhosis (HR, 0.47 [95% CI, 0.41-0.55] vs HR, 0.57 [95% CI, 0.52-0.62]; P = .02). Conclusions and Relevance In this cohort study, DAA treatment appeared to be associated with a decrease in mortality among Medicare beneficiaries with or without cirrhosis. These findings suggest that increasing access to DAA drugs for all patients with HCV infection, regardless of disease progression, could improve population health.
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Affiliation(s)
- Yamini Kalidindi
- Now with The Moran Company, Arlington, Virginia
- Department of Health Policy and Administration, College of Health and Human Development, The Pennsylvania State University, University Park
| | - Jeah Jung
- Department of Health Policy and Administration, College of Health and Human Development, The Pennsylvania State University, University Park
| | - Roger Feldman
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis
| | - Thomas Riley
- Department of Medicine, College of Medicine, Pennsylvania State University Milton S. Hershey Medical Center, Hershey
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Jung J, Feldman R, Kalidindi Y, Riley T. Association of Direct-Acting Antiviral Therapy for Hepatitis C With After-Treatment Costs Among Medicare Beneficiaries. JAMA Netw Open 2020; 3:e208081. [PMID: 32602909 PMCID: PMC7327546 DOI: 10.1001/jamanetworkopen.2020.8081] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022] Open
Abstract
IMPORTANCE Direct-acting antiviral (DAA) therapy for hepatitis C is highly effective but expensive. Evidence is scarce on whether DAA therapy reduces downstream medical costs. OBJECTIVE To examine the association of DAA therapy with posttreatment medical costs among Medicare beneficiaries. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study obtained data from various Medicare claims files for 2013 to 2017. The study population comprised patients with a hepatitis C diagnosis in 2014 who were enrolled in fee-for-service Medicare and Part D. Multivariate regression models were used to compare changes in medical costs over a 30-month posttreatment follow-up period between patients who used DAA therapy (treatment group) and a propensity score-matched cohort of patients who did not use DAA (control group). The model was estimated separately for patients with and those without cirrhosis. Data were analyzed between September 1, 2019, and March 31, 2020. EXPOSURES Completion of DAA therapy. MAIN OUTCOMES AND MEASURES Two outcomes were established: hepatitis C or liver disease-related costs and total medical costs. Costs were measured by Medicare-allowed payments, which included Medicare reimbursements, patient responsibilities, and third-party payments. RESULTS A propensity score-matched cohort of 15 198 patients (9038 men [59.5%]; mean [SD] age, 60.2 [10.8] years) was analyzed. During the first 6 months after DAA therapy, hepatitis C or liver disease-related costs decreased by $2498 (95% CI, -$3356 to -$1640) in patients with cirrhosis and by $486 (95% CI, -$603 to -$369) in patients without cirrhosis compared with control or untreated patients. Cumulative reductions in hepatitis C or liver disease-related costs during 30 months after DAA treatment were $15 808 (95% CI, -$22 530 to -$9085) in patients with cirrhosis and $5372 (95% CI, -$6384 to -$4360) in patients without cirrhosis. Among those who used DAA therapy compared with control patients, total medical costs decreased by $2905 (95% CI, -$4832 to -$979) in patients with cirrhosis and by $1287 (95% CI, -$2393 to -$283) in patients without cirrhosis during the first 6 months after DAA therapy. No statistically significant association was found between DAA therapy and total medical cost reductions after 12 months of follow-up. Cumulative reductions in total costs during 30 months after DAA therapy were $7074 (95% CI, -$18 448 to $4298) in patients with cirrhosis and $7497 (95% CI, -$14 287 to -$709) in patients without cirrhosis. CONCLUSIONS AND RELEVANCE This study reported that DAA therapy appeared to be associated with a decrease in hepatitis C or liver disease-related costs for 30 months after treatment and with reduction in total medical costs for only 12 months after treatment in patients with or without cirrhosis. Longer-term follow-up studies with diverse outcomes are necessary to assess the value of DAA therapy.
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Affiliation(s)
- Jeah Jung
- Department of Health Policy and Administration, The Pennsylvania State University College of Health and Human Development, University Park
| | - Roger Feldman
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis
| | - Yamini Kalidindi
- Department of Health Policy and Administration, The Pennsylvania State University College of Health and Human Development, University Park
| | - Thomas Riley
- Department of Medicine, The Pennsylvania State University College of Medicine, Hershey
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Jung J, Du P, Feldman R, Kong L, Riley T. Racial/Ethnic and Socioeconomic Disparities in Use of Direct-Acting Antivirals Among Medicare Beneficiaries with Chronic Hepatitis C, 2014-2016. J Manag Care Spec Pharm 2020; 25:1236-1242. [PMID: 31663464 DOI: 10.18553/jmcp.2019.25.11.1236] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Jeah Jung
- Department of Health Policy and Administration, The Pennsylvania State University, University Park
| | - Ping Du
- Department of Public Health Sciences, College of Medicine
| | - Roger Feldman
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis
| | - Lan Kong
- Department of Public Health Sciences, College of Medicine
| | - Thomas Riley
- Department of Medicine, College of Medicine, The Pennsylvania State University, Hershey
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Universal Screening for Hepatitis C: An Important Step in Virus Elimination. Clin Gastroenterol Hepatol 2019; 17:835-837. [PMID: 30528843 DOI: 10.1016/j.cgh.2018.12.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 12/03/2018] [Accepted: 12/05/2018] [Indexed: 02/07/2023]
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Rhodes T, Lancaster K, Harris M, Treloar C. Evidence-making controversies: the case of hepatitis C treatment and the promise of viral elimination. CRITICAL PUBLIC HEALTH 2018. [DOI: 10.1080/09581596.2018.1459475] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Tim Rhodes
- Centre for Social Research in Health, University of New South Wales, Sydney, Australia
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London, UK
| | - Kari Lancaster
- Centre for Social Research in Health, University of New South Wales, Sydney, Australia
| | - Magdalena Harris
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London, UK
| | - Carla Treloar
- Centre for Social Research in Health, University of New South Wales, Sydney, Australia
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Saeed S, Strumpf EC, Moodie EE, Young J, Nitulescu R, Cox J, Wong A, Walmsely S, Cooper C, Vachon ML, Martel-Laferriere V, Hull M, Conway B, Klein MB. Disparities in direct acting antivirals uptake in HIV-hepatitis C co-infected populations in Canada. J Int AIDS Soc 2018; 20. [PMID: 29116684 PMCID: PMC5810331 DOI: 10.1002/jia2.25013] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 09/25/2017] [Indexed: 12/27/2022] Open
Abstract
Background Direct acting antivirals (DAAs) have revolutionized hepatitis C (HCV) treatment with >90% cure rates even in real‐world studies, giving hope that HCV can be eliminated. However, for DAAs to have a population‐level impact on the burden of HCV disease, treatment uptake needs to be expanded. We investigated temporal trends in HCV treatment uptake and evaluated factors associated with second‐generation DAA initiation and efficacy among key HIV‐HCV co‐infected populations in Canada. Methods The Canadian HIV‐HCV Co‐Infection Cohort Study prospectively follows 1699 participants from 18 centres. Among HCV RNA+ participants, we determined the incidence of HCV treatment initiation per year overall and by key populations between 2007 and 2015. Key populations were based on World Health Organization (WHO) guidelines including: people who actively inject drugs (PWID) (reporting injection drug use, last 6 months); Indigenous people; women and men who have sex with men (MSM). Multivariate Cox models were used to estimate adjusted hazard ratios (aHR) and 2‐year probability of initiating second‐generation DAAs for each of the key populations. Results Overall, HCV treatment initiation rates increased from 8 (95% CI, 6–11) /100 person‐years in 2013 to 28 (95% CI, 23–33) /100 person‐years in 2015. Among 911 HCV RNA + participants, there were 202 second‐generation DAA initiations (93% with interferon‐free regimens). After adjustment (aHR, 95% CI), active PWID (0.60, 0.38–0.94 compared to people not injecting drugs) and more generally, people with lower income (<$18 000 CAD/year) (0.50, 0.35, 0.71) were less likely to initiate treatment. Conversely, MSM were more likely to initiate 1.95 (1.33, 2.86) compared to heterosexual men. In our cohort, the population profile with the lowest 2‐year probability of initiating DAAs was Indigenous, women who inject drugs (5%, 95% CI 3–8%). Not having any of these risk factors resulted in a 35% (95% CI 32–38%) probability of initiating DAA treatment. Sustained virologic response (SVR) rates were >82% in all key populations. Conclusion While treatment uptake has increased with the availability of second‐generation DAAs, marginalized populations, already engaged in care, are still failing to access treatment. Targeted strategies to address barriers are needed to avoid further health inequities and to maximize the public health impact of DAAs.
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Affiliation(s)
- Sahar Saeed
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada.,Division of Infectious Diseases/Chronic Viral Illness Service, Department of Medicine, Glen site, McGill University Health Centre, Montreal, QC, Canada
| | - Erin C Strumpf
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada.,Department of Economics, McGill University, Montreal, QC, Canada
| | - Erica Em Moodie
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada
| | - Jim Young
- Division of Infectious Diseases/Chronic Viral Illness Service, Department of Medicine, Glen site, McGill University Health Centre, Montreal, QC, Canada
| | - Roy Nitulescu
- Division of Infectious Diseases/Chronic Viral Illness Service, Department of Medicine, Glen site, McGill University Health Centre, Montreal, QC, Canada
| | - Joseph Cox
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada.,Division of Infectious Diseases/Chronic Viral Illness Service, Department of Medicine, Glen site, McGill University Health Centre, Montreal, QC, Canada
| | | | - Sharon Walmsely
- University Health Network, Toronto, ON, Canada.,CIHR Canadian HIV Trials Network, Vancouver, BC, Canada
| | - Curtis Cooper
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | | | | | - Mark Hull
- Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, BC, Canada
| | - Brian Conway
- Vancouver Infectious Diseases Centre, Vancouver, BC, Canada
| | - Marina B Klein
- Division of Infectious Diseases/Chronic Viral Illness Service, Department of Medicine, Glen site, McGill University Health Centre, Montreal, QC, Canada.,CIHR Canadian HIV Trials Network, Vancouver, BC, Canada
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Living donor liver transplantation: eliminating the wait for death in end-stage liver disease? Nat Rev Gastroenterol Hepatol 2017; 14:373-382. [PMID: 28196987 DOI: 10.1038/nrgastro.2017.2] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Adult-to-adult living donor liver transplantation (A2ALDLT), outside of Asia, remains an important yet underutilized gift of life. For patients with end-stage liver disease, A2ALDLT is a proven transplantation option, with lower waiting list mortality and suffering, and equivalent or better allograft and patient survival than deceased-donor liver transplantation (DDLT). The risks to living donors and the benefit to their recipients have been carefully defined with long-term level 1 and 2 evidence-based study. An overview of the development and practice of living donor liver transplant (LDLT), including donor and recipient surgical allograft innovation, is provided. The issues of recipient selection, outcomes and morbidity, including disease-variable study and challenges past and present are presented in comparison with DDLT cohorts, and future insights are described. Central to practice is the careful and concise review of donor evaluation and selection and donor outcome, morbidity, quality of life and present and future strategies for donor advocacy and growth of the technique.
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Cost-Effective but Bad for Health? Hepatitis C Treatment, Moral Hazard, and Opportunity Cost. Clin Gastroenterol Hepatol 2017; 15:838-840. [PMID: 28259743 DOI: 10.1016/j.cgh.2017.02.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 02/22/2017] [Accepted: 02/24/2017] [Indexed: 02/07/2023]
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Harris M. Managing expense and expectation in a treatment revolution: Problematizing prioritisation through an exploration of hepatitis C treatment 'benefit'. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2017; 47:161-168. [PMID: 28455145 DOI: 10.1016/j.drugpo.2017.03.015] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 03/08/2017] [Accepted: 03/22/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Direct-acting antivirals (DAAs) have transformed the hepatitis C (HCV) treatment landscape. These highly effective drugs are, however, not available to all. In a context of DAA rationing, clinicians are advised to "manage patient expectations" about the benefits of a HCV cure. This directive particularly pertains to people with minimal liver damage and those who have ceased injecting: populations negated in contemporary prioritisation debates. METHODS This paper engages with the assumptions underpinning HCV treatment prioritisation discourses to explore the concept of treatment 'benefit' from patient perspectives. Data are from a qualitative longitudinal study exploring treatment transitions and decision-making from 2012-2015. Participants comprised 28 people living with HCV, ten treatment providers and eight stakeholders, based in London, United Kingdom (UK). One hundred hours of clinic observations were conducted at two HCV treatment hospitals. Thematic analyses pertaining to treatment expectation and outcome inform this paper. RESULTS Twenty-two participants commenced treatment. The majority who were unable to access DAAs chose to commence interferon-based treatment immediately rather than wait. Participants accounted for treatment urgency in relation to three interrelated narratives of hope and expectation. HCV treatment promised: social reconnection; social redemption and a return to 'normality'. For many with successful treatment outcomes, these benefits appeared to be realised. CONCLUSION The DAA era heralds a discursive shift: from 'managing [interferon] risk and difficulty' to 'managing [DAA] expense and expectation'. Calls to 'manage patient expectations' about the benefits of HCV cure are predicated on clinical benefits only, negating the social impacts of living with HCV. The public health priorities commonly articulated in treatment prioritisation debates are not consistent with those of people managing illness in their daily lives. During this 'treatment revolution' there is a need to be cognisant of the multiple publics living with the virus and the treatment needs of those who do not fit population-health scenarios.
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Affiliation(s)
- Magdalena Harris
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H9SH, UK.
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12
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Khan MQ, Anand V, Hessefort N, Hassan A, Ahsan A, Sonnenberg A, Fimmel CJ. Utility of Electronic Medical record-based Fibrosis Scores in Predicting Advanced Cirrhosis in Patients with Hepatitic C Virus Infection. J Transl Int Med 2017; 5:43-48. [PMID: 28680838 DOI: 10.1515/jtim-2017-0011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE To determine whether advanced cirrhosis - defined by the detection of nodular liver contours or portal venous collaterals on imaging studies - could be predicted by fibrosis algorithms, calculated using laboratory and demographic features extracted from patients' electronic medical records. To this end, we compared seven EMR-based fibrosis scores with liver imaging studies in a cohort of HCV patients. METHODS A search of our health system's patient data warehouse identified 867 patients with chronic HCV infection. A total of 565 patients had undergone at least one liver imaging study and had no confounding medical condition affecting the imaging features or fibrosis scores. Demographic and laboratory data were used to calculate APRI, Fib4, Fibrosis Index, Forns, GUCI, Lok Index and Vira-HepC scores for all viremic patients who had undergone liver imaging. Data points selected for the calculation of these scores were based on laboratory results obtained within the shortest possible time from the imaging study. Areas under the receiver operating curves (AUROC), optimum cut-offs, sensitivities, specificities and positive and negative predictive values were calculated for each score. RESULTS Seven algorithms were performed similarly in predicting cirrhosis. Sensitivities ranged from 0.65 to 1.00, specificities from 0.67 to 0.90, positive predictive values from 0.33 to 0.38, and negative predictive values from 0.93 to 1.00. No individual test was superior, as the confidence intervals of all AUROCs overlapped. CONCLUSIONS EMR-based scoring systems performed relatively well in ruling out advanced, radiologically-defined cirrhosis. However, their moderate sensitivity and positive predictive values limit their reliability for EMR-based diagnosis.
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Affiliation(s)
| | - Vijay Anand
- North Shore University Health System, Evanston, IL, USA
| | | | - Ammar Hassan
- North Shore University Health System, Evanston, IL, USA
| | - Alya Ahsan
- North Shore University Health System, Evanston, IL, USA
| | - Amnon Sonnenberg
- Portland VA Medical Center and the Oregon Health & Science University, Portland, OR, USA
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Buzzetti E, Parikh PM, Gerussi A, Tsochatzis E. Gender differences in liver disease and the drug-dose gender gap. Pharmacol Res 2017; 120:97-108. [PMID: 28336373 DOI: 10.1016/j.phrs.2017.03.014] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 03/17/2017] [Accepted: 03/17/2017] [Indexed: 12/14/2022]
Abstract
Although gender-based medicine is a relatively recent concept, it is now emerging as an important field of research, supported by the finding that many diseases manifest differently in men and women and therefore, might require a different treatment. Sex-related differences regarding the epidemiology, progression and treatment strategies of certain liver diseases have long been known, but most of the epidemiological and clinical trials still report results only about one sex, with consequent different rate of response and adverse reactions to treatment between men and women in clinical practice. This review reports the data found in the literature concerning the gender-related differences for the most representative hepatic diseases.
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Affiliation(s)
- Elena Buzzetti
- UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK.
| | - Pathik M Parikh
- UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
| | - Alessio Gerussi
- UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK; Internal Medicine Unit, Department of Experimental and Clinical Medical Sciences, University of Udine, Udine, Italy
| | - Emmanuel Tsochatzis
- UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
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14
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Identification and Fibrosis Staging of Hepatitis C Patients Using the Electronic Medical Record System. J Clin Gastroenterol 2016; 50:664-9. [PMID: 26974763 DOI: 10.1097/mcg.0000000000000519] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND AIMS The aim of this study was to noninvasively assess the severity of chronic hepatitis C virus (HCV) in large patient populations. It would be helpful if fibrosis scores could be calculated solely on the basis of data contained in the patients' electronic medical records (EMR). We performed a pilot study to identify all HCV-infected patients in a large health care system, and predict their fibrosis stage on the basis of demographic and laboratory data using common data from their EMR. MATERIALS AND METHODS HCV-infected patients were identified using the EMR. The liver biopsies of 191 HCV patients were graded using the Ishak and Metavir scoring systems. Demographic and laboratory data were extracted from the EMR and used to calculate the aminotransferase to platelet ratio index, Fib-4, Fibrosis Index, Forns, Göteborg University Cirrhosis Index, Lok Index, and Vira-HepC. RESULTS In total, 869 HCV-infected patients were identified from a population of over 1 million. In the subgroup of patients with liver biopsies, all 7 algorithms were significantly correlated with the fibrosis stage. The degree of correlation was moderate, with correlation coefficients ranging from 0.22 to 0.60. For the detection of advanced fibrosis (Metavir 3 or 4), the areas under the receiver operating characteristic curve ranged from 0.71 to 0.84, with no significant differences between the individual scores. Sensitivities, specificities, and positive and negative predictive values were within the previously reported range. All scores tended to perform better for higher fibrosis stages. CONCLUSIONS Our study demonstrates that HCV-infected patients can be identified and their fibrosis staged using commonly available EMR-based algorithms.
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Kanwal F, Kramer JR, El-Serag HB, Frayne S, Clark J, Cao Y, Taylor T, Smith D, White D, Asch SM. Race and Gender Differences in the Use of Direct Acting Antiviral Agents for Hepatitis C Virus. Clin Infect Dis 2016; 63:291-9. [PMID: 27131869 PMCID: PMC6276931 DOI: 10.1093/cid/ciw249] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 04/14/2016] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Direct acting antiviral agents (DAA) are highly effective yet expensive. Disparities by race and/or gender often exist in the use of costly medical advances as they become available. METHODS We examined a cohort of hepatitis C virus (HCV) patients who received care at the Veterans Administration facilities nationwide. We evaluated the effect of race and gender on DAA receipt after adjusting for socioeconomic status, liver disease severity, comorbidity, and propensity for healthcare use. To determine if disparities had changed over time, we conducted a similar analysis of HCV patients who were seen in the previous standard of care treatment era. RESULTS Of the 145 596 patients seen in the current DAA era, 17 791 (10.2%) received treatment during the first 16 months of DAA approval. Black patients had 21% lower odds of receiving DAA than whites (odds ratio [OR] = 0.79; 95% confidence interval [CI], .75, .84). Overall, women were as likely to receive treatment as men (OR = 0.99; 95% CI, .90-1.09). However, the odds of receiving DAAs were 29% lower for younger women compared with younger men (OR = 0.71, 95% CI, .54-.93). Similar to the DAA cohort, black patients had significantly lower odds of receiving treatment than whites (OR = 0.74, 95% CI, .69-.79) in the previous treatment era. The racial difference between the 2 eras did not reach statistical significance. CONCLUSIONS There were unexplained differences among HCV population subgroups in the receipt of new DAA treatment. Targeted interventions are needed for black patients and younger women.
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Affiliation(s)
- Fasiha Kanwal
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center Section of Gastroenterology and Hepatology Section of Health Services Research Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Jennifer R Kramer
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center Section of Health Services Research
| | - Hashem B El-Serag
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center Section of Gastroenterology and Hepatology Section of Health Services Research Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Susan Frayne
- Center for Innovation to Implementation (Ci2i): Fostering High Value Care, VA Palo Alto Healthcare System, and Stanford, California
| | - Jack Clark
- Center for Healthcare Organization and Implementation, Edith Nourse Rogers Memorial Veterans Hospital, Boston, Massachusetts Department of Health Policy and Management, Boston University School of Public Health, Massachusetts
| | - Yumei Cao
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center
| | - Thomas Taylor
- Center for Innovation to Implementation (Ci2i): Fostering High Value Care, VA Palo Alto Healthcare System, and Stanford, California
| | - Donna Smith
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center
| | - Donna White
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center Section of Health Services Research
| | - Steven M Asch
- Center for Innovation to Implementation (Ci2i): Fostering High Value Care, VA Palo Alto Healthcare System, and Stanford, California
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16
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El-Serag HB, Kanwal F, Richardson P, Kramer J. Risk of hepatocellular carcinoma after sustained virological response in Veterans with hepatitis C virus infection. Hepatology 2016; 64:130-7. [PMID: 26946190 PMCID: PMC4917456 DOI: 10.1002/hep.28535] [Citation(s) in RCA: 290] [Impact Index Per Article: 36.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 02/17/2016] [Accepted: 03/03/2016] [Indexed: 12/24/2022]
Abstract
UNLABELLED The long-term prognosis in terms of risk or predictors of developing hepatocellular carcinoma (HCC) among patients with sustained virological response (SVR) remains unclear. We conducted a retrospective cohort study using data from the Veterans Affairs VA hepatitis C virus (HCV) Clinical Case Registry in patients with positive HCV RNA between October 1999 and August 2009 and follow-up through December 2010. HCV treatment (interferon with or without ribavirin) and SVR (RNA test negative at least 12 weeks after the end of treatment) were determined. We used Cox's proportional hazards models to calculate hazard ratios (HRs) for potential predictors (demographic, virological, and clinical) associated with HCC development post-SVR. We identified 33,005 HCV-infected individuals who received treatment, of whom 10,817 achieved SVR. Among these patients, 100 developed new HCC during a total follow-up of 30,562 person-years for an overall incidence rate of 0.33% per year. Annual risk of HCC remained considerably high among patients with cirrhosis (1.39%) and those cured after age 64 (0.95%). Patients with diabetes (adjusted HR = 1.88; 1.21-2.91) or genotype 3 infection (adjusted HR = 1.62; 0.96-2.734) were significantly more likely to develop HCC. CONCLUSIONS Risk of HCC after HCV cure, though considerably reduced, remains relatively high at 0.33% per year. Older age and/or presence of cirrhosis at the time of SVR are associated with a high enough risk to warrant surveillance. Diabetes is also a risk factor for post-SVR HCC. (Hepatology 2016;64:130-137).
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Affiliation(s)
- Hashem B. El-Serag
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas,Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Fasiha Kanwal
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas,Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Peter Richardson
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Jennifer Kramer
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
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17
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Harris M, Ward E, Gore C. Finding the undiagnosed: a qualitative exploration of hepatitis C diagnosis delay in the United Kingdom. J Viral Hepat 2016; 23:479-86. [PMID: 26924296 DOI: 10.1111/jvh.12513] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Accepted: 01/14/2016] [Indexed: 01/31/2023]
Abstract
Hepatitis C virus (HCV)-related morbidity and mortality will continue to rise unless HCV testing and treatment uptake increases. In the European region, an estimated nine million people live with HCV, yet only 10-40% are diagnosed. Over 100 000 undiagnosed people live with HCV in the United Kingdom (UK). For some, a late diagnosis can come too late. The aim of this qualitative study was to explore the context of a diagnosis delay among people living with HCV in the UK. Participants were recruited through two London Hospitals and The Hepatitis C Trust. Eligible participants identified a recent (<3 years) HCV diagnosis and a historical HCV transmission risk period (>15 years). The primary method of data collection was in-depth interviews (12 participants) and focus groups (16 participants). Analysis was informed by grounded theory principles. The sample, 17 men and 11 women, reported an average gap of 28 years between their HCV-risk period and first HCV test. Forty per cent had cirrhosis at HCV diagnosis. Diagnosis delay was attributed to limited HCV relevance, felt wellness, stigma, compartmentalization of former injecting practices, unexplained symptoms and general practitioner inaction. Diagnosis context involved a change of health care providers or a chance medical encounter. Trust in providers was impacted by a delayed diagnosis, with implications for future engagement in care. These data indicate that risk awareness does not necessarily result in action. A multipronged approach is needed to increase HCV case finding in the UK, particularly among 'hidden populations' such as former injectors and transfusion recipients.
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Affiliation(s)
- M Harris
- London School of Hygiene & Tropical Medicine, London, UK
| | - E Ward
- The Hepatitis C Trust, London, UK
| | - C Gore
- The Hepatitis C Trust, London, UK.,The World Hepatitis Alliance, London, UK
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18
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Petrick JL, Kelly SP, Altekruse SF, McGlynn KA, Rosenberg PS. Future of Hepatocellular Carcinoma Incidence in the United States Forecast Through 2030. J Clin Oncol 2016; 34:1787-94. [PMID: 27044939 PMCID: PMC4966339 DOI: 10.1200/jco.2015.64.7412] [Citation(s) in RCA: 329] [Impact Index Per Article: 41.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Hepatocellular carcinoma (HCC) incidence rates have been increasing in the United States for the past 35 years. Because HCC has a poor prognosis, quantitative forecasts could help to inform prevention and treatment strategies to reduce the incidence and burden of HCC. METHODS Single-year HCC incident case and population data for the years 2000 to 2012 and ages 35 to 84 years were obtained from the SEER 18 Registry Database. We forecast incident HCC cases through 2030, using novel age-period-cohort models and stratifying by sex, race/ethnicity, and age. Rates are presented because absolute numbers may be influenced by population increases. RESULTS Rates of HCC increased with each successive birth cohort through 1959. However, rates began to decrease with the 1960 to 1969 birth cohorts. Asians/Pacific Islanders (APIs) have had the highest HCC rates in the United States for many years, but the rates have stabilized and begun to decline in recent years. Between 2013 and 2030, rates among APIs are forecast to decline further, with estimated annual percentage changes of -1.59% among men and -2.20% among women. Thus, by 2030, Asians are forecast to have the lowest incidence rates among men, and Hispanics are forecast to have the highest rates among men (age-standardized rate, 44.2). Blacks are forecast to have the highest rate among women (age-standardized rate, 12.82). CONCLUSION Although liver cancer has long had some of the most rapidly increasing incidence rates, the decreasing rates seen among APIs, individuals younger than 65 years, and cohorts born after 1960 suggest that there will be declines in incidence of HCC in future years. Prevention efforts should be focused on individuals in the 1950 to 1959 birth cohorts, Hispanics, and blacks.
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Affiliation(s)
| | - Scott P Kelly
- All authors: National Cancer Institute, Bethesda, MD
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19
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Natarajan Y, Kanwal F. Pay for Performance in Chronic Liver Disease. Clin Gastroenterol Hepatol 2015; 13:2042-7. [PMID: 26164221 DOI: 10.1016/j.cgh.2015.06.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 06/29/2015] [Accepted: 06/30/2015] [Indexed: 02/07/2023]
Abstract
With the advent of the Affordable Care Act, pay-for-performance programs have become widespread in the United States and are here to stay. The Centers for Medicare and Medicaid Services started its pay-for-performance program, the Physician Quality Reporting Initiative, in 2007, and made it a permanent system, the Physician Quality Reporting System, in 2011. Although it started off as a pay-for-performance initiative, in which physicians and other health care professionals were rewarded for satisfactorily reporting on selected quality measures, it now has evolved into a penalty-based program. The Physician Quality Reporting System includes measures that target hepatitis C virus infection. It is important for gastroenterologists to be aware of these measures and the submission process to avoid penalties or other difficulties with reimbursement. This review describes the current measures in chronic liver disease, rates of submission, as well as the submission process and associated challenges.
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Affiliation(s)
- Yamini Natarajan
- Department of Gastroenterology, Baylor College of Medicine, Houston, Texas.
| | - Fasiha Kanwal
- Department of Gastroenterology, Baylor College of Medicine, Houston, Texas
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20
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Zuchowski JL, Hamilton AB, Pyne JM, Clark JA, Naik AD, Smith DL, Kanwal F. Qualitative analysis of patient-centered decision attributes associated with initiating hepatitis C treatment. BMC Gastroenterol 2015; 15:124. [PMID: 26429337 PMCID: PMC4591706 DOI: 10.1186/s12876-015-0356-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 09/23/2015] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND In this era of a constantly changing landscape of antiviral treatment options for chronic viral hepatitis C (CHC), shared clinical decision-making addresses the need to engage patients in complex treatment decisions. However, little is known about the decision attributes that CHC patients consider when making treatment decisions. We identify key patient-centered decision attributes, and explore relationships among these attributes, to help inform the development of a future CHC shared decision-making aid. METHODS Semi-structured qualitative interviews with CHC patients at four Veterans Health Administration (VHA) hospitals, in three comparison groups: contemplating CHC treatment at the time of data collection (Group 1), recently declined CHC treatment (Group 2), or recently started CHC treatment (Group 3). Participant descriptions of decision attributes were analyzed for the entire sample as well as by patient group and by gender. RESULTS Twenty-nine Veteran patients participated (21 males, eight females): 12 were contemplating treatment, nine had recently declined treatment, and eight had recently started treatment. Patients on average described eight (range 5-13) decision attributes. The attributes most frequently reported overall were: physical side effects (83%); treatment efficacy (79%), new treatment drugs in development (55%); psychological side effects (55%); and condition of the liver (52%), with some variation based on group and gender. Personal life circumstance attributes (such as availability of family support and the burden of financial responsibilities) influencing treatment decisions were also noted by all participants. Multiple decision attributes were interrelated in highly complex ways. CONCLUSIONS Participants considered numerous attributes in their CHC treatment decisions. A better understanding of these attributes that influence patient decision-making is crucial in order to inform patient-centered clinical approaches to care (such as shared decision-making augmented with relevant decision-making aids) that respond to patients' needs, preferences, and circumstances.
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Affiliation(s)
- Jessica L Zuchowski
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, 16111 Plummer St. Bldg. 25, North Hills, CA, 91343, USA.
| | - Alison B Hamilton
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, 16111 Plummer St. Bldg. 25, North Hills, CA, 91343, USA. .,Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA, 90095, USA.
| | - Jeffrey M Pyne
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, 2200 Fort Roots Drive, North Little Rock, AR, 72114, USA. .,Psychiatric Research Institute, University of Arkansas for Medical Sciences, 4300 West 7th Street, Little Rock, AR, 72205, USA.
| | - Jack A Clark
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, 200 Springs Rd, Bedford, MA, 01730, USA. .,Department of Health Policy and Management, Boston University School of Public Health, 715 Albany St. #358w, Boston, MA, 02118, USA.
| | - Aanand D Naik
- VA HSR&D Center for Innovations in Quality, Effectiveness & Safety, Michael E DeBakey VA Medical Center, 2002 Holcombe Boulevard, Houston, TX, 77030, USA. .,Department of Medicine, Baylor College of Medicine, One Baylor Plaza, Houston, TX, 77030, USA.
| | - Donna L Smith
- VA HSR&D Center for Innovations in Quality, Effectiveness & Safety, Michael E DeBakey VA Medical Center, 2002 Holcombe Boulevard, Houston, TX, 77030, USA.
| | - Fasiha Kanwal
- VA HSR&D Center for Innovations in Quality, Effectiveness & Safety, Michael E DeBakey VA Medical Center, 2002 Holcombe Boulevard, Houston, TX, 77030, USA. .,Department of Medicine, Baylor College of Medicine, One Baylor Plaza, Houston, TX, 77030, USA.
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Chhatwal J, Chen Q, Kanwal F. Why We Should Be Willing to Pay for Hepatitis C Treatment. Clin Gastroenterol Hepatol 2015; 13:1711-3. [PMID: 26091736 PMCID: PMC4575858 DOI: 10.1016/j.cgh.2015.06.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Revised: 06/06/2015] [Accepted: 06/09/2015] [Indexed: 12/23/2022]
Affiliation(s)
- Jagpreet Chhatwal
- Institute for Technology Assessment, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Qiushi Chen
- Department of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, GA USA
| | - Fasiha Kanwal
- Houston Veterans Affairs Health Services Research and Development Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center,Department of Medicine, Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX USA
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22
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High efficacy and safety of triple therapy in HCV genotype 1 and moderate fibrosis: a multicenter study of clinical practice in Spain. Ann Hepatol 2015. [DOI: 10.1016/s1665-2681(19)31169-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
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23
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Harris M, Albers E, Swan T. The promise of treatment as prevention for hepatitis C: Meeting the needs of people who inject drugs? THE INTERNATIONAL JOURNAL OF DRUG POLICY 2015; 26:963-9. [PMID: 26143385 DOI: 10.1016/j.drugpo.2015.05.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 04/24/2015] [Accepted: 05/12/2015] [Indexed: 12/19/2022]
Abstract
Treatment as prevention (TasP) is a concept common to the HIV sector. In this commentary we draw on the literature addressing HIV and HCV TasP, alongside qualitative HCV research, to critically appraise the promise of TasP for HCV and assess the needs of PWID in the future of HCV care. With the advent of highly effective direct-acting antiviral HCV treatments, TasP is now under consideration for HCV. A growing body of literature documents numerous social structural barriers to HCV treatment access and uptake for PWID, among whom HCV is highly prevalent. Yet these barriers - and suggestions for surmounting them - are rarely included in emergent literature on HCV TasP. Although HCV TasP has important advocacy potential for increasing treatment access among PWID, critical reflection on its implications are warranted. We outline potential limitations of TasP for HCV and the conditions under which it might be optimised. We argue that HCV treatment as a prevention strategy can only be realisable in a context of enhanced harm reduction access, meaningful community engagement, and enabling environment interventions informed by the needs and perspectives of PWID.
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24
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Chhatwal J, Kanwal F, Roberts MS, Dunn MA. Cost-effectiveness and budget impact of hepatitis C virus treatment with sofosbuvir and ledipasvir in the United States. Ann Intern Med 2015; 162:397-406. [PMID: 25775312 PMCID: PMC4435698 DOI: 10.7326/m14-1336] [Citation(s) in RCA: 271] [Impact Index Per Article: 30.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Sofosbuvir and ledipasvir, which have recently been approved for treatment of chronic hepatitis C virus (HCV) infection, are more efficacious and safer than the old standard of care (oSOC) but are substantially more expensive. Whether and in which patients their improved efficacy justifies their increased cost is unclear. OBJECTIVE To evaluate the cost-effectiveness and budget impact of sofosbuvir and ledipasvir. DESIGN Microsimulation model of the natural history of HCV infection. DATA SOURCES Published literature. TARGET POPULATION Treatment-naive and treatment-experienced HCV population defined on the basis of HCV genotype, age, and fibrosis distribution in the United States. TIME HORIZON Lifetime. PERSPECTIVE Third-party payer. INTERVENTION Simulation of sofosbuvir-ledipasvir compared with the oSOC (interferon-based therapies). OUTCOME MEASURES Quality-adjusted life-years (QALYs), incremental cost-effectiveness ratios (ICERs), and 5-year spending on antiviral drugs. RESULTS OF BASE-CASE ANALYSIS Sofosbuvir-based therapies added 0.56 QALY relative to the oSOC at an ICER of $55 400 per additional QALY. The ICERs ranged from $9700 to $284 300 per QALY depending on the patient's status with respect to treatment history, HCV genotype, and presence of cirrhosis. At a willingness-to-pay threshold of $100 000 per QALY, sofosbuvir-based therapies were cost-effective in 83% of treatment-naive and 81% of treatment-experienced patients. Compared with the oSOC, treating eligible HCV-infected persons in the United States with the new drugs would cost an additional $65 billion in the next 5 years, whereas the resulting cost offsets would be $16 billion. RESULTS OF SENSITIVITY ANALYSIS Results were sensitive to drug price, drug efficacy, and quality of life after successful treatment. LIMITATION Data on real-world effectiveness of new antivirals are lacking. CONCLUSION Treatment of HCV is cost-effective in most patients, but additional resources and value-based patient prioritization are needed to manage patients with HCV. PRIMARY FUNDING SOURCE National Institutes of Health.
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Affiliation(s)
- Jagpreet Chhatwal
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Fasiha Kanwal
- Department of Medicine, Baylor College of Medicine, Houston, TX USA
- Houston Veterans Affairs Health Services Research and Development Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center
| | - Mark S. Roberts
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Michael A. Dunn
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh, Pittsburgh, PA, USA
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Coughlin SS. "Test, Listen, Cure" (TLC) Hepatitis C Community Awareness Campaign. JMIR Res Protoc 2015; 4:e13. [PMID: 25677459 PMCID: PMC4342624 DOI: 10.2196/resprot.3822] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Revised: 11/05/2014] [Accepted: 11/06/2014] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Improved drugs have been approved for the treatment of hepatitis C virus (HCV), but many people are unaware of improved therapies that are now available to cure the illness in a high percentage of patients. OBJECTIVE The objectives of the Test, Listen, Cure (TLC) Hepatitis C Community Awareness Campaign include the development and implementation of a health education and promotion campaign in Memphis, Tennessee, and surrounding areas of western Tennessee, eastern Arkansas, and northern Mississippi, to increase community awareness about HCV, and to provide up-to-date provider education on HCV screening and treatment. The health education and promotion campaign, which will be conducted in collaboration with area hospitals, clinics, and nonprofit organizations, will provide information about how HCV infection is transmitted, risk factors for the disease, the importance of screening and treatment, and the availability of improved treatment for the disease. A second objective will be to provide continuing professional education on HCV screening and treatment to a minimum of 200 area health care providers, including primary care and internal medicine physicians and residents, physician assistants, nurse practitioners, providers who care for homeless persons, and dialysis unit nurses. METHODS Health education materials will be developed for this community awareness campaign that is culturally appropriate for African Americans and suitable for people with lower health literacy and educational attainment. Information will be compiled and disseminated about area providers who provide screening services and treatment for persons with HCV in order to facilitate linkages to care. Four focus groups of 8-10, African American adults aged 40-64, will be conducted to test the health education materials. The provider education on HCV will also address patient-physician communication and cultural competency. The National Medical Association regional chapters and expert physician consultants will provide assistance with delivering the education program. RESULTS Results from this one year project will be available in early 2016. CONCLUSIONS Depending on the availability of funding and successful implementation of the project, the TLC campaign will be extended to similar cities in the United States.
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