1
|
Abboud Y, Shah VP, Bebawy M, Al-Khazraji A, Hajifathalian K, Gaglio PJ. Mapping the Hidden Terrain of Hepatocellular Carcinoma: Exploring Regional Differences in Incidence and Mortality across Two Decades by Using the Largest US Datasets. J Clin Med 2024; 13:5256. [PMID: 39274469 PMCID: PMC11396507 DOI: 10.3390/jcm13175256] [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: 07/29/2024] [Revised: 08/23/2024] [Accepted: 08/29/2024] [Indexed: 09/16/2024] Open
Abstract
Background: There is an observed variation in the burden of hepatocellular carcinoma (HCC) across different US populations. Our study aims to comprehensively assess variations in HCC incidence and mortality rates across different regions of the US. Understanding these geographical differences is crucial, given prior evidence indicating variations in the incidence of viral hepatitis and metabolic dysfunction-associated steatotic liver disease and varying access to curative HCC treatment among states. Methods: HCC age-adjusted incidence rates between 2001 and 2021 were obtained from the United States Cancer Statistics (USCS) database (which covers approximately 98% of the US population). HCC age-adjusted mortality rates between 2000 and 2022 were obtained from the National Center of Health Statistics (NCHS) database (covering approximately 100% of the US population). The rates were categorized by US geographical region into West, Midwest, Northeast, and South. Incidence rates were also categorized by race/ethnicity. Time trends [annual percentage change (APC) and average APC (AAPC)] were estimated by using Joinpoint Regression via the weighted Bayesian Information Criteria (p < 0.05). Results: Between 2001 and 2021, there were 491,039 patients diagnosed with HCC in the US (74.2% males). The highest incidence rate per 100,000 population was noted in the West (7.38), followed by the South (6.85). Overall incidence rates increased between 2001 and 2015 and then significantly decreased until 2021 (APC = -2.29). Most cases were in the South (38.8%), which also had the greatest increase in incidence (AAPC = 2.74). All four geographical regions exhibited an overall similar trend with an increase in incidence over the first 10-15 years followed by stable or decreasing rates. While stratification of the trends by race/ethnicity showed slight variations among the regions and groups, the findings are largely similar to all race/ethnic groups combined. Between 2000 and 2022, there were 370,450 patients whose death was attributed to HCC in the US (71.6% males). The highest mortality rate per 100,000 population was noted in the South (5.02), followed by the West (4.99). Overall mortality rates significantly increased between 2000 and 2013 (APC = 1.90), then stabilized between 2013 and 2016, and then significantly decreased till 2022 (APC = -1.59). Most deaths occurred in the South (35.8%), which also had the greatest increase in mortality (AAPC = 1.33). All four geographical regions followed an overall similar trend, with an increase in mortality over the first 10-15 years, followed by stable or decreasing rates. Conclusions: Our analysis, capturing about 98% of the US population, demonstrates an increase in HCC incidence and mortality rates in all geographical regions from 2000 to around 2014-2016, followed by stabilizing and decreasing incidence and mortality rates. We observed regional variations, with the highest incidence and mortality rates noted in the West and South regions and the fastest increase in both incidence and mortality noted in the South. Our findings are likely attributable to the introduction of antiviral therapy. Furthermore, demographic, socioeconomic, and comorbid variability across geographical regions in the US might also play a role in the observed trends. We provide important epidemiologic data for HCC in the US, prompting further studies to investigate the underlying factors responsible for the observed regional variations in HCC incidence and mortality.
Collapse
Affiliation(s)
- Yazan Abboud
- Department of Internal Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, USA
| | - Vraj P Shah
- Department of Internal Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, USA
| | - Michael Bebawy
- Department of Internal Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, USA
| | - Ahmed Al-Khazraji
- Division of Gastroenterology and Hepatology, Rutgers New Jersey Medical School, Newark, NJ 07103, USA
| | - Kaveh Hajifathalian
- Division of Gastroenterology and Hepatology, Rutgers New Jersey Medical School, Newark, NJ 07103, USA
| | - Paul J Gaglio
- Division of Gastroenterology and Hepatology, Rutgers New Jersey Medical School, Newark, NJ 07103, USA
| |
Collapse
|
2
|
Kusnik A, Najim M, Renjith KM, Vyas C, Renjithlal SLM, Alweis R. The Influence of Urbanization on the Patterns of Hepatocellular Carcinoma Mortality From 1999 to 2020. Gastroenterology Res 2024; 17:116-125. [PMID: 38993549 PMCID: PMC11236338 DOI: 10.14740/gr1743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Accepted: 06/15/2024] [Indexed: 07/13/2024] Open
Abstract
Background Hepatocellular carcinoma (HCC) remains one of the leading causes of cancer-related fatalities despite early diagnosis and treatment progress, creating a significant public health issue in the United States. This investigation utilized death certificate data from the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research (CDC WONDER) database to investigate HCC mortality patterns and death locations from 1999 to 2020. The objective was to analyze trends in HCC mortality across different population groups, considering the impact of urbanicity. Methods In this study, death certificate data obtained from the CDC WONDER database were utilized to investigate the trends in HCC mortality and location of death between 1999 and 2020. The annual percent change (APC) method was applied to estimate the average annual rate of change during the specified timeframe for the relevant health outcome. Furthermore, including data on the location of death and geographic areas allowed us to gain deeper insights into the patterns and characteristics of HCC and its impact on different regions. Results Between 1999 and 2020, there were 184,073 reported deaths attributed to HCC, and data on the location of death were available for all cases. Most deaths occurred during inpatient admissions (34.93%) or at home (41.19%). The study also found that the highest age-adjusted mortality rate (AAMR) for HCC was observed among male patients, particularly among those identified as Asian or Pacific Islander. Variations in AAMR were determined based on the level of urbanization or rurality of the area, with higher rates observed in more densely populated and urbanized regions. In contrast, less urbanized and populated areas experienced a profound increase in AAMR over the past two decades. Conclusion The HCC-related AAMRs have worsened over time for most ethnic groups, except for Asian or Pacific Islanders, which showed a reduction in APC despite having the worst AAMR. Although rural and less densely populated areas have substantially increased AAMR over the past two decades, more urbanized areas continued to have higher AAMR rates.
Collapse
Affiliation(s)
- Alexander Kusnik
- Department of Internal Medicine, Unity Hospital, Rochester, NY, USA
| | - Mostafa Najim
- Department of Internal Medicine, Unity Hospital, Rochester, NY, USA
| | | | - Charmee Vyas
- Division of Palliative Care, University of Kentucky, Lexington, KY, USA
| | | | - Richard Alweis
- Department of Internal Medicine, Unity Hospital, Rochester, NY, USA
| |
Collapse
|
3
|
Ramani A, Tapper EB, Griffin C, Shankar N, Parikh ND, Asrani SK. Hepatocellular Carcinoma-Related Mortality in the USA, 1999-2018. Dig Dis Sci 2022; 67:4100-4111. [PMID: 35288828 DOI: 10.1007/s10620-022-07433-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 12/13/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS The burden of hepatocellular carcinoma (HCC) is increasing, and certain groups may be at higher risk. METHODS We analyzed trends in HCC-related mortality in the USA (1999-2018) using national death data. Age-adjusted trends in death rates (annual percentage change, APC) were calculated using joinpoint regression analysis. RESULTS HCC-related death rates increased by 2.1% (95% CI 1.9 to 2.3) annually. Hepatitis C (HCV)-related HCC death rates increased from 1999 to 2012 (8.9%, 95% CI 7.6 to 10.2) followed by a -1.3% (95% CI -3.5 to 0.9) decrease annually. For adults > 65 years, HCV-related HCC death rates increased (7.3% annually, 95% CI 6.5 to 8.1), especially for rural areas (11.1% annually, 95% CI 6.9 to 15.5) with high rates among African-Americans and Hispanics. Increases in non-HCV-related HCC death rates were larger: 13.5% annually (95% CI 3.6 to 24.3, 2005-2010) followed by 4.2% annually (95% CI 2.3 to 6.2, 2010-2018). Annual rates of increase were similar for men (6.8%, 95% CI 5.9 to 7.8) and women (7.0%, 95% CI 5.5 to 8.4) from 1999 to 2018. Rate of increase across races was Whites 8.3% (95% CI 7.2 to 9.4, 1999-2018), African-Americans 11.2% (95% CI -6.6 to 32.3, 2015-2018), and Hispanics 3.7% (95% CI 1.0 to 6.5, 2012-2018). CONCLUSION HCC-related mortality has increased, driven by increases in non-HCV-related mortality with important demographic and regional trends. In addition, HCV-HCC mortality remains high particularly in older persons and those in rural areas despite advances in HCV therapy. These data underscore the need for targeted approaches to mitigate the burden of HCC-related mortality similar to efforts for other cancers.
Collapse
Affiliation(s)
- Azaan Ramani
- Baylor University Medical Center, Baylor Scott and White, 3410 Worth Street, Suite 860, Dallas, TX, 75246, USA
| | - Elliot B Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, Michigan, MI, USA.,Gastroenterology Section, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Connor Griffin
- Baylor University Medical Center, Baylor Scott and White, 3410 Worth Street, Suite 860, Dallas, TX, 75246, USA
| | - Nagasri Shankar
- Baylor University Medical Center, Baylor Scott and White, 3410 Worth Street, Suite 860, Dallas, TX, 75246, USA
| | - Neehar D Parikh
- Division of Gastroenterology and Hepatology, University of Michigan, Michigan, MI, USA
| | - Sumeet K Asrani
- Baylor University Medical Center, Baylor Scott and White, 3410 Worth Street, Suite 860, Dallas, TX, 75246, USA.
| |
Collapse
|
4
|
Du P, Yin X, Kong L, Jung J. A Telementoring Program and Hepatitis C Virus Care in Rural Patients. TELEMEDICINE REPORTS 2021; 2:143-147. [PMID: 34041510 PMCID: PMC8142682 DOI: 10.1089/tmr.2021.0001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/12/2021] [Indexed: 06/12/2023]
Abstract
Background: Rural patients with chronic hepatitis C virus (HCV) infection may be less likely to access HCV care than those in urban areas. A telementoring, task-shifting model has been implemented to address the unmet needs of HCV care. Evidence is needed on whether this intervention improves HCV care in rural HCV patients. Methods: We compared three key HCV care indicators among Medicare patients with chronic hepatitis C in 2014-2016 by urban-rural status between New Mexico with a telementoring program and Pennsylvania without such a program. We classified each patient's urban-rural status based on his or her ZIP code of residence. We used multivariable log-binomial regressions to examine the relative probability of receiving HCV care by urban and rural status in two states. Results: In New Mexico, 41.3% of HCV patients resided in rural areas (N = 1155). In Pennsylvania, rural patients accounted for 13.2% (N = 1775). The unadjusted overall rates of receiving HCV RNA or genotype testing within 12 months before HCV treatment were 76.1% in "rural-New Mexico" versus 73.3% in "rural-Pennsylvania," 66.2% in "urban-New Mexico," and 70.2% in "urban-Pennsylvania." Post-treatment HCV RNA testing rate was also high in "rural-New Mexico" (83.0%). After adjusting for demographic and clinical characteristics, "rural-New Mexico" HCV patients who received HCV treatment still had the highest probability of taking HCV RNA or genotype testing before HCV treatment, compared with other groups (relative risk [95% confidence interval]: 0.91 [0.84-1.00] in "rural-Pennsylvania," 0.85 [0.78-0.93] in "urban-New Mexico," and 0.93 [0.87-1.00] in "urban-Pennsylvania"). Conclusions: The telementoring program may help improve HCV care in rural patients.
Collapse
Affiliation(s)
- Ping Du
- Department of Medicine, College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania, USA
- Department of Public Health Sciences, College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania, USA
| | - Xin Yin
- Department of Public Health Sciences, College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania, USA
| | - Lan Kong
- Department of Public Health Sciences, College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania, USA
| | - Jeah Jung
- Department of Health Policy and Administration, College of Health and Human Development, The Pennsylvania State University, University Park, Pennsylvania, USA
| |
Collapse
|
5
|
Du P, Wang X, Kong L, Riley T, Jung J. Changing Urban-Rural Disparities in the Utilization of Direct-Acting Antiviral Agents for Hepatitis C in U.S. Medicare Patients, 2014-2017. Am J Prev Med 2021; 60:285-293. [PMID: 33221144 PMCID: PMC7855597 DOI: 10.1016/j.amepre.2020.08.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 08/26/2020] [Accepted: 08/30/2020] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The advent of direct-acting antiviral agents for treating hepatitis C virus infection has made hepatitis C virus elimination possible. Rural patients with hepatitis C virus infection may be less likely to access direct-acting antiviral agents, but the real-world evidence is scarce on urban-rural disparities in direct-acting antiviral agent utilization. METHODS This retrospective cohort study was conducted in 2019-2020 using Medicare data to examine urban-rural disparities in direct-acting antiviral agent utilization among newly diagnosed patients with hepatitis C virus infection in 2014-2016. Direct-acting antiviral agent use was defined as filling ≥1 prescription for direct-acting antiviral agents during 2014-2017, and patient's urban-rural status was classified on the basis of their ZIP code of residence. This study evaluated the associations between multilevel factors and direct-acting antiviral agent use with a focus on urban-rural disparities. It also assessed changes over time in urban-rural disparities in direct-acting antiviral agent utilization using multivariable cause-specific Cox regression analyses with time-varying hazard ratios. RESULTS Among 204,018 new patients with hepatitis C virus infection, about 30% received direct-acting antiviral agents during 2014-2017. Cumulative direct-acting antiviral agent use gradually increased over time in both urban and rural patients. However, the increase was greater in urban patients than in rural patients. In the first year of follow-up, rural patients had a similar rate of receiving direct-acting antiviral agents (adjusted hazard ratio=1.03, 95% CI=1.00, 1.07), but they were less likely to use direct-acting antiviral agents in later years than urban patients (adjusted hazard ratio=0.85, 95% CI=0.81, 0.90 in the second year, adjusted hazard ratio=0.82, 95% CI=0.76, 0.89 in the third year, and adjusted hazard ratio=0.76, 95% CI=0.64, 0.90 in the fourth year of follow-up). CONCLUSIONS This study reveals important gaps in hepatitis C virus treatment and suggests increasing urban-rural disparities in direct-acting antiviral agent utilization. Enhancing direct-acting antiviral agent uptake in rural populations with hepatitis C virus infection will help reduce hepatitis C virus‒related health disparities and reach the national goal of eliminating hepatitis C virus infection.
Collapse
Affiliation(s)
- Ping Du
- Department of Medicine, College of Medicine, Pennsylvania State University, Hershey, Pennsylvania; Department of Public Health Sciences, College of Medicine, Pennsylvania State University, Hershey, Pennsylvania.
| | - Xi Wang
- Department of Public Health Sciences, College of Medicine, Pennsylvania State University, Hershey, Pennsylvania
| | - Lan Kong
- Department of Public Health Sciences, College of Medicine, Pennsylvania State University, Hershey, Pennsylvania
| | - Thomas Riley
- Department of Medicine, College of Medicine, Pennsylvania State University, Hershey, Pennsylvania
| | - Jeah Jung
- Department of Health Policy and Administration, College of Health and Human Development, Pennsylvania State University, University Park, Pennsylvania
| |
Collapse
|
6
|
Rural-Urban Geographical Disparities in Hepatocellular Carcinoma Incidence Among US Adults, 2004-2017. Am J Gastroenterol 2021; 116:401-406. [PMID: 32976121 PMCID: PMC8136433 DOI: 10.14309/ajg.0000000000000948] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 08/28/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION To evaluate impact of urbanicity and household income on hepatocellular carcinoma (HCC) incidence among US adults. METHODS HCC incidence was evaluated by rural-urban geography and median annual household income using 2004-2017 Surveillance, Epidemiology, and End Results data. RESULTS Although overall HCC incidence was highest in large metropolitan regions, average annual percent change in HCC incidence was greatest among more rural regions. Individuals in lower income categories had highest HCC incidence and greatest average annual percent change in HCC incidence. DISCUSSION Disparities in HCC incidence by urbanicity and income likely reflect differences in risk factors, health-related behaviors, and barriers in access to healthcare services.
Collapse
|
7
|
Wong RJ, Kim D, Ahmed A, Singal AK. Patients with hepatocellular carcinoma from more rural and lower-income households have more advanced tumor stage at diagnosis and significantly higher mortality. Cancer 2021; 127:45-55. [PMID: 33103243 DOI: 10.1002/cncr.33211] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 08/10/2020] [Accepted: 08/12/2020] [Indexed: 01/18/2023]
Abstract
BACKGROUND Patients from rural and low-income households may have suboptimal access to liver disease care, which may translate into worse HCC outcomes. The authors provide a comprehensive update of HCC incidence and outcomes among US adults, focusing on the effect of rural geography and household income on tumor stage and mortality. METHODS The authors retrospectively evaluated adults with HCC using Surveillance, Epidemiology, and End Results data from 2004 to 2017. HCC incidence was reported per 100,000 persons and was compared using z-statistics. Tumor stage at diagnosis used the Surveillance, Epidemiology, and End Results staging system and was evaluated with multivariate logistic regression. HCC mortality was evaluated using Kaplan-Meier and multivariate Cox proportional hazards methods. RESULTS HCC incidence plateaued for most groups, with the exception of American Indians/Alaska Natives (2004-2017: APC, 4.17%; P < .05) and patients in the lowest household income category (<$40,000; 2006-2017: APC, 2.80%; P < .05). Compared with patients who had HCC in large metropolitan areas with a population >1 million, patients in more rural regions had higher odds of advanced-stage HCC at diagnosis (odds ratio, 1.10; 95% CI, 1.00-1.20; P = .04) and higher mortality (hazard ratio, 1.05; 95% CI, 1.01-1.08; P = .02). Compared with the highest income group (≥$70,000), patients with HCC who earned <$40,000 annually had higher odds of advanced-stage HCC (odds ratio, 1.15; 95% CI, 1.01-1.32; P = .03) and higher mortality (hazard ratio, 1.23; 95% CI, 1.16-1.31; P < .001). CONCLUSIONS Patients from rural regions and lower-income households had more advanced tumor stage at diagnosis and significantly higher HCC mortality. These disparities likely reflect suboptimal access to consistent high-quality liver disease care, including HCC surveillance.
Collapse
Affiliation(s)
- Robert J Wong
- Division of Gastroenterology and Hepatology, Veterans Affairs Palo Alto Health Care System, Palo Alto, California.,Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California
| | - Donghee Kim
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California
| | - Aijaz Ahmed
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California
| | - Ashwani K Singal
- Division of Gastroenterology and Hepatology, University of South Dakota, Sioux Falls, South Dakota
| |
Collapse
|
8
|
Evaluation of a Managed Surgical Consultation Network in Malawi. World J Surg 2020; 45:356-361. [PMID: 33026475 DOI: 10.1007/s00268-020-05809-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Access to surgery is a challenge for low-income countries like Malawi due to shortages of specialists, especially in rural areas. District hospitals (DH) cater for the immediate surgical needs of rural patients, sending difficult cases to central hospitals (CH), usually with no prior communication. METHODS In 2018, a secure surgical managed consultation network (MCN) was established to improve communication between specialist surgeons and anaesthetists at Queen Elizabeth and Zomba Central Hospitals, and surgical providers from nine DHs referring to these facilities. RESULTS From May to December 2018, DHs requested specialist advice on 249 surgical cases through the MCN, including anonymised images (52% of cases). Ninety six percent of cases received advice, with a median of two specialists answering. For 74% of cases, a first response was received within an hour, and in 68% of the cases, a decision was taken within an hour from posting the case on MCN. In 60% of the cases, the advice was to refer immediately, in 26% not to refer and 11% to possibly refer at a later stage. CONCLUSION The MCN facilitated quick access to consultations with specialists on how to manage surgical patients in remote rural areas. It also helped to prevent unnecessary referrals, saving costs for patients, their guardians, referring hospitals and the health system as a whole. With time, the network has had spillover benefits, allowing the Ministry of Health closer monitoring of surgical activities in the districts and to respond faster to shortages of essential surgical resources.
Collapse
|
9
|
Du P, Wang X, Kong L, Jung J. Can Telementoring Reduce Urban-Rural Disparities in Utilization of Direct-Acting Antiviral Agents? Telemed J E Health 2020; 27:488-494. [PMID: 32882154 DOI: 10.1089/tmj.2020.0090] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background: Expanding access to direct-acting antiviral agents (DAAs) for treating hepatitis C virus (HCV) infection is the national goal for HCV elimination, but important urban-rural disparities exist in DAA use. Evidence is needed to evaluate intervention efforts to reduce urban-rural disparities in DAA utilization. Methods: We used Medicare data to compare DAA use between urban HCV patients and rural HCV patients in two states: State A with a telementoring approach to train rural providers to treat HCV patients and State B without such an intervention. We focused on DAA utilization among newly diagnosed HCV patients in 2014-2016 and defined DAA use as filling at least one prescription of DAAs during 2014-2017. We classified patient's urban-rural status based on their ZIP code of residence. We assessed overtime changes in urban-rural disparities in DAA utilization for each state using multivariable cause-specific Cox regression analyses with time-varying hazard ratios. Results: Among 1,872 new HCV patients in State A, 135 (17.00%) rural patients and 243 (22.54%) urban patients received DAAs in 2014-2017. Although there was noticeable urban-rural disparities in DAA use during the first 24 months of follow-up (hazard ratios [HRs] = 0.73 [0.51 to 1.03] for 0-12 months and 0.61 [0.39 to 0.95] for 13-24 months), the disparities became nonsignificant afterward (HR = 1.06 [0.58 to 1.93] after 24 months). Most DAA users in rural areas (94, 70%) in State A received DAAs prescribed by primary care providers (PCPs). In State B, among 8,928 new HCV patients, 227 (18.22%) rural patients and 1,600 (20.83%) urban patients received DAAs in 2014-2017. Rural patients were less likely to receive DAAs over time (HR = 1.12 [0.93 to 1.36] in the first 12 months and HR = 0.62 [0.40 to 0.96] after 24 months). Only 81 (36%) DAA users in rural areas in State B were treated by PCPs. Conclusions: Our study suggests that the telementoring approach may help reduce urban-rural disparities in DAA utilization.
Collapse
Affiliation(s)
- Ping Du
- Department of Medicine and The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA.,Department of Public Health Sciences, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Xi Wang
- Department of Public Health Sciences, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Lan Kong
- Department of Public Health Sciences, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Jeah Jung
- Department of Health Policy and Administration, College of Health and Human Development, The Pennsylvania State University, University Park, Pennsylvania, USA
| |
Collapse
|
10
|
Rodriguez Villalvazo Y, McDanel JS, Beste LA, Sanchez AJ, Vaughan-Sarrazin M, Katz DA. Effect of travel distance and rurality of residence on initial surveillance for hepatocellular carcinoma in VA primary care patient with cirrhosis. Health Serv Res 2019; 55:103-112. [PMID: 31763691 DOI: 10.1111/1475-6773.13241] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To determine the relationship between travel distance and surveillance for hepatocellular carcinoma among veterans with cirrhosis. DATA SOURCES Veterans Health Administration (VHA) inpatient and outpatient administrative data were linked to geocoded enrollee files. CMS-VHA merged data were used to assess receipt of Medicare-financed non-VA imaging. STUDY DESIGN A retrospective cohort of US veterans diagnosed with cirrhosis between 2009 and 2015 was examined. First available abdominal imaging following the diagnosis of cirrhosis was analyzed separately as a function of travel distance to the nearest VA medical center (VAMC) and to the patient's assigned VA primary care provider. Veterans with dual use of Medicare and VA services were also examined for receipt of imaging outside of the VA. PRINCIPAL FINDINGS Veterans who resided more than 30 miles from the nearest VAMC were less likely to receive any imaging for HCC surveillance. Among dual users, increased travel distance between the patient's residence and nearest VAMC was associated with an increased likelihood of receiving any abdominal imaging at non-VA facilities. CONCLUSION Increased travel distance to the nearest VA medical center reduces the likelihood of receiving imaging for HCC surveillance in cirrhotic veterans. Future efforts should focus on reducing geographic barriers to HCC surveillance.
Collapse
Affiliation(s)
- Yolanda Rodriguez Villalvazo
- Center for Access and Delivery Research & Evaluation (CADRE), Iowa City VA Healthcare System, Iowa City, Iowa.,Iowa City VA Healthcare System, Iowa City, Iowa.,Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Jennifer S McDanel
- Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Lauren A Beste
- General Medicine Service and Health Services Research and Development, Seattle, Washington.,VA Puget Sound Health Care System, Seattle, Washington.,Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Antonio J Sanchez
- Department of Gastroenterology and Hepatology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Mary Vaughan-Sarrazin
- Center for Access and Delivery Research & Evaluation (CADRE), Iowa City VA Healthcare System, Iowa City, Iowa.,Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - David A Katz
- Center for Access and Delivery Research & Evaluation (CADRE), Iowa City VA Healthcare System, Iowa City, Iowa.,Iowa City VA Healthcare System, Iowa City, Iowa.,Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| |
Collapse
|
11
|
Sinclair M. Controversies in Diagnosing Sarcopenia in Cirrhosis-Moving from Research to Clinical Practice. Nutrients 2019; 11:nu11102454. [PMID: 31615103 PMCID: PMC6836123 DOI: 10.3390/nu11102454] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 10/07/2019] [Accepted: 10/10/2019] [Indexed: 02/07/2023] Open
Abstract
Sarcopenia, defined as loss of muscle mass and function, is increasingly recognized as a common consequence of advanced cirrhosis that is associated with adverse clinical outcomes. Despite the recent proliferation in publications pertaining to sarcopenia in end-stage liver disease, there remains no single 'best method' for its diagnosis. The inability to identify a gold standard is common to other specialties, including geriatrics from which many diagnostic tools are derived. Controversies in diagnosis have implications for the accuracy and reproducibility of cohort studies in the field, largely prohibit the introduction of sarcopenia measurement into routine patient care and impede the development of clinical trials to identify appropriate therapies. Difficulties in diagnosis are partly driven by our ongoing limited understanding of the pathophysiology of sarcopenia in cirrhosis, the mechanisms by which it impacts on patient outcomes, the heterogeneity of patient populations, and the accuracy, availability and cost of assessments of muscle mass and function. This review discusses the currently studied diagnostic methods for sarcopenia in cirrhosis, and outlines why reaching a consensus on sarcopenia diagnosis is important and suggests potential ways to improve diagnostic criteria to allow us to translate sarcopenia research into improvements in clinical care.
Collapse
Affiliation(s)
- Marie Sinclair
- Department of Medicine, The University of Melbourne, Parkville 3050, Australia.
- Austin Health, Liver Transplant Unit, 145 Studley Road, Heidelberg 3084, Australia.
| |
Collapse
|
12
|
Njei B, Esserman D, Krishnan S, Ohl M, Tate JP, Hauser G, Taddei T, Lim J. Regional and Rural-Urban Differences in the Use of Direct-acting Antiviral Agents for Hepatitis C Virus: The Veteran Birth Cohort. Med Care 2019; 57:279-285. [PMID: 30807449 PMCID: PMC6436819 DOI: 10.1097/mlr.0000000000001071] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Veterans with hepatitis C virus (HCV) infection may face geographic obstacles to obtaining treatment. OBJECTIVE We studied the influence of region and rural versus urban residence on receipt of direct-acting antiretroviral (DAA) medications for HCV. SUBJECTS Veterans receiving care within Veterans Affairs Healthcare System born between 1945 and 1965. RESEARCH DESIGN This is a observational study using national electronic health record data. MEASURES Receipt of DAAs was defined as ≥1 filled prescription from January 1, 2014 to December 31, 2016. Region (South, Northeast, Midwest, and West) and residence (urban, rural-micropolitan, small rural towns, and isolated rural towns) variables were created using residential zone improvement plan codes and rural-urban commuting area (RUCA) codes. Multivariable models were adjusted for age, race, sex, severity of liver disease, comorbidities, and prior treatment experience. RESULTS Among 166,353 eligible patients 64,854 received, DAAs. Variation by rural-urban residence depended on region. In unadjusted analyses, receipt varied by rural-urban designations within Midwest, and West regions (P<0.05) but did not vary within the South (P=0.12). Southern rural small town had the lowest incidence of DAA receipt (40.1%), whereas the incidence was 52.9% in Midwestern isolated rural towns. In adjusted logistic analyses, compared with southern urban residents (the largest single group), southern rural small town residents had the lowest odds ratio, 0.85 (95% confidence interval, 0.75-0.93), and Midwestern residents from isolated and small rural towns had the highest odds (odds ratio, both 1.27) to receive treatment. CONCLUSIONS Substantial geographic variation exists in receipt of curative HCV treatment. Efforts are needed to provide more equitable access to DAAs.
Collapse
Affiliation(s)
- Basile Njei
- Department of Gastroenterology and Hepatology, Yale University School of Medicine, VA Connecticut Healthcare System, 333 Cedar Street, New Haven, CT, 06516, (312) 415-7525,
| | - Denise Esserman
- Department of Biostatistics, Yale University School of Public Health, VA Connecticut Healthcare System, 300 George Street, New Haven, CT 06510-3210, (203)785-4297,
| | - Supriya Krishnan
- Department of Internal Medicine, Yale University School of Medicine, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, (203) 932-5711 ×5306,
| | - Michael Ohl
- University of Iowa Carver College of Medicine, Veterans Rural Health Resource Iowa City VA Medical Center, 601 Highway 6 West Iowa City, IA, 52246, (319)338-0581 ext. 3534,
| | - Janet P. Tate
- Department of Internal Medicine, Yale University School of Medicine, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT,06516, (203) 932-5711 ×5371,
| | - George Hauser
- Center for Biomedical Data Science, Yale University School of Medicine, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516 (203)932-5711 ×7140,
| | - Tamar Taddei
- Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, VA Connecticut Healthcare System, 950 Campbell Ave., West Haven, CT, 06516, (203) 932-5711 ×4696,
| | - Joseph Lim
- Department of Internal Medicine Yale University School of Medicine, VA Connecticut Healthcare System, 333 Cedar Street, New Haven CT, 06510, New Haven CT, (203)737-6063,
| |
Collapse
|
13
|
Ourth HL, Groppi JA, Morreale AP, Jorgenson T, Himsel AS, Jacob DA. Increasing access for veterans with hepatitis C by enhancing use of clinical pharmacy specialists. J Am Pharm Assoc (2003) 2019; 59:398-402. [PMID: 30853345 DOI: 10.1016/j.japh.2019.01.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 01/23/2019] [Accepted: 01/29/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVES To increase access to hepatitis C virus (HCV) care and cure by deploying clinical pharmacy specialist (CPS) providers across the largest integrated health care system in the United States. SETTING National integrated health care system. PRACTICE DESCRIPTION In late 2016, the Department of Veterans Affairs (VA) Pharmacy Benefits Management Clinical Pharmacy Practice Office (CPPO) partnered with the VA HIV, Hepatitis, and Related Conditions Program with the central priority of expanding veteran access to novel HCV treatments and timely cure to ultimately prevent morbidity and mortality associated with HCV disease progression. This successful collaboration resulted in clinical resource funding to bolster access to HCV treatment through the deployment of CPS providers. This enterprise-wide initiative to expand clinical pharmacy services for unmet health care needs in HCV treatment resulted in 52 VA facilities submitting full-time employment equivalent (FTEE) funding requests totaling more than $10 million dollars. Facilities may have requested funding for 1 or more FTEEs. RESULTS Facilities hired 47 CPS providers and 5 clinical pharmacy technicians. CPS providers in this project recorded 24,888 patient care encounters providing care for 9593 unique patients and initiated new HCV treatment for 1191 treatment-naïve patients. For an additional 8402 patients, the CPS provided HCV care activities such as evaluation and monitoring before, during, and after treatment. CPPO estimates that the same care delivered by nonpharmacist provider specialists (e.g., specialty physicians) cost an additional $936,535, or 48% more. CONCLUSION The deployment of HCV CPS resulted in a significant number of new HCV patients being screened and treated within the VA system.
Collapse
|
14
|
Belperio PS, Chartier M, Gonzalez RI, Park AM, Ross DB, Morgan TR, Backus LI. Hepatitis C Care in the Department of Veterans Affairs: Building a Foundation for Success. Infect Dis Clin North Am 2019; 32:281-292. [PMID: 29778256 DOI: 10.1016/j.idc.2018.02.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The Department of Veterans Affairs (VA) has made significant progress in treating hepatitis C virus, experiencing more than a 75% reduction in veterans remaining to be treated since the availability of oral direct-acting antivirals. Hepatitis C Innovation Teams use lean process improvement and system redesign, resulting in practice models that address gaps in care. The key to success is creative improvements in veteran access to providers, including expanded use of nonphysician providers, video telehealth, and electronic technologies. Population health management tools monitor and identify trends in care, helping the VA tailor care and address barriers.
Collapse
Affiliation(s)
- Pamela S Belperio
- Patient Care Services/Population Health, Department of Veterans Affairs, Palo Alto Health Care System, 3801 Miranda Avenue (132), Palo Alto, CA 94304, USA
| | - Maggie Chartier
- HIV, Hepatitis and Related Conditions, Office of Specialty Care Services (10P11I), Department of Veterans Affairs, 810 Vermont Avenue, Washington, DC 20420, USA
| | - Rachel I Gonzalez
- Research Health Care Group, VA Long Beach Health Care System, 5901 East 7th Street, Long Beach, CA 90822, USA
| | - Angela M Park
- New England Veterans Engineering Resource Center, Department of Veterans Affairs, 150 South Huntingtin Avenue, Boston, MA 02130, USA
| | - David B Ross
- HIV, Hepatitis and Related Conditions, Office of Specialty Care Services (10P11I), Department of Veterans Affairs, 810 Vermont Avenue, Washington, DC 20420, USA
| | - Tim R Morgan
- Division of Gastroenterology, VA Long Beach Health Care System, 5901 East 7th Street, Long Beach, CA 90822, USA
| | - Lisa I Backus
- Patient Care Services/Population Health, Department of Veterans Affairs, Palo Alto Health Care System, 3801 Miranda Avenue (132), Palo Alto, CA 94304, USA.
| |
Collapse
|
15
|
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.
Collapse
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
| |
Collapse
|
16
|
Chirikov VV, Shaya FT, Onukwugha E, Mullins CD, dosReis S, Howell CD. Tree-based Claims Algorithm for Measuring Pretreatment Quality of Care in Medicare Disabled Hepatitis C Patients. Med Care 2017; 55:e104-e112. [PMID: 29135773 DOI: 10.1097/mlr.0000000000000405] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND To help broaden the use of machine-learning approaches in health services research, we provide an easy-to-follow framework on the implementation of random forests and apply it to identify quality of care (QC) patterns correlated with treatment receipt among Medicare disabled patients with hepatitis C virus (HCV). METHODS Using Medicare claims 2006-2009, we identified 1936 patients with 6 months continuous enrollment before HCV diagnosis. We ran a random forest on 14 pretreatment QC indicators, extracted the forest's representative tree, and aggregated its terminal nodes into 4 QC groups predictive of treatment. To explore determinants of differential QC receipt, we compared patient-level and county-level (linked AHRF data) characteristics across QC groups. RESULTS The strongest predictors of treatment included "liver biopsy," "HCV genotype testing," "specialist visit," "HCV viremia confirmation," and "iron overload testing." High QC [n=360, proportion treated (pt)=33.3%] was defined for patients with at least 2 from the above-mentioned metrics. Good QC patients (n=302, pt=12.3%) had either "HCV genotype testing" or "specialist visit," whereas fair QC (n=282, pt=7.1%) only had "HCV viremia confirmation." Low QC patients (n=992, pt=2.5%) had none of the selected metrics. The algorithm accuracy of predicting treatment was 70% sensitivity and 78% specificity. HIV coinfection, drug abuse, and residence in counties with higher supply of hospitals with immunization and AIDS services correlated with lower QC. CONCLUSIONS Machine-learning techniques could be useful in exploring patterns of care. Among Medicare disabled HCV patients, the receipt of more QC indicators was associated with higher treatment rates. Future research is needed to assess determinants of differential QC receipt.
Collapse
Affiliation(s)
- Viktor V Chirikov
- *University of Maryland School of Pharmacy †University of Maryland School of Medicine, Baltimore, MD ‡Howard University College of Medicine, Washington, DC
| | | | | | | | | | | |
Collapse
|
17
|
Chirikov VV, Shaya FT, Mullins CD, dosReis S, Onukwugha E, Howell CD. Determinants of quality of care and treatment initiation in Medicare disabled patients with chronic hepatitis C. Expert Rev Gastroenterol Hepatol 2016; 9:1447-62. [PMID: 26524244 DOI: 10.1586/17474124.2015.1095087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Aligning with a national priority to bridge health disparities in disadvantaged populations, we explored contextual determinants of pretreatment quality of care and treatment receipt of Medicare disabled patients with hepatitis C virus (HCV) infection. METHODS We used Medicare claims (2006-2009) linked to the Area Health Resource Files. Ordinal partial proportional odds and weighted modified Poisson regressions were used to model the determinants of quality care receipt and interferon-based treatment, respectively. RESULTS We identified 1936 Medicare disabled HCV patients, of whom 10.4% were treated with peg-interferon. Despite the high comorbidity burden among HCV disabled patients, greater engagement in care correlated with greater likelihood of quality care and treatment receipt. CONCLUSION Our study highlights the need for process and linkage to care in Medicare disabled HCV patients, but future research relevant to novel interferon-free agents is needed to assess patterns of quality of care and treatment receipt in this vulnerable population.
Collapse
Affiliation(s)
- Viktor V Chirikov
- a 1 Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, 220 Arch Street, Saratoga Offices 12th Floor, Baltimore, MD 21201, USA
| | - Fadia T Shaya
- a 1 Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, 220 Arch Street, Saratoga Offices 12th Floor, Baltimore, MD 21201, USA.,b 2 University of Maryland School of Medicine, Baltimore, MD, USA
| | - C Daniel Mullins
- a 1 Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, 220 Arch Street, Saratoga Offices 12th Floor, Baltimore, MD 21201, USA
| | - Susan dosReis
- a 1 Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, 220 Arch Street, Saratoga Offices 12th Floor, Baltimore, MD 21201, USA
| | - Ebere Onukwugha
- a 1 Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, 220 Arch Street, Saratoga Offices 12th Floor, Baltimore, MD 21201, USA
| | - Charles D Howell
- c 3 Department of Medicine, Howard University College of Medicine, 2041 Georgia Ave. Suite 5C02, Washington, DC 20060, USA
| |
Collapse
|
18
|
Sbarigia U, Denee TR, Turner NG, Wan GJ, Morrison A, Kaufman AS, Rice G, Dusheiko GM. Conceptual framework for outcomes research studies of hepatitis C: an analytical review. Infect Drug Resist 2016; 9:101-17. [PMID: 27313473 PMCID: PMC4890693 DOI: 10.2147/idr.s99329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Hepatitis C virus infection is one of the main causes of chronic liver disease worldwide. Until recently, the standard antiviral regimen for hepatitis C was a combination of an interferon derivative and ribavirin, but a plethora of new antiviral drugs is becoming available. While these new drugs have shown great efficacy in clinical trials, observational studies are needed to determine their effectiveness in clinical practice. Previous observational studies have shown that multiple factors, besides the drug regimen, affect patient outcomes in clinical practice. Here, we provide an analytical review of published outcomes studies of the management of hepatitis C virus infection. A conceptual framework defines the relationships between four categories of variables: health care system structure, patient characteristics, process-of-care, and patient outcomes. This framework can provide a starting point for outcomes studies addressing the use and effectiveness of new antiviral drug treatments.
Collapse
Affiliation(s)
| | | | - Norris G Turner
- Johnson & Johnson Health Care Systems, Inc., Titusville, NJ, USA
| | - George J Wan
- Mallinckrodt Pharmaceuticals, St. Louis, MO, USA
| | | | | | - Gary Rice
- Diplomat Specialty Pharmacy, Flint, MI, USA
| | - Geoffrey M Dusheiko
- The University College London Medical Institute for Liver and Digestive Health, London, UK
- Kings College Hospital, London, UK
| |
Collapse
|
19
|
Facility- and Patient-Level Factors Associated with Esophageal Variceal Screening in the USA. Dig Dis Sci 2016; 61:62-9. [PMID: 26363933 PMCID: PMC4809672 DOI: 10.1007/s10620-015-3865-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 09/03/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIM The American Association for the Study of Liver Disease (AASLD) recommends screening for esophageal varices (EV) by esophagoduodenoscopy (EGD) in patients with cirrhosis to guide decisions regarding primary prophylaxis for EV hemorrhage. We aimed to identify patient and facility factors associated with EV screening in veterans with hepatitis C (HCV)-associated cirrhosis. METHODS This was a population-based cohort study. Veterans with HCV and newly diagnosed cirrhosis between 1/1/2004 and 12/31/2005 and followed until 12/31/2011 were included. The primary outcome was receipt of EGD within 1 year of cirrhosis diagnosis. Patient- and facility-level factors associated with EV screening were determined. RESULTS A total of 4230 patients with HCV cirrhosis were identified. During median follow-up of 6.1 years (IQR: 4.0-8.0), 21.5 % developed a decompensating event, and 38.3 % died. Fifty-four percent received an EGD, and 33.8 % had an EGD within guidelines. Median time from cirrhosis diagnosis to EGD was 72 days (IQR: 12-176). Factors independently associated with receipt of EV screening were a decompensation event (OR 1.16, CI 1.01-1.32) and gastroenterology/hepatology clinic access (OR 2.1, CI 1.73-2.46), whereas cardiovascular (OR 0.81, CI 0.69-0.95), mental health (OR 0.79, CI 0.68-0.91), and respiratory (OR 0.85, CI 0.72-0.99) comorbidities were associated with reduced likelihood of EV screening. CONCLUSION EV screening per AASLD guidelines occurs in only one-third of patients. This missed opportunity was strongly associated with access to gastroenterology/hepatology specialty care. Additionally, providers may be relying on clinical cues (i.e., decompensation) to prompt referral for endoscopy suggesting education to improve compliance with guidelines is needed.
Collapse
|
20
|
Carey EP, Frank JW, Kerns RD, Ho PM, Kirsh SR. Implementation of telementoring for pain management in Veterans Health Administration: Spatial analysis. ACTA ACUST UNITED AC 2016; 53:147-56. [DOI: 10.1682/jrrd.2014.10.0247] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Revised: 09/11/2015] [Indexed: 11/05/2022]
Affiliation(s)
- Evan P. Carey
- Department of Veterans Affairs (VA) Eastern Colorado Health Care System, Denver, CODepartment of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO
| | - Joseph W. Frank
- Department of Veterans Affairs (VA) Eastern Colorado Health Care System, Denver, CODivision of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Robert D. Kerns
- VA Connecticut Healthcare System, West Haven, CT, and Yale School of Medicine, New Haven, CT
| | - P. Michael Ho
- Department of Veterans Affairs (VA) Eastern Colorado Health Care System, Denver, CODepartment of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Susan R. Kirsh
- Louis Stokes Cleveland VA Medical Center, Cleveland, OH, Department of Medicine, School of Medicine, Case Western Reserve University, Cleveland, OH, and Office of Specialty Care, Veterans Health Administration, Washington, DC
| |
Collapse
|
21
|
Jayasekera CR, Perumpail RB, Chao DT, Pham EA, Aggarwal A, Wong RJ, Ahmed A. Task-Shifting: An Approach to Decentralized Hepatitis C Treatment in Medically Underserved Areas. Dig Dis Sci 2015; 60:3552-7. [PMID: 26467703 DOI: 10.1007/s10620-015-3911-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2015] [Accepted: 09/28/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Despite the availability of safe and effective direct-acting antiviral drugs (DAAs), the vast majority of patients with chronic hepatitis C (HCV) in the USA remain untreated, in part due to lack of access to specialist providers. AIMS To determine the effectiveness of DAA-based treatment in medically underserved areas in California, in a healthcare model dependent on task-shifting--wherein a visiting hepatologist assesses patients for treatment eligibility, but subsequent routine follow-up evaluation of patients prescribed treatment is devolved to a part-time licensed vocational nurse under remote supervision of the hepatologist. METHODS We retrospectively determined rates of sustained virologic response 12 weeks after treatment completion (SVR-12), adverse events, and treatment discontinuations in patients who received sofosbuvir-based DAA regimens between December 2013 and November 2014. RESULTS Despite limited specialist provider involvement in medically underserved areas, all but two of 58 patients completed treatment, and 88 % of patients achieved the curative endpoint of undetectable HCV RNA 12 weeks after completing treatment (sustained virologic response, SVR-12). Almost 80 % of patients with cirrhosis and 85 % of patients with prior treatment experience achieved SVR-12. CONCLUSIONS Treatment effectiveness with sofosbuvir-based regimens in medically underserved areas utilizing task-shifting from a specialist to a mid-level provider is comparable to those achieved in pivotal clinical trials for these regimens, and to “real-world” experiences of tertiary care centers in the USA.
Collapse
|
22
|
A Multicenter Cardiovascular MR Network for Tele-Training and Beyond: Setup and Initial Experiences. J Am Coll Radiol 2015; 12:876-83. [DOI: 10.1016/j.jacr.2015.03.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 03/04/2015] [Indexed: 12/21/2022]
|
23
|
Chirikov VV, Shaya FT, Howell CD. Contextual analysis of determinants of late diagnosis of hepatitis C virus infection in medicare patients. Hepatology 2015; 62:68-78. [PMID: 25754171 DOI: 10.1002/hep.27775] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2014] [Accepted: 03/04/2015] [Indexed: 12/13/2022]
Abstract
UNLABELLED Patient- and county-level characteristics associated with advanced liver disease (ALD) at hepatitis C virus (HCV) diagnosis were examined in three Medicare cohorts: (1) elderly born before 1945; (2) disabled born 1945-1965; and (3) disabled born after 1965. We used Medicare claims (2006-2009) linked to the Area Health Resource Files. ALD was measured over the period of 6 months before to 3 months after diagnosis. Using weighted multivariate modified Poisson regression to address generalizability of findings to all Medicare patients, we modeled the association between contextual characteristics and presence of ALD at HCV diagnosis. We identified 1,746, 3,351, and 592 patients with ALD prevalence of 28.0%, 23.0%, and 15.0% for birth cohorts 1, 2, and 3. Prevalence of drug abuse increased among younger birth cohorts (4.2%, 22.6%, and 35.6%, respectively). Human immunodeficiency virus coinfection (prevalence ratio [PR] = 0.63; 95% confidence interval [CI]: 0.50-0.80; P = 0.001), dual Medicare/Medicaid eligibility (PR = 0.89; 95% CI: 0.80-0.98; P = 0.017), residence in counties with higher median household income (PR = 0.82; 95% CI: 0.71-0.95; P = 0.008), higher density of primary care providers (PR = 0.84; 95% CI: 0.73-0.98; P = 0.022), and more rural health clinics (PR = 0.90; 0.81-1.01; P = 0.081) were associated with lower ALD risk. End-stage renal disease (PR = 1.41; 95% CI: 1.21-1.63; P = 0.001), alcohol abuse (PR = 2.57; 95% CI: 2.33-2.84; P = 0.001), hepatitis B virus (PR = 1.32; 95% CI: 1.09-1.59; P = 0.004), and Midwest residence (PR = 1.22; 95% CI: 1.05-1.41; P = 0.010) were associated with higher ALD risk. Living in rural counties with high screening capacity was protective in the elderly, but associated with higher ALD risk among the disabled born 1945-1965. CONCLUSIONS ALD prevalence patterns were complex and were modified by race, elderly/disability status, and the extent of health care access and screening capacity in the county of residence. These study results help inform treatment strategies for HCV in the context of coordinated models of care.
Collapse
Affiliation(s)
- Viktor V Chirikov
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, MD
| | - Fadia T Shaya
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, MD.,University of Maryland School of Medicine, Baltimore, MD
| | | |
Collapse
|
24
|
Lau M, Beste LA, Kryskalla J, Rongey C. Hepatitis C Clinical Dashboards: Improving Liver Specialty Care Access and Quality. Fed Pract 2015; 32:32S-36S. [PMID: 30766110 PMCID: PMC6375504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Clinical dashboards can improve the health management of the HCV population within the VHA by empowering health care practitioners to deliver wide and effective HCV care.
Collapse
Affiliation(s)
- Marcos Lau
- is an academic detailing data manager, Department of Pharmacy, VHA Pharmacy Benefits Management, Los Angeles, California. is a staff physician, Department of Medicine, Puget Sound VAMC and University of Washington School of Medicine, Seattle, Washington. is the VISN 22 pharmacoeconomist and pharmacy data analyst, Desert Pacific VISN in Long Beach, California. is the Viral Hepatitis National Public Health Clinical Lead, San Francisco VAMC, University of California San Francisco and an assistant professor at the University of California, San Francisco School of Medicine
| | - Lauren A Beste
- is an academic detailing data manager, Department of Pharmacy, VHA Pharmacy Benefits Management, Los Angeles, California. is a staff physician, Department of Medicine, Puget Sound VAMC and University of Washington School of Medicine, Seattle, Washington. is the VISN 22 pharmacoeconomist and pharmacy data analyst, Desert Pacific VISN in Long Beach, California. is the Viral Hepatitis National Public Health Clinical Lead, San Francisco VAMC, University of California San Francisco and an assistant professor at the University of California, San Francisco School of Medicine
| | - Jennifer Kryskalla
- is an academic detailing data manager, Department of Pharmacy, VHA Pharmacy Benefits Management, Los Angeles, California. is a staff physician, Department of Medicine, Puget Sound VAMC and University of Washington School of Medicine, Seattle, Washington. is the VISN 22 pharmacoeconomist and pharmacy data analyst, Desert Pacific VISN in Long Beach, California. is the Viral Hepatitis National Public Health Clinical Lead, San Francisco VAMC, University of California San Francisco and an assistant professor at the University of California, San Francisco School of Medicine
| | - Catherine Rongey
- is an academic detailing data manager, Department of Pharmacy, VHA Pharmacy Benefits Management, Los Angeles, California. is a staff physician, Department of Medicine, Puget Sound VAMC and University of Washington School of Medicine, Seattle, Washington. is the VISN 22 pharmacoeconomist and pharmacy data analyst, Desert Pacific VISN in Long Beach, California. is the Viral Hepatitis National Public Health Clinical Lead, San Francisco VAMC, University of California San Francisco and an assistant professor at the University of California, San Francisco School of Medicine
| |
Collapse
|