Is travel-time to a specialist centre a risk factor for non-referral, non-attendance and loss to follow-up among patients with hepatitis C (HCV) infection?

Hepatitis C micro-elimination through the retrieval strategy of patients lost to follow-up

BACKGROUND AND AIM

World Health Organization sets up an ambitious and attainable goal to eliminate hepatitis C (HCV) by 2030. The previous diagnosed HCV patients lost to follow-up were considered as an important target group for HCV elimination. We conducted a call back program to retrieve the lost to follow-up HCV patients and link them to care in our hospital. By analyzing and comparing our result with that from other studies, we wish to improve our retrieval strategy and provide our experience to the general communities.

METHODS

A list of the patients with a medical record showing seropositive for antibody to HCV (anti-HCV Ab) from 2004 to 2017 was retrieved by the department of intelligent technology of our hospital. Three dedicated staff members reviewed the patients' electronic medical records (EMRs) and recruited the patient lost follow-up to the call back program. The staff members contacted the qualified patients by telephone and inquired about their opinions for treating their chronic HCV infection. We also informed the patients about the retrieval strategy and why we contact them. As our National Health Insurance request, we gave all patient one informed consent for hepatitis C treatment. Informed consents have been obtained from all patients. Referrals to our gastroenterology unit (GU) were arranged for the patients who would like to continue their chronic HCV care in our hospital.

RESULTS

There were 31,275 anti-HCV positive patients. We included 11,934 patients (38.2%) into the call back system and contacted them by telephone. Based on the response to our call, we ascertained 1277 eligible cases (10.7%) for retrieval. The patients who were younger (< 55), lived in Taoyaun City or had tested positive for anti-HCV Ab at the department of internal medicine department had an increased rate of successful call back. There were 563 patients (44.1%) returning to our GU. Of them, 354 patients (62.9%) were positive for HCV viremia. 323 patients (91.2%) received the DAAs treatment. The SVR12 with Grazoprevir + elbasvir, Glecaprevir + pibrentasvir, Sofosbuvir + ledipasvir and Sofosbuvir + velpatasvir were 97.9%, 98.8%, 100% and 97.5%, respectively.

CONCLUSIONS

Call back system can expand our reach to those unaware or ignoring chronic HCV infection patients and link them to treatment.

Patient outcomes in public sector hepatitis C treatment programmes: a retrospective cohort analysis across five low- and middle-income countries

OBJECTIVES

Given limited data on factors associated with hepatitis C virus (HCV) treatment discontinuation and failure in low- and middle-income countries, we aimed to describe patient populations treated for HCV in five countries and identify patient groups that may need additional support.

DESIGN

Retrospective cohort analysis using routinely collected data.

SETTING

Public sector HCV treatment programmes in India (Punjab), Indonesia, Myanmar, Nigeria (Nasarawa) and Vietnam.

PARTICIPANTS

104 957 patients who initiated treatment in 2016-2022 (89% from Punjab).

PRIMARY OUTCOMES

Treatment completion and cure.

RESULTS

Patient characteristics and factors associated with outcomes varied across countries and facilities. Across all patients, median age was 40 years (IQR: 29-52), 30.6% were female, 7.0% reported a history of injecting drugs, 18.2% were cirrhotic and 4.9% were coinfected with HIV. 79.8% were prescribed sofosbuvir+daclastasvir. Of patients with adequate follow-up, 90.6% (89,551) completed treatment. 77.5% (69,426) of those who completed treatment also completed sustained virological testing at 12 weeks (SVR12), and of those, 92.6% (64 305) were cured. In multivariable-adjusted models, in most countries, significantly lower treatment completion was observed among patients on 24-week regimens (vs 12-week regimens) and those initiated in later years of the programme. In several countries, males, younger patients <20 years and certain groups of cirrhotic patients were less likely to complete treatment or be cured. In Punjab, treatment completion was also lower in those with a family history of HCV and people who inject drugs (PWID); in other countries, outcomes were comparable for PWID.

CONCLUSION

High proportions of patients completed treatment and were cured across patient groups and countries. SVR12 follow-up could be strengthened. Males, younger people and those with decompensated cirrhosis on longer regimens may require additional support to complete treatment and achieve cure. Adequate programme financing, minimal user fees and implementation of evidence-based policies will be critical to close gaps.

Cost-effectiveness and Budgetary Impact of Hepatitis C Virus Testing, Treatment, and Linkage to Care in US Prisons

BACKGROUND

Hepatitis C virus (HCV) testing and treatment uptake in prisons remains low. We aimed to estimate clinical outcomes, cost-effectiveness (CE), and budgetary impact (BI) of HCV testing and treatment in United States (US) prisons or linkage to care at release.

METHODS

We used individual-based simulation modeling with healthcare and Department of Corrections (DOC) perspectives for CE and BI analyses, respectively. We simulated a US prison cohort at entry using published data and Washington State DOC individual-level data. We considered permutations of testing (risk factor based, routine at entry or at release, no testing), treatment (if liver fibrosis stage ≥F3, for all HCV infected or no treatment), and linkage to care (at release or no linkage). Outcomes included quality-adjusted life-years (QALY); cases identified, treated, and cured; cirrhosis cases avoided; incremental cost-effectiveness ratios; DOC costs (2016 US dollars); and BI (healthcare cost/prison entrant) to generalize to other states.

RESULTS

Compared to "no testing, no treatment, and no linkage to care," the "test all, treat all, and linkage to care at release" model increased the lifetime sustained virologic response by 23%, reduced cirrhosis cases by 54% at a DOC annual additional cost of $1440 per prison entrant, and would be cost-effective. At current drug prices, targeted testing and liver fibrosis-based treatment provided worse outcomes at higher cost or worse outcomes at higher cost per QALY gained. In sensitivity analysis, fibrosis-based treatment restrictions were cost-effective at previous higher drug costs.

CONCLUSIONS

Although costly, widespread testing and treatment in prisons is considered to be of good value at current drug prices.

Distance to treatment as a factor for loss to follow up of hepatitis C patients in North East England

BACKGROUND

A large proportion of the 200 000 HCV-infected individuals in the UK are undiagnosed or lost to follow-up. Engaging known infected individuals in treatment is essential for elimination.

METHODS

Using PHE surveillance data and HCV treatment registers from North East of England (NE) treatment centres for 1997-2016, we estimated the number of HCV cases not linked to treatment and the proportion with active infection. We compared distances of treated and untreated cases to treatment services, and assessed the effect of expanding HCV treatment into existing drug and alcohol treatment centres in the NEE on treatment accessibility.

RESULTS

The odds of being treated was associated with distance to treatment services. Confirmatory results for ~50% were not reported to PHE NE. Overall, 3385 patients reported to PHE NE had no record of treatment; we estimated 1621 of these may have been lost to follow-up after confirmation of active infection.

CONCLUSIONS

Poor access to healthcare services may contribute to under-diagnosis or loss to follow-up. Expanding HCV treatment delivery into NEE drug and alcohol treatment centres would improve the accessibility of treatment services to people infected with/at risk of HCV. This may increase the proportion receiving treatment and support progress towards elimination.

The balancing perspective of hard-to-reach hepatitis C patients who were lost to follow-up: A qualitative study

Background

In the foreseeable future, patients with hepatitis C virus (HCV) with good healthcare access will all have been cured and the lost to follow-up (LFU) HCV-population will increasingly exist of hard-to-reach patients. Efforts to retrieve these individuals with HCV have been moderately successful so far. A deeper understanding of the reasons for loss to follow-up and the underlying processes is lacking.

Aims

To explore reasons for previous loss to follow-up in patients with HCV who have been brought back into care.

Methods

In 2017, fifteen patients with HCV who were evaluated at the University Medical Center Utrecht (UMCU) Infectious diseases outpatient clinic as part of the “REtrieval And cure of Chronic Hepatitis C” (REACH)-project were included in this study through convenience sampling. Face-to-face semi-structured in-depth interviews were conducted and a qualitative analysis based on the grounded theory was applied.

Results

A basic socio- psychological process named “maintaining the achieved balance” was uncovered in patients with HCV who were LFU. This “achieved balance” is the result of a transformative process following the initial HCV diagnosis. It is a steadfast stance in which participants keep HCV out of sight and in the margin of their lives in order to reestablish an optimal state of well-being. The balancing perspective is subsequently defended by repeated evasive behavioral patterns to avoid confrontation with the disease.

Conclusion

The balancing perspective gives insight into why individuals with HCV were not retained in care but also why they remained LFU thereafter. Physicians should realize that this mindset can be persistent and repeated efforts may be needed to finally trace and retrieve these patients.

Facilitating treatment of HCV in primary care in regional Australia: closing the access gap

BACKGROUND

Australia has unrestricted access to direct-acting antivirals (DAA) for hepatitis C virus (HCV) treatment. In order to increase access to treatment, primary care providers are able to prescribe DAA after fibrosis assessment and specialist consultation. Transient elastography (TE) is recommended prior to commencement of HCV treatment; however, TE is rarely available outside secondary care centres in Australia and therefore a requirement for TE could represent a barrier to access to HCV treatment in primary care.

OBJECTIVES

In order to bridge this access gap, we developed a community-based TE service across the Sunshine Coast and Wide Bay areas of Queensland.

DESIGN

Retrospective analysis of a prospectively recorded HCV treatment database.

INTERVENTIONS

A nurse-led service equipped with two mobile Fibroscan units assesses patients in eight locations across regional Queensland. Patients are referred into the service via primary care and undergo nurse-led TE at a location convenient to the patient. Patients are discussed at a weekly multidisciplinary team meeting and a treatment recommendation made to the referring GP. Treatment is initiated and monitored in primary care. Patients with cirrhosis are offered follow-up in secondary care.

RESULTS

327 patients have undergone assessment and commenced treatment in primary care. Median age 48 years (IQR 38-56), 66% male. 57% genotype 1, 40% genotype 3; 82% treatment naïve; 10% had cirrhosis (liver stiffness >12.5 kPa). The majority were treated with sofosbuvir-based regimens. 26% treated with 8-week regimens. All patients had treatment prescribed and monitored in primary care. Telephone follow-up to confirm sustained virological response (SVR) was performed by clinic nurses. 147 patients remain on treatment. 180 patients have completed treatment. SVR data were not available for 19 patients (lost to follow-up). Intention-to-treat SVR rate was 85.5%. In patients with complete data SVR rate was 95.6%.

CONCLUSION

Community-based TE assessment facilitates access to HCV treatment in primary care with excellent SVR rates.

Associations between access to healthcare, environmental quality, and end-stage renal disease survival time: Proportional-hazards models of over 1,000,000 people over 14 years

Prevalence of end-stage renal disease (ESRD) in the US increased by 74% from 2000 to 2013. To investigate the role of the broader environment on ESRD survival time, we evaluated average distance to the nearest hospital by county (as a surrogate for access to healthcare) and the Environmental Quality Index (EQI), an aggregate measure of ambient environmental quality composed of five domains (air, water, land, built, and sociodemographic), at the county level across the US. Associations between average hospital distance, EQI, and survival time for 1,092,281 people diagnosed with ESRD between 2000 and 2013 (age 18+, without changes in county residence) from the US Renal Data System were evaluated using proportional-hazards models adjusting for gender, race, age at first ESRD service date, BMI, alcohol and tobacco use, and rurality. The models compared the average distance to the nearest hospital (<10, 10-20, >20 miles) and overall EQI percentiles [0-5), [5-20), [20-40), [40-60), [60-80), [80-95), and [95-100], where lower percentiles are interpreted as better EQI. In the full, non-stratified model with both distance and EQI, there was increased survival for patients over 20 miles from a hospital compared to those under 10 miles from a hospital (hazard ratio = 1.14, 95% confidence interval = 1.12-1.15) and no consistent direction of association across EQI strata. In the full model stratified by average hospital distance, under 10 miles from a hospital had increased survival in the worst EQI strata (median survival 3.0 vs. 3.5 years for best vs. worst EQI, respectively), however for people over 20 miles from a hospital, median survival was higher in the best (4.2 years) vs worst (3.4 years) EQI. This association held across different rural/urban categories and age groups. These results demonstrate the importance of considering multiple factors when studying ESRD survival and future efforts should consider additional components of the broader environment.

Hepatitis C among blood donors: cascade of care and predictors of loss to follow-up

OBJECTIVE

To investigate the HCV cascade of care and to identify the factors associated with loss or absence to follow-up of patients identified as infected with hepatitis C through blood donation.

METHODS

Blood donors from 1994 to 2012, identified with positive anti- HCV by enzyme immunoassay and immunoblot tests were invited to participate in the study, through letters or phone calls. Patients who agreed to participate were interviewed and their blood samples were collected for further testing. The following variables were investigated: demographic data, data on comorbidities and history concerning monitoring of hepatitis C. Multiple regression analysis by Poisson regression model was used to investigate the factors associated with non-referral for consultation or loss of follow-up.

RESULTS

Of the 2,952 HCV-infected blood donors, 22.8% agreed to participate: 394 (58.2%) male, median age 48 years old and 364 (53.8%) Caucasian. Of the 676 participants, 39.7% did not receive proper follow-up or treatment after diagnosis: 45 patients referred not to be aware they were infected, 61 did not seek medical attention and 163 started a follow-up program, but were non-adherent. The main reasons for inadequate follow-up were not understanding the need for medical care (71%) and health care access difficulties (14%). The variables showing a significant association with inadequate follow-up after multiple regression analysis were male gender (PR = 1.40; 95%CI 1.15–1.71), age under or equal to 50 years (PR = 1.36; 95%CI 1.12–1.65) and non-Caucasians (PR = 1.53; 95%CI 1.27–1.84).

CONCLUSIONS

About 40.0% of patients did not receive appropriate follow-up. These data reinforce the need to establish strong links between primary care and reference centers and the need to improve access to specialists and treatments.

Magnitude and causes of loss to follow-up among patients with viral hepatitis at a tertiary care hospital in Saudi Arabia

BACKGROUND

Non-adherence with recommended follow-up visits is a major barrier for completing treatment of viral hepatitis and is consequently associated with unfavorable outcomes of health services.

OBJECTIVES

To estimate the magnitude and identify perceived reasons and patient characteristics associated with loss to follow-up in a tertiary care setting.

METHODS

A two-step cross-sectional study design was used, including a chart review (2011) followed by phone survey (2012). Loss to follow-up was recorded among those who were diagnosed with hepatitis B (HBV) or C (HCV) during 2009-2010 but never returned for recommended/scheduled follow-up appointment(s).

RESULTS

A total of 328 patients (202 HBV and 126 HCV) were included in the current analysis. The average age was 49.6±17.9years, and 57% were males. Out of 328, 131 (40%) were not advised to do follow-up, and 98 (30%) were not doing follow-up. Perceived reasons for loss to follow-up were as follows: unaware that a follow-up appointment was scheduled (69%), never informed of need for follow-up by healthcare provider (15%), personal belief that follow-up was not necessary (9%), logistical reasons (3%) and other reasons (5%). Loss to follow-up was higher among those who had been diagnosed with HBV, referred by non-liver-related specialty, never advised to follow-up, unaware of their diagnosis, incorrectly identified their type of hepatitis, lacking hepatitis complications, having full medical coverage, pregnant, and those with low knowledge or negative attitude towards hepatitis.

CONCLUSIONS

Loss to follow-up is a significant problem among patients with hepatitis in a tertiary care center, with several patient and system failures being implicated.

Reasons for missed appointments with a hepatitis C outreach clinic: A qualitative study

BACKGROUND

Non-attendance in drug service hepatitis C outreach clinics means clients miss the opportunity of being given lifestyle advice and referral to hospital for assessment and treatment. A similar problem is experienced in other services throughout the UK. A qualitative study was undertaken to investigate the problem.

METHODS

Clients with a history of not attending the outreach clinic were invited to participate during a routine drug clinic appointment. A contact details sheet with a preferred telephone number was completed by those agreeing to take part. Verbal consent was taken and a telephone interview took place. The participants were remunerated for taking part with a five pounds high street voucher. The 'framework method' was used to analyse the data with key themes identified.

RESULTS

Twenty-eight telephone interviews were undertaken from April to June 2012. All the clients gave 'prima-facie' reasons for non-attendance including 'not a priority' and 'forgot'. However, the study indicates these are insufficient to explain the various experiences and influences. Underlying reasons that impacted upon attendance were identified. These reasons relate to (i) client characteristics e.g. 'priority' to score drugs and the 'cost of travel' and (ii) clinic service e.g. 'difficult journey' to the clinic and timing of the 'appointment'. The reasons operated within a complex context where other factors had an impact including addiction, welfare policy, stigma and the nature of hepatitis C itself.

CONCLUSION

The study revealed that beneath apparently simple explanations for non-attendance, such as clients' chaotic lifestyle resulting in them forgetting or not being bothered to attend, there were far more complex and varied underlying reasons. This has important implications for drug policy including the need to better incorporate clients' perspectives. Policy that is based only on the simple, surface reasons is unlikely to be effective.

Results from a Geographically Focused, Community-Based HCV Screening, Linkage-to-Care and Patient Navigation Program

BACKGROUND

Many of the five million Americans chronically infected with hepatitis C (HCV) are unaware of their infection and are not in care.

OBJECTIVE

We implemented and evaluated HCV screening and linkage-to-care interventions in a community setting.

DESIGN

We developed a comprehensive, community-based HCV screening and linkage-to-care program in a medically underserved neighborhood with high rates of HCV infection in Philadelphia, Pennsylvania. We provided patient navigation services to enroll uninsured patients in insurance programs, facilitate referrals from primary care physicians and link patients to an HCV infectious disease specialist with intention to treat and cure.

PATIENTS

Philadelphia residents were recruited through street outreach.

MAIN MEASURES

We measured anti-HCV seroprevalence and diagnosis, linkage and retention in care outcomes for chronically infected patients.

KEY RESULTS

We screened 1,301 participants for HCV; anti-HCV seroprevalence was 3.9 % and 2.8% of all patients were chronically infected. Half of chronically infected patients were newly diagnosed; the remaining patients were aware of infection but not in care. We provided confirmatory RNA testing and results, assisted patients with attaining insurance and linked most chronically infected patients to a primary care provider. The biggest barrier to retaining patients in care was obtaining referrals for subspecialty providers; however, we obtained referrals for 64% of chronically infected participants and have retained most in subspecialty HCV care. Several have commenced treatment.

CONCLUSIONS

Non-clinical screening programs with patient navigator services are an effective means to diagnose, link, retain and re-engage patients in HCV care. Eliminating referral requirements for subspecialty care might further enhance retention in care for patients chronically infected with HCV.

Awareness of biologically confirmed HCV among a community residing sample of drug users in Baltimore City

The present study sought to examine: (1) the prevalence and correlates of biologically confirmed Hepatitis C (HCV) and (2) the prevalence and correlates of prior HCV diagnosis and an unmet need for HCV treatment, among a community residing sample of drug users. The current study used a subset of HCV tested participants from the larger NEURO-HIV Epidemiologic Study from Baltimore, Maryland (M(age) = 34.81, SD = 9.25; 46% female). All participants were tested for HCV at baseline. Self-report was used to assess awareness of an HCV diagnosis and participation in treatment. Of the 782 participants tested for HCV, 19% reported having received an HCV diagnosis in the past while 48% tested positive for HCV. Only 6% reported having received treatment for any form of hepatitis. Of those who tested HCV positive, 63% reported never being diagnosed, and only 13% received any treatment for HCV. We found that only 35% of those who reported a prior HCV diagnosis received any treatment. The findings regarding lack of HCV awareness and diagnosis were considerable as expected. These deficits suggest that there are numerous gaps in patients' knowledge and beliefs regarding HCV that may interfere at multiple steps along the path from diagnosis to treatment. This study clearly demonstrates that a critical need exists to improve public knowledge of HCV risk factors, the need for testing, and the availability of effective treatment.

The hepatitis C cascade of care among HIV infected patients: a call to address ongoing barriers to care

Background

The aims were to investigate the hepatitis C (HCV) cascade of care among HIV-infected patients and to identify reasons for not referring for and not initiating HCV therapy after completion of HCV treatment staging.

Design and Methods

Retrospective cohort analysis of HIV-infected patients under care at the University of California, San Diego (UCSD). We identified patients screened for and diagnosed with active HCV infection. Logistic regression analyses were used to identify factors associated with lack of referral for HCV therapy. Electronic medical records were reviewed to ascertain reasons for not initiating HCV therapy.

Results

Between 2008 and 2012, 4725 HIV-infected patients received care at the UCSD Owen clinic. Most patients [4534 (96%)] were screened for HCV, 748 (16%) patients had reactive serum HCV antibodies but only 542 patients had active HCV infection. Lack of engagement in care was the most important predictor of non-referral for HCV therapy [odds ratio (OR): 5.08, 95% confidence interval 3.24–6.97, p<0.00001]. Other significant predictors included unstable housing (OR: 2.26), AIDS (OR: 1.83), having a detectable HIV viral load (OR: 1.98) and being non-white (OR: 1.67). The most common reason (40%) for not initiating or deferring HCV therapy was the presence of ongoing barriers to care.

Conclusions

Screening for HCV in HIV-infected patients linked to care is high but almost half of patients diagnosed with HCV are not referred for HCV therapy. Despite improvements in HCV therapy the benefits will not be realized unless effective measures for dealing with barriers to care are implemented.

Factors influencing veterinarian referral to oncology specialists for treatment of dogs with lymphoma and osteosarcoma in Ontario, Canada

OBJECTIVE

To elucidate factors influencing practitioner decisions to refer dogs with cancer to veterinary oncology specialists.

DESIGN

Cross-sectional study.

SAMPLE

2,724 Ontario primary care companion animal veterinarians.

PROCEDURES

Practitioners were invited to participate in a survey involving clinical scenarios of canine cancer patients, offered online and in paper format from October 2010 through January 2011. Analyses identified factors associated with the decision to refer patients to veterinary oncology specialists.

RESULTS

1,071 (39.3%) veterinarians responded, of which 603 (56.3%) recommended referral for dogs with multicentric lymphoma and appendicular osteosarcoma. Most (893/1,059 [84.3%]) practiced within < 2 hours' drive of a specialty referral center, and most (981/1,047 [93.7%]) were completely confident in the oncology service. Few (230/1,056 [21.8%] to 349/1,056 [33.0%]) were experienced with use of chemotherapeutics, whereas more (627/1,051 [59.7%]) were experienced with amputation. Referral was associated with practitioner perception of patient health status (OR, 1.54; 95% confidence interval [CI], 1.15 to 2.07), the interaction between the client's bond with the dog and the client's financial status, practitioner experience with treating cancer (OR, 2.79; 95% CI, 1.63 to 4.77), how worthwhile practitioners considered treatment to be (OR, 1.66 to 3.09; 95% CI, 1.08 to 4.72), and confidence in the referral center (OR, 2.20; 95% CI, 1. 11 to 4.34).

CONCLUSIONS AND CLINICAL RELEVANCE

Several factors influenced practitioner decisions to refer dogs with lymphoma or osteosarcoma for specialty care. Understanding factors that influence these decisions may enable practitioners to appraise their referral decisions and ensure they act in the best interests of patients, clients, and the veterinary profession.

Increasing Hepatitis C treatment uptake among HIV-infected patients using an HIV primary care model

Background

Access to Hepatitis C (HCV) care is low among HIV-infected individuals, highlighting the need for new models to deliver care for this population.

Methods

Retrospective cohort analysis that compared the number of HIV patients who initiated HCV therapy: hepatology (2005–2008) vs. HIV primary care model (2008–2011). Logistic-regression modeling was used to ascertain factors associated with HCV therapy initiation and achievement of sustained viral response (SVR).

Results

Of 196 and 163 patients that were enrolled in the HIV primary care and hepatology models, 48 and 26 were treated for HCV, respectively (p = 0.043). The HIV/HCV-patient referral rate did not differ during the two study periods (0.10 vs. 0.12/patient-yr, p = 0.18). In unadjusted analysis, predictors (p < 0.05) of HCV treatment initiation included referral to the HIV primary care model (OR: 1.7), a CD4+ count ≥400/mm3 (OR: 1.8) and alanine aminotranferase level ≥63U/L (OR: 1.9). Prior psychiatric medication use correlated negatively with HCV treatment initiation (OR: 0.6, p = 0.045). In adjusted analysis the strongest predictor of HCV treatment initiation was CD4+ count (≥400/mm3, OR: 2.1, p = 0.01). There was no significant difference in either clinic model (primary care vs. hepatology) in the rates of treatment discontinuation due to adverse events (29% vs. 16%), loss to follow-up (8 vs. 8%), or HCV SVR (44 vs. 35%).

Conclusions

Using a HIV primary care model increased the number of HIV patients who initiate HCV therapy with comparable outcomes to a hepatology model.