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Jiang X, Vouri SM, Diaby V, Lo-Ciganic W, Parker R, Park H. Health care utilization and costs associated with direct-acting antivirals for patients with substance use disorders and chronic hepatitis C. J Manag Care Spec Pharm 2021; 27:1388-1402. [PMID: 34595949 DOI: 10.18553/jmcp.2021.27.10.1388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
BACKGROUND: Patients with substance use disorders (SUD) and chronic hepatitis C virus infection (HCV) have limited access to direct-acting antivirals (DAAs) due to multilevel issues related to providers (eg, concern about reinfection); patients (eg, refusal); payers (eg, prior authorization); and health system structure, although clinical guidelines recommend timely DAA treatment for patients with SUD and HCV. Effects of DAAs on real-world health care utilization and costs among these patients is unknown. OBJECTIVE: To compare changes in medical service utilization and costs related to liver, SUD, and all-cause morbidity in patients with SUD and HCV treated with DAAs (DAA group) vs not treated with DAAs (non-DAA group). METHODS: We conducted a retrospective cohort study using MarketScan Commercial and Medicare Supplemental Claims databases (2012-2018) for newly diagnosed HCV treatment-naive adults with SUD. We used difference-in-differences analyses, stratified by cirrhosis status, to determine the adjusted ratio of rate ratio (RoRR) to assess the difference in the relative changes from the pre- to posttreatment periods between the 2 groups. RESULTS: 6,266 patients with SUD and HCV were identified. Of these patients who also had cirrhosis (n = 607), 49% (n = 298) initiated DAA therapy for HCV, whereas of those without cirrhosis (n = 5,659), 22% (n = 1,219) initiated DAAs. For patients with cirrhosis (n = 607), the liver-related costs decreased by $6,213 (95% CI = -$8,571, -$3,856) for the DAA group and $1,585 (95% CI = -$4,659, $1,490) for the non-DAA group. The relative decreases in the rate of liver-related costs were larger for the DAA group than for the non-DAA group, and the relative changes between groups were significantly different (RoRR = 0.37, 95% CI = 0.19-0.73). There was no difference in the relative changes after DAAs in the rate of SUD-related visits/costs or all-cause costs between the 2 groups. For patients without cirrhosis (n = 5,659), a similar association was observed. Besides, the relative decreases in the rate of SUD-related emergency department (ED) visits (RoRR = 0.54, 95% CI = 0.38-0.77); SUD-related long-term care visits (RoRR = 0.30, 95% CI = 0.13-0.73); all-cause ED visits (RoRR = 0.75, 95% CI = 0.64-0.88); and all-cause long term-care visits (RoRR = 0.36, 95% CI = 0.18-0.72) were larger in the DAA group than in the non-DAA group. CONCLUSIONS: DAAs are associated with a significant decrease in the rate of SUD-related ED visits and liver-related costs without increasing the rate of all-cause costs among patients with SUD and HCV, suggesting that the benefits of DAAs extended beyond liver-related outcomes, especially in this disadvantaged population. DISCLOSURES: Research reported in this publication was supported in part by the National Institute on Drug Abuse of the National Institutes of Health (K01DA045618). The funder did not have a role in the design, the execution, the analyses, the interpretation of the data, or the decision to submit the results of this study. The authors have no potential conflicts of interest.
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Affiliation(s)
- Xinyi Jiang
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville
| | - Scott Martin Vouri
- Department of Pharmaceutical Outcomes & Policy, Center for Drug Evaluation and Safety (CoDES), College of Pharmacy, University of Florida, Gainesville
| | - Vakaramoko Diaby
- Department of Pharmaceutical Outcomes & Policy, Center for Drug Evaluation and Safety (CoDES), College of Pharmacy, University of Florida, Gainesville
| | - Weihsuan Lo-Ciganic
- Department of Pharmaceutical Outcomes & Policy, Center for Drug Evaluation and Safety (CoDES), College of Pharmacy, University of Florida, Gainesville
| | - Robert Parker
- Department of Biostatistics, College of Public Health & Health Professions, College of Medicine, University of Florida, Gainesville
| | - Haesuk Park
- Department of Pharmaceutical Outcomes & Policy, Center for Drug Evaluation and Safety (CoDES), College of Pharmacy, University of Florida, Gainesville
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Jiang X, Parker RL, Vouri SM, Lo-Ciganic W, Diaby V, Henry L, Park H. Cascade of Hepatitis C Virus Care Among Patients With Substance Use Disorders. Am J Prev Med 2021; 61:576-584. [PMID: 34210584 PMCID: PMC8455419 DOI: 10.1016/j.amepre.2021.04.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 04/02/2021] [Accepted: 04/07/2021] [Indexed: 01/02/2023]
Abstract
INTRODUCTION Hepatitis C virus testing is recommended for people at high risk for infection, including those with substance use disorders. Little is known about the cascade of hepatitis C virus care (including testing, diagnosis, and treatments) among patients with substance use disorders in real-world clinical practice. This study aims to characterize the hepatitis C virus cascade of care and identify the factors associated with hepatitis C virus testing and diagnosis among Florida Medicaid beneficiaries with substance use disorders. METHODS A retrospective cohort analysis of Florida Medicaid data (2013-2018) was conducted in 2020 for patients aged 18-64 years with newly diagnosed substance use disorders (year 2012 was used to ascertain 1-year previous enrollment). A generalized estimating equation identified the factors associated with hepatitis C virus testing; a multivariable logistic model identified the factors associated with hepatitis C virus diagnosis. RESULTS Of the 156,770 patients with substance use disorders, 18% were tested for hepatitis C virus at least once. Among the tested patients, 8% had hepatitis C virus diagnoses. Among the 2,177 patients having a hepatitis C virus diagnosis, 11% initiated hepatitis C virus treatments, and 96% of them completed the hepatitis C virus treatments. Factors associated with being less likely to receive hepatitis C virus testing included being male (AOR=0.73, 95% CI=0.71, 0.75) and White (AOR=0.85, 95% CI=0.83, 0.87), whereas individuals who were male (AOR=1.49, 95% CI=1.35, 1.66) and White (AOR=2.71, 95% CI=2.38, 3.08) were more likely to be diagnosed with hepatitis C virus. The odds of receiving hepatitis C virus testing significantly increased annually (AOR=1.06, 95% CI=1.05, 1.07). CONCLUSIONS Future studies are warranted to investigate the barriers to access hepatitis C virus testing and treatment among Florida Medicaid beneficiaries with substance use disorders, especially for White male individuals.
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Affiliation(s)
- Xinyi Jiang
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Robert L Parker
- Department of Biostatistics, College of Public Health and Health Professions & College of Medicine, University of Florida, Gainesville, Florida
| | - Scott Martin Vouri
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, Florida; Center for Drug Evaluation and Safety, University of Florida, Gainesville, Florida
| | - Weihsuan Lo-Ciganic
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, Florida; Center for Drug Evaluation and Safety, University of Florida, Gainesville, Florida
| | - Vakaramoko Diaby
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, Florida; Center for Drug Evaluation and Safety, University of Florida, Gainesville, Florida
| | - Linda Henry
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Haesuk Park
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, Florida; Center for Drug Evaluation and Safety, University of Florida, Gainesville, Florida.
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Park H, Jiang X, Song HJ, Lo Re V, Childs-Kean LM, Lo-Ciganic WH, Cook RL, Nelson DR. The Impact of Direct-Acting Antiviral Therapy on End-Stage Liver Disease Among Individuals with Chronic Hepatitis C and Substance Use Disorders. Hepatology 2021; 74:566-581. [PMID: 33544904 PMCID: PMC8339171 DOI: 10.1002/hep.31732] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 12/22/2020] [Accepted: 01/19/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIMS Our aim was to evaluate the impact of direct-acting antivirals (DAAs) on decompensated cirrhosis (DCC) and HCC in patients with chronic HCV and substance use disorder (SUD) compared with those without an SUD. APPROACH AND RESULTS This retrospective cohort study used the MarketScan database (2013-2018) to identify 29,228 patients with chronic HCV, where 22% (n = 6,385) had ≥1 SUD diagnosis. The inverse probability of treatment weighted multivariable Cox proportional hazard models were used to compare the risk of developing DCC and HCC. Among the those who were noncirrhotic, treatment reduced the DCC risk among SUD (adjusted hazard ratio [aHR] 0.13; 95% CI, 0.06-0.30) and non-SUD (aHR 0.11; 95% CI, 0.07-0.18), whereas the risk for HCC was not reduced for the SUD group (aHR 0.91; 95% CI, 0.33-2.48). For those with cirrhosis, compared with patients who were untreated, treatment reduced the HCC risk among SUD (aHR, 0.33; 95% CI, 0.13-0.88) and non-SUD (aHR, 0.40; 95% CI, 0.25-0.65), whereas the risk for DCC was not reduced for the SUD group (aHR, 0.64; 95% CI, 0.37-1.13). Among patients with cirrhosis who were untreated, the SUD group had a higher risk of DCC (aHR, 1.52; 95% CI, 1.03-2.24) and HCC (aHR, 1.69; 95% CI, 1.05-2.72) compared with non-SUD group. CONCLUSIONS Among the HCV SUD group, DAA treatment reduced the risk of DCC but not HCC for those who were noncirrhotic, whereas DAA treatment reduced the risk of HCC but not DCC for those with cirrhosis. Among the nontreated, patients with an SUD had a significantly higher risk of DCC and HCC compared with those without an SUD. Thus, DAA treatment should be considered for all patients with HCV and an SUD while also addressing the SUD.
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Affiliation(s)
- Haesuk Park
- Pharmaceutical Outcomes and PolicyCollege of PharmacyUniversity of FloridaGainesvilleFL
| | - Xinyi Jiang
- Pharmaceutical Outcomes and PolicyCollege of PharmacyUniversity of FloridaGainesvilleFL
| | - Hyun Jin Song
- Pharmaceutical Outcomes and PolicyCollege of PharmacyUniversity of FloridaGainesvilleFL
| | - Vincent Lo Re
- Division of Infectious DiseasesDepartment of Medicine and Center for Clinical Epidemiology and BiostatisticsDepartment of Biostatistics, Epidemiology, and InformaticsPerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
| | - Lindsey M Childs-Kean
- Pharmacotherapy and Translational ResearchCollege of PharmacyUniversity of FloridaGainesvilleFL
| | - Wei-Hsuan Lo-Ciganic
- Pharmaceutical Outcomes and PolicyCollege of PharmacyUniversity of FloridaGainesvilleFL
| | - Robert L Cook
- Department of MedicineUniversity of FloridaGainesvilleFL
| | - David R Nelson
- Department of MedicineUniversity of FloridaGainesvilleFL
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Reader SW, Kim HS, El-Serag HB, Thrift AP. Persistent Challenges in the Hepatitis C Virus Care Continuum for Patients in a Central Texas Public Health System. Open Forum Infect Dis 2020; 7:ofaa322. [PMID: 32875004 PMCID: PMC7452366 DOI: 10.1093/ofid/ofaa322] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 07/28/2020] [Indexed: 12/14/2022] Open
Abstract
Background Direct-acting antiviral treatment regimens cure >95% of chronic hepatitis C virus (HCV) infections, but recent studies indicate that <25% of patients in the United States receive treatment. Patients need to overcome barriers on the steps of the care continuum in order to be prescribed treatment. We aimed to examine the steps of the HCV care continuum up to prescription of HCV therapy among patients receiving care within a large safety net health care system in Houston, Texas. Methods We used electronic medical records to identify patients with positive screening tests for HCV antibodies between July 1, 2017, and June 30, 2018, and abstracted data on their advancement through the care continuum for HCV. We used logistic regression to identify factors associated with patient navigation through the continuum. Results Of the 2450 patients screening positive for HCV antibodies, 2016 (82.3%) received quantitative RNA testing, of whom 1081 (53.6%) exhibited chronic infection. Providers referred 915 (84.6%) to specialty care for evaluation, 540 of these patients (50.0%) received their specialist evaluation, and 299 (27.7%) received a prescription for treatment. Patients with history of substance use were less likely to be prescribed treatment (adjusted odds ratio, 0.66; 95% CI, 0.49–0.88). Conclusions We found substantial attrition at each stage of the HCV care continuum. In particular, history of substance abuse was a predictor of nonprescription. Challenges in the care continuum motivate increased provider education as well as the adoption of recent innovations in patient care.
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Affiliation(s)
- Shane W Reader
- Section of Epidemiology & Population Sciences, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Hyun-seok Kim
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Hashem B El-Serag
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Aaron P Thrift
- Section of Epidemiology & Population Sciences, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
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