Restrictions of Hepatitis C Treatment for Substance-Using Medicaid Patients: Cost Versus Ethics

Racial Disparities in Treatment and Outcomes of Patients With Hepatitis C Undergoing Elective Total Joint Arthroplasty

BACKGROUND

African Americans have the highest prevalence of chronic Hepatitis C virus (HCV) infection. Racial disparities in outcome are observed after elective total hip arthroplasty (THA) and total knee arthroplasty (TKA). This study sought to identify if disparities in treatments and outcomes exist between Black and White patients who have HCV prior to elective THA and TKA.

METHODS

Patient demographics, comorbidities, HCV characteristics, perioperative variables, in-hospital outcomes, and postoperative complications at 1-year follow-up were collected and compared between the 2 races. Patients who have preoperative positive viral load (PVL) and undetectable viral load were identified. Chi-square and Fisher's exact tests were used to compare categorical variables, while 2-tailed Student's Kruskal-Wallis t-tests were used for continuous variables. A P value of less than .05 was statistically significant.

RESULTS

The liver function parameters, including aspartate aminotransferase and model for end-stage liver disease scores, were all higher preoperatively in Black patients undergoing THA (P = .01; P < .001) and TKA (P = .03; P = .003), respectively. Black patients were more likely to undergo THA (65.8% versus 35.6%; P = .002) and TKA (72.1% versus 37.3%; 0.009) without receiving prior treatment for HCV. Consequently, Black patients had higher rates of preoperative PVL compared to White patients in both THA (66% versus 38%, P = .006) and TKA (72% versus 37%, P < .001) groups. Black patients had a longer length of stay for both THA (3.7 versus 3.3; P = .008) and TKA (4.1 versus 3.0; P = .02).

CONCLUSIONS

The HCV treatment prior to THA and TKA with undetectable viral load has been shown to be a key factor in mitigating postoperative complications, including joint infection. We noted that Black patients were more likely to undergo joint arthroplasty who did not receive treatment and with a PVL. While PVL rates decreased over time for both races, a significant gap persists for Black patients.

Changes in Use of Hepatitis C Direct-Acting Antivirals After Access Restrictions Were Eased by State Medicaid Programs

Importance

Direct-acting antivirals (DAAs) are safe and highly effective for curing hepatitis C virus (HCV) infection, but their high cost led certain state Medicaid programs to impose coverage restrictions. Since 2015, many of these restrictions have been lifted voluntarily in response to advocacy or because of litigation.

Objective

To estimate how the prescribing of DAAs to Medicaid patients changed after states eased access restrictions.

Design, Setting, and Participants

This modified difference-in-differences analysis of 39 state Medicaid programs included Medicaid beneficiaries who were prescribed a DAA from January 1, 2015, to December 31, 2019. DAA coverage restrictions were measured based on a series of cross-sectional assessments performed from 2014 through 2022 by the US National Viral Hepatitis Roundtable and the Center for Health Law and Policy Innovation.

Exposure

Calendar quarter when states eased or eliminated 3 types of DAA coverage restrictions: limiting treatment to patients with severe liver disease, restricting use among patients with active substance use, and requiring prescriptions to be written by or in consultation with specialists. States with none of these restrictions at baseline were excluded.

Main Outcomes and Measures

Quarterly number of HCV DAA treatment courses per 100 000 Medicaid beneficiaries.

Results

Of 39 states, 7 (18%) eliminated coverage restrictions, 25 (64%) eased restrictions, and 7 (18%) maintained the same restrictions from 2015 to 2019. During this period, the average quarterly use of DAAs increased from 669 to 3601 treatment courses per 100 000 Medicaid beneficiaries. After states eased or eliminated restrictions, the use of DAAs increased by 966 (95% CI, 409-1523) treatment courses per 100 000 Medicaid beneficiaries each quarter compared with states that did not ease or eliminate restrictions.

Conclusions and Relevance

The results of this study suggest that there was greater use of DAAs after states relaxed coverage restrictions related to liver disease severity, sobriety, or prescriber specialty. Further reductions or elimination of these rules may improve access to a highly effective public health intervention for patients with HCV.

Temporal Trends in Hepatitis C-Related Hospitalizations, United States, 2000-2019

BACKGROUND

Hospitalization burden related to hepatitis C virus (HCV) infection is substantial. We sought to describe temporal trends in hospitalization rates before and after release of direct-acting antiviral (DAA) agents.

METHODS

We analyzed 2000-2019 data from adults aged ≥18 years in the National Inpatient Sample. Hospitalizations were HCV-related if (1) hepatitis C was the primary diagnosis, or (2) hepatitis C was any secondary diagnosis with a liver-related primary diagnosis. We analyzed characteristics of HCV-related hospitalizations nationally and examined trends in age-adjusted hospitalization rates.

RESULTS

During 2000-2019, there were an estimated 1 286 397 HCV-related hospitalizations in the United States. The annual age-adjusted hospitalization rate was lowest in 2019 (18.7/100 000 population) and highest in 2012 (29.6/100 000 population). Most hospitalizations occurred among persons aged 45-64 years (71.8%), males (67.1%), White non-Hispanic persons (60.5%), and Medicaid/Medicare recipients (64.0%). The national age-adjusted hospitalization rate increased during 2000-2003 (annual percentage change [APC], 9.4%; P < .001) and 2003-2013 (APC, 1.8%; P < .001) before decreasing during 2013-2019 (APC, -7.6%; P < .001). Comparing 2000 to 2019, the largest increases in hospitalization rates occurred among persons aged 55-64 years (132.9%), Medicaid recipients (41.6%), and Black non-Hispanic persons (22.3%).

CONCLUSIONS

Although multiple factors likely contributed, overall HCV-related hospitalization rates declined steadily after 2013, coinciding with the release of DAAs. However, the declines were not observed equally among age, race/ethnicity, or insurance categories. Expanded access to DAA treatment is needed, particularly among Medicaid and Medicare recipients, to reduce disparities and morbidity and eliminate hepatitis C as a public health threat.

Timing of hepatitis C treatment initiation and retention in office-based opioid treatment with buprenorphine: a retrospective cohort study

BACKGROUND

This study examined associations between receipt of hepatitis C (HCV) treatment and retention in office-based opioid treatment (OBOT) care.

METHODS

We conducted a retrospective cohort study of HCV-infected patients who initiated OBOT treatment between December 2015 and March 2021 to characterize HCV treatment and assess associations with OBOT retention. HCV treatment was characterized as no treatment, early treatment (< 100 days since OBOT initiation) or late treatment (≥ 100 days). We evaluated associations between HCV treatment and cumulative days in OBOT. A secondary analysis using Cox Proportional Hazards regression was done to determine the rate of discharge over time when comparing those who did versus did not receive HCV treatment as a time-varying covariate. We also analyzed a subset of patients retained at least 100 days in OBOT care and evaluated whether HCV treatment during that period was associated with OBOT retention beyond 100 days.

RESULTS

Of 191 HCV-infected OBOT patients, 30% initiated HCV treatment, of whom 31% received early treatment and 69% received late treatment. Median cumulative duration in OBOT was greater among those who received HCV treatment (any: 398 days, early: 284 days and late: 430 days) when compared to those who did not receive treatment (90 days). Compared to no HCV treatment, there were 83% (95% CI: 33-152%, P < 0.001), 95% (95% CI: 28%-197%, p = 0.002 and 77% (95% CI: 25-153%, p = 0.002) more cumulative days in OBOT for any, early and late HCV treatment, respectively. HCV treatment was associated with a lower relative hazard for discharge/drop-out, although results did not meet statistical significance (aHR = 0.59;95% CI: 0.34-1.00; p = 0.052). Among the subset of 84 patients retained in OBOT at least 100 days, 18 received HCV treatment during that period. Compared to those who did not receive treatment within the first 100 days, those who received treatment had 57% (95% CI: -3%-152%, p = 0.065) more subsequent days in OBOT.

CONCLUSIONS

A minority of HCV-infected patients received HCV treatment after initiating OBOT treatment, but those who did had better retention. Further efforts are needed to facilitate rapid HCV treatment and evaluate whether early HCV treatment improves OBOT engagement.

Sustained Virologic Response Rates Before and After Removal of Sobriety Restriction for Hepatitis C Virus Treatment Access

OBJECTIVES

Until November 1, 2018, Illinois Medicaid restricted coverage of hepatitis C virus (HCV) medication to patients with sobriety from alcohol and illicit substances for ≥12 months. This policy limited treatment access for patients with a high risk of HCV transmission, despite clinical trial and real-world data demonstrating high sustained virologic response (SVR) rates among patients with substance use. The objective of this study was to compare HCV SVR rates between patients treated before and after removal of the Illinois Medicaid sobriety restriction.

METHODS

We performed a retrospective cohort study of Medicaid-insured patients who completed direct-acting antiviral treatment at an urban, academic medical center in Illinois from January 1, 2014, through October 21, 2020. The primary endpoint was SVR. We compared group characteristics using χ2 or Fisher exact tests for categorical variables and Wilcoxon rank-sum tests for continuous variables. We used logistic regression to compare SVR rates before and after the policy change, adjusting for differences between groups.

RESULTS

A total of 496 patients (348 pre-policy change; 148 post-policy change) started treatment; excluding loss to follow-up/early discontinuation, SVR rates were 95.4% (309 of 324) pre-policy change and 97.1% (134 of 138) post-policy change. SVR rates did not differ after adjusting for the use of historic HCV regimens and the higher cirrhosis rate in the pre-policy change group compared with the post-policy change group (odds ratio = 0.98; 95% CI, 0.32-3.67).

CONCLUSION

HCV SVR rates were similar before and after removal of the Illinois Medicaid sobriety restriction, regardless of group differences. Results support HCV treatment regardless of documented sobriety to facilitate progress toward HCV elimination.

Health disparities in chronic liver disease

The syndemic of hazardous alcohol consumption, opioid use, and obesity has led to important changes in liver disease epidemiology that have exacerbated health disparities. Health disparities occur when plausibly avoidable health differences are experienced by socially disadvantaged populations. Highlighting health disparities, their sources, and consequences in chronic liver disease is fundamental to improving liver health outcomes. There have been large increases in alcohol use disorder in women, racial and ethnic minorities, and those experiencing poverty in the context of poor access to alcohol treatment, leading to increasing rates of alcohol-associated liver diseases. Rising rates of NAFLD and associated fibrosis have been observed in Hispanic persons, women aged > 50, and individuals experiencing food insecurity. Access to viral hepatitis screening and linkage to treatment are suboptimal for racial and ethnic minorities and individuals who are uninsured or underinsured, resulting in greater liver-related mortality and later-stage diagnoses of HCC. Data from more diverse cohorts on autoimmune and cholestatic liver diseases are lacking, supporting the need to study the contemporary epidemiology of these disorders in greater detail. Herein, we review the existing literature on racial and ethnic, gender, and socioeconomic disparities in chronic liver diseases using a social determinants of health framework to better understand how social and structural factors cause health disparities and affect chronic liver disease outcomes. We also propose potential solutions to eliminate disparities, outlining health-policy, health-system, community, and individual solutions to promote equity and improve health outcomes.

Evaluation of a pilot emergency department linkage to care program for patients previously diagnosed with Hepatitis C

There is a significant number of Emergency Department (ED) patients with known chronic hepatitis C virus (HCV) infection who have not been treated with directly acting antivirals. We implemented a pilot ED-based linkage-to-care program to address this need and evaluated the impact of the program using the HCV Care Continuum metrics. Between March 2015 and May 2016, dedicated patient care navigators identified HCV RNA-positive patients in an urban ED and offered expedited appointments with the on-site viral hepatitis clinic. Patient demographics and care continuum outcomes were abstracted from the EMR and analysed to determine significant factors influencing linkage-to-care (LTC) and treatment initiation rates. The ED linkage-to-care program achieved a 43% linkage-to-care rate (165/384), 22% treatment rate (84/384) and 16% sustained virologic response rate (63/384). Significant associations were found between linkage-to-care and increasing age (OR = 1.03), Medicare insurance (OR = 2.21) and having a primary care physician (PCP) (OR = 4.03). For patients who were linked, the odds of initiating treatment were also positively significantly associated with increasing age (OR = 1.04) and having a PCP (OR = 2.77). For patients who initiated treatment, the odds of sustained virologic response were marginally associated with having a PCP (OR = 4.92).Our ED linkage-to-care program utilized care coordination to successfully link nearly half of approached HCV RNA-positive patients to care. This design can be feasibly replicated by other EDs given limited non-clinical training required for linkage-to-care staff. Adoption of similar programs in other EDs may improve the rates of LTC and treatment initiation for previously diagnosed HCV patients.

Variation in Use of Lung Cancer Targeted Therapies Across State Medicaid Programs, 2020-2021

Importance

Targeted therapies for EGFR (OMIM 131550)- and ALK (OMIM 105590)-altered metastatic non-small cell lung cancer (NSCLC) substantially improve outcomes for some patients. However, use of these therapies is lower among Medicaid patients, and access to oncology care varies across state Medicaid programs. Evidence is lacking on how use of targeted therapies for metastatic NSCLC varies across state Medicaid programs.

Objectives

To characterize state-level variation in the use of targeted therapies among Medicaid patients with metastatic NSCLC and to describe factors associated with this variation.

Design, Setting, and Participants

This cross-sectional study used publicly available data from the Medicaid Drug Utilization Database from 2020 and 2021 and peer-reviewed data on NSCLC incidence, the prevalence of EGFR and ALK alterations, and expected treatment durations to estimate expected use of targeted therapies for EGFR- and ALK-altered NSCLC in 33 states.

Exposures

State-specific Medicaid programs and state policies and characteristics.

Main Outcomes and Measures

The primary outcome was the estimated proportion of person-time of Medicaid patients with EGFR- or ALK-altered NSCLC associated with receipt of targeted therapy in each state Medicaid program. Nested linear regression models examined associations between the observed variation and state policies and characteristics.

Results

There were an estimated 3461 person-years in which EGFR- and ALK-targeted therapies were indicated in 2020 and 2021. During these years, only 2281 person-years of EGFR- and ALK-targeted therapies were dispensed to Medicaid patients, suggesting that an estimated 66% of Medicaid patients with EGFR- and ALK-altered metastatic disease received indicated targeted therapies across all states. Rates of targeted therapy use ranged from 18% in Arkansas to 113% in Massachusetts; 30 of 33 states (91%) had lower rates of targeted therapy use than expected. The observed variation across state Medicaid programs was associated with Medicaid policies, the density of oncologists, and state gross domestic product per capita.

Conclusions and Relevance

This study suggests that rates of targeted therapy use among Medicaid patients with EGFR- and ALK-altered NSCLC were lower than expected and varied across state Medicaid programs. State policies and characteristics were associated with the observed variation, indicating where interventions could improve access to treatment and outcomes for patients with NSCLC.

Cost of providing co-located hepatitis C treatment at a syringe service program exceeds potential reimbursement: Results from a clinical trial

Background

Co-located hepatitis C treatment at syringe service programs (SSP) is an emerging model of care for people who inject drugs (PWID). Implementation of these models can be informed by understanding the program costs.

Methods

We conducted an economic evaluation of a hepatitis C treatment intervention at an SSP in New York City implemented as one arm of a randomized trial from 2017 to 2021. Start-up and operating costs were determined from the treatment program's perspective using micro-costing and were compared to potential Medicaid reimbursement. We applied nationally representative unit costs and wage rates. Results are reported in 2020 USD.

Results

The treatment program was staffed by one physician and one care coordinator. Participants were offered hepatitis C clinical evaluation and treatment, a 45-min reinfection prevention education session, and additional care coordination as needed. The trial enrolled 84 PWID with hepatitis C in the intervention arm; 64 initiated treatment and 55 achieved sustained virological response. Start-up costs including training and equipment totaled $4677. Overhead costs including rent, utilities and software totaled $2229 per month. Clinical and care coordination totaled $4867 per participant, of which $3722 was care coordination. The total cost excluding startup was $6035 per enrolled participant and $7921 per treated participant; estimated potential reimbursement was $628 per enrolled participant.

Conclusion

Our results provide insight to US-based SSPs seeking to provide co-located hepatitis C care and highlight the intensive care coordination services provided. Successful implementation likely requires funding sources beyond health insurers or substantial changes to insurance reimbursement for care coordination.

Characteristics and Treatment Rate of Patients With Hepatitis C Virus Infection in the Direct-Acting Antiviral Era and During the COVID-19 Pandemic in the United States

IMPORTANCE

Clinical data on hepatitis C virus (HCV) treatment rates in the United States are sparse.

OBJECTIVE

To evaluate HCV treatment rates in the era of direct-acting antivirals (DAAs).

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used data from the deidentified Optum Cliniformatics Data Mart Database (2014-2021) on patients with HCV in the DAA and COVID-19 eras. The database includes patients with private health insurance in the US.

MAIN OUTCOMES AND MEASURES

The treatment rate and changes over time were assessed with adjusted log-binomial regression, and factors associated with treatment were examined using multivariable logistic regression.

RESULTS

A total of 133 348 patients with HCV (79 567 [59.7%] men; mean [SD] age, 59.7 [12.3] years; 4448 [3.3%] Asian, 24 662 [18.5%] Black, and 74 750 [56.1%] White individuals) were included; 38 180 (26.8%) had HCV RNA data, and of those, 20 277 (53.1%) had positive HCV RNA. Overall, 13 214 patients with positive HCV RNA tests (65.2%) received DAA treatment; 6456 of 6634 patients treated with DAAs (97.3%) achieved sustained virologic response. After adjusting for age, sex, and race and ethnicity, the treatment rate in 2018 was 0.5 times greater than the rate in 2014 (adjusted prevalence ratio, 1.50; 95% CI, 1.42-1.59) but declined after 2018, decreasing from 64.8% to 61.2%, and especially after 2019, when it decreased to less than 60% (P < .001). The number of patients with viremic HCV identified in between April 2020 and March 2021 also decreased to 496 from 2761 and 3258 in the preceding 2 years. Receiving care from a gastroenterologist or infectious disease specialist with advanced care practitioner (ie, nurse practitioner, physician assistant, or clinical nurse specialist) was independently associated with greater odds of DAA treatment (adjusted odds ratio [aOR], 1.64; 95% CI, 1.07-1.50). Patients with decompensated cirrhosis and/or hepatocellular carcinoma (HCC) were 31% less likely to receive treatment compared with those without (aOR, 0.69; 95% CI, 0.54-0.90).

CONCLUSIONS AND RELEVANCE

In this cohort study, less than two-thirds of insured patients with viremic HCV received DAA treatment, with declines in both the treatment rate and the number of viremic HCV diagnoses since 2019 and especially during the COVID-19 pandemic. Further efforts are needed to increase HCV diagnosis and treatment, especially for those with cirrhosis and HCC. An urgent call for nationwide actions to improve access to DAA treatment, community outreach programs, and specialists through referral pipelines is needed in the United States to stay on track to meet the World Health Organization goal of reducing the burden of viral hepatitis with the eventual goal to eliminate viral hepatitis.

Improving Access to High-Value, High-Cost Medicines: The Use of Subscription Models to Treat Hepatitis C Using Direct-Acting Antivirals in the United States

State payers may face financial incentives to restrict use of high-cost medications. Yet, restrictions on access to high-value medications may have deleterious effects on population health. Direct-acting antivirals (DAAs), available since 2013, can cure chronic infection with hepatitis C virus (HCV). With prices upward of $90,000 for a treatment course, states have struggled to ensure access to DAAs for Medicaid beneficiaries and the incarcerated, populations with a disproportionate share of HCV. Advance purchase commitments (APCs), wherein a payer commits to purchase a certain quantity of medications at lower prices, offer payers incentives to increase access to high-value medications while also offering companies guaranteed revenue. This article discusses the use of subscription models, a type of APC, to support increased access to high-value DAAs for treating HCV. First, the authors provide background information about HCV, its treatment, and state financing of prescription medications. They then review the implementation of HCV subscription models in two states, Louisiana and Washington, and the early evidence of their impact. The article discusses challenges to evaluating state-sponsored subscription models, and it concludes by discussing implications of subscription models that target DAAs and other high-value, high-cost medicines.

Barriers to Hepatitis C Virus Care and How Federally Qualified Health Centers Can Improve Patient Access to Treatment

Background

Despite the availability of direct-acting antiviral agents (DAAs) for hepatitis C virus (HCV) treatment, disparities in HCV care and treatment persist for underserved populations due to demographic-based and insurance-based barriers. We aim to examine the effect of barriers on HCV treatment access for a federally qualified health center (FQHC) population.

Methods

We retrospectively evaluated medical records of adults diagnosed with chronic HCV at an FQHC clinic from 2016 to 2020 with follow-up through 2021. Univariate and bivariate analyses were used to describe the patient population and significant associations between predictors of linkage to HCV care and treatment access. Adjusted multivariate logistic regression analyses were used to identify predictors of starting HCV treatment.

Results

Of 279 total patients with chronic HCV, 162 patients started treatment (58%), 138 patients (50%) completed treatment, and 99 patients (35%) achieved sustained virological response (SVR). Of the total patients, 145 (52%) were seen by their primary care physician (PCP) for their HCV care and treatment, and 134 (48%) were seen by a provider that specializes in management and treatment of HCV (HCV provider). Patients seen by an HCV provider in addition to their PCP were more likely to have had their prior authorization requests for HCV treatment denied by their insurance providers than patients seen only by their PCP for HCV care (30% vs. 14%, P = 0.001). We believe that this discrepancy stems from two issues. One, prior authorizations are reviewed by insurance providers who are not specially trained in HCV management, so the verbiage used perplexes these reviewers, possibly causing them to issue denials. Two, insurance providers often require HCV genotype testing for DAA medication eligibility, and HCV providers order genotype tests for patients only when HCV treatments have failed to cure patients, so this requirement becomes another barrier to DAA medications. Patients who spoke a non-English language, lived in the USA for less than 10 years, and showed inability to pay for treatment had received treatment despite these characteristics being common barriers to HCV treatment. On multivariate regression, factors independently associated with patients starting treatment included prior denial for DAA medication (odds ratio (OR), 8.88; 95% confidence interval (CI), 3.22 - 24.6; P < 0.001) and being seen by an HCV provider (OR, 24.8; 95% CI, 11.7 - 52.5; P < 0.001). However, the most significant barrier to HCV treatment access for the FQHC population was eligibility restrictions from insurance providers.

Conclusions

Demographic-based barriers (e.g., age, race, and income) often impede HCV care and treatment, but insurance-based barriers are the greatest challenge currently that affects treatment outcomes in our study population. Removing these restrictions would, in our opinion, help to increase treatment levels to underserved populations.

Association Between Time to First RNA-Negative Test Result Among People With Hepatitis C Virus Infection and Homelessness or Testing at a Correctional or Substance Use Treatment Facility, New York City

OBJECTIVE

Curative treatments for hepatitis C virus (HCV) infection are available, but access and barriers to treatment can delay initiation. We investigated the time to first negative RNA test result among people with HCV infection and examined differences by homeless status and whether people were tested at a correctional facility or substance use treatment facility.

METHODS

We used surveillance data to identify New York City residents first reported with HCV infection during January 1, 2015-December 31, 2018, with ≥1 positive RNA test result during January 1, 2015-November 1, 2019. We used Kaplan-Meier survival analysis to determine the time from the first positive RNA test result to the first negative RNA test result, with right-censoring at date of death or November 1, 2019. We determined substance use treatment, incarceration, or homelessness by ordering facility name and address or from patient residential address.

RESULTS

Of 13 952 people with an HCV RNA-positive test result first reported during 2015-2018, 6947 (49.8%) subsequently received an RNA-negative test result. Overall, 25% received an RNA-negative test result within 208 (95% CI, 200-216) days and 50% within 902 (95% CI, 841-966) days. Homelessness, incarceration, or substance use treatment was indicated for 4304 (30.9%) people, among whom 25% received an RNA-negative test result within 469 (95% CI, 427-520) days and <50% received an RNA-negative test result during the study period.

CONCLUSIONS

Efforts to connect people to treatment should occur soon after diagnosis, especially for people who could benefit from hepatitis C care coordination.

Medicaid Hepatitis C Virus Treatment Policies: Impact on Testing and Treatment in the Commercially Insured

INTRODUCTION

A total of 23 state Medicaid programs continue to restrict hepatitis C virus (HCV) medication access by liver disease or substance-use criteria, creating obstacles to HCV elimination and significant care disparities. Because public insurers often set precedents for private insurer coverage and clinician practice patterns, this study sought to analyze whether spillover occurs from state Medicaid HCV treatment restrictions to HCV screening and treatment rates in commercially insured individuals.

METHODS

Investigators analyzed 2014‒2017 commercial claims data across 48 U.S. states (721,961,965 person-months) and used an interrupted times series design to compare hepatitis C virus screening and treatment rates before and after state Medicaid HCV treatment policy changes, adjusting for state-level random effects, Medicaid expansion status, and state drug overdose incidence rates, in states that relaxed Medicaid policy over the study period. Analysis occurred during 2019‒2021.

RESULTS

Hepatitis C virus screening rates among commercially insured individuals increased after the corresponding state Medicaid program relaxed HCV treatment policy. Among states that changed Medicaid policy, those that reduced fibrosis or both fibrosis and abstinence restrictions experienced increased HCV screening rates by the study end compared with states that changed only abstinence restrictions (rate ratio=1.29; 95% CI=1.15, 1.44; and rate ratio=1.32; 95% CI=1.17, 1.50, respectively). Similar patterns did not occur in HCV treatment rates, which declined after 2015 across groups.

CONCLUSIONS

These data show that HCV screening rates increased among commercially insured individuals after the removal of Medicaid HCV treatment restrictions in the same state. This suggests that Medicaid treatment policies can spill over to affect health outcomes among commercially insured populations.

Hepatitis C antibody prevalence, correlates and barriers to care among people who inject drugs in Central California

Hepatitis C (HCV) infection among people who inject drugs (PWID) is a major public health concern. We examined correlates of HCV antibody (anti-HCV) seropositivity and characteristics of prior HCV testing and treatment among PWID in Fresno, California, which has among the highest prevalence of injection drug use (IDU) in the United States. We surveyed 494 peer-recruited PWID (≥18 years of age) in 2016 about their experiences with HCV testing and treatment, and conducted HCV and HIV antibody testing for all participants. Bivariate analyses and multivariable logistic regressions were used to identify correlates of anti-HCV seropositivity. A majority (65%) tested positive for anti-HCV, with 32% of those being unaware of their HCV status. Anti-HCV seroprevalence was independently and positively associated with older age (AOR = 1.11 per year, 95% CI = 1.06, 1.17), years injecting (AOR = 1.08 per year, 95% CI = 1.03, 1.13), distributive syringe sharing (AOR = 2.76, 95% CI = 1.29, 5.94), having syringes confiscated by police (AOR = 2.65, 95% CI = 1.22, 5.74), ever trading sex (AOR = 3.51, 95% CI = 1.40, 8.81) and negatively associated with being Black/African American (non-Hispanic) (AOR = 0.06, 95% CI = 0.01, 0.47). Prior HCV testing was associated with older age, ever getting syringes from a syringe services program, and having interactions with police. For those aware of their anti-HCV seropositivity, only 11% had initiated treatment; reasons for not seeing a physician regarding diagnosis included not feeling sick (23%), currently using drugs/alcohol (19%) and not knowing where to go for HCV medical care (19%). Our findings highlight the importance of expanding community-based access to sterile syringes alongside HCV testing and treatment services, particularly at syringe service programs where PWID may be more comfortable seeking testing and treatment.

Adoption of new therapies in the treatment of Hepatitis: a verification of the accuracy of budget impact analysis to guide investment decisions

OBJECTIVES

While there are good Budget Impact Analysis (BIA) guidelines, studies still register potential bias. To do this, we compared the results between theoretical and real-world evidence (RWE) expenditures for medicines for Hepatitis C: boceprevir (BOC) and telaprevir (TVR). While both are not currently recommended in treatment guidelines following recent developments, this is an emblematic case because for 4 years these medicines consumed considerable resources.

METHODS

Theoretical results and RWE expenditures were compared regarding the incorporation of BOC and TVR in 2013-2014 into the Brazilian Public Health System. Theoretical values were extracted from Commission for Technology Incorporation Report and RWE expenditures were extracted from the administrative data records using deterministic-probabilistic linkage.

RESULTS

The estimated number of patients treated (BOC+TVR) was 13,012 versus 7,641 (real). The estimated purchase price for BOC was US$6.20 versus US$11.07 (real) and for TVR was US$42.21 versus US$84.09 (average/real). The estimated budget impact was US$285.16 million versus US$128.58 million (real).

CONCLUSION

This study demonstrates appreciable divergence (US$156.58 million) between the theoretical budget impact and RWE expenditures due to underestimated purchase prices and overestimated populations. The greater the degree of accuracy the more reliable and usable BIAs become for decision-making.

Syringe services programs in the Bluegrass: Evidence of population health benefits using Kentucky Medicaid data

PURPOSE

To evaluate whether Kentucky counties that established a new syringe services program realized a significant decline in the incidence rate of a set of infectious disease diagnoses commonly transmitted via injection drug use.

METHODS

Longitudinal count models of within-county rates of newly diagnosed infections among populations at risk were estimated using Medicaid claims/encounters data. Generalized estimating equation models were used to report incident rate ratios of 6 diagnoses: (1) HIV; (2) hepatitis C; (3) hepatitis B; (4) osteomyelitis; (5) endocarditis; and (6) skin/soft tissue infection. To investigate whether a delay in effect was present, separate models were fit to estimate the effects of establishing a syringe services program: at its opening date, and again at 1, 3, and 6 months postopening date.

FINDINGS

Taken together, the aggregated within-county incidence rate of these 6 diagnoses was significantly lower following the implementation of a syringe services program (P < .05). Our models estimated that counties which opted to open a syringe services program realized an approximate month-over-month decline in new diagnoses of 0.5% among the population at risk.

CONCLUSIONS

These results lend further support to previous conclusions made in the public health literature regarding the efficacy of syringe services programs. Specifically, declines in incidence rates were observable beginning at 1 month post syringe services program opening. These results are particularly notable due to the typical setting in which these syringe services programs operated-rural communities of fewer than 40,000 residents.

Medicaid Subscription-Based Payment Models and Implications for Access to Hepatitis C Medications

Question

Did the use of direct-acting antiviral hepatitis C virus (HCV) medications change after implementation of subscription-based payment models for these drugs in Washington and Louisiana?

Findings

In this cross-sectional study, Louisiana experienced a 534.5% increase in HCV prescription fills after implementation of a subscription-based payment model, but no significant change in prescription fills was observed in Washington.

Meaning

In this study, subscription-based payment models in Louisiana and Washington were differentially associated with use of Medicaid-covered HCV medications, which may reflect state-level differences in implementation, historical restrictions on access to these medications, and responses to the COVID-19 pandemic.

Importance

Hepatitis C virus (HCV) can be cured with direct-acting antiviral medications, but state Medicaid programs often restrict access to these lifesaving medications owing to their high costs. Subscription-based payment models (SBPMs), wherein states contract with a single manufacturer to supply prescriptions at a reduced price, may offer a solution that increases access. Whether SBPMs are associated with changes in HCV medication use is unknown.

Objective

To estimate changes in Medicaid-covered HCV prescription fills after Louisiana and Washington implemented SBPMs on July 1, 2019.

Design, Setting, and Participants

This cross-sectional study examined trends in prescription fills of Medicaid-covered direct-acting antiviral HCV medications in Louisiana and Washington after implementation of SBPMs. A synthetic control approach was used to compare changes in HCV prescription fills between states that did and did not implement SBPMs. The unit of analysis was state-quarter. Outpatient direct-acting antiviral HCV prescription fills from the Medicaid State Drug Utilization Data files were obtained from all 50 US states and the District of Columbia from January 1, 2017, to June 30, 2020.

Exposures

Implementation of SBPMs for Medicaid-covered direct-acting antiviral HCV medications.

Main Outcomes and Measures

Direct-acting antiviral HCV prescriptions filled per 100 000 Medicaid enrollees.

Results

In the year preceding SBPM implementation, the mean (SD) rate of quarterly HCV prescription fills per 100 000 Medicaid enrollees was 43.1 (8.6) prescriptions in Louisiana and 50.1 (4.1) in Washington. After SBPM implementation, the mean (SD) rate of quarterly HCV prescription fills per 100 000 enrollees was 206.0 (51.2) prescriptions in Louisiana and 53.9 (11.0) in Washington. In synthetic control models, SBPM implementation in Louisiana was associated with an increase of 173.5 (95% CI, 74.3-265.3) quarterly prescription fills per 100 000 Medicaid enrollees during the following year, a relative increase of 534.5% (95% CI, 228.7%-1125.0%). Washington did not experience a significant change in prescription fills following SBPM implementation.

Conclusions and Relevance

In this cross-sectional study, Louisiana experienced substantial increases in HCV medication use among its Medicaid-enrolled population following SBPM implementation, whereas Washington did not. These differences may partially be explained by state-level variation in SBPM implementation, historical restrictions on access to HCV medications, and responses to the COVID-19 pandemic.

Modeling Hepatitis C Elimination Among People Who Inject Drugs in New Hampshire

Importance

The success of direct-acting antiviral therapies for chronic hepatitis C virus (HCV) infection led the World Health Organization to set elimination targets by 2030. For the United States to achieve these benchmarks, public health responses must target high-risk populations, such as people who inject drugs (PWID), a group with high rates of HCV incidence and low rates of treatment uptake.

Objective

To evaluate potential improvements in the HCV care cascade among PWID, focusing on improved testing, treatment uptake, and access to harm reduction.

Design, Setting, and Participants

This decision analytic model used a differential equation-based dynamic transmission model based on data from New Hampshire, an illustrative state with a large number of PWID and limited HCV treatment infrastructure. Surveillance data through 2020 was used for model parameterization, and the final analysis was conducted in May 2021.

Main Outcomes and Measures

Model forecasts of chronic HCV cases and advanced-stage HCV outcomes from 2022 to 2045.

Results

A total of 6 scenarios were tested: (1) the base case, (2) improved harm reduction, (3) improved testing, (4) improved treatment, (5) improved testing and treatment, and (6) improved testing, treatment, and harm reduction. All scenarios with improved testing, treatment uptake, and/or access to harm reduction were associated with decreases in forecasted HCV prevalence and HCV-associated mortality compared with the base case. Improving harm reduction, testing, and treatment individually were forecast to reduce prevalence of HCV in 2045 from 69.7% in the base case to 62.8%, 45.7%, and 35.5%, respectively. Combining treatment and testing improvements was associated with a 2045 prevalence of 0.3%; adding harm reduction improvements was associated with further reductions in prevalence forecasts (to 0.2%), with fewer total treatments (10 960 vs 13 219 from 2022-2045).

Conclusions and Relevance

In this modeling study, no single intervention was projected to achieve World Health Organization HCV elimination targets. Scenarios with improvements in both testing and treatment were associated with a prevalence of less than 3% by 2030 and achieved elimination targets. Adding improvements in harm reduction was associated with faster reductions in prevalence and fewer treatments.

Effect of relaxing hepatitis C treatment restrictions on direct-acting antiviral use in a Medicaid program: an interrupted time series analysis

BACKGROUND: Although direct-acting antivirals (DAA) have revolutionized the treatment of chronic hepatitis C virus (HCV), many state Medicaid programs have limited coverage because of their expense. In 2015, the Centers for Medicare & Medicaid Services (CMS) notified states about the legality of Medicaid coverage limitations, particularly within managed care programs. OBJECTIVES: To (1) examine how relaxation and alignment of hepatitis C policies within the Oregon Medicaid program affected DAA utilization and (2) describe changes in DAA coverage policies and patient characteristics of treated individuals over time. METHODS: We manually collected DAA Medicaid drug policies in the state of Oregon before and after the CMS notification was released. After categorizing DAA policies into 2 groups based on baseline prior authorization criteria (restrictive and permissive), we evaluated how changes in these DAA policies affected utilization over 3 time periods (pre-CMS period, post-CMS period, and fibrosis policy alignment). Immediate and gradual changes in trend were assessed using an interrupted time series regression model. Finally, we examined patient characteristics and liver disease complications over time as policy restrictions were removed and aligned with one another. RESULTS: From 2014 to 2018, Oregon's coordinated care organizations and fee-for-service drug policies relaxed liver fibrosis and substance abstinence coverage criteria leading to immediate increases in DAA use in 2016 (0.62 prescriptions per 10,000 enrollees per month; 95% CI = 0.17 to 1.08) and 2018 (1.07 prescriptions per 10,000 enrollees per month; 95% CI = 0.63 to 1.51) among more restrictive coordinated care organizations at baseline. This was followed by a decrease in trend after the 2016 and 2018 impact (-0.05; 95% CI = -0.11 to -0.001 and -0.07; 95% CI = -0.13 to -0.02, respectively). Over the 3 periods, there was a decrease in treated individuals with liver-related complications (P < 0.0001) and an increase in those with a substance use diagnosis (P = 0.0013). CONCLUSIONS: Reducing coverage limitations resulted in treatment of patients with fewer liver-related complications and more substance use disorders. Expanding access to treatment did not result in sustained increases in utilization, and additional interventions may be necessary to meet HCV elimination goals. DISCLOSURES: This study was funded in part by AbbVie Pharmaceuticals, which did not have any role in the study design, collection, analysis and interpretation of data, writing the report, or the decision to submit the report for publication. Hartung received support for his work on this study via a grant from AbbVie Pharmaceuticals. The other authors did not receive any financial support for their contributions to this study. The authors have no other financial disclosures to report. This study was presented at the Academy Health Annual Research Meeting in Washington, DC, on June 3, 2019.

Comparing direct acting antivirals for hepatitis C using observational data - Why and how?

The World Health Organisation's goal of hepatitis C virus (HCV) elimination by 2030 will require lower drug prices. Estimates of comparative efficacy promote competition between pharmaceutical companies but direct acting antivirals have been approved for the treatment of HCV without comparative trials. We emulated a randomized trial to answer the question of whether easy to treat patients with genotype 1 HCV could be treated with sofosbuvir/ledipasvir (SOF/LDV) rather than sofosbuvir/velpatasvir (SOF/VEL). Patients without comorbidities or end stage liver disease were selected from the British Colombia Hepatitis Testers Cohort. To create a conceptual trial, we matched each patient starting SOF/VEL (a ‘case’) to the patient starting SOF/LDV with the closest propensity score (a ‘control’). We estimated the probability of treatment failure under a Bayesian logistic model with a random effect for each case‐control set and used that model to give an estimate of a risk difference for the conceptual trial. Treatment failure was recorded for 27 of 825 (3%) cases and for 29 of 602 (5%) matched controls. Estimates from our model were treatment success rates of 97% (95% credible interval, CrI, 95%‐98%) for treatment with SOF/VEL, 95% (95% CrI 93%‐97%) for treatment with SOF/LDV and a risk difference between treatments of 2% (95% CrI 0%‐4%). This risk difference is evidence that SOF/LDV is not inferior to SOF/VEL for easy to treat patients with genotype 1 HCV. The approach is a template for comparing drugs when there are no data from comparative trials.

Factors predicting staging and treatment initiation for patients with chronic hepatitis C infection: insurance a key predictor

Background

Chronic hepatitis C (HCV) infection affects over 2.4 million Americans and accounts for 18 000 deaths per year. Treatment initiation in this population continues to be low even after introduction of highly effective and shorter duration direct-acting antivirals. This study assesses factors that influence key milestones in the HCV care continuum.

Methods

Retrospective time-to-event analyses were performed to assess factors influencing liver fibrosis staging and treatment initiation among individuals confirmed with chronic HCV infection at University of Illinois Hospital and Health Sciences System between 1 August 2015 and 24 October 2016 and followed through 28 January 2018. Cox regression models were utilized for multivariable analyses.

Results

Individuals tested at the liver clinic (hazard ratio [HR] = 2.03; 95% confidence interval [CI]: 1.19–3.46) and at the federally qualified health center (HR = 3.51; 95% CI: 2.19–5.64) had higher instantaneous probability of being staged compared with individuals tested at the emergency department (ED) or inpatient setting. And probability of treatment initiation increased with advancing liver fibrosis especially for Medicaid beneficiaries (HR = 1.64; 95% CI: 1.35–1.99).

Conclusions

The study demonstrates a need for improving access for patients with early stages of the disease in order to reduce HCV-related morbidity and mortality, especially those tested at nontraditional care locations such as the ED or the inpatient setting.

Hepatitis C testing and treatment uptake among young people who use opioids in New York City: A cross-sectional study

Young people who use drugs have a rising hepatitis C (HCV) incidence in the United States, but they may face barriers to testing and treatment adoption due to stigma. We conducted a cross-sectional study of New York City residents aged 18-29 years who reported non-medical prescription opioid and/or heroin use in the past 30 days. Participants were recruited from the community between 2014-2016 via respondent-driven sampling. Participants completed an in-person structured survey that included questions about HCV testing and treatment and received HCV antibody testing. There were 539 respondents: 353 people who inject drugs (PWID) and 186 non-PWID. For PWID, median age was 25 years, 65% were male and 73% non-Hispanic White. For non-PWID, median age was 23 years, 73% were male and 39% non-Hispanic White. 20% of PWID and 54% of non-PWID had never been tested for HCV (P < .001). Years since first injection (aOR 1.16, CI: 1.02-1.32, P = .02) and history of substance use treatment (aOR 3.17, CI: 1.53-6.61, P = .02) were associated with prior testing among PWID. The seroprevalence of HCV among PWID was 25%, adjusted for sampling weights. Of the 75 who were aware of their HCV-positive status, 53% had received HCV-related medical care, and 28% had initiated treatment. HCV prevalence among young PWID is high, and many have never been tested. Injection experience and treatment engagement is associated with testing. Interventions to increase testing earlier in injection careers, and to improve linkage to HCV treatment, will be critical for young PWID.

Integrative Review of Managed Entry Agreements: Chances and Limitations

BACKGROUND AND OBJECTIVE

Managed entry agreements (MEAs) consist of a set of instruments to reduce the uncertainty and the budget impact of new high-priced medicines; however, there are concerns. There is a need to critically appraise MEAs with their planned introduction in Brazil. Accordingly, the objective of this article is to identify and appraise key attributes and concerns with MEAs among payers and their advisers, with the findings providing critical considerations for Brazil and other high- and middle-income countries.

METHODS

An integrative review approach was adopted. This involved a review of MEAs across countries. The review question was 'What are the health technology MEAs that have been applied around the world?' This review was supplemented with studies not retrieved in the search known to the senior-level co-authors including key South American markets. It also involved senior-level decision makers and advisers providing guidance on the potential advantages and disadvantages of MEAs and ways forward.

RESULTS

Twenty-five studies were included in the review. Most MEAs included medicines (96.8%), focused on financial arrangements (43%) and included mostly antineoplastic medicines. Most countries kept key information confidential including discounts or had not published such data. Few details were found in the literature regarding South America. Our findings and inputs resulted in both advantages including reimbursement and disadvantages including concerns with data collection for outcome-based schemes.

CONCLUSIONS

We are likely to see a growth in MEAs with the continual launch of new high-priced and often complex treatments, coupled with increasing demands on resources. Whilst outcome-based MEAs could be an important tool to improve access to new innovative medicines, there are critical issues to address. Comparing knowledge, experiences, and practices across countries is crucial to guide high- and middle-income countries when designing their future MEAs.

HCV eradication in veterans with underlying mental health disorders and substance use

OBJECTIVE

Hepatitis C virus (HCV) disproportionately affects those with mental health disorders and those with substance use, and the increasing HCV transmission in the United States is driven by the opioid epidemic. However, patients with a mental health disorder, substance use, or combination of both historically have had limited access to HCV treatment. The goal of our study was to compare sustained virologic response (SVR) rates of HCV treatment with direct-acting antivirals (DAAs) between subjects with and without a mental health disorder, substance use, or combination of both.

METHODS

We performed a retrospective chart review at 1 Veterans affairs medical center of patients enrolled in the hepatitis C pharmacy clinic who completed DAA treatment from August 17, 2013 to August 17, 2017. The participants (N = 833 patients) were categorized into 2 groups: those with at least 1 mental health disorder, substance use, or combination of both and those without. Baseline variables relevant to HCV treatment, DAA regimen, number of documented efforts to engage patients, and SVR data were collected.

RESULTS

Of the 833 study participants, 579 patients had a mental health disorder, substance use, or combination of both. The 3 most prevalent disorders were patient-reported substance use (n = 333), substance-related and addictive disorders (n = 176), and depressive disorders (n = 159). The SVR rates and number of documented efforts to engage patients before and during treatment through SVR laboratory completion between those with a mental health disorder, substance use, or combination of both and those without were not statically significant.

CONCLUSION

DAA-based HCV treatment is highly effective with SVR rates exceeding 95% in the entire study cohort, including patients with or without mental health disorders, substance use, or combination of both.

Barriers to the Treatment of Hepatitis C among Predominantly African American Patients Seeking Care in an Urban Teaching Hospital in Washington, D.C

BACKGROUND

In the United States, it is estimated that 2.4 million people are currently infected with the hepatitis C virus (HCV). In order to address HCV infection management in the U.S., several government entities collaborated to develop and release a multistep plan for the prevention, care, and treatment of viral hepatitis. Optimal health outcomes from the plan are contingent upon addressing each of the several steps in the HCV care cascade. Among the critical challenging steps is linkage to care and access to treatment. Of the nearly three million people in the U.S. infected with HCV, only 43% have been linked to care, 16% have received treatment, and 9% have had their infection resolved.

OBJECTIVE

This retrospective study aims to identify predictors within the HCV treatment cascade that contribute to failures in care of HCV-infected patients in an urban hospital setting located in the District of Columbia.

SETTING

The outpatient clinics of a tertiary-care urban teaching hospital.

METHODS

A retrospective study was conducted using electronic medical records of persons 18 years and older who were HCV antibody positive and had at least one visit at any of the outpatient clinics from August 1, 2015 to August 1, 2016. Descriptive analysis of HCV positive persons was conducted, and predictors of HCV treatment were assessed.

RESULTS

A total of 252 patients were included in the study. Overall, patients were predominantly male (63.1%), African American (97.6%), under the age of 65 (71.4%), covered by public insurance (89.3%), and were diagnosed with HCV after the year 2001 (53.2%). Additionally, majority of patients had not been treated for their HCV infection (58%). Multiple barriers resulted in HCV infected patients not obtaining access to treatment. Fibrosis stage (p < 0.001) and prior insurance denial (p < 0.05) were significant predictors of HCV treatment. Age, gender, insurance type, substance abuse, alcohol abuse, and year of HCV diagnosis were not associated with limited access of HCV treatment.

CONCLUSION

HCV infections remain a major public health concern among patients in the District of Columbia. This study identified fibrosis stage and prior insurance denial as primary barriers to access of HCV treatment. While there are many points in the hepatitis cascade of care in which patients can lose access to or fail treatment completion, the primary point of intervention in our patient population appears to be during the initiation of treatment and insurance prior authorization process.

Association of Direct-Acting Antiviral Treatment With Mortality Among Medicare Beneficiaries With Hepatitis C

Importance

Direct-acting antiviral (DAA) drugs are highly effective in curing hepatitis C virus (HCV) infection. Previous simulations showed extended life as a key health advantage of DAA drugs, but real-world evidence on the association between DAA treatment and reduced mortality is limited.

Objectives

To examine the association of DAA treatment with mortality among Medicare beneficiaries with hepatitis C.

Design, Setting, and Participants

This cohort study used Medicare claims data of beneficiaries who sought hepatitis C care for the first time between January 1, 2014, and December 31, 2016, after at least a 1-year washout period. Medicare Part D files were used in identifying DAA therapy initiation and completion. Death dates, demographic data, and indicators of health risks were obtained from the Master Beneficiary Summary Files. Beneficiaries with hepatitis C were considered as patients with DAA treatment if they initiated DAA therapy during the study period. Beneficiaries with hepatitis C who did not initiate DAA therapy during the study period were considered as patients without DAA treatment. Patients without DAA treatment were selected using 1-to-1 propensity score matching. Data were analyzed between September 1, 2019, and March 31, 2020.

Exposures

Completion of DAA treatment.

Main Outcomes and Measures

Time to death from the index date of seeking hepatitis C care after at least a 1-year washout period. Cox proportional hazards regression models with time-varying exposure were used to compare mortality rates between propensity score-matched cohorts of patients with DAA treatment and those without DAA treatment. Separate analyses were performed for patients with or without cirrhosis. Heterogeneity in the association between DAA treatment and mortality by sex and dual-eligibility status was examined.

Results

A propensity score-matched sample of 51 478 Medicare beneficiaries with a mean (SD) age of 59.4 (11.1) years and 30 473 men (59.2%) was assessed. Of this total, 8240 patients (16.0%) had cirrhosis (5224 men [63.4%]; mean [SD] age, 62.3 [9.7] years) and 43 238 patients (84.0%) had no cirrhosis (25 249 men [58.4%]; mean [SD] age, 58.8 [11.3] years). The adjusted hazard ratio (HR) of dying between patients with DAA treatment and those without DAA treatment in the cirrhosis group was 0.51 (95% CI, 0.46-0.57). The association of DAA treatment with mortality did not differ by sex (women vs men: HR, 0.46 [95% CI, 0.38-0.56] vs HR, 0.53 [95% CI, 0.47-0.60]; P = .27) or dual-eligibility status (non-dual-eligible HR, 0.52 [95% CI, 0.43-0.63] vs dual-eligible HR, 0.50 [95% CI, 0.44-0.57]; P = .80) in the cirrhosis group. The adjusted HR of dying between patients with DAA treatment and those without DAA treatment among patients without cirrhosis was 0.54 (95% CI, 0.50-0.58). The association of DAA treatment with mortality did not differ by sex (women vs men: HR, 0.53 [95% CI, 0.46-0.60] vs HR, 0.55 [95% CI, 0.50-0.60]; P = .66) among patients without cirrhosis. However, the survival advantage associated with DAAs for non-dual-eligible beneficiaries was statistically significantly higher than for dual-eligible beneficiaries among patients without cirrhosis (HR, 0.47 [95% CI, 0.41-0.55] vs HR, 0.57 [95% CI, 0.52-0.62]; P = .02).

Conclusions and Relevance

In this cohort study, DAA treatment appeared to be associated with a decrease in mortality among Medicare beneficiaries with or without cirrhosis. These findings suggest that increasing access to DAA drugs for all patients with HCV infection, regardless of disease progression, could improve population health.

Clients' perceptions of barriers and facilitators to implementing hepatitis C virus care in homeless shelters

Background

Hepatitis C virus (HCV) is highly prevalent among homeless persons, yet barriers continue to impede HCV testing and treatment in this population. We studied the experiences of homeless individuals related to accessing HCV care to inform the design of a shelter-based HCV prevention and treatment program.

Methods

Homeless shelter clients (10 women and 10 men) of a large shelter in San Francisco participated in gender segregated focus groups. Focus groups followed a semi-structured interview format, which assessed individual, program/system, and societal-level barriers and facilitators to universal HCV testing and linkage to HCV care. Focus group interviews were transcribed, coded, and analyzed using thematic analysis.

Results

We identified key barriers to HCV testing and treatment at the individual level (limited knowledge and misconceptions about HCV infection, mistrust of health care providers, co-morbid conditions of substance use, psychiatric and chronic medical conditions), system level (limited advocacy for HCV services by shelter staff), and social level (stigma of homelessness). Individual, system, and social facilitators to HCV care described by participants included internal motivation, financial incentives, prior experiences with rapid HCV testing, and availability of affordable direct acting antiviral (DAA) treatment, respectively.

Conclusions

Interrelated individual- and social-level factors were the predominant barriers affecting homeless persons’ decisions to engage in HCV prevention and treatment. Integrated models of care for homeless persons at risk for or living with HCV address many of these factors, and should include interventions to improve patient knowledge of HCV and the availability of effective treatments.

Successful Implementation of a Shared Medical Appointment Model for Hepatitis C Treatment at a Community Health Center

Highly efficacious direct acting antiviral (DAA) therapy for treatment of Hepatitis C Virus (HCV) infection is largely inaccessible to communities facing a shortage of available specialist providers. Though less demanding than previous interferon regimens, DAA therapy requires patients to adhere to 8-12 weeks of daily treatment, which can be challenging for some patient populations. Duffy Health Center, located on Cape Cod, Massachusetts, provides integrated medical, mental health and case management services to people who are homeless or at risk for homelessness. The goal of this manuscript is to evaluate the outcomes of treatment of HCV infection with a shared medical appointment (SMA) model. The primary outcome was sustained virologic response (SVR-12), or HCV RNA ≤ 15 IU/mL at 12 weeks post-treatment. There were 102 patients recruited, with a total of 104 treatments administered. Over three-fourths of patients who attended one SMA visit (78 of 102) continued in SMA for the duration of treatment. Of these patients opting for SMA, 99% (77 of 78) completed the full treatment course, and 91% (71 of 78) of SMA patients achieved SVR-12. DAA therapy provided by non-specialist providers using the SMA model yielded comparable response rates to those achieved by specialist providers, and has the potential to substantially increase access to HCV treatment for patient populations within high-risk communities.

Prevalence of Viremic Hepatitis C Virus Infection by Age, Race/Ethnicity, and Birthplace and Disease Awareness Among Viremic Persons in the United States, 1999-2016

BACKGROUND

Athough curative therapy is now available for hepatitis C virus (HCV) infection in the United States, it is not clear whether all affected persons have been diagnosed and/or linked to care.

METHODS

This cross-sectional study utilized data from the National Health and Nutrition Examination Survey (1999-2016) and included 46 465 nonincarcerated and noninstitutionalized participants.

RESULTS

Viremic HCV prevalence decreased from 1.32% in 1999-2004 to 0.80% in 2011-2016, although most of the decrease occurred in US-born whites and blacks but not the foreign-born or those born after 1985. In 2011-2016, approximately 1.90 million US adults remained viremic with HCV, and 0.33 million were at higher risk for advanced fibrosis, but only 49.8% were aware of their HCV infection, with higher disease awareness in those with health insurance coverage and US-born persons.

CONCLUSIONS

The prevalence of viremic HCV has decreased in recent years among US born whites and blacks but not in other race/ethnicities and foreign-born persons and birth cohort born after 1985. Less than half of the viremic population was aware of having HCV infection. Improved HCV screening and linkage to care are needed, especially for the uninsured, foreign-born, birth cohort after 1985 and certain ethnic minorities.

State Medicaid Hepatitis C Treatment Eligibility Criteria and Use of Direct-Acting Antivirals

Medicaid program criteria for accessing hepatitis C treatment are changing. Medicaid drug utilization data from 2014 to 2016 show that programs that have relaxed their criteria have seen significant increases in treatment utilization, as have states with Medicaid expansions.

Has Access to Hepatitis C Virus Therapy Changed for Patients With Mental Health or Substance Use Disorders in the Direct-Acting-Antiviral Period?

Direct-acting antivirals (DAA) for hepatitis C virus (HCV) became available in 2014, but the role of mental health or substance use disorders (MH/SUD) on access to treatment is unknown. The objective of this study was to examine the extent and predictors of HCV treatment in the pre-DAA and post-DAA periods in four large, diverse health care settings in the United States. We conducted a retrospective analysis of 29,544 adults with chronic HCV who did or did not receive treatment from January 1, 2011, to February 28, 2017. Kaplan-Meier curve was used to examine cumulative risk for receiving HCV treatment stratified by MH/SUD. Predictors of HCV treatment in the pre-DAA (January 1, 2011, to December 31, 2013) and post-DAA (January 1, 2014, to February 28, 2017) cohorts were analyzed using multivariate generalized estimating equations and a modified Poisson model. Overall, 21.7% (2,879/13,240) of those with chronic HCV post-DAA were treated compared with 3.5% (574/16,304) in the pre-DAA period. Compared with non-Hispanic whites, Hispanic whites (adjusted odds ratio [AOR] 0.36; 95% confidence interval [CI], 0.25, 0.52) were less likely to be treated in the post-DAA period. Those with concurrent nonalcoholic fatty liver disease (AOR 1.39; 95% CI, 1.05, 1.83), cirrhosis (AOR 2.00; 95% CI, 1.74, 2.31), and liver transplant (AOR 2.72; 95% CI, 1.87, 3.94) were more likely to be treated post-DAA. Those with MH/SUD were less likely to be treated both before (AOR 0.46; 95% CI, 0.36, 0.60) and after (AOR 0.63; 95% CI, 0.55, 0.71) DAA therapy was available. Overall, the cumulative risk for receiving HCV treatment from 2011 to 2017 among those with versus without MH/SUD was 13.6% versus 21.6%, respectively (P < 0.001). Conclusion: The volume of patients treated for HCV has increased in the post-DAA period, especially among those with liver-related comorbidities, but disparities in access to treatment continue among those with MH/SUD.

Change in Health Insurance Coverage After Liver Transplantation Can Be Associated with Worse Outcomes

BACKGROUND

Health insurance coverage changes for many patients after liver transplantation, but the implications of this change on long-term outcomes are unclear.

AIMS

To assess post-transplant patient and graft survival according to change in insurance coverage within 1 year of transplantation.

METHODS

We queried the United Network for Organ Sharing for patients between ages 18-64 years undergoing liver transplantation in 2002-2016. Patients surviving > 1 year were categorized by insurance coverage at transplantation and the 1-year transplant anniversary. Multivariable Cox regression characterized the association between coverage pattern and long-term patient or graft survival.

RESULTS

Among 34,487 patients in the analysis, insurance coverage patterns included continuous private coverage (58%), continuous public coverage (29%), private to public transition (8%) and public to private transition (4%). In multivariable analysis of patient survival, continuous public insurance (HR 1.29, CI 1.22, 1.37, p < 0.001), private to public transition (HR 1.17, CI 1.07, 1.28, p < 0.001), and public to private transition (HR 1.14, CI 1.00, 1.29, p = 0.044), were associated with greater mortality hazard, compared to continuous private coverage. After disaggregating public coverage by source, mortality hazard was highest for patients transitioning from private insurance to Medicaid (HR vs. continuous private coverage = 1.32; 95% CI 1.14, 1.52; p < 0.001). Similar differences by insurance category were found for death-censored graft failure.

CONCLUSION

Post-transplant transition to public insurance coverage is associated with higher risk of adverse outcomes when compared to retaining private coverage.

"Impact of drug-reimbursement policies on prescribing: A case-study of a newly marketed long-acting injectable antipsychotic among relapsed schizophrenia patients"

OBJECTIVE

To quantify and explain variation in use of long-acting injectable antipsychotics (LAIs) in the United States, and understand the relationship between patient characteristics, drug reimbursement policies, and LAI prescribing after relapse.

METHODS

A cohort of recently relapsed patients with schizophrenia ages 18 to 64, were identified immediately after discharge from a related inpatient hospitalization, partial hospitalization, or emergency room visit, drawn from 2004 to 2006 Medicaid claims, and followed for 90 days until LAI initiation. Data on state-level Medicaid prior authorization (PA) policies for LAIs were collected. Sequential longitudinal Poisson regression models were developed to understand the relationship between patient and PA policy variables and LAI prescribing, including prior adherence to oral antipsychotics, demographics, clinical variables, and presence of PA policy for LAI.

RESULTS

Among 36 282 patients, 3.1% received risperidone LAI, and 3.8% received a first-generation (FGA) LAI with wide variation across states. Prior adherence ranged from 29% to 89% but was marginally associated with initiation and did not explain variation for LAI prescribing. FGA initiation was associated with geography and race/ethnicity but not PA policy. For risperidone LAI initiation, demographics and clinical factors explained, respectively, 5.0% and 3.0% of the variation; PA policy had a large negative association with initiation (RR = 0.41; 95%CI 0.20-0.87) and explained 8.4% of the variation.

CONCLUSIONS

PA policies may represent a major treatment barrier for risperidone LAI among relapsed patients. Non-adherence plays a little role in predicting which patients receive LAIs. Policy makers and health insurers will need to consider these findings when guiding the use of LAIs. KEY POINTS Among a nationwide cohort of relapsed schizophrenia patients enrolled in US Medicaid, 3.1% received Risperdal Consta, a long-acting injectable antipsychotic (LAI), and 3.8% initiated a first-generation first-generation LAI within 90 days after discharge. During 2004 to 2006, there was marked variation in 90 day post-relapse initiation of Risperdal-Consta-a newly marketed medication during this period-and also marked variation in 90 day post-relapse initiation of any first-generation LAI, which appeared to be associated with race/ethnicity and geography. Prior authorization policies were associated with substantially lower initiation of Risperdal Consta in this cohort of relapsed patients even after accounting for clinical indication (non-adherence), relapse history, demographics, adjunctive medication, and mental health service use.

Improving patient access to hepatitis C virus treatment

OBJECTIVES

To discuss the current barriers to hepatitis C virus (HCV) treatment; to provide information and resources to assist health care providers with the prior authorization process; to provide resources for potential access to medications if a patient's third-party payer may not be an option; and to discuss the pharmacist's vital role as a patient advocate and considerations once medications are approved.

SUMMARY

Access to HCV medications is often restricted by third-party payers. Pharmacists are poised to fill an immediate need and assist with providing the necessary clinical evidence to gain access to HCV medications and advocate on the patient's behalf. Once approval for HCV treatment has been obtained, considerations must be given to procurement of therapy, refills, monitoring, and avoid interruptions in therapy.

CONCLUSION

The assistance of a pharmacist should be sought to overcome barriers related to medication access. Once therapy has been obtained, the pharmacist can assist the entire patient care team to ensure timely refills, appropriate monitoring, tolerability of therapy, and continued medication access.

Vedroprevir in the management of hepatitis C virus infection

INTRODUCTION

Hepatitis C Virus (HCV) is a chronic infection of the liver and the leading cause of liver failure and liver transplantation worldwide. While prior HCV therapies were prolonged and had variable success rates, the advent of direct-acting antivirals (DAAs) has dramatically improved HCV therapy with minimal side effects, shorter treatment durations, and higher cure rates. Areas covered: In this paper, we review the literature discussing the use of Vedroprevir (GS-9451) in treatment of HCV in a variety of patient populations. Articles accessible on MEDLINE/PubMed were reviewed to provide context on chemistry, pharmacology, and efficacy of Vedroprevir in HCV treatment. Expert opinion: Vedroprevir is highly effective in reducing treatment duration in combination with other DAAs without compromising treatment success rates. GS-9451 is insufficient as HCV monotherapy due to low threshold for development of high level of resistance and must be combined with other DAAs to achieve sustained virologic response (SVR).