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Gutiérrez-Rojas L, de la Gándara Martín JJ, García Buey L, Uriz Otano JI, Mena Á, Roncero C. Patients with severe mental illness and hepatitis C virus infection benefit from new pangenotypic direct-acting antivirals: Results of a literature review. GASTROENTEROLOGIA Y HEPATOLOGIA 2023; 46:382-396. [PMID: 35718017 DOI: 10.1016/j.gastrohep.2022.06.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 05/25/2022] [Accepted: 06/07/2022] [Indexed: 05/09/2023]
Abstract
INTRODUCTION Hepatitis C virus (HCV) infection is a global health problem that can results in cirrhosis, hepatocellular carcinoma and even death. HCV infection is 3-20-fold more prevalent among patients with versus without severe mental illness (SMI), such as major depressive disorder, personality disorder, bipolar disorder and schizophrenia. Treatment options for HCV were formerly based on pegylated interferon alpha, which is associated with neuropsychiatric adverse events, and this contributed to the exclusion of patients with SMI from HCV treatment, elimination programmes, and clinical trials. Moreover, the assumption of poor adherence, scant access to healthcare and the stigma and vulnerability of this population emerged as barriers and contributed to the low rates of treatment and efficacy. METHODS This paper reviews the literature published between December 2010 and December 2020 exploring the epidemiology of HCV in patients with SMI, and vice versa, the effect of HCV infection, barriers to the management of illness in these patients, and benefits of new therapeutic options with pangenotypic direct antiviral agents (DAAs). RESULTS The approval of DAAs has changed the paradigm of HCV infection treatment. DAAs have proven to be an equally efficacious and safe option that improves quality of life (QoL) in patients SMI. CONCLUSIONS Knowledge of the consequences of the HCV infection and the benefits of treatment with new pangenotypic DAAs among psychiatrists can increase screening, referral and treatment of HCV infection in patients with SMI.
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Affiliation(s)
| | | | - Luisa García Buey
- Gastroenterology Department, Liver Unit, Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid, Madrid, Spain
| | - Juan I Uriz Otano
- Gastroenterology Department, Liver Unit, Complejo Hospitalario de Navarra, Instituto de Investigación Sanitaria de Navarra, Pamplona, Spain
| | - Álvaro Mena
- Infectious Diseases Unit, Internal Medicine Service, Clinical Virology Group, Instituto de Investigación Biomédica de A Coruña (INIBIC)-Complejo Hospitalario Universitario de A Coruña (CHUAC), Universidade da Coruña, Coruña, Spain
| | - Carlos Roncero
- Psychiatry Service, University of Salamanca Health Care Complex and Psychiatric Unit, School of Medicine, Institute of Biomedicine, University of Salamanca, Salamanca, Spain
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Grebely J, Robaeys G, Bruggmann P, Aghemo A, Backmund M, Bruneau J, Byrne J, Dalgard O, Feld JJ, Hellard M, Hickman M, Kautz A, Litwin A, Lloyd AR, Mauss S, Prins M, Swan T, Schaefer M, Taylor LE, Dore GJ. Recommandations pour la prise en charge de l'infection par le virus de l'hépatite C chez les usagers de drogues par injection. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 111:101669. [PMID: 26847504 DOI: 10.1016/j.drugpo.2015.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
| | - Geert Robaeys
- Department of Gastroenterology and Hepatology, Ziekenhuis Oost Limburg, Genk, Belgium; Department of Hepatology, UZ Leuven, Leuven, Belgium; Faculty of Medicine and Life Sciences, Limburg Clinical Research Program, Hasselt University, Hasselt, Belgium
| | | | - Alessio Aghemo
- A.M. Migliavacca Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Markus Backmund
- Ludwig-Maximilians-University, Munich, Germany; Praxiszentrum im Tal Munich, Munich, Germany
| | | | - Jude Byrne
- International Network of People who Use Drugs, Canberra, Australia
| | - Olav Dalgard
- Department of Infectious Diseases, Akershus University Hospital, Lørenskog, Norway
| | | | - Margaret Hellard
- Burnet Institute, Melbourne, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Matthew Hickman
- School of Social & Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Achim Kautz
- European Liver Patients Association, Cologne, Germany
| | - Alain Litwin
- Division of General Internal Medicine, Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, United States
| | - Andrew R Lloyd
- Inflammation and Infection Research Centre, School of Medical Sciences, UNSW Australia, Sydney, Australia
| | - Stefan Mauss
- Center for HIV and Hepatogastroenterology, Düsseldorf, Germany
| | - Maria Prins
- Department of Research, Cluster Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, The Netherlands; Department of Internal Medicine, CINIMA, Academic Medical Centre, Amsterdam, The Netherlands
| | - Tracy Swan
- Treatment Action Group, New York, United States
| | - Martin Schaefer
- Department of Psychiatry, Psychotherapy and Addiction Medicine, Kliniken Essen-Mitte, Essen, Germany; Department of Psychiatry and Psychotherapy-CCM, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Lynn E Taylor
- Department of Medicine, Brown University, Providence, RI, United States
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Grebely J, Robaeys G, Bruggmann P, Aghemo A, Backmund M, Bruneau J, Byrne J, Dalgard O, Feld JJ, Hellard M, Hickman M, Kautz A, Litwin A, Lloyd AR, Mauss S, Prins M, Swan T, Schaefer M, Taylor LE, Dore GJ. Empfehlungen zur Hepatitis Versorgung bei Drogenkonsumierenden. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 111:101670. [PMID: 26749563 DOI: 10.1016/j.drugpo.2015.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
| | - Geert Robaeys
- Department of Gastroenterology and Hepatology, Ziekenhuis Oost Limburg, Genk, Belgium; Department of Hepatology, UZ Leuven, Leuven, Belgium; Faculty of Medicine and Life Sciences, Limburg Clinical Research Program, Hasselt University, Hasselt, Belgium
| | | | - Alessio Aghemo
- A.M. Migliavacca Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Markus Backmund
- Ludwig-Maximilians-University, Munich, Germany; Praxiszentrum im Tal Munich, Munich, Germany
| | | | - Jude Byrne
- International Network of People who Use Drugs, Canberra, Australia
| | - Olav Dalgard
- Department of Infectious Diseases, Akershus University Hospital, Lørenskog, Norway
| | | | - Margaret Hellard
- Burnet Institute, Melbourne, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Matthew Hickman
- School of Social & Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Achim Kautz
- European Liver Patients Association, Cologne, Germany
| | - Alain Litwin
- Division of General Internal Medicine, Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, United States
| | - Andrew R Lloyd
- Inflammation and Infection Research Centre, School of Medical Sciences, UNSW Australia, Sydney, Australia
| | - Stefan Mauss
- Center for HIV and Hepatogastroenterology, Düsseldorf, Germany
| | - Maria Prins
- Department of Research, Cluster Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, The Netherlands; Department of Internal Medicine, CINIMA, Academic Medical Centre, Amsterdam, The Netherlands
| | - Tracy Swan
- Treatment Action Group, New York, United States
| | - Martin Schaefer
- Department of Psychiatry, Psychotherapy and Addiction Medicine, Kliniken Essen-Mitte, Essen, Germany; Department of Psychiatry and Psychotherapy-CCM, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Lynn E Taylor
- Department of Medicine, Brown University, Providence, RI, United States
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Factors Associated with the Refusal of Direct-Acting Antiviral Agents for the Treatment of Hepatitis C in Taiwan. Medicina (B Aires) 2022; 58:medicina58040521. [PMID: 35454360 PMCID: PMC9031294 DOI: 10.3390/medicina58040521] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 03/29/2022] [Accepted: 04/01/2022] [Indexed: 12/12/2022] Open
Abstract
Background and Objectives: Direct-acting antiviral agents (DAA) are a safe and highly effective treatment for hepatitis C virus (HCV) infection. However, the uptake of DAA treatment remains a challenge. This study aims to examine the reasons for DAA refusal among HCV patients covered by the Taiwan National Health Insurance system. Materials and Methods: This retrospective observational study covered the period from January 2009 to December 2019 and was conducted at a single hepatitis treatment center in Taiwan. This study involved chart reviews and phone-based surveys to confirm treatment status and refusal causes. To confirm treatment status, subjects with HCV without treatment records were phone-contacted to confirm treatment status. Patients who did not receive treatment were invited back for treatment. If the patient refused, the reason for refusal was discussed. Results: A total of 3566 patients were confirmed with DAA treatment; 418 patients (179 patients who were lost to contact or refused the survey and 239 patients who completed the survey of DAA refusal) were included in the no-DAA-therapy group. Factors associated with receiving DAAs were hemoglobin levels, hepatitis B virus co-infection, and regular gastroenterology visits. Meanwhile, male sex, platelet levels, and primary care physician visits were associated with DAA refusal. The leading causes of treatment refusal were multiple comorbidities, low health literacy, restricted access to hospitals, nursing home residence, and old age. The rate of DAA refusal remains high (10%). Conclusions: The reasons for treatment refusal are multifactorial, and addressing them requires complex interventions.
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Johnson KM, Newman KL, Green PK, Berry K, Cornia PB, Wu P, Beste LA, Itani K, Harris AHS, Kamath PS, Ioannou GN. Incidence and Risk Factors of Postoperative Mortality and Morbidity After Elective Versus Emergent Abdominal Surgery in a National Sample of 8193 Patients With Cirrhosis. Ann Surg 2021; 274:e345-e354. [PMID: 31714310 DOI: 10.1097/sla.0000000000003674] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To describe the incidence and risk factors for mortality and morbidity in patients with cirrhosis undergoing elective or emergent abdominal surgeries. BACKGROUND Postoperative morbidity and mortality are higher in patients with cirrhosis; variation by surgical procedure type and cirrhosis severity remain unclear. METHODS We analyzed prospectively-collected data from the Veterans Affairs (VA) Surgical Quality Improvement Program for 8193 patients with cirrhosis, 864 noncirrhotic controls with chronic hepatitis B infection, and 5468 noncirrhotic controls without chronic liver disease, who underwent abdominal surgery from 2001 to 2017. Data were analyzed using random-effects models controlling for potential confounders. RESULTS Patients with cirrhosis had significantly higher 30-day mortality than noncirrhotic patients with chronic hepatitis B [4.4% vs 1.3%, adjusted odds ratio (aOR) 2.80, 95% confidence interval (CI) 1.57-4.98] or with no chronic liver disease (0.8%, aOR 4.68, 95% CI 3.27-6.69); mortality difference was highest in patients with Model for End-stage Liver Disease (MELD) score ≥10. Among patients with cirrhosis, postoperative mortality was almost 6 times higher after emergent rather than elective surgery (17.2% vs. 2.1%, aOR 5.82, 95% CI 4.66-7.27). For elective surgeries, 30-day mortality was highest after colorectal resection (7.0%) and lowest after inguinal hernia repair (0.6%). Predictors of postoperative mortality included cirrhosis-related characteristics (high MELD score, low serum albumin, ascites, encephalopathy), surgery-related characteristics (emergent vs elective, type of surgery, intraoperative blood transfusion), comorbidities (chronic obstructive pulmonary disease, cancer, sepsis, ventilator dependence, functional status), and age. CONCLUSIONS Accurate preoperative risk assessments in patients with cirrhosis should account for cirrhosis severity, comorbidities, type of procedure, and whether the procedure is emergent versus elective.
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Affiliation(s)
- Kay M Johnson
- Hospital and Specialty Medicine Service Line, Veterans Affairs Puget Sound Health Care System, Seattle, WA
- Division of General Internal Medicine, University of Washington School of Medicine, Seattle, WA
| | - Kira L Newman
- Internal Medicine Residency Program, University of Washington School of Medicine, Seattle, WA
| | - Pamela K Green
- Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA
| | - Kristin Berry
- Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA
| | - Paul B Cornia
- Hospital and Specialty Medicine Service Line, Veterans Affairs Puget Sound Health Care System, Seattle, WA
- Division of General Internal Medicine, University of Washington School of Medicine, Seattle, WA
| | - Peter Wu
- Department of Surgery, Veterans Affairs Puget Sound Health Care System and University of Washington School of Medicine, Seattle, WA
| | - Lauren A Beste
- Division of General Internal Medicine, University of Washington School of Medicine, Seattle, WA
- Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA
- Primary Care Service, Veterans Affairs Puget Sound Health Care System, Seattle, WA
| | - Kamal Itani
- Department of Surgery, Boston VA Health Care System, and Department of Surgery, Boston University, Boston, MA
| | - Alex H S Harris
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Patrick S Kamath
- Division of Gastroenterology, Department of Medicine, Mayo Clinic, Rochester, MN
| | - George N Ioannou
- Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA
- Division of Gastroenterology, Department of Medicine Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA
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Sanvisens A, Rivas I, Faure E, Espinach N, Hernandez-Rubio A, Majó X, Colom J, Muga R. Monitoring hepatitis C virus treatment rates in an Opioid Treatment Program: A longitudinal study. World J Gastroenterol 2020; 26:5874-5883. [PMID: 33132641 PMCID: PMC7579757 DOI: 10.3748/wjg.v26.i38.5874] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 08/12/2020] [Accepted: 09/17/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Direct-acting antivirals (DAAs) are recommended for the treatment of hepatitis C virus (HCV) infection in patients treated with methadone or buprenorphine.
AIM To assess HCV treatment rates in an Opioid Treatment Program (OTP).
METHODS This longitudinal study included 501 patients (81.4% men, median age: 45 years; interquartile range: 39-50 years) enrolled in an OTP between October 2015 and September 2017. Patients were followed until September 2019. Data on socio-demographics, substance use, HCV infection, human immunodeficiency virus (HIV) infection and laboratory parameters were collected at entry. We analyzed medical records to evaluate HCV treatment. Kaplan-Meier methods and Cox regression models were used to analyze the DAA treatment uptake and to identify treatment predictors.
RESULTS Prevalence of HCV and HIV infection was 70% and 34%, respectively. Among anti-HCV-positive (n = 336) patients, 47.2%, 41.3%, and 31.9% used alcohol, cannabis, and cocaine, respectively. HCV-RNA tests were positive in 233 (69.3%) patients. Twentyeight patients (8.3%) cleared the infection, and 59/308 (19.1%) had received interferon-based treatment regimens before 2015. Among 249 patients eligible, 111 (44.6%) received DAAs. Treatment rates significantly increased over time from 7.8/100 person-years (p-y) (95%CI: 5.0-12.3) in 2015 to 18.9/100 p-y (95%CI: 11.7-30.3) in 2019. In a multivariate analysis, patients with HIV co-infection were twice as likely to receive DAAs (HR = 1.94, 95%CI: 1.21-3.12) than patients with HCV mono-infection. Current drug use was an independent risk factor for not receiving treatment against infection (HR = 0.48, 95%CI: 0.29-0.80).
CONCLUSION HCV treatment is evolving in patients with HCV-HIV co-infection. Ongoing drug use while in an OTP might negatively impact the readiness to treat infection.
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Affiliation(s)
- Arantza Sanvisens
- Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Badalona 08916, Spain
| | - Inmaculada Rivas
- Mental Health and Addiction Service, Badalona Serveis Assistencials-BSA, Badalona 08911, Spain
| | - Eva Faure
- Mental Health and Addiction Service, Badalona Serveis Assistencials-BSA, Badalona 08911, Spain
| | - Néstor Espinach
- Mental Health and Addiction Service, Badalona Serveis Assistencials-BSA, Badalona 08911, Spain
| | - Anna Hernandez-Rubio
- Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona 08916, Spain
| | - Xavier Majó
- Program on HIV, STIs and Viral Hepatitis - PCAVIHV Public Health Agency of Catalonia, Generalitat de Catalunya, Barcelona 08005, Spain
| | - Joan Colom
- Program on HIV, STIs and Viral Hepatitis - PCAVIHV Public Health Agency of Catalonia, Generalitat de Catalunya, Barcelona 08005, Spain
| | - Robert Muga
- Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona 08916, Spain
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Chiu WC, Lu ML, Chang CC. Mental Disorders and Interferon Nontreatment in Hepatitis C Virus Infection-a Population Based Cohort Study. Psychiatry Investig 2020; 17:268-274. [PMID: 32151125 PMCID: PMC7113179 DOI: 10.30773/pi.2019.0254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 01/08/2020] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE This study investigates the association between mental disorders and interferon nontreatment in patients with chronic hepatitis C virus (HCV) infection in a large national sample. METHODS Using the National Health Insurance Research Database of Taiwan, we conducted a nationwide population-based study. Each case was matched to five controls by age, sex, urbanization, and income. Conditional logistic regression was used to assess odds of HCV nontreatment in different mental disorders. RESULTS From 1999 to 2013, we identified 92,970 subjects with HCV infection and 15,495 HCV cases (16.7%) had received IFN therapy. Other than chronic obstructive pulmonary disease, the medical diseases and mental disorders were significantly different between IFN and non-IFN treated HCV patients. After adjusting for medical diseases, depressive disorder and anxiety disorder was positively associated with receiving IFN therapy. Patients with schizophrenia, bipolar disorders and alcohol use disorders were significantly less likely to receive interferon. Antidepressant exposure (cumulative daily exposure or cumulative daily dose) was associated with lower odds of IFN treatment. CONCLUSION Our nationwide cohort study demonstrated that INF nontreatment rate was lower in certain mental disorders. Antidepressant exposure might lower the chance of receiving IFN treatment. Our results may help to identify and to overcome the obstacles for HCV treatment and further apply to DAAs regimen.
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Affiliation(s)
- Wei-Che Chiu
- Department of Psychiatry, Cathay General Hospital, Taipei, Taiwan.,School of Medicine, Fu Jen Catholic University, Taipei, Taiwan
| | - Mong-Liang Lu
- Department of Psychiatry, Wan-Fang Hospital, Taipei, Taiwan.,School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Cheng-Chen Chang
- Department of Psychiatry, Changhua Christian Hospital, Changhua, Taiwan.,School of Medicine, Chung Shan Medical University, Taichung, Taiwan.,Center of General Education, Tunghai University, Taichung, Taiwan
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Behzadifar M, Azari S, Gorji HA, Rezapour A, Bragazzi NL. The challenges of hepatitis C management in Iran: A qualitative study with patients. Int J Health Plann Manage 2019; 35:e56-e65. [PMID: 31679166 DOI: 10.1002/hpm.2927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 10/08/2019] [Accepted: 10/08/2019] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND The patient's perspective concerning the treatment process and the knowledge of the challenges and problems that they encounter can help to improve their treatment conditions. AIM The present study aimed at analyzing the experiences of hepatitis C virus (HCV) patients in Iran and the challenges encountered during the management and treatment process. METHODS Semi-structured in-depth and face-to-face interviews were conducted. The criteria for selecting patients were as follows: HCV-positive subjects, with confirmed diagnosis of HCV, and under treatment. Content analysis was used to analyze the data. MAXQDA Ver11 software was used to better manage data. This study is based on the "Consolidated Criteria for Reporting Qualitative Research" (COREQ) checklist. RESULTS Twenty-one HCV patients were interviewed. The mean age of participants was 36.14 ± 11.29 years. Seven themes with 20 subthemes emerged from the content analysis of the interviews, namely, (a) disease-related stigma, (b) lack of knowledge, (c) psychological problems, (d) financial problems, (e) complications of treatment, (f) lack of family and community support, and (g) health-care system. CONCLUSION The findings of this study showed that a range of economic, social, and cultural problems could affect the treatment of HCV patients. Health policy and decision makers should try to provide them with a better management.
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Affiliation(s)
- Masoud Behzadifar
- Social Determinants of Health Research Center, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Samad Azari
- Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Hasan Abolghasem Gorji
- Department of Health Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Aziz Rezapour
- Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Nicola Luigi Bragazzi
- Postgraduate School of Public Health, Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy.,Laboratory for Industrial and Applied Mathematics (LIAM), Department of Mathematics and Statistics, York University, Toronto, ON, Canada
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Ioannou GN, Beste LA, Green PK, Singal AG, Tapper EB, Waljee AK, Sterling RK, Feld JJ, Kaplan DE, Taddei TH, Berry K. Increased Risk for Hepatocellular Carcinoma Persists Up to 10 Years After HCV Eradication in Patients With Baseline Cirrhosis or High FIB-4 Scores. Gastroenterology 2019; 157:1264-1278.e4. [PMID: 31356807 PMCID: PMC6815714 DOI: 10.1053/j.gastro.2019.07.033] [Citation(s) in RCA: 245] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 07/03/2019] [Accepted: 07/22/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS It is unclear if hepatocellular carcinoma (HCC) risk declines over time after hepatitis C virus (HCV) eradication. We analyzed changes in HCC annual incidence over time following HCV eradication and identified dynamic markers of HCC risk. METHODS We identified 48,135 patients who initiated HCV antiviral treatment from 2000 through 2015 and achieved a sustained virologic response (SVR) in the Veterans Health Administration (29,033 treated with direct-acting antiviral [DAA] agents and 19,102 treated with interferon-based regimens). Patients were followed after treatment until February 14, 2019 (average 5.4 years), during which 1509 incident HCCs were identified. RESULTS Among patients with cirrhosis before treatment with DAAs (n = 9784), those with pre-SVR fibrosis-4 (FIB-4) scores ≥3.25 had a higher annual incidence of HCC (3.66%/year) than those with FIB-4 scores <3.25 (1.16%/year) (adjusted hazard ratio 2.14; 95% confidence interval 1.66-2.75). In DAA-treated patients with cirrhosis and FIB-4 scores ≥3.25, annual HCC risk decreased from 3.8%/year in the first year after SVR to 2.4%/year by the fourth year (P=.01). In interferon-treated patients with FIB-4 scores ≥3.25, annual HCC risk remained above 2%/year, even 10 years after SVR. A decrease in FIB-4 scores from ≥3.25 pre-SVR to <3.25 post-SVR was associated with an approximately 50% lower risk of HCC, but the absolute annual risk remained above 2%/year. Patients without cirrhosis before treatment (n = 38,351) had a low risk of HCC, except for those with pre-SVR FIB-4 scores ≥3.25 (HCC risk 1.22%/year) and post-SVR FIB-4 scores ≥3.25 (HCC risk 2.39%/year); risk remained high for many years after SVR. CONCLUSIONS Patients with cirrhosis before an SVR to treatment for HCV infection continue to have a high risk for HCC (>2%/year) for many years, even if their FIB-4 score decreases, and should continue surveillance. Patients without cirrhosis but with FIB-4 scores ≥3.25 have a high enough risk to merit HCC surveillance, especially if FIB-4 remains ≥3.25 post-SVR.
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Affiliation(s)
- George N. Ioannou
- Division of Gastroenterology, Department of Medicine, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA.,Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA
| | - Lauren A Beste
- Division of General Internal Medicine, Department of Medicine, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA
| | - Pamela K. Green
- Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA
| | - Amit G. Singal
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas TX
| | - Elliot B. Tapper
- Division of Gastroenterology and Hepatology, VA Ann Arbor Healthcare System and University of Michigan, Ann Arbor MI
| | - Akbar K. Waljee
- Division of Gastroenterology and Hepatology, VA Ann Arbor Healthcare System and University of Michigan, Ann Arbor MI
| | - Richard K. Sterling
- Division of Gastroenterology, Department of Medicine, Virginia Commonwealth University, Richmond, VA
| | - Jordan J. Feld
- Toronto Centre for Liver Disease, University Health Network, Sandra Rotman Centre for Global Health, University of Toronto
| | - David E. Kaplan
- Division of Gastroenterology, Department of Medicine, Corporal Michael J. Crescenz Veterans Affairs Medical Center and Perelman University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Tamar H. Taddei
- Section of Digestive Diseases, Yale School of Medicine, New Haven, CT and VA Connecticut Healthcare System, West Haven, CT
| | - Kristin Berry
- Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA
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10
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Ioannou GN, Green P, Kerr KF, Berry K. Models estimating risk of hepatocellular carcinoma in patients with alcohol or NAFLD-related cirrhosis for risk stratification. J Hepatol 2019; 71:523-533. [PMID: 31145929 PMCID: PMC6702126 DOI: 10.1016/j.jhep.2019.05.008] [Citation(s) in RCA: 128] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Revised: 03/12/2019] [Accepted: 05/03/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS Hepatocellular carcinoma (HCC) risk varies dramatically in patients with cirrhosis according to well-described, readily available predictors. We aimed to develop simple models estimating HCC risk in patients with alcohol-related liver disease (ALD)-cirrhosis or non-alcoholic fatty liver disease (NAFLD)-cirrhosis and calculate the net benefit that would be derived by implementing HCC surveillance strategies based on HCC risk as predicted by our models. METHODS We identified 7,068 patients with NAFLD-cirrhosis and 16,175 with ALD-cirrhosis who received care in the Veterans Affairs (VA) healthcare system in 2012. We retrospectively followed them for the development of incident HCC until January 2018. We used Cox proportional hazards regression to develop and internally validate models predicting HCC risk using baseline characteristics at entry into the cohort in 2012. We plotted decision curves of net benefit against HCC screening thresholds. RESULTS We identified 1,278 incident cases of HCC during a mean follow-up period of 3.7 years. Mean annualized HCC incidence was 1.56% in NAFLD-cirrhosis and 1.44% in ALD-cirrhosis. The final models estimating HCC were developed separately for NAFLD-cirrhosis and ALD-cirrhosis and included 7 predictors: age, gender, diabetes, body mass index, platelet count, serum albumin and aspartate aminotransferase to √alanine aminotransferase ratio. The models exhibited very good measures of discrimination and calibration and an area under the receiver operating characteristic curve of 0.75 for NAFLD-cirrhosis and 0.76 for ALD-cirrhosis. Decision curves showed higher standardized net benefit of risk-based screening using our prediction models compared to the screen-all approach. CONCLUSIONS We developed simple models estimating HCC risk in patients with NAFLD-cirrhosis or ALD-cirrhosis, which are available as web-based tools (www.hccrisk.com). Risk stratification can be used to inform risk-based HCC surveillance strategies in individual patients or healthcare systems or to identify high-risk patients for clinical trials. LAY SUMMARY Patients with cirrhosis of the liver are at risk of getting hepatocellular carcinoma (HCC or liver cancer) and therefore it is recommended that they undergo surveillance for HCC. However, the risk of HCC varies dramatically in patients with cirrhosis, which has implications on if and how patients get surveillance, how providers counsel patients about the need for surveillance, and how healthcare systems approach and prioritize surveillance. We used readily available predictors to develop models estimating HCC risk in patients with cirrhosis, which are available as web-based tools at www.hccrisk.com.
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Affiliation(s)
- George N Ioannou
- Division of Gastroenterology, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA, United States; Department of Medicine, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA, United States; Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA, United States.
| | - Pamela Green
- Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA, United States
| | - Kathleen F Kerr
- Department of Biostatistics, University of Washington, Seattle, WA, United States
| | - Kristin Berry
- Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA, United States
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11
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Antwi SO, Van Houten HK, Sangaralingham LR, Patel T. Risk of De Novo Hepatocellular Carcinoma Following Use of Direct Acting Antiviral Medications for Treatment of Chronic Hepatitis C. Cancer Prev Res (Phila) 2019; 12:891-902. [PMID: 31451519 DOI: 10.1158/1940-6207.capr-19-0162] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 07/17/2019] [Accepted: 08/19/2019] [Indexed: 12/17/2022]
Abstract
Direct-acting antivirals (DAA) are now the mainstay of treatment for patients with chronic hepatitis C virus (HCV); however, there is some controversy over whether use of DAAs for HCV, as compared with IFN-based regimens, leads to an increased risk for hepatocellular carcinoma (HCC) development. We investigated the association between use of DAAs and subsequent development of HCC in longitudinal data from patients with HCV from diverse backgrounds (various ages, ethnicities, and geographic regions) across the United States. The design was a retrospective study performed using medical and pharmacy claims from OptumLabs. HCV treatment exposure was categorized as DAA-only, DAA + IFN, any-DAA, or IFN-only. To account for confounding by indication, inverse probability of treatment weighting was performed. Cox proportional hazard models were used to calculate hazard ratios (HR) and 95% confidence intervals (CI). We identified 5,781 patients with HCV with no history of HCC at baseline. Compared with IFN-only regimen, no significant increase in HCC risk was found for use of DAA-only (HR, 1.53; 95% CI, 0.73-3.23), DAA + IFN (HR, 1.02; 95% CI, 0.51-2.06), or any-DAA (HR, 1.04; 95% CI, 0.65-1.65). When stratified by sustained virological response (SVR), we noted a higher HCC risk for DAA-only among patients who achieved SVR post-treatment (HR, 7.53; 95% CI, 1.48-38.34), but the CIs were wide, which might be due to the small sample size of the subgroups. Among those who did not achieve SVR, no association was found for use of DAA-only (HR, 0.59; 95% CI, 0.19-1.91). These findings do not provide compelling evidence for the conception that use of DAAs for HCV is associated with increased risk of HCC development.
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Affiliation(s)
- Samuel O Antwi
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, Florida.
| | - Holly K Van Houten
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota.,OptumLabs, Cambridge, Massachusetts
| | - Lindsey R Sangaralingham
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota.,OptumLabs, Cambridge, Massachusetts
| | - Tushar Patel
- Department of Transplantation, Mayo Clinic, Jacksonville, Florida.
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12
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Ioannou GN, Green PK, Berry K, Graf SA. Eradication of Hepatitis C Virus Is Associated With Reduction in Hematologic Malignancies: Major Differences Between Interferon and Direct-Acting Antivirals. Hepatol Commun 2019; 3:1124-1136. [PMID: 31388632 PMCID: PMC6671776 DOI: 10.1002/hep4.1389] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 05/17/2019] [Indexed: 12/15/2022] Open
Abstract
It is unclear whether eradication of hepatitis C virus (HCV) leads to a reduction in the risk of hematologic malignancies. We aimed to determine the impact of sustained virologic response (SVR) induced by either direct-acting antivirals (DAAs) or interferon (IFN) on the risk of hematologic malignancies. We identified 69,581 patients who initiated antiviral treatment in the Veterans Affairs national health care system from January 1, 1999, to December 31, 2015, including 40,410 (58%) IFN-only regimens, 4,546 (6.5%) DAA + IFN regimens, and 24,625 (35%) DAA-only regimens. We retrospectively followed patients to identify incident cases of hematologic malignancies or monoclonal gammopathy of unknown significance (MGUS), a premalignant precursor of multiple myeloma. Among patients treated with IFN, SVR was significantly associated with a reduction in the risk of lymphoma (adjusted hazard ratio [AHR], 0.70; 95% confidence interval [CI], 0.51-0.97), multiple myeloma (AHR, 0.40; 95% CI, 0.20-0.77), MGUS (AHR, 0.65; 95% CI, 0.42-0.99), or all hematologic malignancies and MGUS combined (AHR, 0.67; 95% CI, 0.53-0.84) over a mean follow-up of 10.6 years. In contrast, among patients treated with DAA, SVR was not associated with the risk of lymphoma, multiple myeloma, MGUS, or all hematologic malignancies and MGUS combined (AHR, 1.08; 95% CI, 0.66-1.78) during a mean follow-up of 2.9 years. Neither IFN-induced SVR nor DAA-induced SVR was associated with risk of colon cancer or prostate cancer, which were chosen a priori as comparison/control malignancies. Conclusion: We describe novel strong associations between IFN-induced SVR and lymphoma, multiple myeloma, MGUS, and all hematologic malignancies combined. Surprisingly, these associations were not observed with DAA-induced SVR.
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Affiliation(s)
- George N. Ioannou
- Division of Gastroenterology, Department of MedicineVeterans Affairs Puget Sound Health Care System and University of WashingtonSeattleWA
- Research and DevelopmentVeterans Affairs Puget Sound Health Care SystemSeattleWA
| | - Pamela K. Green
- Research and DevelopmentVeterans Affairs Puget Sound Health Care SystemSeattleWA
| | - Kristin Berry
- Research and DevelopmentVeterans Affairs Puget Sound Health Care SystemSeattleWA
| | - Solomon A. Graf
- Division of Oncology, Department of MedicineVeterans Affairs Puget Sound Health Care System and University of WashingtonSeattleWA
- Clinical Research DivisionFred Hutch Cancer Research CenterSeattleWA
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13
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Thomas DD, Waring ME, Ameli O, Reisman JI, Vimalananda VG. Patient Characteristics Associated with Receipt of Prescription Weight-Management Medications Among Veterans Participating in MOVE! Obesity (Silver Spring) 2019; 27:1168-1176. [PMID: 31090207 PMCID: PMC6591039 DOI: 10.1002/oby.22503] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 03/15/2019] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Weight-management medications (WMM) are recommended for the treatment of obesity. This study examined characteristics associated with initial receipt of WMM among eligible veterans in the first year following enrollment in the Veterans Health Administration (VHA) MOVE! behavioral weight-management program. METHODS We conducted a retrospective cohort study of VHA patients with obesity or overweight and obesity-related comorbidities who enrolled in MOVE! from October 2013 to September 2016 (N = 153,939). Multivariable logistic regression models estimated predictors of having a filled prescription for WMM and for orlistat. RESULTS A total of 1.1% of these veterans received WMM. The most common WMM included orlistat (70.4%), phentermine/topiramate (11.2%), and bupropion/naltrexone (9.7%). Female sex, higher BMI, obstructive sleep apnea, osteoarthritis, depression, lower back pain, and alcohol abuse were associated with greater odds of use of WMM, whereas age over 65 years, Hispanic ethnicity, and required co-payments were associated with lower odds. Among patients receiving WMM, older age, black race, female sex, higher BMI, cardiovascular disease, lower back pain, and congestive heart failure were associated with use of orlistat versus any other WMM. CONCLUSIONS Of patients engaged in MOVE! in the VHA, 1.1% received WMM. WMM are underutilized among veterans. Additional research is needed to understand barriers to incorporating WMM into comprehensive obesity treatment plans.
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Affiliation(s)
- Dylan D. Thomas
- Section of Endocrinology, Diabetes, Nutrition, and Weight Management, Department of Medicine; Boston University School of Medicine. Boston, MA
| | - Molly E. Waring
- Department of Allied Health Sciences, University of Connecticut. Storrs, CT
| | - Omid Ameli
- Center for Healthcare Organization and Implementation Research (CHOIR), Edith Nourse Rogers Memorial Veterans Affairs Medical Center. Bedford, MA
| | - Joel I. Reisman
- Center for Healthcare Organization and Implementation Research (CHOIR), Edith Nourse Rogers Memorial Veterans Affairs Medical Center. Bedford, MA
| | - Varsha G. Vimalananda
- Section of Endocrinology, Diabetes, Nutrition, and Weight Management, Department of Medicine; Boston University School of Medicine. Boston, MA
- Center for Healthcare Organization and Implementation Research (CHOIR), Edith Nourse Rogers Memorial Veterans Affairs Medical Center. Bedford, MA
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Brezzi M, Bertisch B, Roelens M, Moradpour D, Terziroli Beretta-Piccoli B, Semmo N, Müllhaupt B, Semela D, Negro F, Keiser O. Impact of geographic origin on access to therapy and therapy outcomes in the Swiss Hepatitis C Cohort Study. PLoS One 2019; 14:e0218706. [PMID: 31233524 PMCID: PMC6590815 DOI: 10.1371/journal.pone.0218706] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 06/08/2019] [Indexed: 12/11/2022] Open
Abstract
Late diagnosis and treatment may increase morbidity and mortality among persons with hepatitis C virus (HCV) infection. We included all participants of the Swiss Hepatitis C Cohort Study (SCCS). We used unadjusted and adjusted logistic and Cox regressions to determine the association between the geographic origin of the participants and the following outcomes: antiviral treatment status; sustained virologic response; cirrhosis at enrolment; incident cirrhosis; loss to follow-up (LTFU); and mortality. The analyses were adjusted for sex, baseline age, education, source of income, alcohol consumption, injection drug use (IDU), HCV genotype, HIV or HBV coinfection, duration of HCV infection, time since enrolment, cirrhosis, (type of) HCV treatment, and centre at enrolment. Among 5,356 persons, 1,752 (32.7%) were foreign-born. IDU was more common among Swiss- (64.1%) than foreign-born (36.6%) persons. Cirrhosis at enrolment was more frequent among foreign- than Swiss-born persons, reflecting the high frequency of cirrhosis among Italian-born persons who acquired HCV between 1950 and 1970 in Italian healthcare settings. Although antiviral treatment coverage was similar, the sustained viral response rate was increased and the mortality was lower among foreign-vs. Swiss-born persons, with the lowest mortality in persons from Asia/Oceania. LTFU was more frequent in persons from Germany, Eastern and Southern Europe, and the Americas. In conclusion, in Switzerland, a country with universal healthcare, geographic origin had no influence on hepatitis C treatment access, and the better treatment outcomes among foreign-born persons were likely explained by their lower prevalence of IDU and alcohol consumption than among Swiss-born persons.
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Affiliation(s)
- Matteo Brezzi
- Institute of Global Health, University of Geneva, Geneva, Switzerland
| | - Barbara Bertisch
- Institute of Global Health, University of Geneva, Geneva, Switzerland
| | - Maroussia Roelens
- Institute of Global Health, University of Geneva, Geneva, Switzerland
| | - Darius Moradpour
- Division of Gastroenterology and Hepatology, University Hospital Lausanne, Lausanne, Switzerland
| | | | - Nasser Semmo
- Department for BioMedical Research, Hepatology, University of Bern, Bern, Switzerland
| | - Beat Müllhaupt
- Swiss Hepato-Pancreato-Biliary Center and Department of Gastroenterology and Hepatology, University Hospital Zürich, Zürich, Switzerland
| | - David Semela
- Division of Gastroenterology and Hepatology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Francesco Negro
- Divisions of Gastroenterology and Hepatology and of Clinical Pathology, University Hospitals Geneva, Geneva, Switzerland
| | - Olivia Keiser
- Institute of Global Health, University of Geneva, Geneva, Switzerland
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15
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Ward JW, Hinman AR. What Is Needed to Eliminate Hepatitis B Virus and Hepatitis C Virus as Global Health Threats. Gastroenterology 2019; 156:297-310. [PMID: 30391470 DOI: 10.1053/j.gastro.2018.10.048] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Revised: 10/23/2018] [Accepted: 10/30/2018] [Indexed: 02/06/2023]
Abstract
Hepatitis B virus (HBV) and hepatitis C virus (HCV) cause 1.3 million deaths annually. To prevent more than 7 million deaths by 2030, the World Health Organization set goals to eliminate HBV and HCV, defined as a 90% reduction in new infections and a 65% reduction in deaths, and prevent more than 7 million related deaths by 2030. Elimination of HBV and HCV is feasible because of characteristics of the viruses, reliable diagnostic tools, and available cost-effective or cost-saving interventions. Broad implementation of infant immunization against HBV, blood safety, and infection-control programs have greatly reduced the burden of HBV and HCV infections. To achieve elimination, priorities include implementation of HBV vaccine-based strategies to prevent perinatal transmission, safe injection practices and HCV treatment for persons who inject drugs, and testing and treatment for HBV- and HCV-infected persons. With sufficient capacity, HBV and HCV elimination programs can meet their goals.
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Affiliation(s)
- John W Ward
- The Task Force for Global Health, Decatur, Georgia; Centers for Disease Control and Prevention, Atlanta, Georgia.
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16
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Mun EJ, Green P, Berry K, Ioannou GN. No difference between direct-acting antivirals for hepatitis C in hepatocellular carcinoma risk. Eur J Gastroenterol Hepatol 2019; 31:47-52. [PMID: 30142097 PMCID: PMC6279503 DOI: 10.1097/meg.0000000000001242] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND AIMS It is unclear whether there are differences between direct-acting antivirals (DAAs) for hepatitis C virus in risk of hepatocellular carcinoma (HCC) after antiviral therapy. We aimed to compare different DAA regimens with respect to risk of de novo HCC following antiviral therapy. PATIENTS AND METHODS We identified 33 137 patients who initiated hepatitis C virus antiviral treatment in the Veterans Affair healthcare system between 6 December 2013 and 31 December 2015 with one of four DAA-only regimens (± ribavirin): paritaprevir/ritonavir/ombitasvir/dasabuvir (n=6289), sofosbuvir (n=4356), sofosbuvir+simeprevir (n=3210), and ledipasvir/sofosbuvir (n=19 282). We retrospectively followed patients until 15 June 2017 to identify incident (de novo) cases of HCC. We used propensity score-adjusted Cox proportional hazards regression to compare different DAA regimens with respect to HCC risk. RESULTS During a mean follow-up of 1.52 years, 741 new cases of HCC were diagnosed after antiviral treatment (annual incidence=1.47%). Patients treated with sofosbuvir+simeprevir had the highest annual HCC incidence (2.47%), followed by sofosbuvir (1.91%), ledipasvir/sofosbuvir (1.26%), and paritaprevir/ritonavir/ombitasvir/dasabuvir (0.95%). However, there were great differences between DAA-treated patients in the prevalence of cirrhosis, markers of advanced fibrosis, thrombocytopenia, and other HCC risk factors. After adjustment for baseline characteristics associated with HCC, there were no significant differences in HCC risk between the four DAA regimens. CONCLUSION There are no significant differences between DAA regimens in HCC risk after antiviral treatment. This suggests that DAAs do not have direct carcinogenic effects as it would be unlikely that different DAAs would have identical carcinogenic effects.
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Affiliation(s)
- Elijah J Mun
- Department of Internal Medicine, University of Washington
| | - Pamela Green
- Health Services Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, Washington, USA
| | - Kristin Berry
- Health Services Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, Washington, USA
| | - George N Ioannou
- Division of Gastroenterology, Department of Medicine, Veterans Affairs Puget Sound Healthcare System and University of Washington
- Health Services Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, Washington, USA
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17
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Chossegros P, Di Nino F. Associating conditional cash transfer to universal access to treatment could be the solution to the HCV epidemic among drug users (DUs). Harm Reduct J 2018; 15:63. [PMID: 30541570 PMCID: PMC6292040 DOI: 10.1186/s12954-018-0264-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Accepted: 03/06/2018] [Indexed: 11/11/2022] Open
Abstract
Background To understand the limits of HCV screening programs to reach all drug users (DUs). Method The association of the recruitment of a representative sample of a population of DUs in a specific area with the use of a questionnaire that included 250 items allowed the use of uni- and multifactorial analysis to explore the relationship between HCV screening and dimensions until now restricted to qualitative studies. Results We recruited, in less than 2 months, 327 DUs representing about 6% of the total population of DUs. They belonged to a single community whose drug use was the only common characteristic. While almost all DUs (92.6%) who had access to care providers had been screened, this proportion was much lower in out-of-care settings (64%). HCV prevalence among those who had performed a test was low (22.8%). For DUs, the life experience of hepatitis C has not changed in the last 10 years. Screening, studied for the first time according to this life experience, was not influenced by a rational knowledge of the risk taken or the knowledge of treatment efficacy, showing a gap between DUs’ representations and medical recommendations which explains the low level of active screening. Police crackdown on injections, disrupting the previous illusion of safe practices, was the only prior history leading to active screenings. Screenings were related to an access to care providers. GPs held a preponderant position as a source of information and care by being able to give appropriate answers regarding hepatitis C and prescribing opioid substitution treatments (OST). If 48 % of DUs screened positive for HCV had been treated, half of them had been prescribed before 2006. Conclusion While hepatitis has become a major issue for society and, consequently, for services for DUs (SDUs) and GPs, it is not the case for DUs. A widespread screening, even in a city where the offer of care is diversified and free, seems unlikely to reach a universal HCV screening over a short time. The model of respondent-driven sampling recruitment could be a new approach to conditional cash transfer, recruiting and treating DUs who remain outside the reach of care providers, a prerequisite for the universal access to HCV treatments to impact the HCV epidemic.
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Affiliation(s)
- Philippe Chossegros
- UHSI de Lyon, Centre Hospitalier Lyon SUD, Hospices Civils de LYON, Chemin du Grand Revoyet, 69495, Pierre-Bénite, France.
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18
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Cipriano LE, Liu S, Shahzada KS, Holodniy M, Goldhaber-Fiebert JD. Economically Efficient Hepatitis C Virus Treatment Prioritization Improves Health Outcomes. Med Decis Making 2018; 38:849-865. [PMID: 30132410 PMCID: PMC8826843 DOI: 10.1177/0272989x18792284] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The total cost of treating the 3 million Americans chronically infected with hepatitis C virus (HCV) represents a substantial affordability challenge requiring treatment prioritization. This study compares the health and economic outcomes of alternative treatment prioritization schedules. METHODS We developed a multiyear HCV treatment budget allocation model to evaluate the tradeoffs of 7 prioritization strategies. We used optimization to identify the priority schedule that maximizes population net monetary benefit (NMB). We compared prioritization schedules in terms of the number of individuals treated, the number of individuals who progress to end-stage liver disease (ESLD), and population total quality-adjusted life years (QALYs). We applied the model to the population of treatment-naive patients with a total annual HCV treatment budget of US$8.6 billion. RESULTS First-come, first-served (FCFS) treats the fewest people with advanced fibrosis, prevents the fewest cases of ESLD, and gains the fewest QALYs. A schedule developed from optimizing population NMB prioritizes treatment in the first year to patients with moderate to severe fibrosis who are younger than 65 years, followed by older individuals with moderate to severe fibrosis. While this strategy yields the greatest population QALYs, prioritization by disease severity alone prevents more cases of ESLD. Sensitivity analysis indicated that the differences between prioritization schedules are greater when the budget is smaller. A 10% annual treatment price reduction enabled treatment 1 year sooner to several patient subgroups, specifically older patients and those with less severe liver fibrosis. CONCLUSION In the absence of a sufficient budget to treat all patients, explicit prioritization targeting younger people with more severe disease first provides the greatest health benefits. We provide our spreadsheet model so that decision makers can compare health tradeoffs of different budget levels and various prioritization strategies with inputs tailored to their population.
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Affiliation(s)
| | - Shan Liu
- Industrial and Systems Engineering, University of Washington, Seattle, WA, U.S.A
| | | | - Mark Holodniy
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, U.S.A
- Department of Medicine, Stanford University, Stanford, Stanford, CA, U.S.A
- Division of Infectious Diseases & Geographic Medicine, Stanford University, Stanford, CA, U.S.A
| | - Jeremy D. Goldhaber-Fiebert
- Stanford Health Policy, Center for Health Policy and Center for Primary Care and Outcomes Research, Department of Medicine, Stanford University, Stanford, CA, U.S.A
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Ioannou GN, Green P, Lowy E, Mun EJ, Berry K. Differences in hepatocellular carcinoma risk, predictors and trends over time according to etiology of cirrhosis. PLoS One 2018; 13:e0204412. [PMID: 30260995 PMCID: PMC6160079 DOI: 10.1371/journal.pone.0204412] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 09/06/2018] [Indexed: 12/15/2022] Open
Abstract
Background and aims Hepatocellular carcinoma (HCC) risk is high in cirrhosis. We sought to describe differences in HCC risk, predictors and trends over time according to etiology of cirrhosis. Methods We identified 116,404 patients with cirrhosis diagnosed between 2001–2014 in the VA healthcare system and determined incident HCC cases occurring from the date of cirrhosis diagnosis until 01/31/2017. Patients were divided by cirrhosis etiology into hepatitis C virus (HCV, n = 52,671), alcoholic liver disease (ALD, n = 35,730), nonalcoholic fatty liver disease (NAFLD, n = 17,354), or OTHER (n = 10,649). Results During a mean follow-up of 4.3 years, 10,042 new HCC cases were diagnosed. Patients with HCV had >3 times higher incidence of HCC (3.3 per 100 patient-years) than patients with ALD (0.86/100 patient-years), NAFLD (0.90/100 patient-years) or OTHER (1.0/100 patient-years), an association that persisted after adjusting for baseline characteristics. HCC incidence was 1.6 times higher in patients with cirrhosis diagnosed in 2008–2014 (2.47/100 patient-years) than in 2001–2007 (1.55/100 patient-years). Independent predictors of HCC among all cirrhosis etiologies included: age, male sex, Hispanic ethnicity, high serum alpha fetoprotein, alkaline phosphatase and AST/√ALT ratio and low serum albumin and platelet count. Diabetes was associated with HCC in ALD-cirrhosis and NAFLD-cirrhosis, and BMI in ALD-cirrhosis. Conclusions HCC risk is 3 times greater in cirrhotic patients with HCV than ALD or NAFLD. HCC risk continues to increase over time in analyses extending to 2017 in cirrhosis of all etiologies. Multiple readily available risk factors for HCC were identified that were influenced by cirrhosis etiology and could be used to develop HCC risk estimation models.
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Affiliation(s)
- George N. Ioannou
- Division of Gastroenterology, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, Washington, United States of America
- Department of Medicine, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, Washington, United States of America
- Health Services Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, Washington, United States of America
- * E-mail:
| | - Pamela Green
- Health Services Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, Washington, United States of America
| | - Elliott Lowy
- Health Services Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, Washington, United States of America
| | - Elijah J. Mun
- Department of Internal Medicine, University of Washington, Seattle, Washington, United States of America
| | - Kristin Berry
- Health Services Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, Washington, United States of America
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A Multi-Fidelity Rollout Algorithm for Dynamic Resource Allocation in Population Disease Management. Health Care Manag Sci 2018; 22:727-755. [PMID: 30194509 DOI: 10.1007/s10729-018-9454-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 08/20/2018] [Indexed: 12/09/2022]
Abstract
Dynamic resource allocation for prevention, screening, and treatment interventions in population disease management has received much attention in recent years due to excessive healthcare costs. In this paper, our goal is to design a model and an efficient algorithm to optimize sequential intervention policies under resource constraints to improve population health outcomes. We consider a discrete-time finite-horizon budget allocation problem with disease progression within a closed birth-cohort population. To address the computational challenges associated with large-state and multiple-period dynamic decision-making problems, we propose a low-fidelity approximation that preserves the population dynamics under a stationary policy. To improve the healthcare interventions in terms of population health outcomes, we then embed the low-fidelity approximation into a high-fidelity optimization model to efficiently identify a good non-stationary sequential intervention policy. Our approach is illustrated by a numerical example of screening and treatment policy implementation for chronic hepatitis C virus (HCV) infection over a budget planning period. We numerically compare our Multi-Fidelity Rollout Algorithm (MF-RA) to a grid search approach and demonstrate the similarity of sequential policy trends and closeness of overall health outcomes measured by quality-adjusted life-years (QALYs) and the total number of individuals that undergo screening and treatment for different annual budgets and birth-cohorts. We also show how our approach scales well to problems with high dimensionality due to many decision periods by studying time to elimination of HCV.
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Barnett PG, Joyce VR, Lo J, Gidwani-Marszowski R, Goldhaber-Fiebert JD, Desai M, Asch SM, Holodniy M, Owens DK. Effect of Interferon-Free Regimens on Disparities in Hepatitis C Treatment of US Veterans. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2018; 21:921-930. [PMID: 30098669 DOI: 10.1016/j.jval.2017.12.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 12/07/2017] [Accepted: 12/11/2017] [Indexed: 06/08/2023]
Abstract
OBJECTIVES To determine whether implementation of interferon-free treatment for hepatitis C virus (HCV) reached groups less likely to benefit from earlier therapies, including patients with genotype 1 virus or contraindications to interferon treatment, and groups that faced treatment disparities: African Americans, patients with HIV co-infection, and those with drug use disorder. METHODS Electronic medical records of the US Veterans Health Administration (VHA) were used to characterize patients with chronic HCV infection and the treatments they received. Initiation of treatment in 206,544 patients with chronic HCV characterized by viral genotype, demographic characteristics, and comorbid medical and mental illness was studied using a competing events Cox regression over 6 years. RESULTS With the advent of interferon-free regimens, the proportion treated increased from 2.4% in 2010 to 18.1% in 2015, an absolute increase of 15.7%. Patients with genotype 1 virus, poor response to previous treatment, and liver disease had the greatest increase. Large absolute increases in the proportion treated were observed in patients with HIV co-infection (18.6%), alcohol use disorder (11.9%), and drug use disorder (12.6%) and in African American (13.7%) and Hispanic (13.5%) patients, groups that were less likely to receive interferon-containing treatment. The VHA spent $962 million on interferon-free treatments in 2015, 1.5% of its operating budget. CONCLUSIONS The proportion of patients with HCV treated in VHA increased sevenfold. The VHA was successful in implementing interferon treatment in previously undertreated populations, and this may become the community standard of care.
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Affiliation(s)
- Paul G Barnett
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, CA, USA; VA Center for Innovation to Implementation, Menlo Park, CA, USA.
| | - Vilija R Joyce
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, CA, USA
| | - Jeanie Lo
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, CA, USA
| | - Risha Gidwani-Marszowski
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, CA, USA; VA Center for Innovation to Implementation, Menlo Park, CA, USA; Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Jeremy D Goldhaber-Fiebert
- Stanford Health Policy, Centers for Health Policy and Primary Care and Outcomes Research, Stanford University, Stanford, CA, USA
| | - Manisha Desai
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Steven M Asch
- VA Center for Innovation to Implementation, Menlo Park, CA, USA; Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Mark Holodniy
- Public Health Research Center, VA Palo Alto Health Care System, Palo Alto, CA, USA; Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Douglas K Owens
- VA Center for Innovation to Implementation, Menlo Park, CA, USA; Stanford Health Policy, Centers for Health Policy and Primary Care and Outcomes Research, Stanford University, Stanford, CA, USA
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22
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Simmons R, Ireland G, Irving W, Hickman M, Sabin C, Ijaz S, Ramsay M, Lattimore S, Mandal S. Establishing the cascade of care for hepatitis C in England-benchmarking to monitor impact of direct acting antivirals. J Viral Hepat 2018; 25:482-490. [PMID: 29239130 DOI: 10.1111/jvh.12844] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 10/31/2017] [Indexed: 01/01/2023]
Abstract
Little is known about engagement and retention in care of people diagnosed with chronic hepatitis C (HCV) in England. Establishing a cascade of care informs targeted interventions for improving case finding, referral, treatment uptake and retention in care. Using data from the sentinel surveillance of blood-borne virus (SSBBV) testing between 2005 and 2014, we investigate the continuum of care of those tested for HCV in England. Persons ≥1 year old with an anti-HCV test and subsequent RNA tests between 2005 and 2014 reported to SSBBV were collated. We describe the cascade of care, as the patient pathway from a diagnostic test, referral into care, treatment and patient outcomes. Between 2005 and 2014, 2 390 507 samples were tested for anti-HCV, corresponding to 1 766 515 persons. A total of 53 038 persons (35 190 men and 17 165 women) with anti-HCV positive were newly reported to SSBBV. An RNA test was conducted on 77.0% persons who were anti-HCV positive, 72.3% of whom were viraemic (RNA positive) during this time period, 21.4% had evidence of treatment and 3130 49.5% had evidence of a sustained virological response (SVR). In multivariable models, confirmation of viraemia by RNA test varied by age and region/test setting; evidence of treatment varied by age, year of test and region/test setting; and SVR varied by age, year of test and region/setting of test. In conclusion, our findings provide HCV cascade of care estimates prior to the introduction of direct acting antivirals. These findings provide important baseline cascade estimates to benchmark progress towards elimination of HCV as a major public health threat.
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Affiliation(s)
- R Simmons
- Immunisation, Hepatitis, and Blood Safety Department, Public Health England, London, UK.,The National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Blood Borne and Sexually Transmitted Infections, University College London, London, UK
| | - G Ireland
- Immunisation, Hepatitis, and Blood Safety Department, Public Health England, London, UK.,The National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Blood Borne and Sexually Transmitted Infections, University College London, London, UK
| | - W Irving
- Gastrointestinal and Liver Disorders Theme, NIHR Nottingham Biomedical Research Centre at the Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - M Hickman
- School of Social and Community Medicine, NIHR HPRU in Evaluation, University of Bristol, Bristol, UK
| | - C Sabin
- The National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Blood Borne and Sexually Transmitted Infections, University College London, London, UK.,Infection & Population Health, Institute for Global Health, University College London, London, UK
| | - S Ijaz
- The National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Blood Borne and Sexually Transmitted Infections, University College London, London, UK.,Blood Borne Virus Unit, Public Health England, London, UK
| | - M Ramsay
- Immunisation, Hepatitis, and Blood Safety Department, Public Health England, London, UK
| | - S Lattimore
- Immunisation, Hepatitis, and Blood Safety Department, Public Health England, London, UK.,The National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Blood Borne and Sexually Transmitted Infections, University College London, London, UK
| | - S Mandal
- Immunisation, Hepatitis, and Blood Safety Department, Public Health England, London, UK.,The National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Blood Borne and Sexually Transmitted Infections, University College London, London, UK
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23
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Johnson K, Green PK, Ioannou GN. Implications of HCV RNA level at week 4 of direct antiviral treatments for hepatitis C. J Viral Hepat 2017; 24:966-975. [PMID: 28585416 PMCID: PMC5839805 DOI: 10.1111/jvh.12731] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 05/09/2017] [Indexed: 12/22/2022]
Abstract
We aimed to determine whether the HCV viral load after four weeks of treatment (W4VL) with direct-acting antiviral agents (DAAs) predicts sustained virologic response (SVR) in a real-world clinical setting. We identified 21 095 patients who initiated DAA-based antiviral treatment in the national Veterans Affairs (VA) healthcare system from 01/01/2014 to 06/30/2015. Week 4 viral load was categorized as undetectable, detectable below quantification (DBQ), detectable above quantification (DAQ) with viral load ≤42 IU/mL and DAQ with viral load >42 IU/mL. Week 4 viral load was undetectable in 36.1%, detectable below quantification in 45.6%, DAQ ≤42 in 9.3%, DAQ >42 in 9.1%. Detectable above quantification was much more common and undetectable week 4 viral load much less common when tested with the Abbott RealTime HCV assay vs the Roche COBAS AmpliPrep/COBAS TaqMan Version 2 assay. Compared to patients with undetectable week 4 viral load (SVR=93.5%), those with detectable below quantification (SVR=91.8%, adjusted odds ratio [AOR] 0.79, P-value=.001), DAQ ≤42 (SVR=90.0%, AOR 0.63, P-value<.001) and DAQ >42 (SVR=86.2%, AOR 0.52, P-value<.001) had progressively lower likelihood of achieving SVR after adjusting for baseline characteristics and treatment duration. Among genotype 1-infected patients who were potentially eligible for 8-week sofosbuvir/ledipasvir monotherapy, we did not find evidence that treatment for 12 weeks instead of 8 weeks was associated with higher SVR, even among those with detectable above quantification. In summary, DBQ and DAQ W4VL are very common in real-world practice, contrary to what was reported in clinical trials, and strongly predict reduced SVR across genotypes and clinically relevant patient subgroups. Whether and how week 4 viral load results should influence treatment decisions requires further study.
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Affiliation(s)
- K Johnson
- Division of General Internal Medicine, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA, USA
| | - P K Green
- Division of Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA, USA
| | - G N Ioannou
- Division of General Internal Medicine, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA, USA
- Division of Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA, USA
- Division of Gastroenterology, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA, USA
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24
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Lin M, Kramer J, White D, Cao Y, Tavakoli-Tabasi S, Madu S, Smith D, Asch SM, El-Serag HB, Kanwal F. Barriers to hepatitis C treatment in the era of direct-acting anti-viral agents. Aliment Pharmacol Ther 2017; 46:992-1000. [PMID: 28949020 PMCID: PMC5800315 DOI: 10.1111/apt.14328] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Revised: 05/22/2017] [Accepted: 08/26/2017] [Indexed: 01/04/2023]
Abstract
BACKGROUND Direct-acting anti-virals (DAA) are safe, effective treatment of hepatitis C virus (HCV). Suboptimal linkage to specialists and access to DAAs are the leading barriers to treatment; however, data are limited. AIM To determine predictors of follow-up, receipt of DAAs, and reasons for the lack thereof. METHODS We used clinical data from retrospective cohort of HCV-infected patients with previously established HCV care in the US Department of Veterans Affairs to examine predictors of follow-up in HCV clinics and DAA treatment (during 12/1/2013-4/30/2015). We then conducted a structured review of medical charts of HCV patients to determine reasons for lack of follow-up and treatment. RESULTS We identified 84 221 veterans who were previously seen in HCV clinics during the pre-DAA era. Of these, 47 165 (56.0%) followed-up in HCV specialty clinics, 13 532 (28.7%) of whom received DAAs. Older age, prior treatment, presence of cirrhosis or HCC, HIV/HBV co-infection and psychiatric illness were predictors of follow-up. Alcohol/drug abuse and medical co-morbidity were predictors of lack of treatment. Of the 905 prospectively recruited patients, 56.2% patients had a specialist visit and 28% received DAAs. Common reasons for lack of follow-up were relocation (n = 148, 37.4%) and missed/cancelled appointments (n = 63, 15.9%). Reasons for lack of treatment included waiting for newer therapy (n = 99, 38.8%), co-morbidities (n = 66, 25.9%) and alcohol/drug abuse (n = 63, 24.7%). CONCLUSIONS Half of patients with established HCV care were followed-up in the DAA era and only 29% received DAAs. Targeted efforts focusing on patient and system-levels may improve the reach of treatment with the new DAAs.
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Affiliation(s)
- Michael Lin
- Department of Gastroenterology and Hepatology, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX, USA
| | - Jennifer Kramer
- Center of Innovation, Effectiveness and Quality, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA,Sections of Health Services Research, Baylor College of Medicine, Houston, TX, USA
| | - Donna White
- Center of Innovation, Effectiveness and Quality, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA,Sections of Health Services Research, Baylor College of Medicine, Houston, TX, USA
| | - Yumei Cao
- Center of Innovation, Effectiveness and Quality, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA,Sections of Health Services Research, Baylor College of Medicine, Houston, TX, USA
| | - Shahriar Tavakoli-Tabasi
- Department of Infectious Diseases, Michael E. DeBakey Veterans Affairs Medical Center, Baylor College of Medicine, Houston, TX, USA
| | - Stella Madu
- Department of Gastroenterology and Hepatology, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX, USA
| | - Donna Smith
- Department of Gastroenterology and Hepatology, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX, USA,Center of Innovation, Effectiveness and Quality, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Steven M. Asch
- Center for Innovation to Implementation (Ci2i), Palo Alto Veterans Affairs Medical Center, Palo Alto, California,Division of General Medical Disciplines, Stanford University, Palo Alto, California
| | - Hashem B. El-Serag
- Department of Gastroenterology and Hepatology, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX, USA,Center of Innovation, Effectiveness and Quality, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA,Sections of Health Services Research, Baylor College of Medicine, Houston, TX, USA
| | - Fasiha Kanwal
- Department of Gastroenterology and Hepatology, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX, USA,Center of Innovation, Effectiveness and Quality, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA,Sections of Health Services Research, Baylor College of Medicine, Houston, TX, USA
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25
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Vutien P, Jin M, Le MH, Nguyen P, Trinh S, Huang JF, Yu ML, Chuang WL, Nguyen MH. Regional differences in treatment rates for patients with chronic hepatitis C infection: Systematic review and meta-analysis. PLoS One 2017; 12:e0183851. [PMID: 28877190 PMCID: PMC5587234 DOI: 10.1371/journal.pone.0183851] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 08/12/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND & AIMS Treatment rates with interferon-based therapies for chronic hepatitis C have been low. Our aim was to perform a systematic review of available data to estimate the rates and barriers for antiviral therapy for chronic hepatitis C. METHODS We conducted a systematic review and meta-analysis searching MEDLINE, SCOPUS through March 2016 and abstracts from recent major liver meetings for primary literature with available hepatitis C treatment rates. Random-effects models were used to estimate effect sizes and meta-regression to test for potential sources of heterogeneity. RESULTS We included 39 studies with 476,443 chronic hepatitis C patients. The overall treatment rate was 25.5% (CI: 21.1-30.5%) and by region 34% for Europe, 28.3% for Asia/Pacific, and 18.7% for North America (p = 0.008). On multivariable meta-regression, practice setting (tertiary vs. population-based, p = 0.04), region (Europe vs. North America p = 0.004), and data source (clinical chart review vs. administrative database, p = 0.025) remained significant predictors of heterogeneity. The overall treatment eligibility rate was 52.5%, and 60% of these received therapy. Of the patients who refused treatment, 16.2% cited side effects, 13.8% cited cost as reasons for treatment refusal, and 30% lacked access to specialist care. CONCLUSIONS Only one-quarter of chronic hepatitis C patients received antiviral therapy in the pre-direct acting antiviral era. Treatment rates should improve in the new interferon-free era but, cost, co-morbidities, and lack of specialist care will likely remain and need to be addressed. Linkage to care should even be of higher priority now that well-tolerated cure is available.
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Affiliation(s)
- Philip Vutien
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, United States of America
- Rush University Medical Center, Chicago, Illinois, United States of America
| | - Michelle Jin
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, United States of America
| | - Michael H. Le
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, United States of America
| | - Pauline Nguyen
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, United States of America
| | - Sam Trinh
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, United States of America
| | - Jee-Fu Huang
- Hepatobiliary Section, Department of Internal Medicine and Hepatitis Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ming-Lung Yu
- Hepatobiliary Section, Department of Internal Medicine and Hepatitis Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wan-Long Chuang
- Hepatobiliary Section, Department of Internal Medicine and Hepatitis Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Mindie H. Nguyen
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, United States of America
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26
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Ioannou GN, Green PK, Berry K. HCV eradication induced by direct-acting antiviral agents reduces the risk of hepatocellular carcinoma. J Hepatol 2017; 68:S0168-8278(17)32273-0. [PMID: 28887168 PMCID: PMC5837901 DOI: 10.1016/j.jhep.2017.08.030] [Citation(s) in RCA: 342] [Impact Index Per Article: 48.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 08/16/2017] [Accepted: 08/27/2017] [Indexed: 12/04/2022]
Abstract
BACKGROUND & AIMS It is unclear whether direct-acting antiviral (DAA) treatment-induced sustained virologic response (SVR) reduces the risk of hepatocellular carcinoma (HCC) in patients with HCV infection. Therefore, in the current study, our aim was to determine the impact of DAA-induced SVR on HCC risk. METHODS We identified 62,354 patients who initiated antiviral treatment in the Veterans Affairs (VA) national healthcare system from 1 January 1999 to 31 December 2015, including 35,871 (58%) interferon (IFN)-only regimens, 4,535 (7.2%) DAA + IFN regimens, and 21,948 (35%) DAA-only regimens. We retrospectively followed patients until 15 June 2017 to identify incident cases of HCC. We used Cox proportional hazards regression to determine the association between SVR and HCC risk or between type of antiviral regimen (DAA-only vs. DAA + IFN vs. IFN-only) and HCC risk. RESULTS We identified 3,271 incident cases of HCC diagnosed at least 180 days after initiation of antiviral treatment during a mean follow-up of 6.1 years. The incidence of HCC was highest in patients with cirrhosis and treatment failure (3.25 per 100 patient-years), followed by cirrhosis and SVR (1.97), no cirrhosis and treatment failure (0.87), and no cirrhosis and SVR (0.24). SVR was associated with a significantly decreased risk of HCC in multivariable models irrespective of whether the antiviral treatment was DAA-only (adjusted hazard ratio [AHR] 0.29; 95% CI 0.23-0.37), DAA + IFN (AHR 0.48; 95% CI 0.32-0.73) or IFN-only (AHR 0.32; 95% CI 0.28-0.37). Receipt of a DAA-only or DAA + IFN regimen was not associated with increased HCC risk compared with receipt of an IFN-only regimen. CONCLUSIONS DAA-induced SVR is associated with a 71% reduction in HCC risk. Treatment with DAAs is not associated with increased HCC risk compared with treatment with IFN. LAY SUMMARY It was unclear whether direct-acting antiviral treatment-induced sustained virologic response reduces the risk of liver cancer in patients with HCV infection. We demonstrated that eradication of HCV infection with direct-acting antiviral agents reduces the risk of liver cancer by 71%.
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Affiliation(s)
- George N Ioannou
- Division of Gastroenterology, Department of Medicine Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA, USA; Health Services Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA, USA.
| | - Pamela K Green
- Health Services Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA, USA
| | - Kristin Berry
- Health Services Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA, USA
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27
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Hum J, Jou JH, Green PK, Berry K, Lundblad J, Hettinger BD, Chang M, Ioannou GN. Improvement in Glycemic Control of Type 2 Diabetes After Successful Treatment of Hepatitis C Virus. Diabetes Care 2017; 40:1173-1180. [PMID: 28659309 DOI: 10.2337/dc17-0485] [Citation(s) in RCA: 114] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 06/02/2017] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Hepatitis C virus (HCV) infection is associated with diabetes and may worsen glycemic control in patients with diabetes. We aimed to investigate whether eradication of HCV infection with direct-acting antiviral (DAA) agents is associated with improved glycemic control in patients with diabetes. RESEARCH DESIGN AND METHODS We identified 2,435 patients with diabetes who underwent interferon-free and ribavirin-free DAA-based antiviral treatment for HCV in the national Veterans Affairs health care system. Changes in average hemoglobin A1c (HbA1c) level and use of antidiabetic medications 1 year before and after antiviral treatment were compared between patients who achieved sustained virologic response (SVR) and those who did not. RESULTS Among patients with elevated baseline HbA1c, the drop in HbA1c associated with antiviral treatment was greater in those who achieved SVR (0.98%) than in those who sustained treatment failure (0.65%) (adjusted mean difference 0.34, P = 0.02). Use of antidiabetic medications decreased more in patients who achieved SVR than in those who sustained treatment failure, especially for the use of insulin, which dropped significantly from 41.3% to 38% in patients achieving SVR compared with a slight increase from 49.8% to 51% in those who sustained treatment failure. CONCLUSIONS DAA-based eradication of HCV is associated with improved glycemic control in patients with diabetes as evidenced by decreased mean HbA1c and decreased insulin use. These endocrine benefits of SVR provide additional justification for considering antiviral treatment in all patients with diabetes.
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Affiliation(s)
- Justine Hum
- Division of Gastroenterology, Portland Veterans Affairs Medical Center, Portland, OR
| | - Janice H Jou
- Division of Gastroenterology, Portland Veterans Affairs Medical Center, Portland, OR
| | - Pamela K Green
- Health Services Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA
| | - Kristin Berry
- Health Services Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA
| | - James Lundblad
- Division of Endocrinology, Portland Veterans Affairs Medical Center, Portland, OR
| | - Barbara D Hettinger
- Division of Endocrinology, Portland Veterans Affairs Medical Center, Portland, OR
| | - Michael Chang
- Division of Gastroenterology, Portland Veterans Affairs Medical Center, Portland, OR
| | - George N Ioannou
- Health Services Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA .,Division of Gastroenterology, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA
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28
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Primary Care and Hepatology Provider-Perceived Barriers to and Facilitators of Hepatitis C Treatment Candidacy and Adherence. Dig Dis Sci 2017; 62:1933-1943. [PMID: 28523579 DOI: 10.1007/s10620-017-4608-9] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 05/04/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Provider perceptions regarding barriers to and facilitators of hepatitis C (HCV) treatment initiation and adherence have not been fully evaluated in the interferon-free treatment era. New treatments have provided opportunities for non-specialists to treat HCV, underscoring the importance of understanding primary care provider (PCP) and specialist perspectives. METHODS Based on qualitative sampling principles, 12 PCPs and 12 hepatology providers (HPs) from the VA Pittsburgh Healthcare System completed audio-recorded semi-structured interviews. Qualitative analysts coded perceived barriers and facilitators from the interviews with 100% double coding. Codes were thematized and analyzed using Atlas.ti. RESULTS Key barriers to treatment described by HPs and PCPs included patients' substance use disorders, mental health, transportation availability, history of non-adherence, and concern about side effects. PCPs also focused on medication cost as a system-based barrier. The main facilitators of treatment initiation and adherence described by both HPs and PCPs were provider education and encouragement. HPs focused almost exclusively on provider-based facilitators, while PCPs noted patient-based facilitators including past adherence, media exposure to information about HCV medications, a desire to clear the virus, and positive feedback regarding treatment response. CONCLUSIONS Providers generally focused on perceived patient-level barriers to HCV treatment initiation and adherence, as well as provider-level facilitators; PCPs additionally noted patient preferences and system-level issues that guide decision making regarding treatment initiation. While HPs focused almost exclusively on provider-level facilitators, PCPs additionally focused on patient-level facilitators of treatment. These data provide novel insights and suggest focusing on patient, provider, and system-level strategies to further improve HCV treatment initiation and adherence.
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29
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Beste LA, Green PK, Berry K, Kogut MJ, Allison SK, Ioannou GN. Effectiveness of hepatitis C antiviral treatment in a USA cohort of veteran patients with hepatocellular carcinoma. J Hepatol 2017; 67:32-39. [PMID: 28267622 PMCID: PMC6590903 DOI: 10.1016/j.jhep.2017.02.027] [Citation(s) in RCA: 105] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 01/20/2017] [Accepted: 02/18/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS Hepatitis C virus (HCV) treatment for patients with hepatocellular carcinoma (HCC) was uncommon before direct-acting antiviral (DAA) medications. Real-world effectiveness of DAAs for HCV in patients with HCC is unclear. We describe rates of sustained virologic response (SVR) with DAA regimens by HCV genotype in patients with a history of HCC. METHODS We identified patients who initiated antiviral treatment between January 1, 2014 and June 30, 2015 in the national Veterans Affairs health care system. Regimens included sofosobuvir, ledipasvir/sofosbuvir, and paritaprevir/ritonavir/ombitasvir and dasabuvir with or without ribavirin. HCC patients were divided into those who were treated with liver transplantation after HCC diagnosis ("HCC/LT" group) and those treated with other modalities prior to antiviral therapy ("HCC" group). RESULTS Of 17,487 HCV treatment recipients, 624 (3.6%) had prior HCC, including 142 with HCC/LT and 482 with HCC. Overall SVR was 91.1% in non-HCC, 74.4% in HCC, and 94.0% in HCC/LT. Among HCC patients, genotype 1 had the highest SVR overall (79.1% in HCC and 96.4% in HCC/LT), and genotype 3 the lowest (47.0% in HCC and 88.9% in HCC/LT). After adjustment for confounders, the presence of HCC was associated with lower likelihood of SVR overall (AOR 0.38 [95% CI 0.29, 0.48], p<0.001). CONCLUSION HCV can be cured with DAAs in the majority of patients with prior HCC, and in virtually all HCC patients post-liver transplant. Deferral of HCV treatment until the post-transplant setting may be considered among HCC patients listed for transplantation. LAY SUMMARY Over three-quarters of patients with hepatocellular carcinoma who have hepatitis C can achieve viral cure with direct-acting antiviral drugs. Among patients with hepatocellular carcinoma who subsequently received liver transplantation, over 90% of patients can achieve viral cure.
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Affiliation(s)
- Lauren A. Beste
- General Medicine Service, Veterans Affairs Puget Sound Health Care System, United States,Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, United States,Division of General internal Medicine, University of Washington, United States, Corresponding author. Address: Veterans Affairs Puget Sound Health Care System, 1660 S. Columbian Way (S-111-Gastro), Seattle, WA 98108, United States. Tel.: +1 206 277 4511; fax: +1 206 764 2232. , (L.A. Beste).
| | - Pamela K. Green
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, United States
| | - Kristin Berry
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, United States
| | - Matthew J. Kogut
- Diagnostic Imaging Service, Veterans Affairs Puget Sound Health Care System, United States,Division of interventional Radiology, University of Washington, United States
| | - Stephen K. Allison
- Diagnostic Imaging Service, Veterans Affairs Puget Sound Health Care System, United States,Division of interventional Radiology, University of Washington, United States
| | - George N. Ioannou
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, United States,Gastroenterology Service, Veterans Affairs Puget Sound Health Care System, United States,Division of Gastroenterology, University of Washington, United States
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Direct-acting antivirals are effective for chronic hepatitis C treatment in elderly patients: a real-world study of 17 487 patients. Eur J Gastroenterol Hepatol 2017; 29:686-693. [PMID: 28195877 PMCID: PMC6534142 DOI: 10.1097/meg.0000000000000858] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The mean age of patients with chronic hepatitis C virus (HCV) infection in the USA has been increasing. Despite the increasing proportion of HCV-infected elderly patients, this group is under-represented in clinical trials of HCV treatment. AIM We aimed to describe the real-world effectiveness of direct-acting antivirals (DAAs) among elderly patients. PATIENTS AND METHODS We retrospectively identified 17 487 HCV-infected patients who were started on treatment with sofosbuvir, ledipasvir/sofosbuvir, or paritaprevir/ombitasvir/ritonavir/dasabuvir-based regimens in the Veterans Affairs Healthcare System between 1 January 2014 and 30 June 2015. We ascertained sustained virologic response (SVR) rates in patients aged below 55, 55-59, 60-64, 65-69, 70-74, and 75 years or older and performed multivariable logistic regression to determine whether age predicted SVR. RESULTS Overall unadjusted SVR rates were 91.2% [95% confidence interval (CI): 89.7-92.4], 89.8% (95% CI: 88.8-90.7), 90.8% (95% CI: 90.1-91.6), 91.1% (95% CI: 90.1-91.9), 90.0% (95% CI: 86.9-92.4), and 93.8% (95% CI: 88.8-96.7) in patients aged below 55, 55-59, 60-64, 65-69, 70-74, and 75 years or older. Unadjusted SVR rates were similar in all age groups after stratifying by genotype, treatment regimen, stage of liver disease, and treatment experience. In multivariate models, age was not predictive of SVR after adjusting for confounders. CONCLUSION DAAs produce high rates of SVR in all age groups, including patients in our oldest age category (≥75 years). Advanced age in and of itself should not be considered a barrier to initiating DAA treatment.
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Moon AM, Green PK, Berry K, Ioannou GN. Transformation of hepatitis C antiviral treatment in a national healthcare system following the introduction of direct antiviral agents. Aliment Pharmacol Ther 2017; 45:1201-1212. [PMID: 28271521 PMCID: PMC5849458 DOI: 10.1111/apt.14021] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 02/07/2017] [Accepted: 02/09/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Highly effective direct antiviral agents (DAAs) for hepatitis C virus (HCV) were introduced recently. Their utilisation has been limited by high cost and low access to care. AIM To describe the effect of DAAs on HCV treatment and cure rates in the United States Veterans Affairs (VA) national healthcare system. METHODS We identified all HCV antiviral treatment regimens initiated from 1 January 1999 to 31 December 2015 (n = 105 369) in the VA national healthcare system, and determined if they resulted in sustained virological response (SVR). RESULTS HCV antiviral treatment rates were low (1981-6679 treatments/year) in the interferon era (1999-2010). The introduction of simeprevir and sofosbuvir in 2013 and ledipasvir/sofosbuvir and paritaprevir/ombitasvir/ritonavir/dasabuvir in 2014 were followed by increases in annual treatment rates to 9180 in 2014 and 31 028 in 2015. The number of patients achieving SVR was 1313 in 2010, the last year of the interferon era, and increased 5.6-fold to 7377 in 2014 and 21-fold to 28 084 in 2015. The proportion of treated patients who achieved SVR increased from 19.2% in 1999 and 36.0% in 2010 to 90.5% in 2015. Within 2015, monthly treatment rates ranged from 727 in July to 6868 in September correlating with the availability of funds for DAAs. CONCLUSIONS DAAs resulted in a 21-fold increase in the number of patients achieving HCV cure. Treatment rates in 2015 were limited primarily by the availability of funds. Further increases in funding and cost reductions of DAAs in 2016 suggest that the VA could cure the majority of HCV-infected Veterans in VA care within the next few years.
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Affiliation(s)
- A M Moon
- Divisions of General Internal Medicine, University of Washington, Seattle, WA, USA
| | - P K Green
- Health Services Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA, USA
| | - K Berry
- Health Services Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA, USA
| | - G N Ioannou
- Divisions of General Internal Medicine, University of Washington, Seattle, WA, USA
- Health Services Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA, USA
- Gastroenterology, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA, USA
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Su F, Green PK, Berry K, Ioannou GN. The association between race/ethnicity and the effectiveness of direct antiviral agents for hepatitis C virus infection. Hepatology 2017; 65:426-438. [PMID: 27775854 PMCID: PMC6535089 DOI: 10.1002/hep.28901] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 09/28/2016] [Accepted: 10/12/2016] [Indexed: 12/14/2022]
Abstract
Black race and Hispanic ethnicity were associated with lower rates of sustained virologic response (SVR) to interferon-based treatments for chronic hepatitis C virus infection, whereas Asian race was associated with higher SVR rates compared to white patients. We aimed to describe the association between race/ethnicity and effectiveness of new direct-acting antiviral regimens in the Veterans Affairs health care system nationally. We identified 21,095 hepatitis C virus-infected patients (11,029 [52%] white, 6,171 [29%] black, 1,187 [6%] Hispanic, 348 [2%] Asian/Pacific Islander/American Indian/Alaska Native, and 2,360 [11%] declined/missing race or ethnicity) who initiated antiviral treatment with regimens containing sofosbuvir, simeprevir + sofosbuvir, ledipasvir/sofosbuvir, or paritaprevir/ombitasvir/ritonavir/dasabuvir during the 18-month period from January 1, 2014, to June 30, 2015. Overall SVR rates were 89.8% (95% confidence interval [CI] 89.2-90.4) in white, 89.8% (95% CI 89.0-90.6) in black, 86.0% (95% CI 83.7-88.0) in Hispanic, and 90.7% (95% CI 87.0-93.5) in Asian/Pacific Islander/American Indian/Alaska Native patients. However, after adjustment for baseline characteristics, black (adjusted odds ratio = 0.77, P < 0.001) and Hispanic (adjusted odds ratio = 0.76, P = 0.007) patients were less likely to achieve SVR than white patients, a difference that was not explained by early treatment discontinuations. Among genotype 1-infected patients treated with ledipasvir/sofosbuvir monotherapy, black patients had significantly lower SVR than white patients when treated for 8 weeks but not when treated for 12 weeks. CONCLUSION Direct-acting antivirals produce high SVR rates in white, black, Hispanic, and Asian/Pacific Islander/American Indian/Alaska Native patients; but after adjusting for baseline characteristics, black race and Hispanic ethnicity remain independent predictors of treatment failure. Short 8-week ledipasvir/sofosbuvir monotherapy regimens should perhaps be avoided in black patients with genotype 1 hepatitis C virus. (Hepatology 2017;65:426-438).
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Affiliation(s)
- Feng Su
- Division of Gastroenterology/Medicine, Veterans Affairs Puget Sound Health Care System and University of Washington, Seattle, WA
| | - Pamela K Green
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, WA
| | - Kristin Berry
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, WA
| | - George N Ioannou
- Division of Gastroenterology/Medicine, Veterans Affairs Puget Sound Health Care System and University of Washington, Seattle, WA
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, WA
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Depression, Anxiety, and Stress Among People With Chronic Hepatitis C Virus Infection and a History of Injecting Drug Use in New South Wales, Australia. J Addict Med 2017; 11:10-18. [DOI: 10.1097/adm.0000000000000261] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Tsui JI, Williams EC, Green PK, Berry K, Su F, Ioannou GN. Alcohol use and hepatitis C virus treatment outcomes among patients receiving direct antiviral agents. Drug Alcohol Depend 2016; 169:101-109. [PMID: 27810652 PMCID: PMC6534140 DOI: 10.1016/j.drugalcdep.2016.10.021] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 09/30/2016] [Accepted: 10/01/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND It is unclear whether alcohol use negatively impacts HCV treatment outcomes in the era of direct antiviral agents (DAAs). We aimed to evaluate the associations between current levels of drinking and treatment response among persons treated for HCV with DAAs in the national Veterans Affairs (VA) healthcare system. METHODS We identified patients who initiated HCV DAAs over 18 months (1/1/14-6/30/15) and had documented alcohol screening with the Alcohol Use Disorders Identification Test Consumption (AUDIT-C) questionnaire within one year prior to initiating therapy. DAAs included: sofosbuvir (SOF), ledipasvir/sofosbuvir (LDV/SOF) or ombitasvir-paritaprevir-ritonavir, and dasabuvir (PrOD). AUDIT-C scores were categorized as 0 (abstinence), 1-3 (low-level drinking) and 4-12 (unhealthy drinking) in men or 0, 1-2 and 3-12 in women. RESULTS Among 17,487 patients who initiated DAAs, 15,151 (87%) completed AUDIT-C screening: 10,387 (68.5%) were categorized as abstinent, 3422 (22.6%) as low-level drinking and 1342 (8.9%) as unhealthy drinking. There were no significant differences in sustained virologic response (SVR) rates between abstinent (SVR 91%; 95% CI: 91-92%), low-level drinking (SVR 93%; 95% CI 92-94%) or unhealthy drinking (SVR 91%; 95% 89-92) categories in univariable analysis or in multivariable logistic regression models. However, after imputing missing SVR data, unhealthy drinkers were less likely to achieve SVR in multivariable analysis (AOR 0.75, 95% CI 0.60-0.92). CONCLUSION Absolute SVR rates were uniformly high among all persons regardless of alcohol use, with only minor differences in those who report unhealthy drinking, which supports clinical guidelines that do not recommend excluding persons with alcohol use.
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Affiliation(s)
| | - Emily C. Williams
- Department of Health Services, University of Washington, Seattle, WA, United States,Health Services Research and Development, Seattle, WA, United States,Center of Innovation for Veteran-Centered Value-Driven Care (COIN), Veterans Affairs Puget Sound Health Care System, Seattle, WA, United States
| | - Pamela K. Green
- Health Services Research and Development, Seattle, WA, United States
| | - Kristin Berry
- Health Services Research and Development, Seattle, WA, United States
| | - Feng Su
- Division of Gastroenterology/Medicine, Veterans Affairs Puget Sound Health Care System and University of Washington, Seattle, WA, United States
| | - George N. Ioannou
- Health Services Research and Development, Seattle, WA, United States,Division of Gastroenterology/Medicine, Veterans Affairs Puget Sound Health Care System and University of Washington, Seattle, WA, United States,Corresponding author at: Veterans Affairs Puget Sound Health Care System,Gastroenterology, S-111-Gastro 1660 S. Columbian Way, Seattle, WA 98108, United States. (G.N. Ioannou)
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Ioannou GN, Beste LA, Chang MF, Green PK, Lowy E, Tsui JI, Su F, Berry K. Effectiveness of Sofosbuvir, Ledipasvir/Sofosbuvir, or Paritaprevir/Ritonavir/Ombitasvir and Dasabuvir Regimens for Treatment of Patients With Hepatitis C in the Veterans Affairs National Health Care System. Gastroenterology 2016; 151:457-471.e5. [PMID: 27267053 PMCID: PMC5341745 DOI: 10.1053/j.gastro.2016.05.049] [Citation(s) in RCA: 179] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 05/25/2016] [Accepted: 05/26/2016] [Indexed: 01/05/2023]
Abstract
BACKGROUND & AIMS We investigated the real-world effectiveness of sofosbuvir, ledipasvir/sofosbuvir, and paritaprevir/ritonavir/ombitasvir and dasabuvir (PrOD) in treatment of different subgroups of patients infected with hepatitis C virus (HCV) genotypes 1, 2, 3, or 4. METHODS We performed a retrospective analysis of data from 17,487 patients with HCV infection (13,974 with HCV genotype 1; 2131 with genotype 2; 1237 with genotype 3; and 135 with genotype 4) who began treatment with sofosbuvir (n = 2986), ledipasvir/sofosbuvir (n = 11,327), or PrOD (n = 3174), with or without ribavirin, from January 1, 2014 through June 20, 2015 in the Veterans Affairs health care system. Data through April 15, 2016 were analyzed to assess completion of treatments and sustained virologic response 12 weeks after treatment (SVR12). Mean age of patients was 61 ± 7 years, 97% were male, 52% were non-Hispanic white, 29% were non-Hispanic black, 32% had a diagnosis of cirrhosis (9.9% with decompensated cirrhosis), 36% had a Fibrosis-4 index score >3.25 (indicator of cirrhosis), and 29% had received prior antiviral treatment. RESULTS An SVR12 was achieved by 92.8% (95% confidence interval [CI], 92.3%-93.2%) of subjects with HCV genotype 1 infection (no significant difference between ledipasvir/sofosbuvir and PrOD regimens), 86.2% (95% CI, 84.6%-87.7%) of those with genotype 2 infection (treated with sofosbuvir and ribavirin), 74.8% (95% CI, 72.2%-77.3%) of those with genotype 3 infection (77.9% in patients given ledipasvir/sofosbuvir plus ribavirin, 87.0% in patients given sofosbuvir and pegylated-interferon plus ribavirin, and 70.6% of patients given sofosbuvir plus ribavirin), and 89.6% (95% CI 82.8%-93.9%) of those with genotype 4 infection. Among patients with cirrhosis, 90.6% of patients with HCV genotype 1, 77.3% with HCV genotype 2, 65.7% with HCV genotype 3, and 83.9% with HCV genotype 4 achieved an SVR12. Among previously treated patients, 92.6% with genotype 1; 80.2% with genotype 2; 69.2% with genotype 3; and 93.5% with genotype 4 achieved SVR12. Among treatment-naive patients, 92.8% with genotype 1; 88.0% with genotype 2; 77.5% with genotype 3; and 88.3% with genotype 4 achieved SVR12. Eight-week regimens of ledipasvir/sofosbuvir produced an SVR12 in 94.3% of eligible patients with HCV genotype 1 infection; this regimen was underused. CONCLUSIONS High proportions of patients with HCV infections genotypes 1-4 (ranging from 75% to 93%) in the Veterans Affairs national health care system achieved SVR12, approaching the results reported in clinical trials, especially in patients with genotype 1 infection. An 8-week regimen of ledipasvir/sofosbuvir is effective for eligible patients with HCV genotype 1 infection and could reduce costs. There is substantial room for improvement in SVRs among persons with cirrhosis and genotype 2 or 3 infections.
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Affiliation(s)
- George N. Ioannou
- Division of Gastroenterology, Veterans Affairs Puget Sound Health Care System, Seattle, Washington,Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington,Division of Gastroenterology, University of Washington, Seattle, Washington
| | - Lauren A. Beste
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington,Division of General Internal Medicine, Veterans Affairs Puget Sound Health Care System, Seattle, Washington,Division of General Internal Medicine, University of Washington, Seattle, Washington
| | - Michael F. Chang
- Division of Gastroenterology, Veterans Affairs Portland Health Care System, Portland, Oregon,Oregon Health Sciences University, Portland, Oregon
| | - Pamela K. Green
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Elliott Lowy
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Judith I. Tsui
- Division of General Internal Medicine, University of Washington, Seattle, Washington
| | - Feng Su
- Division of General Internal Medicine, University of Washington, Seattle, Washington
| | - Kristin Berry
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
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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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Mellinger JL, Moser S, Welsh DE, Yosef MT, Van T, McCurdy H, Rakoski MO, Moseley RH, Glass L, Waljee AK, Volk ML, Sales A, Su GL. Access to Subspecialty Care And Survival Among Patients With Liver Disease. Am J Gastroenterol 2016; 111:838-44. [PMID: 27021199 PMCID: PMC6907155 DOI: 10.1038/ajg.2016.96] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 02/01/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Access to subspecialty care may be difficult for patients with liver disease, but it is unknown whether access influences outcomes among this population. Our objectives were to determine rates and predictors of access to ambulatory gastrointestinal (GI) subspecialty care for patients with liver disease and to determine whether access to subspecialty GI care is associated with better survival. METHODS We studied 28,861 patients within the Veterans Administration VISN 11 Liver Disease cohort who had an ICD-9-CM diagnosis code for liver disease from 1 January 2000 through 30 May 2011. Access was defined as a completed outpatient clinic visit with a gastroenterologist or hepatologist at any time after diagnosis. Multivariable logistic regression was used to determine predictors of access to a GI subspecialist. Survival curves were compared between those who did and those who did not see a specialist, with propensity score adjustment to account for other covariates that may affect access. RESULTS Overall, 10,710 patients (37%) had a completed GI visit. On multivariable regression, older patients (odds ratio (OR) 0.98, P<0.001), those with more comorbidities (OR 0.98, P=0.01), and those living farther from a tertiary-care center (OR 0.998/mi, P<0.001) were less likely to be seen in clinic. Patients who were more likely to be seen included those who had hepatitis C (OR 1.5, P<0.001) or cirrhosis (OR 3.5, P<0.001) diagnoses prior to their initial visit. Patients with an ambulatory GI visit at any time after diagnosis were less likely to die at 5 years when compared with propensity-score-matched controls (hazard ratio 0.81, P<0.001). CONCLUSIONS Access to ambulatory GI care was associated with improved 5-year survival for patients with liver disease. Innovative care coordination techniques may prove beneficial in extending access to care to liver disease patients.
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Affiliation(s)
- Jessica L Mellinger
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Stephanie Moser
- VA Center for Clinical Management Research, Ann Arbor, Michigan, USA
- VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Deborah E Welsh
- VA Center for Clinical Management Research, Ann Arbor, Michigan, USA
- VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Matheos T Yosef
- VA Center for Clinical Management Research, Ann Arbor, Michigan, USA
| | - Tony Van
- VA Center for Clinical Management Research, Ann Arbor, Michigan, USA
| | | | - Mina O Rakoski
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Richard H Moseley
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Lisa Glass
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Akbar K Waljee
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- VA Center for Clinical Management Research, Ann Arbor, Michigan, USA
- VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Michael L Volk
- Loma Linda Medical Center Transplantation Institute, Loma Linda, California, USA
| | - Anne Sales
- VA Center for Clinical Management Research, Ann Arbor, Michigan, USA
- VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- School of Nursing, University of Michigan, Ann Arbor, Michigan, USA
| | - Grace L Su
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
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Cozen ML, Ryan JC, Shen H, Cheung R, Kaplan DE, Pocha C, Brau N, Aytaman A, Schmidt WN, Pedrosa M, Anand BS, Chang KM, Morgan T, Monto A. Improved Survival Among all Interferon-α-Treated Patients in HCV-002, a Veterans Affairs Hepatitis C Cohort of 2211 Patients, Despite Increased Cirrhosis Among Nonresponders. Dig Dis Sci 2016; 61:1744-56. [PMID: 27059981 PMCID: PMC5308124 DOI: 10.1007/s10620-016-4122-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 03/06/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND As the era of interferon-alpha (IFN)-based therapy for hepatitis C ends, long-term treatment outcomes are now being evaluated. AIM To more fully understand the natural history of hepatitis C infection by following a multisite cohort of patients. METHODS Patients with chronic HCV were prospectively enrolled in 1999-2000 from 11 VA medical centers and followed through retrospective medical record review. RESULTS A total of 2211 patients were followed for an average of 8.5 years after enrollment. Thirty-one percent of patients received HCV antiviral therapy, 15 % with standard IFN/ribavirin only, 16 % with pegylated IFN/ribavirin, and 26.7 % of treated patients achieved sustained virologic response (SVR). Cirrhosis developed in 25.8 % of patients. Treatment nonresponders had a greater than twofold increase in the hazard of cirrhosis and hepatocellular carcinoma, compared to untreated patients, whereas SVR patients were only marginally protected from cirrhosis. Nearly 6 % developed hepatocellular carcinoma, and 27.1 % died during the follow-up period. Treated patients, regardless of response, had a significant survival benefit compared to untreated patients (HR 0.58, CI 0.46-0.72). Improved survival was also associated with college education, younger age, lower levels of alcohol consumption, and longer duration of medical service follow-up-factors typically associated with treatment eligibility. CONCLUSIONS As more hepatitis C patients are now being assessed for all-oral combination therapy, these results highlight that patient compliance and limiting harmful behaviors contribute a significant proportion of the survival benefit in treated patients and that the long-term clinical benefits of SVR may be less profound than previously reported.
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Affiliation(s)
- Myrna L Cozen
- San Francisco VA Medical Center and University of California San Francisco, 4150 Clement St #111B, San Francisco, CA, 94121, USA
| | - James C Ryan
- San Francisco VA Medical Center and University of California San Francisco, 4150 Clement St #111B, San Francisco, CA, 94121, USA
| | - Hui Shen
- San Francisco VA Medical Center and University of California San Francisco, 4150 Clement St #111B, San Francisco, CA, 94121, USA
| | - Ramsey Cheung
- Palo Alto VA Medical Center and Stanford University, 3801 Miranda Ave, GI/Hepatology #154C, Palo Alto, CA, 94304-1207, USA
| | - David E Kaplan
- Philadelphia VA Medical Center and University of Pennsylvania, A212 Medical Research, University and Woodland Ave, Philadelphia, PA, 19104, USA
| | - Christine Pocha
- Minneapolis VA Medical Center, 1 Veterans Drive, GI, Minneapolis, MN, 55417, USA
| | - Norbert Brau
- Bronx VA Medical Center, 130 W. Kingsbridge Rd, Bronx, NY, 10468, USA
| | - Ayse Aytaman
- New York Harbor Brooklyn and Manhattan VA Medical Centers, 800 Poly Pl, Brooklyn, NY, 11209, USA
| | - Warren N Schmidt
- Iowa City VA Medical Center and the University of Iowa, 200 Hawkins Dr, Iowa City, IA, 52242, USA
| | - Marcos Pedrosa
- Boston VA Health Care System and AbbVie Pharmaceuticals, 85 E. Concord St. #7700, Boston, MA, 02118, USA
| | - Bhupinderjit S Anand
- Houston VA Medical Center and Baylor University, Digestive Disease Section, #111D, 2002 Holcombe Blvd, Houston, TX, 77030-4211, USA
| | - Kyong-Mi Chang
- Philadelphia VA Medical Center and University of Pennsylvania, A212 Medical Research, University and Woodland Ave, Philadelphia, PA, 19104, USA
| | - Timothy Morgan
- Long Beach VA Medical Center and University of California Irvine, #111G, 5901 E. 7th Street, Long Beach, CA, 90822-5201, USA
| | - Alexander Monto
- San Francisco VA Medical Center and University of California San Francisco, 4150 Clement St #111B, San Francisco, CA, 94121, USA.
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Wade AJ, Veronese V, Hellard ME, Doyle JS. A systematic review of community based hepatitis C treatment. BMC Infect Dis 2016; 16:202. [PMID: 27184661 PMCID: PMC4867528 DOI: 10.1186/s12879-016-1548-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Accepted: 05/06/2016] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Hepatitis C virus (HCV) treatment uptake globally is low. A barrier to treatment is the necessity to attend specialists, usually in a tertiary hospital. We investigate the literature to assess the effect of providing HCV treatment in the community on treatment uptake and cure. METHODS Three databases were searched for studies that contained a comparison between HCV treatment uptake or sustained virologic response (SVR) in a community site and a tertiary site. Treatment was with standard interferon with or without ribavirin, or pegylated interferon and ribavirin. A narrative synthesis was conducted. RESULTS Thirteen studies fulfilled the inclusion criteria. Six studies measured treatment uptake; three demonstrated an increase in uptake at the community site, two demonstrated similar rates between sites and one demonstrated decreased uptake at the community site. Nine studies measured SVR; four demonstrated higher SVR rates in the community, four demonstrated similar SVR rates, and one demonstrated inferior SVR rates in the community compared to the tertiary site. CONCLUSION The data available supports the efficacy of HCV treatment in the community, and the potential for community based treatment to increase treatment uptake. Whilst further studies are required, these findings highlight the potential benefit of providing community based HCV care - benefits that should be realised as interferon-free therapy become available. (PROSPERO registration number CRD42015025505).
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Affiliation(s)
- Amanda J Wade
- Centre for Population Health, Burnet Institute, Melbourne, Australia.
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
| | - Vanessa Veronese
- Centre for Population Health, Burnet Institute, Melbourne, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Margaret E Hellard
- Centre for Population Health, Burnet Institute, Melbourne, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Infectious Diseases, The Alfred Hospital, Melbourne, Australia
| | - Joseph S Doyle
- Centre for Population Health, Burnet Institute, Melbourne, Australia
- Department of Infectious Diseases, The Alfred Hospital, Melbourne, Australia
- Department of Medicine, University of Melbourne, Melbourne, Australia
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Reau N, Fried MW, Nelson DR, Brown RS, Everson GT, Gordon SC, Jacobson IM, Lim JK, Pockros PJ, Reddy KR, Sherman KE. HCV Council--critical appraisal of data: recommendations for clinical practice in a rapidly evolving therapeutic landscape. Liver Int 2016; 36:488-502. [PMID: 26509462 PMCID: PMC5063106 DOI: 10.1111/liv.12993] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 10/21/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS HCV Council 2014, like its predecessor HCV Council 2011, assembled leading clinicians and researchers in the field of hepatitis C to critically evaluate current data regarding best practices for managing patients with chronic hepatitis C virus (HCV). METHODS Clinical practice statements were developed that reflect the areas of potential controversy with high clinical impact. Faculty members were responsible for reviewing the literature to support or reject these statements. After a review and comprehensive discussion of the data, the HCV Council faculty voted on the nature of the evidence and the level of support for each statement. RESULTS The results of the detailed analysis with expert opinion are summarized in this article. CONCLUSION Numerous questions regarding optimal management of certain populations and clinical scenarios remain unanswered. The discussion in the article provides a summary of evidenced-based expert opinion that may help guide clinicians as additional information is developed.
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Affiliation(s)
- Nancy Reau
- Rush University Medical CenterChicagoILUSA
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41
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Rogal SS, Arnold RM, Chapko M, Hanusa BV, Youk A, Switzer GE, Sevick MA, Bayliss NK, Zook CL, Chidi A, Obrosky DS, Zickmund SL. The Patient-Provider Relationship Is Associated with Hepatitis C Treatment Eligibility: A Prospective Mixed-Methods Cohort Study. PLoS One 2016; 11:e0148596. [PMID: 26900932 PMCID: PMC4763474 DOI: 10.1371/journal.pone.0148596] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 12/17/2015] [Indexed: 12/11/2022] Open
Abstract
Hepatitis C virus (HCV) treatment has the potential to cure the leading cause of cirrhosis and hepatocellular carcinoma. However, only those deemed eligible for treatment have the possibility of this cure. Therefore, understanding the determinants of HCV treatment eligibility is critical. Given that effective communication with and trust in healthcare providers significantly influences treatment eligibility decisions in other diseases, we aimed to understand patient-provider interactions in the HCV treatment eligibility process. This prospective cohort study was conducted in the VA Pittsburgh Healthcare System. Patients were recruited after referral for gastroenterology consultation for HCV treatment with interferon and ribavirin. Consented patients completed semi-structured interviews and validated measures of depression, substance and alcohol use, and HCV knowledge. Two coders analyzed the semi-structured interviews. Factors associated with patient eligibility for interferon-based therapy were assessed using multivariate logistic regression. Of 339 subjects included in this analysis, only 56 (16.5%) were deemed eligible for HCV therapy by gastroenterology (GI) providers. In the multivariate logistic regression, patients who were older (OR = 0.96, 95%CI = 0.92-0.99, p = .049), reported concerns about the GI provider (OR = 0.40, 95%CI = 0.10-0.87, p = 0.02) and had depression symptoms (OR = 0.32, 95%CI = 0.17-0.63, p = 0.001) were less likely to be eligible. Patients described barriers that included feeling stigmatized and poor provider interpersonal or communication skills. In conclusion, we found that patients' perceptions of the relationship with their GI providers were associated with treatment eligibility. Establishing trust and effective communication channels between patients and providers may lower barriers to potential HCV cure.
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Affiliation(s)
- Shari S. Rogal
- Center for Health Equity Research and Promotion, Veteran’s Administration, Pittsburgh Healthcare Service, Pittsburgh, Pennsylvania, United States of America
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
- * E-mail:
| | - Robert M. Arnold
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Michael Chapko
- Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Veteran’s Administration Healthcare Service, Seattle, Washington, United States of America
| | - Barbara V. Hanusa
- Center for Health Equity Research and Promotion, Veteran’s Administration, Pittsburgh Healthcare Service, Pittsburgh, Pennsylvania, United States of America
| | - Ada Youk
- Center for Health Equity Research and Promotion, Veteran’s Administration, Pittsburgh Healthcare Service, Pittsburgh, Pennsylvania, United States of America
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Galen E. Switzer
- Center for Health Equity Research and Promotion, Veteran’s Administration, Pittsburgh Healthcare Service, Pittsburgh, Pennsylvania, United States of America
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Mary Ann Sevick
- Department of Population Health, New York University School of Medicine, New York, New York, United States of America
| | - Nichole K. Bayliss
- Center for Health Equity Research and Promotion, Veteran’s Administration, Pittsburgh Healthcare Service, Pittsburgh, Pennsylvania, United States of America
| | - Carolyn L. Zook
- School of Medicine, Oregon Health Sciences University, Portland, Oregon, United States of America
| | - Alexis Chidi
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - David S. Obrosky
- Center for Health Equity Research and Promotion, Veteran’s Administration, Pittsburgh Healthcare Service, Pittsburgh, Pennsylvania, United States of America
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Susan L. Zickmund
- Center for Health Equity Research and Promotion, Veteran’s Administration, Pittsburgh Healthcare Service, Pittsburgh, Pennsylvania, United States of America
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
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42
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Alavi M, Micallef M, Fortier E, Dunlop AJ, Balcomb AC, Day CA, Treloar C, Bath N, Haber PS, Dore GJ, Grebely J. Effect of treatment willingness on specialist assessment and treatment uptake for hepatitis C virus infection among people who use drugs: the ETHOS study. J Viral Hepat 2015; 22:914-25. [PMID: 25996567 DOI: 10.1111/jvh.12415] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 03/01/2015] [Indexed: 12/13/2022]
Abstract
Among people who inject drugs (PWID) with chronic HCV, the association between HCV treatment willingness and intent, and HCV specialist assessment and treatment were evaluated. The Enhancing Treatment for Hepatitis C in Opioid Substitution Settings (ETHOS) is a prospective observational cohort. Recruitment was through six opioid substitution treatment clinics, two community health centres and one Aboriginal community controlled health organisation in Australia. Analyses were performed using logistic regression. Among 415 participants (mean age 41 years, 71% male), 67% were 'definitely willing' to receive HCV treatment and 70% reported plans to initiate therapy 12 months postenrolment. Those definitely willing to receive HCV treatment were more likely to undergo specialist assessment (64% vs 32%, P < 0.001) and initiate therapy (36% vs 9%, P < 0.001), compared to those with lower treatment willingness. Those with early HCV treatment plans were more likely to undergo specialist assessment (65% vs 27%, P < 0.001) and initiate therapy (36% vs 5%, P < 0.001), compared to those without early plans. In adjusted analyses, HCV treatment willingness independently predicted specialist assessment (aOR 3.06, 95% CI 1.90, 4.94) and treatment uptake (aOR 4.33, 95% CI 2.14, 8.76). In adjusted analysis, having early HCV treatment plans independently predicted specialist assessment (aOR 4.38, 95% CI 2.63, 7.29) and treatment uptake (aOR 9.79, 95% CI 3.70, 25.93). HCV treatment willingness was high and predicted specialist assessment and treatment. Strategies for enhanced HCV care should be developed with an initial focus on people willing to receive treatment and to increase treatment willingness among those less willing.
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Affiliation(s)
- M Alavi
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - M Micallef
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - E Fortier
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia.,Université de Montréal, Montréal, QC, Canada
| | - A J Dunlop
- University of Newcastle, Newcastle, NSW, Australia.,Drug and Alcohol Clinical Services, Hunter New England Local Health District, Newcastle, NSW, Australia
| | - A C Balcomb
- Clinic 96, Kite St Community Health Centre, Orange, NSW, Australia
| | - C A Day
- Drug Health Service, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Discipline of Addiction Medicine, Central Clinical School, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - C Treloar
- Centre for Social Research in Health, The University of New South Wales, Sydney, NSW, Australia
| | - N Bath
- NSW Users & AIDS Association, Inc., Sydney, NSW, Australia
| | - P S Haber
- Drug Health Service, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - G J Dore
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - J Grebely
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
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43
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Grebely J, Robaeys G, Bruggmann P, Aghemo A, Backmund M, Bruneau J, Byrne J, Dalgard O, Feld JJ, Hellard M, Hickman M, Kautz A, Litwin A, Lloyd AR, Mauss S, Prins M, Swan T, Schaefer M, Taylor LE, Dore GJ. Recomendaciones para el manejo de la infección por el virus de la hepatitis C entre usuarios de drogas por vía parenteral. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2015. [DOI: 10.1016/j.drugpo.2015.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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44
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Grebely J, Robaeys G, Bruggmann P, Aghemo A, Backmund M, Bruneau J, Byrne J, Dalgard O, Feld JJ, Hellard M, Hickman M, Kautz A, Litwin A, Lloyd AR, Mauss S, Prins M, Swan T, Schaefer M, Taylor LE, Dore GJ. Recommendations for the management of hepatitis C virus infection among people who inject drugs. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2015; 26:1028-38. [PMID: 26282715 PMCID: PMC6130980 DOI: 10.1016/j.drugpo.2015.07.005] [Citation(s) in RCA: 140] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Revised: 06/30/2015] [Accepted: 07/07/2015] [Indexed: 02/07/2023]
Abstract
In high income countries, the majority of new and existing hepatitis C virus (HCV) infections occur among people who inject drugs (PWID). In many low and middle income countries large HCV epidemics have also emerged among PWID populations. The burden of HCV-related liver disease among PWID is increasing, but treatment uptake remains extremely low. There are a number of barriers to care which should be considered and systematically addressed, but should not exclude PWID from HCV treatment. The rapid development of interferon-free direct-acting antiviral (DAA) therapy for HCV infection has brought considerable optimism to the HCV sector, with the realistic hope that therapeutic intervention will soon provide near optimal efficacy with well-tolerated, short duration, all oral regimens. Further, it has been clearly demonstrated that HCV treatment is safe and effective across a broad range of multidisciplinary healthcare settings. Given the burden of HCV-related disease among PWID, strategies to enhance HCV assessment and treatment in this group are urgently needed. These recommendations demonstrate that treatment among PWID is feasible and provide a framework for HCV assessment and care. Further research is needed to evaluate strategies to enhance testing, linkage to care, treatment, adherence, viral cure, and prevent HCV reinfection among PWID, particularly as new interferon-free DAA treatments for HCV infection become available.
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Affiliation(s)
| | - Geert Robaeys
- Department of Gastroenterology and Hepatology, Ziekenhuis Oost Limburg, Genk, Belgium; Department of Hepatology, UZ Leuven, Leuven, Belgium; Faculty of Medicine and Life Sciences, Limburg Clinical Research Program, Hasselt University, Hasselt, Belgium
| | | | - Alessio Aghemo
- A.M. Migliavacca Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Markus Backmund
- Ludwig-Maximilians-University, Munich, Germany; Praxiszentrum im Tal Munich, Munich, Germany
| | | | - Jude Byrne
- International Network of People who Use Drugs, Canberra, Australia
| | - Olav Dalgard
- Department of Infectious Diseases, Akershus University Hospital, Lørenskog, Norway
| | | | - Margaret Hellard
- Burnet Institute, Melbourne, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Matthew Hickman
- School of Social & Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Achim Kautz
- European Liver Patients Association, Cologne, Germany
| | - Alain Litwin
- Division of General Internal Medicine, Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, United States
| | - Andrew R Lloyd
- Inflammation and Infection Research Centre, School of Medical Sciences, UNSW Australia, Sydney, Australia
| | - Stefan Mauss
- Center for HIV and Hepatogastroenterology, Düsseldorf, Germany
| | - Maria Prins
- Department of Research, Cluster Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, The Netherlands; Department of Internal Medicine, CINIMA, Academic Medical Centre, Amsterdam, The Netherlands
| | - Tracy Swan
- Treatment Action Group, New York, United States
| | - Martin Schaefer
- Department of Psychiatry, Psychotherapy and Addiction Medicine, Kliniken Essen-Mitte, Essen, Germany; Department of Psychiatry and Psychotherapy-CCM, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Lynn E Taylor
- Department of Medicine, Brown University, Providence, RI, United States
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Lee SS, Jeong SH, Jang ES, Kim YS, Lee YJ, Jung EU, Kim IH, Bae SH, Lee HC. Treatment rate and factors related to interferon-based treatment initiation for chronic hepatitis C in South Korea. J Med Virol 2015. [PMID: 26211752 DOI: 10.1002/jmv.24335] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Under-recognition and under-treatment of chronic hepatitis C virus (HCV) infection is an important determinant of the disease outcome. The aim of this study was to investigate the treatment rate and factor of initiation of interferon-based antiviral treatment for chronic hepatitis C patients in a prospective, multicenter Korean HCV cohort. Treatment-naïve 759 patients with chronic HCV infection were prospectively followed from January 2007-2013 at six university hospitals during a median (interquartile range) follow-up of 769 (76-1,427) days. The subjects consisted of patients with chronic hepatitis C (n = 553, 72.9%), liver cirrhosis (n = 127, 16.7%), and hepatocellular carcinoma (n = 79, 10.4%), and were treated usually using pegylated interferon alpha and ribavirin. Treatment initiation rate and its related factors were analysed. The initiation rate of antiviral treatment was 37.3% (n = 273), and the cumulative probability of treatment initiation over 5 years was 39.4%. Multivariate analysis showed that age <58 years (hazard ratio [HR] = 1.588, 95% CI = 1.151-2.193), job employment (HR = 1.737, 95% CI = 1.279-2.363), absence of HCC (chronic hepatitis, HR = 2.534, 95% CI = 1.003-6.400; liver cirrhosis, HR = 2.873, 95% CI = 1.101-7.494), alanine transaminase (ALT) >40 IU/L (HR = 1.682, 95% CI = 1.228-2.303), and genotype 2 (HR = 1.364, 95% CI = 1.034-1.798) were independent factors related to treatment initiation. Interferon-based antiviral treatment was initiated in more than one third of chronic HCV infected patients visiting university hospitals, who were young, employed, HCV genotype 2, and with abnormal ALT without HCC, in Korea.
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Affiliation(s)
- Sang Soo Lee
- Department of Internal Medicine, Gyeongsang National University Hospital, Gyeongsang National University College of Medicine, Jinju, Republic of Korea
| | - Sook-Hyang Jeong
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Eun Sun Jang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Young Seok Kim
- Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Republic of Korea
| | - Youn Jae Lee
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Eun Uk Jung
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - In Hee Kim
- Department of Internal Medicine, Chonbuk National University Hopital, Chonbuk National University College of Medicine, Chonju, Republic of Korea
| | - Si Hyun Bae
- Department of Internal Medicine, The Catholic University of Korea Seoul Saint Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Republic of Korea
| | - Han Chu Lee
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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46
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Beste LA, Ioannou GN. Prevalence and treatment of chronic hepatitis C virus infection in the US Department of Veterans Affairs. Epidemiol Rev 2015; 37:131-43. [PMID: 25600415 DOI: 10.1093/epirev/mxu002] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Chronic hepatitis C virus (HCV) is the most common blood-borne pathogen in the United States. HCV disproportionately affects Veterans Affairs (VA) health-care users: 174,302 HCV-infected veterans were in VA care in 2013, making the VA the world's largest HCV care provider. This systematic review identified 546 articles related to HCV in the VA. After assessment by 2 independent reviewers, 28 articles describing prevalence and treatment of HCV in VA users ultimately met inclusion criteria. Most VA patients currently living with HCV infection were born between 1945 and 1965 and were infected with HCV between 1970 and 1990. To prevent HCV-related complications such as cirrhosis, hepatocellular carcinoma, and death, medical personnel must identify and treat HCV. However, antiviral therapy has historically been limited by medication side effects, contraindications, and patient acceptance. Although treatment initiation rates are higher in the VA than in the general United States, only 23% of VA HCV patients have received treatment and, of those, only a minority were cured. Recent development of more effective and tolerable antiviral agents represents a major pharmacological breakthrough. Eradication of HCV is theoretically possible for the majority of HCV patients for the first time, although new barriers, such as high drug costs, may limit future uptake.
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47
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Walling AM, Schreibeis-Baum H, Pimstone N, Asch SM, Robinson L, Korlekar S, Lorenz K, Nwajuaku T, Rosenfeld K. Proactive case finding to improve concurrently curative and palliative care in patients with end-stage liver disease. J Palliat Med 2014. [PMID: 25493552 DOI: 10.1089/jpm.2014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Palliative care and preparation for liver transplantation are often perceived as conflicting for patients with end-stage liver disease (ESLD). We sought to improve both simultaneously through a case finding and care coordination quality improvement intervention. METHODS We identified patients with cirrhosis using validated ICD-9 codes and screened them for ESLD by assessing medical records at a VA hospital for either a model for end-stage liver disease (MELD) ≥14 or a diagnosis of hepatocellular carcinoma (HCC) between October 2012 and January 2013. A care coordinator followed veterans from the index hospitalization through April 2013 and encouraged treating physicians to submit liver transplant evaluation consults for all veterans with a MELD ≥14 and palliative care consults for all veterans with a MELD ≥20 or inoperable HCC. RESULTS We compared rates of consultation for 49 hospitalized veterans and compared their outcomes to 61 pre-intervention veterans. Veterans were more likely to be considered for liver transplantation (77.6% versus 31.1%, p<0.001) and receive palliative care consultation during the intervention period, although the latter finding did not reach statistical significance (62.5% versus 47.1%, p=0.38). CONCLUSIONS Active case finding improved consideration for liver transplantation without decreasing palliative care consultation.
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Affiliation(s)
- Anne M Walling
- 1 Greater Los Angeles Veterans Affairs Healthcare System, David Geffen School of Medicine at University of California , Los Angeles, California
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48
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Walling AM, Schreibeis-Baum H, Pimstone N, Asch SM, Robinson L, Korlekar S, Lorenz K, Nwajuaku T, Rosenfeld K. Proactive case finding to improve concurrently curative and palliative care in patients with end-stage liver disease. J Palliat Med 2014; 18:378-81. [PMID: 25493552 DOI: 10.1089/jpm.2014.0265] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Palliative care and preparation for liver transplantation are often perceived as conflicting for patients with end-stage liver disease (ESLD). We sought to improve both simultaneously through a case finding and care coordination quality improvement intervention. METHODS We identified patients with cirrhosis using validated ICD-9 codes and screened them for ESLD by assessing medical records at a VA hospital for either a model for end-stage liver disease (MELD) ≥14 or a diagnosis of hepatocellular carcinoma (HCC) between October 2012 and January 2013. A care coordinator followed veterans from the index hospitalization through April 2013 and encouraged treating physicians to submit liver transplant evaluation consults for all veterans with a MELD ≥14 and palliative care consults for all veterans with a MELD ≥20 or inoperable HCC. RESULTS We compared rates of consultation for 49 hospitalized veterans and compared their outcomes to 61 pre-intervention veterans. Veterans were more likely to be considered for liver transplantation (77.6% versus 31.1%, p<0.001) and receive palliative care consultation during the intervention period, although the latter finding did not reach statistical significance (62.5% versus 47.1%, p=0.38). CONCLUSIONS Active case finding improved consideration for liver transplantation without decreasing palliative care consultation.
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Affiliation(s)
- Anne M Walling
- 1 Greater Los Angeles Veterans Affairs Healthcare System, David Geffen School of Medicine at University of California , Los Angeles, California
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49
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Arain A, Robaeys G. Eligibility of persons who inject drugs for treatment of hepatitis C virus infection. World J Gastroenterol 2014; 20:12722-12733. [PMID: 25278674 PMCID: PMC4177459 DOI: 10.3748/wjg.v20.i36.12722] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Accepted: 05/19/2014] [Indexed: 02/06/2023] Open
Abstract
In this decade, an increase is expected in end-stage liver disease and hepatocellular carcinoma, most commonly caused by hepatitis C virus (HCV) infection. Although people who inject drugs (PWID) are the major source for HCV infection, they were excluded from antiviral treatments until recently. Nowadays there is incontrovertible evidence in favor of treating these patients, and substitution therapy and active substance use are no longer contraindications for antiviral treatment. The viral clearance in PWID after HCV antiviral treatment with interferon or pegylated interferon combined with ribavirin is comparable to the viral clearance in non-substance users. Furthermore, multidisciplinary approaches to delivering treatment to PWID are advised, and their treatment should be considered on an individualized basis. To prevent the spread of HCV in the PWID community, recent active PWID are eligible for treatment in combination with needle exchange programs and substitution therapy. As the rate of HCV reinfection is low after HCV antiviral treatment, there is no need to withhold HCV treatment due to concerns about reinfection alone. Despite the advances in treatment efficacies and data supporting their success, HCV assessment of PWID and initiation of antiviral treatment remains low. However, the proportion of PWID assessed and treated for HCV is increasing, which can be further enhanced by understanding the barriers to and facilitators of HCV care. Removing stigmatization and implementing peer support and group treatment strategies, in conjunction with greater involvement by nurse educators/practitioners, will promote greater treatment seeking and adherence by PWID. Moreover, screening can be facilitated by noninvasive methods for detecting HCV antibodies and assessing liver fibrosis stages. Recently, HCV clearance has become a major endpoint in the war against drugs for the Global Commission on Drug Policy. This review highlights the most recent evidence concerning HCV infection and treatment strategies in PWID.
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50
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Alavi M, Raffa JD, Deans GD, Lai C, Krajden M, Dore GJ, Tyndall MW, Grebely J. Continued low uptake of treatment for hepatitis C virus infection in a large community-based cohort of inner city residents. Liver Int 2014; 34:1198-206. [PMID: 24164865 DOI: 10.1111/liv.12370] [Citation(s) in RCA: 85] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Accepted: 10/20/2013] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Despite advances in HCV treatment, recent data on treatment uptake is sparse. HCV treatment uptake and associated factors were evaluated in a community-based cohort in Vancouver, Canada. METHODS The CHASE study is a cohort of inner city residents recruited from January 2003-June 2004. HCV status and treatment were retrospectively and prospectively determined through data linkages with provincial virology and pharmacy databases. Logistic regression analyses were used to identify factors associated with HCV treatment uptake. RESULTS Among 2913, HCV antibody testing was performed in 2405, 64% were HCV antibody-positive (n = 1533). Individuals with spontaneous clearance (18%, n = 276) were excluded. Among the remaining 1257 HCV antibody-positive participants (mean age 42, 71% male), 29% were Aboriginal. At enrolment, the majority reported recent injecting (60%) and non-injecting drug use (87%). Between January 1998 and March 2010, 6% (77 of 1257) initiated HCV treatment. In adjusted analyses, Aboriginal ethnicity [adjusted odds ratio (AOR) 0.23; 95% CI 0.10, 0.51] and crack cocaine use (AOR 0.61; 95% CI 0.37, 0.99) were associated with a decreased odds of receiving HCV treatment, while methamphetamine injecting (AOR 0.16; 95% CI 0.02, 1.18) trended towards a lower odds of receiving treatment. HCV treatment uptake ranged from 0.2 (95% CI 0.0, 0.7) per 100 person-years (PYs) in 2003 to 1.6 (95% CI 0.9, 2.6) per 100 PYs in 2009. CONCLUSION HCV treatment uptake remains low in this large community-based cohort of inner city residents with a high HCV prevalence and access to universal healthcare.
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Affiliation(s)
- Maryam Alavi
- The Kirby Institute for Infection and Immunity in Society, The University of New South Wales, Sydney, Australia
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