1
|
Artenie A, Stone J, Facente SN, Fraser H, Hecht J, Rhodes P, McFarland W, Wilson E, Hickman M, Vickerman P, Morris MD. Impact of HCV Testing and Treatment on HCV Transmission Among Men Who Have Sex With Men and Who Inject Drugs in San Francisco: A Modelling Analysis. J Infect Dis 2023; 228:662-673. [PMID: 37486337 PMCID: PMC10503949 DOI: 10.1093/infdis/jiad169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 05/26/2023] [Indexed: 07/25/2023] Open
Abstract
BACKGROUND Men who have sex with men who ever injected drugs (ever MSM-IDU) carry a high hepatitis C virus (HCV) burden. We estimated whether current HCV testing and treatment in San Francisco can achieve the 2030 World Health Organization (WHO) HCV elimination target on HCV incidence among ever MSM-IDU. METHODS A dynamic HCV/HIV transmission model among MSM was calibrated to San Francisco data, including HCV antibody (15.5%, 2011) and HIV prevalence (32.8%, 2017) among ever MSM-IDU. MSM had high HCV testing (79%-86% ever tested, 2011-2019) and diagnosed MSM had high HCV treatment (65% ever treated, 2018). Following coronavirus disease 2019 (COVID-19)-related lockdowns, HCV testing and treatment decreased by 59%. RESULTS Among all MSM, 43% of incident HCV infections in 2022 were IDU-related. Among ever MSM-IDU in 2015, HCV incidence was 1.2/100 person-years (95% credibility interval [CrI], 0.8-1.6). Assuming COVID-19-related declines in HCV testing/treatment persist until 2030, HCV incidence among ever MSM-IDU will decrease by 84.9% (95% CrI, 72.3%-90.8%) over 2015-2030. This decline is largely attributed to HCV testing and treatment (75.8%; 95% CrI, 66.7%-89.5%). Slightly greater decreases in HCV incidence (94%-95%) are projected if COVID-19 disruptions recover by 2025 or 2022. CONCLUSIONS We estimate that HCV incidence will decline by >80% over 2015-2030 among ever MSM-IDU in San Francisco, achieving the WHO target.
Collapse
Affiliation(s)
- Adelina Artenie
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Jack Stone
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Shelley N Facente
- School of Public Health, University of California Berkeley, Berkeley, California, USA
- Facente Consulting, Richmond, California, USA
| | - Hannah Fraser
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Jennifer Hecht
- San Francisco AIDS Foundation, San Francisco, California, USA
- Springboard HealthLab, Berkeley, California, USA
| | - Perry Rhodes
- Facente Consulting, Richmond, California, USA
- University of California San Francisco Alliance Health Project, San Francisco, California, USA
| | - Willi McFarland
- San Francisco Department of Public Health, San Francisco, California, USA
| | - Erin Wilson
- San Francisco Department of Public Health, San Francisco, California, USA
| | - Matthew Hickman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Peter Vickerman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Meghan D Morris
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
| |
Collapse
|
2
|
Kapadia SN, Zhang H, Gonzalez CJ, Sen B, Franco R, Hutchings K, Wethington E, Talal A, Lloyd A, Dharia A, Wells M, Bao Y, Shapiro MF. Hepatitis C Treatment Initiation Among US Medicaid Enrollees. JAMA Netw Open 2023; 6:e2327326. [PMID: 37540513 PMCID: PMC10403776 DOI: 10.1001/jamanetworkopen.2023.27326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 06/16/2023] [Indexed: 08/05/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Shashi N. Kapadia
- Division of Infectious Diseases, Weill Cornell Medicine, New York, New York
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York
| | - Hao Zhang
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York
| | | | - Bisakha Sen
- Department of Health Policy and Organization, University of Alabama at Birmingham, Birmingham
| | - Ricardo Franco
- Division of Infectious Diseases, University of Alabama at Birmingham
| | - Kayla Hutchings
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York
| | - Elaine Wethington
- Department of Sociology and Department of Psychology, Cornell University, Ithaca, New York
| | - Andrew Talal
- Division of Gastroenterology, Hepatology, and Nutrition, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York
| | - Audrey Lloyd
- Division of Infectious Diseases, University of Alabama at Birmingham
| | - Arpan Dharia
- Division of Gastroenterology, Hepatology, and Nutrition, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York
| | - Martin Wells
- Department of Statistics and Data Science, Cornell University, Ithaca, New York
| | - Yuhua Bao
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York
| | - Martin F Shapiro
- Division of General Internal Medicine, Weill Cornell Medicine, New York, New York
| |
Collapse
|
3
|
Yousafzai MT, Bajis S, Alavi M, Grebely J, Dore GJ, Hajarizadeh B. Global cascade of care for chronic hepatitis C virus infection: A systematic review and meta-analysis. J Viral Hepat 2021; 28:1340-1354. [PMID: 34310812 DOI: 10.1111/jvh.13574] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 05/22/2021] [Accepted: 06/26/2021] [Indexed: 12/14/2022]
Abstract
The World Health Organization 2030 targets for hepatitis C virus (HCV) elimination include diagnosing 90% of people with HCV and treating 80% of people diagnosed with HCV. This systematic review assessed reported data on the HCV care cascade in various countries and populations, with a focus on direct-acting antiviral (DAA) treatment uptake. Bibliographic databases and conference presentations were searched for studies reporting the HCV care cascade (DAA treatment uptake was a requirement) among the overall population with HCV or sub-populations at greater risk of HCV. Population-based studies, with participants representative of a city, province/state or country were eligible. Twenty eligible studies were included, reporting HCV care cascade in 28 populations/sub-populations from 11 countries. DAA treatment uptake at national levels was reported from Iceland (95%), Egypt (92%), Georgia (79%), Norway (18%) and Sweden (8%), and at sub-national levels from the Netherlands (52%), Canada (50%), the United States (29%) and Denmark (5%). Among people with HIV-HCV co-infection, DAA treatment uptake was 62% in Canada, 44% in the Netherlands, 21% in Switzerland and 18% in the United States. Among people who inject drugs, DAA treatment uptake was 50% in Georgia, 40% in Canada, 37% in Australia and 13% in the United States. Data among people experiencing homelessness were only available from the United States (treatment uptake: 12%-14%). We found no eligible study reporting HCV care cascade data in prisons. Relatively few countries reported HCV care cascade at the national level. DAA treatment uptake was widely varied across populations/sub-populations, with higher rates reported in recent years.
Collapse
Affiliation(s)
| | - Sahar Bajis
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | - Maryam Alavi
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | - Jason Grebely
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | - Gregory J Dore
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | | |
Collapse
|
4
|
van Boemmel-Wegmann S, Lo Re V, Park H. Early Treatment Uptake and Cost Burden of Hepatitis C Therapies Among Newly Diagnosed Hepatitis C Patients with a Particular Focus on HIV Coinfection. Dig Dis Sci 2020; 65:3159-3174. [PMID: 31938995 PMCID: PMC7358122 DOI: 10.1007/s10620-019-06037-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 12/30/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Despite the high efficacy and safety associated with direct-acting antivirals (DAAs), access to HCV treatment has been frequently restricted because of the high DAA drug costs. OBJECTIVES To (1) compare HCV treatment initiation rates between HCV monoinfected and HCV/HIV coinfected patients before (pre-DAA period) and after (post-DAA period) all-oral DAAs became available; and to (2) estimate the HCV treatment costs for payers and patients. RESEARCH DESIGN AND METHODS A retrospective analysis of the MarketScan® Databases (2009-2016) was conducted for newly diagnosed HCV patients. Multivariable logistic regression was used to estimate the odds ratio (OR) of initiating HCV treatments during the pre-DAA and post-DAA periods. Kruskal-Wallis test was used to compare drug costs for dual, triple and all-oral therapies. RESULTS A total of 15,063 HCV patients [382 (2.5%) HIV coinfected] in the pre-DAA period and 14,896 [429 (2.9%) HIV coinfected] in the post-DAA period were included. HCV/HIV coinfected patients had lower odds of HCV treatment uptake compared to HCV monoinfected patients during the pre-DAA period [OR, 0.59; 95% confidence interval (CI), 0.45-0.78], but no significant difference in odds of HCV treatment uptake was observed during the post-DAA period (OR, 1.08; 95% CI, 0.87-1.33). From 2009 to 2016, average payers' treatment costs (dual, $20,820; all-oral DAAs, $99,661; p < 0.001) as well as average patients' copayments (dual, $593; all-oral DAAs $933; p < 0.001) increased significantly. CONCLUSIONS HCV treatment initiation rates increased, especially among HCV/HIV coinfected patients, from the pre-DAA to the post-DAA period. However, payers' expenditures per course of therapy saw an almost fivefold increase and patients' copayments increased by 55%.
Collapse
Affiliation(s)
- Sascha van Boemmel-Wegmann
- Department of Pharmaceutical Outcomes and Policy, University of Florida College of Pharmacy, HPNP Building Room 3325, 1225 Center Drive, Gainesville, FL, 32610, USA
| | - Vincent Lo Re
- Division of Infectious Diseases, Department of Medicine and Center for Clinical Epidemiology and Biostatistics, Center for Pharmacoepidemiology Research and Training, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Haesuk Park
- Department of Pharmaceutical Outcomes and Policy, University of Florida College of Pharmacy, HPNP Building Room 3325, 1225 Center Drive, Gainesville, FL, 32610, USA.
| |
Collapse
|
5
|
Travaglini LE, Kreyenbuhl J, Graydon M, Brown CH, Goldberg R, Himelhoch S, Fang LJ, Slade E. Access to Direct-Acting Antiviral Treatment for Hepatitis C Virus Among Veterans With Serious Mental Illness. Psychiatr Serv 2020; 71:192-195. [PMID: 31615365 DOI: 10.1176/appi.ps.201900227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
OBJECTIVE This study examined whether serious mental illness is associated with initiating and with completing sofosbuvir-based treatment for hepatitis C virus (HCV) among veterans who started treatment after the Veterans Health Administration (VHA) received expanded funding for HCV care. METHODS Administrative health care data from fiscal years 2016-2017 revealed 4,288 treatment-naïve patients with HCV, of whom 1,311 had initiated sofosbuvir-based treatment. Dependent variables were initiation and completion of ≥8 weeks of sofosbuvir treatment. Associations with serious mental illness were estimated with adjusted odds ratios from multivariable logistic regression analyses. RESULTS No statistically significant differences were found in the proportion of veterans with and veterans without serious mental illness who initiated (p=0.628) or completed ≥8 weeks (p=0.301) of sofosbuvir treatment. CONCLUSIONS Veterans with and without serious mental illness initiated and completed sofosbuvir treatment at similar rates. The VA should continue to provide equitable access to HCV treatments and support medication adherence.
Collapse
Affiliation(s)
- Letitia E Travaglini
- Veterans Affairs (VA) Capitol Healthcare Network (VISN 5) Mental Illness Research, Education and Clinical Center (MIRECC), Baltimore (Travaglini, Kreyenbuhl, Brown, Goldberg); Division of Psychiatric Services Research, Department of Psychiatry (Kreyenbuhl, Goldberg, Fang, Slade), and Department of Epidemiology and Public Health (Brown), University of Maryland School of Medicine, Baltimore; VA Maryland Health Care System, Baltimore (Graydon); Department of Psychiatry, University of Kentucky College of Medicine, Lexington (Himelhoch); Johns Hopkins University School of Nursing, Baltimore (Slade)
| | - Julie Kreyenbuhl
- Veterans Affairs (VA) Capitol Healthcare Network (VISN 5) Mental Illness Research, Education and Clinical Center (MIRECC), Baltimore (Travaglini, Kreyenbuhl, Brown, Goldberg); Division of Psychiatric Services Research, Department of Psychiatry (Kreyenbuhl, Goldberg, Fang, Slade), and Department of Epidemiology and Public Health (Brown), University of Maryland School of Medicine, Baltimore; VA Maryland Health Care System, Baltimore (Graydon); Department of Psychiatry, University of Kentucky College of Medicine, Lexington (Himelhoch); Johns Hopkins University School of Nursing, Baltimore (Slade)
| | - Meagan Graydon
- Veterans Affairs (VA) Capitol Healthcare Network (VISN 5) Mental Illness Research, Education and Clinical Center (MIRECC), Baltimore (Travaglini, Kreyenbuhl, Brown, Goldberg); Division of Psychiatric Services Research, Department of Psychiatry (Kreyenbuhl, Goldberg, Fang, Slade), and Department of Epidemiology and Public Health (Brown), University of Maryland School of Medicine, Baltimore; VA Maryland Health Care System, Baltimore (Graydon); Department of Psychiatry, University of Kentucky College of Medicine, Lexington (Himelhoch); Johns Hopkins University School of Nursing, Baltimore (Slade)
| | - Clayton H Brown
- Veterans Affairs (VA) Capitol Healthcare Network (VISN 5) Mental Illness Research, Education and Clinical Center (MIRECC), Baltimore (Travaglini, Kreyenbuhl, Brown, Goldberg); Division of Psychiatric Services Research, Department of Psychiatry (Kreyenbuhl, Goldberg, Fang, Slade), and Department of Epidemiology and Public Health (Brown), University of Maryland School of Medicine, Baltimore; VA Maryland Health Care System, Baltimore (Graydon); Department of Psychiatry, University of Kentucky College of Medicine, Lexington (Himelhoch); Johns Hopkins University School of Nursing, Baltimore (Slade)
| | - Richard Goldberg
- Veterans Affairs (VA) Capitol Healthcare Network (VISN 5) Mental Illness Research, Education and Clinical Center (MIRECC), Baltimore (Travaglini, Kreyenbuhl, Brown, Goldberg); Division of Psychiatric Services Research, Department of Psychiatry (Kreyenbuhl, Goldberg, Fang, Slade), and Department of Epidemiology and Public Health (Brown), University of Maryland School of Medicine, Baltimore; VA Maryland Health Care System, Baltimore (Graydon); Department of Psychiatry, University of Kentucky College of Medicine, Lexington (Himelhoch); Johns Hopkins University School of Nursing, Baltimore (Slade)
| | - Seth Himelhoch
- Veterans Affairs (VA) Capitol Healthcare Network (VISN 5) Mental Illness Research, Education and Clinical Center (MIRECC), Baltimore (Travaglini, Kreyenbuhl, Brown, Goldberg); Division of Psychiatric Services Research, Department of Psychiatry (Kreyenbuhl, Goldberg, Fang, Slade), and Department of Epidemiology and Public Health (Brown), University of Maryland School of Medicine, Baltimore; VA Maryland Health Care System, Baltimore (Graydon); Department of Psychiatry, University of Kentucky College of Medicine, Lexington (Himelhoch); Johns Hopkins University School of Nursing, Baltimore (Slade)
| | - Li Juan Fang
- Veterans Affairs (VA) Capitol Healthcare Network (VISN 5) Mental Illness Research, Education and Clinical Center (MIRECC), Baltimore (Travaglini, Kreyenbuhl, Brown, Goldberg); Division of Psychiatric Services Research, Department of Psychiatry (Kreyenbuhl, Goldberg, Fang, Slade), and Department of Epidemiology and Public Health (Brown), University of Maryland School of Medicine, Baltimore; VA Maryland Health Care System, Baltimore (Graydon); Department of Psychiatry, University of Kentucky College of Medicine, Lexington (Himelhoch); Johns Hopkins University School of Nursing, Baltimore (Slade)
| | - Eric Slade
- Veterans Affairs (VA) Capitol Healthcare Network (VISN 5) Mental Illness Research, Education and Clinical Center (MIRECC), Baltimore (Travaglini, Kreyenbuhl, Brown, Goldberg); Division of Psychiatric Services Research, Department of Psychiatry (Kreyenbuhl, Goldberg, Fang, Slade), and Department of Epidemiology and Public Health (Brown), University of Maryland School of Medicine, Baltimore; VA Maryland Health Care System, Baltimore (Graydon); Department of Psychiatry, University of Kentucky College of Medicine, Lexington (Himelhoch); Johns Hopkins University School of Nursing, Baltimore (Slade)
| |
Collapse
|
6
|
Gidwani-Marszowski R, Owens DK, Lo J, Goldhaber-Fiebert JD, Asch SM, Barnett PG. The Costs of Hepatitis C by Liver Disease Stage: Estimates from the Veterans Health Administration. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2019; 17:513-521. [PMID: 31030359 DOI: 10.1007/s40258-019-00468-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND The release of highly effective but costly medications for the treatment of hepatitis C virus combined with a doubling in the incidence of hepatitis C virus have posed substantial financial challenges for many healthcare systems. We provide estimates of the cost of treating patients with hepatitis C virus that can inform the triage of pharmaceutical care in systems with limited healthcare resources. METHODS We conducted an observational study using a national US cohort of 206,090 veterans with laboratory-identified hepatitis C virus followed from Fiscal Year 2010 to 2014. We estimated the cost of: non-advanced Fibrosis-4; advanced Fibrosis-4; hepatocellular carcinoma; liver transplant; and post-liver transplant. The former two stages were ascertained using laboratory result data; the latter stages were ascertained using administrative data. Costs were obtained from the Veterans Health Administration's activity-based cost accounting system and more closely represent the actual costs of providing care, an improvement on the charge data that generally characterizes the hepatitis C virus cost literature. Generalized estimating equations were used to estimate and predict costs per liver disease stage. Missing data were multiply imputed. RESULTS Annual costs of care increased as patients progressed from non-advanced Fibrosis-4 to advanced Fibrosis-4, hepatocellular carcinoma, and liver transplant (all p < 0.001). Post-liver transplant, costs decreased significantly (p < 0.001). In simulations, patients were estimated to incur the following annual costs: US $17,556 for non-advanced Fibrosis-4; US $20,791 for advanced Fibrosis-4; US $46,089 for liver cancer; US $261,959 in the year of the liver transplant; and US $18,643 per year after the liver transplant. CONCLUSIONS Cost differences of treating non-advanced and advanced Fibrosis-4 are relatively small. The greatest cost savings would be realized from avoiding progression to liver cancer and transplant.
Collapse
Affiliation(s)
- Risha Gidwani-Marszowski
- VA Health Economics Resource Center, VA Palo Alto Health Care System, 795 Willow Rd. (152 MPD), Menlo Park, CA, 94025, USA.
- VA Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA.
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.
| | - Douglas K Owens
- VA Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA
- Center for Primary Care and Outcomes Research/Center for Health Policy, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Jeanie Lo
- VA Health Economics Resource Center, VA Palo Alto Health Care System, 795 Willow Rd. (152 MPD), Menlo Park, CA, 94025, USA
| | - Jeremy D Goldhaber-Fiebert
- Center for Primary Care and Outcomes Research/Center for Health Policy, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Steven M Asch
- VA Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Paul G Barnett
- VA Health Economics Resource Center, VA Palo Alto Health Care System, 795 Willow Rd. (152 MPD), Menlo Park, CA, 94025, USA
- VA Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA
- Center for Primary Care and Outcomes Research/Center for Health Policy, Department of Medicine, Stanford University, Stanford, CA, USA
| |
Collapse
|