Knowledge about infection is the only predictor of treatment in patients with chronic hepatitis C

The Challenge of a Recall Program from a Community-Based Hepatitis C Screening Campaign: The Effectiveness in HCV Microelimination

The optimal strategy for the microelimination of HCV within community settings remains ambiguous. We evaluated the percentage of participants who achieved linkage to care (LTC) following the conclusion of a screening campaign and examined the diverse factors influencing LTC among these individuals. The effectiveness of recall intervention for the non-LTC population and its barriers were analyzed. We initiated an HCV patient recall program to identify HCV participants who might not be treated after the HCV screening campaign. The program staff recalled HCV participants who were lost to follow-up via telephone from March 2019 to June 2019. They were informed of HCV treatment's importance, efficacy, availability, and safety. Among 185 participants infected with HCV, 109 (58.9%) obtained LTC. Compared with those who had LTC, those without LTC were older, had lower education levels, were less aware of their HCV infection, less frequently lived in urban areas, and had less health insurance. At the end of the recall program, 125 (67.6%) persons had linkage to care. The proportion of LTC increased by 8.7%. In total, 119 persons had an HCV RNA test, and 82 (68.9%) had viremia. Of the 82 patients with viremia, 78 (95.1%) received antiviral therapy, and 76 (97.4%) achieved a sustained virological response. After a community screening campaign, 59% of participants with anti-HCV-positive tests had LTC. The recall program increased this by 9%. However, 32% of HCV participants still could not be linked to care. Outreach care for non-LTC patients is a method worth trying in order to achieve the microelimination of HCV in rural communities.

The Global Burden of Liver Disease

Chronic liver disease (CLD) and its associated complications (cirrhosis and liver cancer) cause significant mortality, morbidity, and economic burden. Published data from the World Health Organization and/or the Global Burden of Disease show that the burden of CLD is large and increasing, primarily owing to the increasing burden of nonalcoholic fatty liver disease and alcohol-related liver disease (ALD). Middle Eastern, Northern African, and Asian regions of the globe are most affected by hepatitis B and hepatitis C virus. Furthermore, Middle Eastern and North African regions also are affected by nonalcoholic fatty liver disease, and Eastern European, West African, and Central Asian regions are affected by ALD. In this context, the rate of increase for cirrhosis is highest in the Middle East, as well as in middle high and high sociodemographic index (SDI) regions. On the other hand, the highest SDI countries are experiencing increasing rates of hepatocellular carcinoma (HCC). Assessing HCC burden based on country and etiology shows that China, Korea, India, Japan, and Thailand have the highest hepatitis B virus-related HCC cases, while China, Japan, and the United States have the highest hepatitis C virus-related HCC cases. Additionally, the United States has the highest ALD-related HCC cases, while India, the United States, and Thailand have the highest nonalcoholic steatohepatitis-related HCC cases. Although the burden of CLD is increasing globally, regions of the world are impacted differently as a result of a number of sociodemographic factors.

Mental Health, Quality of Life, and Stigmatization in Danish Patients with Liver Disease

The mental health of patients with liver diseases is often overlooked when assessing their overall health and planning care and treatment. The aim of this study was to assess anxiety, depression, hopelessness, quality of life, and the perception of stigmatization in a large cohort of patients with chronic liver disease of different aetiology and severity, as well as to identify predictors associated with mental health disorders. A total of 340 patients completed a survey assessing mental health using the Beck Anxiety Inventory, the Beck Hopelessness Scale, and the Major Depression Inventory. Quality of life was measured with the Chronic Liver Disease Questionnaire and the European Quality-of-Life visual analogue scale. To assess stigmatization, validated questions from the Danish Nationwide Survey of Patient Experiences were used. Predictors associated with anxiety, hopelessness, and depression were analysed using univariable and multivariable logistic regression analyses. Overall, 15% of the patients had moderate or severe anxiety, 3% had moderate or pronounced hopelessness, and 8% had moderate or severe depression. The prevalence of all three was highest in patients with cirrhosis and was associated with a low quality of life. More patients with cirrhosis had perceived stigmatization compared to patients with liver disease without cirrhosis, which affected their self-perception, and more than one-third of the patients refrained from telling others about their liver disease. The results emphasize the need for increased focus on mental health problems and awareness on preventing the discrimination of patients with liver disease.

Depression and Anxiety Are Common Among Patients With Cirrhosis

BACKGROUND & AIMS

Depression and anxiety can have negative effects on patients and are important to treat. There have been few studies of their prevalence among patients with cirrhosis. We aimed to characterize the prevalence and risk factors for depression and anxiety in a large multi-center cohort of patients with cirrhosis.

METHODS

We conducted a telephone-based survey of patients with cirrhosis at 3 health systems in the United States (a tertiary-care referral center, a safety net system, and a Veterans hospital) from April through December 2018. Of 2871 patients approached, 1021 (35.6%) completed the survey. Depression and anxiety were assessed using the PHQ-9 (range 0-25) and STAI (range 20-80) instruments, with clinically significant values defined as PHQ-9 ≥15 and STAI ≥40. We performed multivariate logistic regression analysis to identify factors associated with significant depression and anxiety.

RESULTS

The median PHQ-9 score was 7 (25th percentile-75th percentile, 3-12) and the median STAI score was 33 (25th percentile-75th percentile, 23-47); 15.6% of patients had moderately severe to severe depression and 42.6% of patients had high anxiety. In multivariable analyses, self-reported poor health (odds ratio [OR], 4.08; 95% CI, 1.79-9.28), being widowed (OR, 2.08; 95% CI, 1.07-4.05), fear of hepatocellular carcinoma (OR, 1.89; 95% CI, 1.04-3.42), higher household income (OR, 0.30; 95% CI, 0.10-0.95), and Hispanic ethnicity (OR, 0.57; 95% CI, 0.33-0.97) were associated with moderately severe to severe depression. Male sex (OR, 0.71; 95% CI, 0.51-0.98), self-reported poor health (OR, 2.73; 95% CI, 1.73-4.32), and fear of hepatocellular carcinoma (OR, 2.24; 95% CI, 1.33-3.78) were associated with high anxiety.

CONCLUSIONS

Nearly 1 in 6 patients with cirrhosis have moderately severe to severe depression and nearly half have moderate-severe anxiety. Patients with cirrhosis should be evaluated for both of these disorders.

Hepatitis C Treatment Cascade in a Federally Qualified Health Center

Hepatitis C (HCV) care cascades have been described in diverse clinical settings, patient populations and countries, highlighting the steps in HCV care where improvements can be made and resources allocated. However, more research is needed to examine barriers to HCV treatment in rural, underserved populations and in Federally Qualified Health Centers (FQHCs). As part of a quality improvement (QI) project, this study aimed to describe and evaluate the HCV treatment cascade in an FQHC serving a large rural patient population in the Western United States. Standardized chart abstraction was utilized to aggregate data regarding patient demographics, the percentage of patients achieving each step in the treatment cascade, and relevant patient (i.e., viral load) and service variables (i.e., whether and when patients received treatment or medication). 389 patients were identified as having HCV and 86% were aware of their diagnosis. Fifty-five percent had their infection confirmed via viral load, 21% were staged for liver disease, 24% received a prescription for treatment, and 19% achieved cure. Compared to national data, the current regional sample had greater rates of diagnosis awareness and access to care, as well as sustained virologic response (SVR), but lower rates of viral load confirmation. Current findings suggest that rural patients living with HCV who receive care at FQHCs struggle to navigate the treatment cascade and achieve a cure, particularly with regard to infection confirmation, liver staging, and prescription. However, compared to national estimates, patients had greater rates of diagnosis awareness/treatment access and SVR.

Universal HCV Screening of Baby Boomers is Feasible, but It is Difficult

BACKGROUND/OBJECTIVE

Our objective was to assess the impact of mass mailing and the inclusion of Best Practice Advisory (BPA) "Pop-Up" tool in the electronic medical record (EMR) on HCV screening rates.

METHODS

Between June 2015 and March 2020, two interventions were developed for primary care physicians (PCP). An educational letter along with a blood requisition form, signed on behalf of the PCPs, was sent to patients. We also developed a BPA "Pop-Up" screening tool to alert PCPs to order HCV screening tests on patients with no previous screening. Data were collected and analyzed prospectively.

RESULTS

When we started the screening program in June 2015, 33,736 baby boomers were eligible for screening, and the hospital system added an additional 26,027 baby boomers between June 2015 and March 2020. Of the 89 primary care providers employed by the hospital, 75 agreed to participate at different time periods. We screened 23,291 (43.5%) of 53,526 eligible patients during study period. Of these, 399 (1.7%) had HCV antibody, but HCV RNA was positive in only 195 (1%). HCV antibody positivity rates were higher in men, blacks, and in 1951-1960 birth cohorts. Spontaneous clearance rates appeared to be lower in men (OR 0.59, 95% CI 0.39-0.90, P = 0.015) and in blacks (OR 0.31, 95% CI 0.20-0.50, P < 0.001).

CONCLUSION

Although a formal screening program increased screening rates for HCV among baby boomers, about 50% of baby boomers remained unscreened. In this community screening program, we found that men and blacks are less likely to have spontaneous HCV clearance.

Increasing Viral Hepatitis Knowledge Among Urban Ethnic Minority Youth: Findings from a Community Based Prevention Intervention

Viral hepatitis (VH) knowledge among youth is understudied in the United States. There has been a rise in VH cases in the U.S. in the wake of the opioid epidemic. Innovative approaches to preventing the infection are needed especially in urban communities. This study presents preliminary findings from a community-based HIV/AIDS, substance abuse, and VH prevention education intervention for ethnic minority youth in a northeastern urban community. We aimed to evaluate VH knowledge and factors associated with knowledge. Participants in the study completed a baseline survey followed by an exit survey measuring VH knowledge after the intervention. The survey was completed by 691 individuals. Logistic regression analyses were conducted and indicated that there was a significant increase (82.3%) in VH knowledge among youth who participated in the intervention. The development and implementation of VH knowledge interventions can be crucial in alleviating the rise of VH infections in the U.S.

Awareness of Birth Cohort Hepatitis C Testing Recommendation Among Baby Boomers: An Exploratory Survey Study

OBJECTIVES

To examine population awareness of the Centers for Disease Control and Prevention's (CDC) hepatitis C virus (HCV) testing recommendation for the 1945 to 1965 birth cohort and explore the factors associated with awareness of the testing recommendation, its association with HCV testing, and respondents' data sources about the recommendation.

METHODS

A cross-sectional survey was conducted to assess awareness of the CDC birth cohort testing recommendation among adults born 1945-1965 who were managed at a single academic center's internal medicine clinics or by visiting a local health fair. Data were collected on respondents' demographics and HCV-related domains, including risk factors, awareness, data sources, prior testing, and interest in information about testing.

RESULTS

There were a total of 563 respondents to the survey. Forty percent were aware of the CDC's testing recommendation, with Hispanic ethnicity being the only significant predictor (odds ratio 0.59, 95% confidence interval 0.38-0.90). HCV testing rates were higher among those aware of the CDC's recommendation, as compared with those unaware (33.6% vs 24.0%, P = 0.0269). Television was the most common initial data source for the testing recommendation (64.8%), whereas healthcare providers accounted for 22.4%.

CONCLUSIONS

Awareness of the CDC's testing recommendation was reported in fewer than half of the respondents and was adversely affected by minority status. Although mass media may be a key venue for HCV-related data outreach, further studies are needed on interventions to enhance the role played by healthcare providers.

Improving hepatitis C screening and diagnosis in patients born between 1945 and 1965 in a safety-net primary care clinic

Individuals born between 1945-1965 represent 81% of all persons chronically infected with hepatitis C virus (HCV) in the USA and are largely unaware of their positive status. The baseline HCV screening rate in this population in an academic internal medicine clinic at a US hospital was less than 3.0%. The goal was to increase the rate of HCV screening in patients born between 1945 and 1965 to 20% within 24 months. The quality improvement team used the Plan Do Study Act Model. Outcome measures included HCV antibody screening, HCV RNA positive rate and linkage to hepatology care. Process measures included HCV antibody order and completion rates. The quality improvement team performed a root cause analysis and identified barriers for HCV screening and linkage to care. The key elements of interventions included redesigning nursing workflow, use of health information technology and educating patients, physicians and nursing staff about HCV. The HCV screening rate was 30.3% (391/1291) within 24 months. The HCV antibody positive rate was 43.5% (170/391), and HCV RNA positive rate was 95.3% (162/170). HCV infection was diagnosed in 12.5% (162/1291) of patients or 41.4% (162/391) of the screened population. Of those positive, 70% (114/162) were linked to hepatology care within the 24-month project timeframe. Eighty percent of patients seen by a hepatologist were treated with direct-acting antivirals agents. The HCV screening rate was sustained at 25.4% during the post-project 1-year period. Engagement of a multidisciplinary team and education to patients, physicians and nursing staff were the key drivers for success.

Electronic medical record alert improves HCV testing for baby boomers in primary care setting: adults born during 1945-1965

METHOD

This project aims to implement the HCV birth cohort screening guidelines over a 9-month period in the primary care setting at the University of Kansas Health System General Internal Medicine Division. The project team measured the number of patients in the baby boomer population who received a one-time screen for HCV. An electronic medical record (EMR) intervention was implemented to identify baby boomers who did not have an HCV screening or diagnosis. Additionally, education was provided to all primary care providers in the clinic to increase awareness of the HCV birth cohort screening.

RESULTS

The quality improvement methods increased the percentage of baby boomers who obtained a one-time screening test for HCV from a baseline of 30% to a 55% screening rate during the nine-month project period.

CONCLUSION

Identifying the HCV screening needs and creating a visual reminder in the EMR can be used to facilitate sustainable awareness and improvement of screening rates. The project team recognizes that continued work is required to close the HCV screening care gaps in the primary care setting.

Regional differences in treatment rates for patients with chronic hepatitis C infection: Systematic review and meta-analysis

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.

Economic Burden of Hepatitis C Infection

The economic burden of chronic hepatitis C might exceed $10 billion annually in the United States alone. This disease has a worldwide prevalence of up to 3%, making the global burden of the disease comparably tremendous. The cost of the disease includes direct medical expenses for its hepatic and extrahepatic manifestations, and also indirect costs incurred from impaired quality of life and the loss of work productivity. Recent emergence of treatment options that are not only highly effective and safe but also costly has emphasized the need to study the disease from the economic point of view.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Impact of an Electronic Medical Record-Based System to Promote Human Immunodeficiency Virus/Hepatitis C Virus Screening in Public Hospital Primary Care Clinics

Background

United States guidelines recommend that all adolescents and adults be tested for human immunodeficiency virus (HIV) and that persons born between 1945 and 1965 be tested for hepatitis C virus (HCV).

Methods

We used electronic medical record (EMR) data to identify patients in 3 primary care clinics in Seattle, Washington who met national criteria for routine HCV or HIV testing and had no documented history of prior testing. Clinic staff received daily lists of untested patients with scheduled appointments. We used generalized linear models to compare the percentage of patients tested and newly diagnosed with HIV and HCV in the 18 months before and during the intervention.

Results

A total of 16784 patients aged 18–64 and 9370 patients born between 1945 and 1965 received care from January 2011 to December 2015. Comparing the preintervention and intervention periods, the percentage of previously untested patients tested for HIV and HCV increased from 14.9% to 30.8% and from 18.0% to 35.5%, respectively (P < .0001 for both). Despite this increase in testing, there was no change in the percentage of patients newly diagnosed with HIV (0.7% in both periods, P = .96) or HCV (3.6% vs 3.7%, P = .81). We estimate that 1.2%–15% of HCV-infected primary care patients in our medical center are undiagnosed.

Conclusions

EMR-based HCV/HIV testing promotion increased testing but not case finding among primary care patients in our medical center. In our institution, most HCV-infected patients are already diagnosed, primarily through risk-based and clinical screening, highlighting the need to concentrate future efforts on increasing HCV treatment.

The Hepatitis C virus treatment cascade at an urban postincarceration transitions clinic

Transitions clinics, which provide medical care to individuals who have been released from incarceration, reach a population at high risk for hepatitis C Virus (HCV) infection. We used the HCV treatment cascade to describe HCV care at an urban postincarceration transitions clinic, identifying gaps in care and determining reasons for lapses in care. In this retrospective cohort study, we reviewed electronic health records for all formerly incarcerated individuals receiving care at the Bronx Transitions Clinic. HCV treatment cascade measures included the following: detection of HCV antibodies, confirmation of chronic infection, specialist referral, specialist evaluation, initiation of treatment, completion of treatment and achievement of SVR. We recorded reasons for lapses in care. Of 451 patients accessing care, 317 (70%) were screened for HCV antibodies, and 106 (33%) tested positive. Of the 106 antibody-positive patients, 93 (88%) were evaluated for HCV viremia and 84 (79%) were confirmed to have chronic HCV infection; 19% of the total sample had chronic HCV infection. Of these 84 with chronic HCV, 48 (57%) received specialist referral, 30 (36%) were evaluated, 8 (10%) initiated treatment, and 5 (6%) completed treatment and achieved SVR. Some treatment lapses occurred because patients were deemed unstable for treatment (12%) or were re-incarcerated (5%). Chronic HCV infection was common among transitions clinic patients. Few were treated and cured. Patients lost contact with providers before consideration for antiviral therapy. Referral to specialty providers was a gap in care. Increasing HCV treatment in this population will likely require intensive delivery models.

Presence of hepatitis C (HCV) infection in Baby Boomers with Medicare is independently associated with mortality and resource utilisation

BACKGROUND

Hepatitis C virus is common among Baby Boomers (BB). As this cohort ages, they will increasingly become Medicare eligible.

AIM

To evaluate resource utilisation and mortality of BB-Medicare recipients with HCV.

METHODS

We used in-patient and out-patient Medicare databases (2005-2010). HCV was identified using ICD-9 codes. Outcomes included resource utilisation [payment/case and in-patient length of stay (LOS)] and short-term mortality.

RESULTS

Of 1 153 862 BB Medicare recipients (2005-2010), 3.2% (N = 37 365) had HCV. During this period, in-patient Medicare-BB (39 793-55 235) and their claims (78 924-106 232) increased. Furthermore, their overall mortality increased from 8.94% to 10.25% (P < 0.0001). In multivariate analysis, HCV [OR = 1.23 (1.16-1.29)], older age [OR = 1.98 (1.82-2.14)], male gender [OR = 1.25 (1.22-1.29)], ESRD [OR = 1.31 (1.26-1.36)], Charlson score [OR = 1.41 (1.40-1.42)] and LOS [OR = 1.02 (1.02-1.02)] predicted mortality. LOS decreased from 12.98 to 11.74 days (P < 0.0001), whereas total payments increased from $22 157 to $23 185 (P < .0001). During the study, the number of out-patient Medicare BB patients (123 097-192 110) and claims (863 978-1 340 260) also increased. Furthermore, overall mortality increased from 3.15% to 3.31% (P = 0.0131). Again, HCV [OR = 1.23 (1.16-1.30)], older age [OR = 2.03 (1.89-2.17)], ESRD [OR = 3.40 (3.28-3.51)], disabled status [OR = 1.49 (1.40-1.58)] and Charlson score [OR = 1.39 (1.38-1.40)] predicted mortality. Annual total out-patient payments increased from $3781 to $4001 (P < 0.0001). HCV [36.04% [34.28-37.82%)], 45-49 age [4.21% (3.14-5.28%)], ESRD [966.31% (954.86-977.88%)], disabled status [43.22% (41.67-44.80%)], Charlson score [46.78% (46.31-47.26%)] and study year [2.72% (2.58-2.85%)] independently predicted increases in payments.

CONCLUSIONS

In Baby Boomer Medicare recipients, diagnosis of HCV is independently associated with higher mortality and resource utilisation.

Implementation of baby boomer hepatitis C screening and linking to care in gastroenterology practices: a multi-center pilot study

Background

Estimates suggest that only 20 % of HCV-infected patients have been identified and <10 % treated. However, baby boomers (1945-1965) are identified as having a higher prevalence of HCV which has led the Centers for Disease Control and Prevention to make screening recommendations. The aim of this study was to implement the CDC’s screening recommendations in the unique setting of gastroenterology practices in patients previously unscreened for HCV.

Methods

After obtaining patient informed consent, demographics, clinical and health-related quality of life (HRQOL) data were collected. A blood sample was screened for HCV antibody (HCV AB) using the OraQuick HCV Rapid Antibody Test. HCV AB-positive patients were tested for presence of HCV RNA and, if HCV RNA positive, patients underwent treatment discussions.

Results

We screened 2,000 individuals in 5 gastroenterology centers located close to large metropolitan areas on the East Coast (3 Northeast, 1 Mid-Atlantic and 1 Southeast). Of the screened population, 10 individuals (0.5 %) were HCV AB-positive. HCV RNA testing was performed in 90 % (9/10) of HCV AB-positive individuals. Of those, 44.4 % (4/9) were HCV RNA-positive, and all 4 (100 %) were linked to caregiver. Compared to HCV AB negative subjects, HCV AB-positive individuals tended to be black (20.0 vs. 5.2 %, p = 0.09) and reported significantly higher rates of depression: 60.0 vs. 21.5 %, p = 0.009. These individuals also reported a significantly lower HRQOL citing having more fatigue, poorer concentration, and a decreased level of energy (p < 0.05).

Discussion

Although the prevalence of HCV AB-positive was low in previously unscreened subjects screened in the gastroenterology centers, the linkage to care was very high. The sample of patients used in this study may be biased, so further studies are needed to assess the effectiveness of the CDC screening recommendations.

Conclusion

Implementation of the Baby Boomer Screening for HCV requires identifying screening environement with high prevalence of HCV+ individuals as well as an efficient process of linking them to care.

Interferon-Free Regimens for Chronic Hepatitis C: Barriers Due to Treatment Candidacy and Insurance Coverage

BACKGROUND

Recently developed interferon- and ribavirin-free regimens to treat hepatitis C virus infection (HCV) have low side effect profile accompanied by high efficacy.

AIM

To assess the potential access to these regimens using the most recent data on candidacy and insurance coverage for HCV-positive Americans.

METHODS

The National Health and Nutrition Examination Survey (NHANES) cycles 2005-2008 and 2009-2012 were used in this cross-sectional study.

RESULTS

A total of 10,799 and 11,840 adult (18+) NHANES participants were included from the two cycles, respectively. Of these, 1.19 and 0.94%, respectively, showed detectable viremia (HCV+). The proportion of HCV+ individuals aged ≥65 increased from 1.7 to 6.8% (p = 0.0144). HCV+ individuals were less likely to be insured than HCV- regardless of the study year (HCV+: 63.8% vs. HCV-: 80.1%, p = 0.0005). Between the study cycles, the rates of insurance coverage (60.2 and 67.4%, respectively) and treatment eligibility based on medical contraindications for interferon-based treatment (66.6 and 74.1%, respectively) were not different (p > 0.05). With minimal contraindications for interferon- and ribavirin-free treatment, 95.1 and 97.7% of HCV+ patients could be eligible for treatment despite aging of the study population and unchanged rates of comorbid conditions. Considering both treatment eligibility and insurance coverage, potential access to anti-HCV treatment increased from 35.1% for interferon-based to 66.6% for interferon-free regimens (p = 0.0003).

CONCLUSIONS

A large proportion of HCV+ individuals remain uninsured or under-insured. The lack of adequate coverage limits their access to the newly developed interferon- and ribavirin-free regimens for HCV that are highly effective with minimal contraindications.

Improvement of health-related quality of life and work productivity in chronic hepatitis C patients with early and advanced fibrosis treated with ledipasvir and sofosbuvir

BACKGROUND & AIMS

New interferon-free anti-HCV regimens are highly efficacious with a favorable safety profile. We assessed health-related quality of life (HRQL) and work productivity in patients with different stages of hepatic fibrosis treated with sofosbuvir+ledipasvir.

METHODS

Four questionnaires [Chronic Liver Disease Questionnaire-HCV (CLDQ-HCV), Short Form-36 (SF-36), Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F), Work Productivity and Activity Index:Specific Health Problem (WPAI:SHP)] were administered at baseline, during, and after treatment with sofosbuvir+ledipasvir+ribavirin or sofosbuvir+ledipasvir (ION-1,2,3 clinical trials). Metavir fibrosis stage was determined from pre-treatment liver biopsies.

RESULTS

There were 1005 patients included (stage F0: n=94; F1: n=311; F2: n=301; F3: n=197; F4: n=102). At baseline, patients with more advanced fibrosis had more HRQL impairments, predominantly related to physical functioning (stage 0 vs. stage 4 by up to 0.126 on a normalized 0-1 scale p<0.0001). During and post-treatment, HRQL remained lower in patients with advanced fibrosis. After achieving sustained virologic response, significant improvements from baseline in most HRQL domains were observed regardless of fibrosis stage (by 0.024-0.103 on a 0-1 scale; all p>0.05 across fibrosis stages). In multivariate analysis, advanced fibrosis was independently associated with impairment of HRQL and work productivity (beta up to -0.056 in comparison with none-to-mild fibrosis, p<0.05). However, improvement of HRQL and work productivity after viral clearance was not related to the stage of fibrosis (all p>0.05).

CONCLUSIONS

Although advanced hepatic fibrosis is associated with HRQL and work productivity impairment, viral eradication with sofosbuvir+ledipasvir leads to HRQL improvement regardless of fibrosis stage. HCV patients with early fibrosis experience similar improvement of patient reported outcomes as those with advanced fibrosis.

The Utility of Commonly Used Laboratory Tests to Screen for Excessive Alcohol Use in Clinical Practice

BACKGROUND

This current study was undertaken to carefully assess the accuracy of routinely used laboratory tests in detecting excessive/recent alcohol use. We also determined the kinetics of these markers in subjects who underwent an intensive alcohol rehabilitation program.

METHODS

The study cohort consisted of 210 nonexcessive drinkers, 272 excessive drinkers, and 76 with alcoholic cirrhosis. To determine the kinetics of these markers during alcohol abstinence, we followed 45 subjects with history of excessive alcohol use for 12 weeks during the intensive alcohol treatment program.

RESULTS

Percentage of carbohydrate deficient transferrin (%CDT) provided the highest diagnostic performance (area under the curve [AUC] 0.77) followed by gamma-glutamyl transferase (GGT) (AUC 0.68) to detect excessive drinkers. The percentage of excessive drinkers with aspartate aminotransferase:alanine aminotransferase (AST:ALT) > 2 was only 2%, whereas 51% of subjects with alcoholic cirrhosis had AST:ALT > 2. In the multivariate analysis, the levels of GGT and %CDT were associated with the level of alcohol consumed during the past 30 days. The levels of GGT, mean corpuscular volume (MCV), and %CDT were significantly lower compared to those at baseline before alcohol rehabilitation, whereas the AST, ALT, and AST:ALT ratio were unchanged. The percent reduction was ~2.7% (for MCV), 19% (for GGT), and 43% (for %CDT) at the end of the 12-week follow-up compared to the baseline.

CONCLUSIONS

%CDT are useful markers to screen for excessive alcohol use and for follow-up of abstinence. Most subjects with excessive alcohol use do not have a high AST:ALT ratio. Rather, the AST:ALT > 2 is suggestive of alcoholic cirrhosis. The performance of the %CDT to screen for heavy alcohol use is still not ideal. Further research to identify the noninvasive marker(s) (i.e., using proteomic or metabolomics approach) should be considered.

Unrecognized chronic hepatitis C virus infection among baby boomers in the emergency department

The Centers for Disease Control and Prevention and U.S. Preventive Services Task Force have highlighted public screening as an essential strategy for increasing hepatitis C virus (HCV) detection in persons born between 1945 and 1965 ("baby boomers"). Because earlier HCV screening efforts have not targeted emergency department (ED) baby boomer patients, we describe early experience with integrated opt-out HCV antibody (Ab) screening of medically stable baby boomers presenting to an urban academic ED. We performed HCV Ab testing 24 hours per day and confirmed positive test results using polymerase chain reaction (PCR). The primary outcome was prevalence of unrecognized HCV infection. Among 2,325 unique HCV-unaware baby boomers, 289 (12.7%) opted out of HCV screening. We performed HCV Ab tests on 1,529 individuals, of which 170 (11.1%) were reactive. Among Ab reactive cases, follow-up PCR was performed on 150 (88.2%), of which 102 (68.0%) were confirmed RNA positive. HCV Ab reactivity was more likely in males compared to females (14.7% vs. 7.4%; P<0.001), African Americans compared to whites (13.3% vs. 8.8%; P=0.010), and underinsured/ uninsured patients compared to insured patients (16.8%/16.9% vs. 5.0%; P=0.001). Linkage-to-care service activities were recorded for 100 of the 102 confirmed cases. Overall, 54 (54%) RNA-positive individuals were successfully contacted by phone within five call-back attempts. We confirmed initial follow-up appointments for 38 (70.4%) RNA-positive individuals successfully contacted, and 21 (55.3%) individuals with confirmed appointments attended their initial visit with a liver specialist; 3 (7.9%) are awaiting an upcoming scheduled appointment.

CONCLUSION

We observed high prevalence of unrecognized chronic HCV infection in this series of baby boomers presenting to the ED, highlighting the ED as an important venue for high-impact HCV screening and linkage to care.

Costs and absence of HCV-infected employees by disease stage

OBJECTIVES

Quantify the costs and absenteeism associated with stages of the Hepatitis C virus (HCV).

STUDY DESIGN

Retrospective analysis of the HCMS integrated database from multiple geographically diverse, US-based employers with employee information on medical, prescription, and absenteeism claims.

METHODS

Employee data were extracted from July 2001-March 2013. Employees with HCV were identified by ICD-9-CM codes and classified into disease severity cohorts using diagnosis/procedure codes assigning the first date of most severe claim as the index date. Non-HCV employees (controls) were assigned random index dates. Inclusion required 6-month pre-/post-index eligibility. Medical, prescription, and absenteeism cost and time were analyzed using two-part regression (logistic/generalized linear) models, controlling for potentially confounding factors. Costs were inflation adjusted to September 2013.

RESULTS

All direct costs comparisons were statistically significant (p ≤ 0.05) with mean medical costs of $1813 [SE = $3] for controls (n = 727,588), $4611 [SE = $211] for non-cirrhotic (n = 1007), $4646 [SE = $721] for compensated cirrhosis (CC, n = 87), $12,384 [SE = $1122] for decompensated cirrhosis (DCC, n = 256), $33,494 [SE = $11,753] for hepatocellular carcinoma (HCC, n = 17) and $97,724 [SE = $32,437] for liver transplant (LT, n = 19) cohorts. Mean short-term disability days/costs were significantly greater for the non-cirrhotic (days = 2.03 [SE = 0.36]; $299 [SE = $53]), DCC (days = 6.20 [SE = 1.36]; $763 [SE = $169]), and LT cohorts (days = 21.98 [SE = 8.21]; $2537 [SE = $972]) compared to controls (days = 1.19 [SE = 0.01]; $155 [SE = $1]). Mean sick leave costs were significantly greater for non-cirrhotic ($373 [SE = $22]) and DCC ($460 [SE = $54]) compared to controls ($327 [SE = $1]).

CONCLUSIONS

Employees with HCV were shown to have greater direct and indirect costs compared to non-HCV employee controls. Costs progressively increased in the more severe HCV disease categories. Slowing or preventing disease progression may avert the costs of more severe liver disease stages and enable employees with HCV to continue as productive members of the workforce.

Impact of birth cohort screening for hepatitis C

Hepatitis C (HCV) is a leading cause of liver-related complications, and the burden of liver disease is expected to increase. Given the over-representation of HCV-related liver disease in persons born between 1945 and 1965, and the failure of risk-based screening to identify many infected persons, birth cohort screening has been advocated and endorsed by both the Centers for Disease Control and United States Preventive Services Task Force, regardless of the presence of risk factors. Birth cohort testing is more cost-effective than risk-based screening especially when those with more advanced disease are given priority for treatment. Several barriers exist at the patient and provider level that need to be overcome to fully realize the potential benefit of birth cohort screening in reducing HCV-related morbidity and mortality.

Patients' preferences and health utility assessment with SF-6D and EQ-5D in patients with chronic hepatitis C treated with sofosbuvir regimens

BACKGROUND

Health utilities measure patients' preferences for a health state.

AIM

To assess health utilities for sofosbuvir-containing therapy for chronic hepatitis C.

METHODS

The SF-6D utility scores were derived from the SF-36 instrument administered at baseline, during and post-treatment to participants of the previously reported clinical trials of sofosbuvir. EQ-5D utility scores were also approximated from the SF-36 using a regression model.

RESULTS

Nine hundred and ninety-four patients were enrolled. Baseline SF-6D and EQ-5D scores were 0.66 ± 0.13 and 0.71 ± 0.22, respectively (the POSITRON trial), 0.71 ± 0.16 and 0.76 ± 0.23 (FISSION), 0.70 ± 0.14 and 0.75 ± 0.22 (FUSION), 0.72 ± 0.15 and 0.79 ± 0.22 (NEUTRINO). In all studies, SF-6D and EQ-5D scores were highly correlated with each other. (r = 0.83-0.87, P < 0.0001). After 12 weeks, patients receiving sofosbuvir + ribavirin (POSITRON) had similar utility scores to placebo (P > 0.05). Patients receiving 12 and 16 weeks of sofosbuvir + ribavirin (FUSION) had similar utility scores (P > 0.05). In FISSION, patients receiving sofosbuvir + ribavirin had significantly better utilities compared to patients receiving interferon + ribavirin (P < 0.001). Patients receiving sofosbuvir + ribavirin + interferon (NEUTRINO) had a decrease in utilities during treatment (SF-6D: from 0.72 to 0.62, EQ-5D: 0.79 to 0.65; P < 0.0001) similar to that observed in patients receiving pegylated interferon + ribavirin for 24 weeks in FISSION (0.72 to 0.62 and 0.77 to 0.65, respectively, P < 0.0001). After 12 weeks post-treatment, patients with SVR (FUSION) had improvement in SF-6D (+0.026 from baseline, P = 0.013) and EQ-5D (+0.043, P = 0.013). In multivariate analyses, baseline depression, anxiety, fatigue, insomnia and treatment-related anaemia were the most consistent predictors of utilities.

CONCLUSIONS

Patients' health utilities are minimally impacted by sofosbuvir + ribavirin treatment, as compared to interferon-based, therapy regardless of treatment duration. Clinical trials' numbers: NCT01542788 (POSITRON), NCT01497366 (FISSION), NCT01604850 (FUSION), NCT01641640 (NEUTRINO).

Patient-reported outcomes assessment in chronic hepatitis C treated with sofosbuvir and ribavirin: the VALENCE study

BACKGROUND & AIM

Interferon (IFN) negatively impacts patients' well-being and patient-reported outcomes (PROs). Our aim was to assess PROs during treatment with an IFN-free regimen [sofosbuvir (SOF)+ribavirin (RBV)].

METHODS

Four PRO questionnaires [Short Form-36 (SF-36), Chronic Liver Disease Questionnaire-HCV (CLDQ-HCV), Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F), Work Productivity and Activity Index: Specific Health Problem (WPAI:SHP)] were administered at baseline, end-of-treatment and post-treatment to 334 HCV genotype 2 and 3 patients (naïve or treatment-experienced) enrolled in the VALENCE study. Of these, 250 genotype 3 patients were treated for 24 weeks while 73 genotype 2 and 11 genotype 3 patients received 12 weeks of treatment.

RESULTS

Baseline PRO scores were similar between the two arms of the study. Throughout and after treatment, patients receiving 12 or 24 weeks had similar FACIT-F, CLDQ-HCV, SF-36 and WPAI:SHP scores (all p>0.05). Compared to their own baseline scores, patients receiving SOF+RBV experienced modest declines in some aspects of SF-36, CLDQ-HCV, fatigue and WPAI:SHP scores (p = 0.04 to <0.0001). By follow-up week 12, all PRO scores returned to the pre-treatment levels (p>0.05). In patients achieving SVR-12 (regardless of the regimen), significant improvements were noted in general health (p = 0.0004), CLDQ-HCV (p<0.0001), fatigue (p = 0.005), emotional well-being (p<0.0001) and physical component summary score of SF-36 (p = 0.0022). In multivariate analysis, baseline depression, fatigue, insomnia, cirrhosis, and treatment-related adverse events were the most consistent predictors of PRO impairment (all p<0.05).

CONCLUSIONS

PROs are minimally impacted by SOF+RBV regimens. An additional 12 weeks of treatment does not substantially add to the PRO burden.

Ending hepatitis C in the United States: the role of screening

The US faces at least two distinct epidemics of hepatitis C virus infection (HCV), and due largely to revised screening recommendations and novel therapeutic agents, corresponding opportunities. As only 49%-75% of HCV-infected persons in the US are aware of their infection, any chance of addressing HCV in the US is dependent upon screening to identify undiagnosed infections. Most HCV in the US consists of longstanding infections among persons born during 1945-1965 who are suffering escalating rates of liver-related morbidity and mortality. Mathematical modeling supports aggressive action to reach and treat these persons to minimize the subsequent burden of advanced liver disease on patients and the health care system. Incident infection is primarily among persons who inject drugs, less than 10% of whom have been treated for HCV. Expanded screening and treatment of active persons who inject drugs raises the prospect of utilizing "treatment as prevention" to stem the tide of incident HCV infections in this population. HIV-positive men who have sex with men (MSM) represent a population at risk for sexually transmitted HCV who may also benefit from adjusted screening guidelines to identify both acute and chronic infections. Prisoners also represent a critical population for aggressive screening and treatment. Finally, the two-stage testing algorithm for HCV diagnosis is problematic and difficult for patients and providers to navigate. While emerging therapeutics raise the prospect of reducing HCV-related morbidity and mortality, as well as eliminating new infections, major barriers remain with regard to identifying infections, improving access to treatment, and ensuring payer coverage of costly new therapeutic regimens.

The treatment cascade for chronic hepatitis C virus infection in the United States: a systematic review and meta-analysis

Background

Identifying gaps in care for people with chronic hepatitis C virus (HCV) infection is important to clinicians, public health officials, and federal agencies. The objective of this study was to systematically review the literature to provide estimates of the proportion of chronic HCV-infected persons in the United States (U.S.) completing each step along a proposed HCV treatment cascade: (1) infected with chronic HCV; (2) diagnosed and aware of their infection; (3) with access to outpatient care; (4) HCV RNA confirmed; (5) liver fibrosis staged by biopsy; (6) prescribed HCV treatment; and (7) achieved sustained virologic response (SVR).

Methods

We searched MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews for articles published between January 2003 and July 2013. Two reviewers independently identified articles addressing each step in the cascade. Studies were excluded if they focused on specific populations, did not present original data, involved only a single site, were conducted outside of the U.S., or only included data collected prior to 2000.

Results

9,581 articles were identified, 117 were retrieved for full text review, and 10 were included. Overall, 3.5 million people were estimated to have chronic HCV in the U.S. Fifty percent (95% CI 43–57%) were diagnosed and aware of their infection, 43% (CI 40–47%) had access to outpatient care, 27% (CI 27–28%) had HCV RNA confirmed, 17% (CI 16–17%) underwent liver fibrosis staging, 16% (CI 15–16%) were prescribed treatment, and 9% (CI 9–10%) achieved SVR.

Conclusions

Continued efforts are needed to improve HCV care in the U.S. The proposed HCV treatment cascade provides a framework for evaluating the delivery of HCV care over time and within subgroups, and will be useful in monitoring the impact of new screening efforts and advances in antiviral therapy.

National estimates of healthcare utilization by individuals with hepatitis C virus infection in the United States

BACKGROUND

Hepatitis C virus (HCV) infection is a major public health problem in the United States. Although prior studies have evaluated the HCV-related healthcare burden, these studies examined a single treatment setting and did not account for the growing "baby boomer" population (individuals born during 1945-1965).

METHODS

Data from the National Ambulatory Medical Care Survey, the National Hospital Ambulatory Medical Care Survey, and the Nationwide Inpatient Sample were analyzed. We sought to characterize healthcare utilization by individuals infected with HCV in the United States, examining adult (≥18 years) outpatient, emergency department (ED), and inpatient visits among individuals with HCV diagnosis for the period 2001-2010. Key subgroups included persons born before 1945 (older), between 1945 and 1965 (baby boomer), and after 1965 (younger).

RESULTS

Individuals with HCV infection were responsible for >2.3 million outpatient, 73 000 ED, and 475 000 inpatient visits annually. Persons in the baby boomer cohort accounted for 72.5%, 67.6%, and 70.7% of care episodes in these settings, respectively. Whereas the number of outpatient visits remained stable during the study period, inpatient admissions among HCV-infected baby boomers increased by >60%. Inpatient stays totaled 2.8 million days and cost >$15 billion annually. Nonwhites, uninsured individuals, and individuals receiving publicly funded health insurance were disproportionately affected in all healthcare settings.

CONCLUSIONS

Individuals with HCV infection are large users of outpatient, ED, and inpatient health services. Resource use is highest and increasing in the baby boomer generation. These observations illuminate the public health burden of HCV infection in the United States.

Minimal impact of sofosbuvir and ribavirin on health related quality of life in chronic hepatitis C (CH-C)

BACKGROUND & AIMS

Treatment for CH-C contains interferon with substantial associated side effects and health-related quality of life (HRQL) impairment. Currently, there is no published data assessing the impact of interferon-free regimens on HRQL. The aim is to report the HRQL of patients who participated in clinical trials of sofosbuvir (SOF) for CH-C.

METHODS

CH-C patients were treated with sofosbuvir (SOF), pegylated interferon (PegIFN), ribavirin (RBV), or placebo in different combinations and duration (POSITRON, FISSION, FUSION, and NEUTRINO phase III trials). HRQL was assessed using SF-36 at baseline, during treatment, at the end of treatment, and at follow-up, and compared between treatment arms.

RESULTS

HRQL scores decreased over the course of treatment for all treatment arms in all studies; however, patients returned to their baseline score by the end of follow-up. Compared to placebo, SOF and RBV was not associated with HRQL impairment (POSITRON). Compared to SOF and RBV, HRQL was significantly more impaired in the PegIFN and RBV arm (FISSION). For those treated with SOF and RBV, there was no difference in HRQL between 12 weeks or 16 weeks of treatment (FUSION). Multivariate analysis demonstrated that depression, fatigue, and insomnia were important predictors of patients' HRQL prior, during or after treatment. Additionally, anemia and receiving interferon were predictors of HRQL impairment during treatment. Achieving sustained virologic response after 12 weeks of follow-up (SVR-12) with SOF and RBV was associated with improvement in HRQL scores from baseline.

CONCLUSIONS

Treatment-related HRQL impairment during SOF and RBV regimen is mild, and does not increase with longer treatment duration. Achieving SVR-12 with SOF and RBV is associated with an improvement in HRQL.

Treatment as prevention and cure towards global eradication of hepatitis C virus

The availability of curative, direct-acting antiviral drugs against hepatitis C virus (HCV) sparks an ethical call for HCV eradication and provides essential tools to spearhead the effort. Challenges include increasing awareness of the chronic hepatitis C epidemic, garnering sufficient public, private, and governmental financial will to invest in the necessary resources, developing pangenotypic drug regimens for global application, and mitigating ethical concerns. To achieve these goals, stakeholders including clinicians, public health professionals, legislators, advocates, and industry can employ a variety of strategies such as increasing HCV screening, implementing treatment as prevention, and improving linkage to care, as well as developing innovative pricing and payment solutions, stimulating innovation through local drug development in high-prevalence regions, continuing vaccine development, and creating efficiencies in the marketing and distribution of educational materials and drug treatments.