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Tian F, Forouzannia F, Feng Z, Biondi MJ, Mendlowitz AB, Feld JJ, Sander B, Wong WW. Feasibility of hepatitis C elimination by screening and treatment alone in high-income countries. Hepatology 2024; 80:440-450. [PMID: 38478751 PMCID: PMC11251502 DOI: 10.1097/hep.0000000000000779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 12/27/2023] [Indexed: 03/23/2024]
Abstract
BACKGROUND AND AIMS Despite the availability of highly effective direct-acting antiviral therapy, chronic hepatitis C (CHC) continues to cause a major public health burden. In many high-income countries, treatment rates have been declining, which was exacerbated by the impact of the COVID-19 pandemic, threatening the ability to meet the World Health Organization (WHO)'s targets for eliminating HCV as a public health threat by 2030. We sought to model the impact of CHC in Canada, a resource-rich country with ongoing immigration from HCV-endemic regions; which relies exclusively on risk-based screening for case identification. APPROACH AND RESULTS We developed an agent-based model to characterize the HCV epidemic in a high-income country with ongoing immigration. Combinations of prevention such as harm reduction, screening, and treatment strategies were considered. Model parameters were estimated from the literature and calibrated against historical HCV data. Sensitivity analyses were performed to assess uncertainty. Under the current status quo of risk-based screening, we predict the incidence of CHC-induced decompensated cirrhosis, HCC, and liver-related deaths would decrease by 79.4%, 76.1%, and 62.1%, respectively, between 2015 and 2030, but CHC incidence would only decrease by 11.1%. The results were sensitive to HCV transmission rate and an annual number of people initiating treatment. CONCLUSIONS Current risk-based screening, and subsequent treatment, will be inadequate to achieve WHO goals. With extensive scale-up in screening, and treatment, the mortality target may be achievable, but the target for preventing new CHC cases is unlikely reachable, highlighting the importance of developing enhanced harm-reduction strategies for HCV elimination.
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Affiliation(s)
- Feng Tian
- School of Pharmacy, University of Waterloo, Kitchener, Ontario, Canada
| | | | - Zeny Feng
- Department of Mathematics and Statistics, University of Guelph, Guelph, Ontario, Canada
| | - Mia J. Biondi
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
- School of Nursing, York University, Toronto, Ontario, Canada
| | - Andrew B. Mendlowitz
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
- Toronto Health Economics and Technology Assessment Collaborative (THETA), University Health Network, Toronto, Ontario, Canada
| | - Jordan J. Feld
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
| | - Beate Sander
- Toronto Health Economics and Technology Assessment Collaborative (THETA), University Health Network, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Public Health Ontario, Toronto, Ontario, Canada
| | - William W.L. Wong
- School of Pharmacy, University of Waterloo, Kitchener, Ontario, Canada
- Toronto Health Economics and Technology Assessment Collaborative (THETA), University Health Network, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
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Konstantelos N, Shakeri A, McCormack D, Campos-Meade A, Gomes T, Murti M, Pierre-Pierre V, Tadrous M. Regional differences in access to direct-acting antiviral treatments for hepatitis C across Ontario: A cross-sectional study. CANADA COMMUNICABLE DISEASE REPORT = RELEVE DES MALADIES TRANSMISSIBLES AU CANADA 2022; 48:179-180. [PMID: 35480701 PMCID: PMC9018058 DOI: 10.14745/ccdr.v48i04a08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Background Direct-acting antivirals (DAAs) are curative treatments for hepatitis C virus (HCV) infection, a condition affecting over 100,000 Ontarians. Although DAAs are covered under the public drug programs in Ontario, receiving prescriptions depends on access to healthcare. The aim of this study is to understand the relationship between DAA treatment rates and distance to prescriber in Ontario, Canada. Methods We conducted a cross-sectional study and identified patients who filled a DAA prescription through the Ontario Drug Benefit (ODB) in 2019. We calculated crude (per 100,000 ODB recipients) and adjusted (by a regional HCV infection rate) DAA treatment rates by public health unit (PHU). We reported median distances to provider for all visit types, in-person visits, virtual visits, and proportions of visits that were virtual. Results In 2019, the crude DAA treatment rate for Ontario is 83.0 patients per 100,000 ODB recipients. The HCV-adjusted DAA treatment rate ranges from 28.2 (Northwestern Ontario) to 188.5 (Eastern Ontario) per 100,000. In our primary analysis, patients in rural PHUs, including Northwestern and Porcupine, were among the highest median distances to prescriber for all visit types (1,195 km and 556 km, respectively). These PHUs also had the highest proportions of virtual visits (greater than 60%). Urban PHUs, such as Toronto and Ottawa, had smaller median distances for all visit types, with smaller proportions of virtual visits (10.8% and 12.4%, respectively). Conclusion We observed heterogeneity in treatment rates, distance to DAA prescribers and use of virtual care in the management of HCV. Increasing use of telemedicine in regions with limited utilization of DAAs may improve access.
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Affiliation(s)
- Natalia Konstantelos
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON
- Women’s College Research Institute, Toronto, ON
| | - Ahmad Shakeri
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON
- Women’s College Research Institute, Toronto, ON
| | | | | | - Tara Gomes
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON
- ICES, Toronto, ON
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, ON
| | - Michelle Murti
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON
| | | | - Mina Tadrous
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON
- Women’s College Research Institute, Toronto, ON
- ICES, Toronto, ON
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Petrosyan Y, Simmons JG, Kelly E, Cooper CL. Uptake and factors associated with direct-acting antiviral therapy for hepatitis C and treatment outcomes among Canadian immigrants: A retrospective cohort analysis. CANADIAN LIVER JOURNAL 2022; 5:388-401. [DOI: 10.3138/canlivj-2021-0037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 01/15/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND: We sought to compare rates and factors associated with Direct Acting Antiviral (DAA) treatment uptake and sustained virological response (SVR) between Canadian-born and foreign-born patients. METHODS: The study was conducted utilizing a retrospective cohort of hepatitis C virus (HCV)-infected patients assessed at The Ottawa Hospital Viral Hepatitis Clinic between January 2015 and October 2021. Risk factors, income, and clinical characteristics of HCV infection associated with DAA therapy uptake and SVR were compared by immigration status using logistic regression. RESULTS: Of 1,459 HCV-infected patients, 264 (18.1%) were born outside of the country. A median 17 years passed from immigration to first assessment at the clinic. The proportion of patients initiating DAA therapy was similar between groups (65.2% versus 69.5%, p = 0.17). Characteristics associated with DAA therapy uptake included age at first assessment (OR = 1.02; 95% CI 1.01 to 1.03) and being cirrhotic (OR = 3.19; 95% CI 1.99 to 2.13). Crude SVR rate was higher in immigrants than in Canadian-born patients (91.5% versus 83.7%, p = 0.01). After controlling for other variables, only advancing age was associated with the likelihood of achieving crude SVR (OR = 1.04, 95% CI 1.02 to 1.05). CONCLUSIONS: We found that DAA therapy uptake and HCV cure rates were high in both groups suggesting equity of opportunity in those referred to our program. The older age at presentation suggests missed opportunities to diagnose and engage immigrants in HCV care. These findings emphasize the importance of early large-scale screening and engagement in care for HCV infection of immigrant populations to prevent future complications.
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Affiliation(s)
- Yelena Petrosyan
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Erin Kelly
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Curtis L Cooper
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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Wong WWL, Wong J, Bremner KE, Saeed Y, Mason K, Phoon A, Feng Z, Feld JJ, Mitsakakis N, Powis J, Krahn M. Time Costs and Out-of-Pocket Costs in Patients With Chronic Hepatitis C in a Publicly Funded Health System. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022; 25:247-256. [PMID: 35094798 DOI: 10.1016/j.jval.2021.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 06/28/2021] [Accepted: 08/18/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVES Chronic hepatitis C (CHC) infection affects more than 70 million people worldwide and imposes considerable health and economic burdens on patients and society. This study estimated 2 understudied components of the economic burden, patient out-of-pocket (OOP) costs and time costs, in patients with CHC in a tertiary hospital clinic setting and a community clinic setting. METHODS This was a multicenter, cross-sectional study with hospital-based (n = 174) and community-based (n = 101) cohorts. We used a standardized instrument to collect healthcare resource use, time, and OOP costs. OOP costs included patient-borne costs for medical services, nonprescription drugs, and nonmedical expenses related to healthcare visits. Patient and caregiver time costs were estimated using an hourly wage value derived from patient-reported employment income and, where missing, derived from the Canadian census. Sensitivity analysis explored alternative methods of valuing time. Costs were reported in 2020 Canadian dollars. RESULTS The mean 3-month OOP cost was $55 (95% confidence interval [CI] $21-$89) and $299 (95% CI $170-$427) for the community and hospital cohorts, respectively. The mean 3-month patient time cost was $743 (95% CI $485-$1002) (community) and $465 (95% CI $248-$682) (hospital). The mean 3-month caregiver time cost was $31 (95% CI $0-$63) (community) and $277 (95% CI $174-$380) (hospital). Patients with decompensated cirrhosis bore the highest costs. CONCLUSIONS OOP costs and patient and caregiver time costs represent a considerable economic burden to patient with CHC, equivalent to 14% and 21% of the reported total 3-month income for the hospital-based and community-based cohorts, respectively.
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Affiliation(s)
- William W L Wong
- School of Pharmacy, University of Waterloo, Kitchener, Ontario, Canada; Toronto Health Economics and Technology Assessment Collaborative, University Health Network, Toronto, Ontario, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada.
| | - Josephine Wong
- Toronto Health Economics and Technology Assessment Collaborative, University Health Network, Toronto, Ontario, Canada
| | - Karen E Bremner
- Toronto Health Economics and Technology Assessment Collaborative, University Health Network, Toronto, Ontario, Canada
| | - Yasmin Saeed
- Toronto Health Economics and Technology Assessment Collaborative, University Health Network, Toronto, Ontario, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Kate Mason
- Toronto Community Hepatitis C Program, Toronto, Ontario, Canada
| | - Arcturus Phoon
- Toronto Health Economics and Technology Assessment Collaborative, University Health Network, Toronto, Ontario, Canada
| | - Zeny Feng
- Department of Mathematics and Statistics, University of Guelph, Guelph, Ontario, Canada
| | - Jordan J Feld
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
| | - Nicholas Mitsakakis
- Toronto Health Economics and Technology Assessment Collaborative, University Health Network, Toronto, Ontario, Canada
| | - Jeff Powis
- Michael Garron Hospital, Toronto, Ontario, Canada
| | - Murray Krahn
- Toronto Health Economics and Technology Assessment Collaborative, University Health Network, Toronto, Ontario, Canada
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Impact of COVID-19 on Prescribing Trends of Direct-Acting Antivirals for the Treatment of Hepatitis C in Ontario, Canada. Am J Gastroenterol 2021; 116:1738-1740. [PMID: 34587128 DOI: 10.14309/ajg.0000000000001287] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 03/26/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Direct-acting antivirals (DAAs) are curative treatments for hepatitis C. However, initiation of these treatments requires adequate healthcare access. Coronavirus 2019 (COVID-19) resulted in restrictions to healthcare services in March 2020. We examined the impact of COVID-19 on the number of individuals dispensed DAAs. METHODS This is a cross-sectional study examining the number of individuals dispensed DAAs in Ontario, Canada, from 2018 to 2020. Time-series models determined the impact of healthcare restrictions on DAA dispensations. RESULTS Healthcare restrictions resulted in a 49.3% decrease in DAA dispensations (P = 0.026). DISCUSSION COVID-19-related healthcare restrictions significantly affected access to DAAs. Studies exploring the long-term effects on reduced treatment are needed.
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