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Tao MH, Gordon SC, Wu T, Trudeau S, Rupp LB, Gonzalez HC, Daida YG, Schmidt MA, Lu M. Antiviral Treatment and Response are Associated With Lower Risk of Dementia Among Hepatitis C Virus-Infected Patients. Am J Geriatr Psychiatry 2024; 32:611-621. [PMID: 38199936 DOI: 10.1016/j.jagp.2023.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 12/15/2023] [Accepted: 12/19/2023] [Indexed: 01/12/2024]
Abstract
OBJECTIVE Eradication of hepatitis C virus (HCV) infection has been linked with improvement in neurocognitive function, but few studies have evaluated the effect of antiviral treatment/ response on risk of dementia. Using data from the Chronic Hepatitis Cohort Study (CHeCS), we investigated how antiviral therapy impacts the risk of developing dementia among patients with HCV. METHODS A total of 17,485 HCV patients were followed until incidence of dementia, death, or last follow-up. We used an extended landmark modeling approach, which included time-varying covariates and propensity score justification for treatment selection bias, as well as generalized estimating equations (GEE) with a link function as multinominal distribution for a discrete time-to-event data. Death was considered a competing risk. RESULTS After 15 years of follow-up, 342 patients were diagnosed with incident dementia. Patients who achieved sustained virological response (SVR) had significantly decreased risk of dementia compared to untreated patients, with hazard ratios (HRs) of 0.32 (95% CI 0.22-0.46) among patients who received direct-acting antiviral (DAA) treatment and 0.41 (95% CI 0.26-0.60) for interferon-based (IFN) treatment. Risk reduction remained even when patients failed antiviral treatment (HR 0.38, 95% CI 0.38-0.51). Patients with cirrhosis, Black/African American patients, and those without private insurance were at significantly higher risk of dementia. CONCLUSION Antiviral treatment independently reduced the risk of dementia among HCV patients, regardless of cirrhosis. Our findings support the importance of initiation antiviral therapy in chronic HCV-infected patients.
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Affiliation(s)
- Meng-Hua Tao
- Department of Public Health Sciences (M-HT, TW, ST, HCG, ML), Henry Ford Health, Detroit MI.
| | - Stuart C Gordon
- Department of Gastroenterology and Hepatology (SCG, HCG), Henry Ford Health, Detroit MI; School of Medicine (SCG, HCG), Wayne State University, Detroit MI
| | - Trueman Wu
- Department of Public Health Sciences (M-HT, TW, ST, HCG, ML), Henry Ford Health, Detroit MI
| | - Sheri Trudeau
- Department of Public Health Sciences (M-HT, TW, ST, HCG, ML), Henry Ford Health, Detroit MI
| | - Loralee B Rupp
- Department of Health Policy and Health Services Research (LBR), Henry Ford Health, Detroit MI
| | - Humberto C Gonzalez
- Department of Public Health Sciences (M-HT, TW, ST, HCG, ML), Henry Ford Health, Detroit MI; Department of Gastroenterology and Hepatology (SCG, HCG), Henry Ford Health, Detroit MI; School of Medicine (SCG, HCG), Wayne State University, Detroit MI
| | - Yihe G Daida
- Center for Integrated Health Care Research (YGD), Kaiser Permanente Hawaii, Honolulu, HI
| | - Mark A Schmidt
- Center for Health Research (MAS), Kaiser Permanente Northwest, Portland, OR
| | - Mei Lu
- Department of Public Health Sciences (M-HT, TW, ST, HCG, ML), Henry Ford Health, Detroit MI
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Lu M, Rupp LB, Melkonian C, Trudeau S, Daida YG, Schmidt MA, Gordon SC. Correction to: Real-World Safety and Effectiveness of an 8-Week Regimen of Glecaprevir/Pibrentasvir in Patients with Hepatitis C and Cirrhosis. Adv Ther 2024:10.1007/s12325-024-02858-1. [PMID: 38598114 DOI: 10.1007/s12325-024-02858-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Affiliation(s)
- Mei Lu
- Department of Public Health Sciences, Henry Ford Health, One Ford Place, Detroit, MI, 48202, USA.
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing, MI, USA.
| | - Loralee B Rupp
- Department of Health Policy and Health Services Research, Henry Ford Health, Detroit, MI, USA
| | - Christina Melkonian
- Department of Public Health Sciences, Henry Ford Health, One Ford Place, Detroit, MI, 48202, USA
| | - Sheri Trudeau
- Department of Public Health Sciences, Henry Ford Health, One Ford Place, Detroit, MI, 48202, USA
| | - Yihe G Daida
- Center for Integrated Health Care Research, Kaiser Permanente Hawaii, Honolulu, HI, USA
| | - Mark A Schmidt
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
| | - Stuart C Gordon
- Department of Gastroenterology and Hepatology, Henry Ford Health, Detroit, MI, USA
- School of Medicine, Wayne State University, Detroit, MI, USA
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Lu M, Rupp LB, Melkonian C, Trudeau S, Daida YG, Schmidt MA, Gordon SC. Persistent pruritus associated with worse quality of life in patients with chronic hepatitis. Liver Int 2024; 44:577-588. [PMID: 38082499 DOI: 10.1111/liv.15803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 11/06/2023] [Accepted: 11/12/2023] [Indexed: 01/31/2024]
Abstract
INTRODUCTION Prevalence and severity of pruritus among US patients with chronic hepatitis B and C (HBV, HCV) are not well-documented. Chronic Hepatitis Cohort Study (CHeCS) patients were surveyed to examine pruritus prevalence and impact on quality of life (QoL). METHODS Patients who reported experiencing pruritus ≥3 on a Numeric Rating Scale (NRS) within the past 30 days were invited to participate in a 6-month study using the SF-36 questionnaire. General regression (univariate followed by multivariable modelling) was used to analyse pruritus intensity and eight QoL dimensions. RESULTS Among 1654 patients (HBV = 358, HCV = 1296, HBV/HCV = 6), pruritus prevalence was significantly higher among patients with HCV than those with HBV (44% vs. 35%; p < .05). One hundred and twenty-three patients (21 HBV and 102 HCV) participated in the QoL study (72% ≥60 years; 50% men; 25% Black; 37% with cirrhosis; 66% had BMI > 25). Mean NRS was 4.9-5.3. QoL responses for social functioning and emotional well-being were higher (70-72 points) than responses for energy/fatigue (50-51). Antiviral treatment rates were higher in HCV (92%, SVR 99%) than HBV (71% ever, 43% ongoing). Multivariable analyses showed no significant effect of hepatitis type or antiviral treatments on itch. Antihistamines were associated with severe itch. Higher NRS was associated with significantly reduced QoL. Each unit increase in NRS was associated with a 2-3 unit decline in emotional well-being, general health, physical function, energy/fatigue, social functioning and emotional health. CONCLUSION Pruritus negatively affects many viral hepatitis patients, regardless of antiviral treatment status. Improved treatment options are needed to address its impact on QoL.
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Affiliation(s)
- Mei Lu
- Department of Public Health Sciences, Henry Ford Health, Detroit, Michigan, USA
| | - Loralee B Rupp
- Department of Health Policy and Health Services Research, Henry Ford Health, Detroit, Michigan, USA
| | - Christina Melkonian
- Department of Public Health Sciences, Henry Ford Health, Detroit, Michigan, USA
| | - Sheri Trudeau
- Department of Public Health Sciences, Henry Ford Health, Detroit, Michigan, USA
| | - Yihe G Daida
- Center for Integrated Health Care Research, Kaiser Permanente Hawaii, Honolulu, Hawaii, USA
| | - Mark A Schmidt
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA
| | - Stuart C Gordon
- Department of Gastroenterology and Hepatology, Henry Ford Health, Detroit, Michigan, USA
- School of Medicine, Wayne State University, Detroit, Michigan, USA
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Lu M, Rupp LB, Melkonian C, Trudeau S, Daida YG, Schmidt MA, Gordon SC. Real-World Safety and Effectiveness of an 8-Week Regimen of Glecaprevir/Pibrentasvir in Patients with Hepatitis C and Cirrhosis. Adv Ther 2024; 41:744-758. [PMID: 38169058 PMCID: PMC11006752 DOI: 10.1007/s12325-023-02748-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 11/21/2023] [Indexed: 01/05/2024]
Abstract
INTRODUCTION In 2019, an 8-week regimen of glecaprevir/ pibrentasvir (GLE/PIB) was FDA-approved for treatment of chronic hepatitis C (HCV) in patients with cirrhosis. We used data from the Chronic Hepatitis Cohort Study (CHeCS) to evaluate treatment response and adverse events among patients with HCV and cirrhosis under routine clinical care. METHODS Using an intention-to-treat (ITT)/modified ITT (mITT) approach, endpoints were (1) sustained virological response (SVR) at 12 weeks (SVR12) post-treatment; and (2) adverse events (AEs)/serious AEs during treatment. Patients with cirrhosis from two CHeCS sites were included if they were prescribed GLE/PIB from August 2017 to June 2020. Detailed treatment and clinical data were collected. Patient baseline characteristics were described with mean/standard deviation (std) for continuous variables, and proportions for categorical variables. Analyses were propensity score adjusted. The final model retained variables that were significant with p value < 0.05. RESULTS The ITT sample included 166 patients, with 43, 116, and 7 patients in the 8-week, 12-week, and > 12-week planned treatment groups. Among them, 159 had confirmed SVR (95.8%, LCL 93.2%). The mITT analysis included 160 patients after excluding 6 with unknown HCV RNA results; 159 achieved SVR (99.4%, LCL 98.3%). There were no significant differences in rates of SVR between the 8-week and 12-week regimens in either analysis, nor any association with patient characteristics. SAEs were experienced by 1 patient (2%) in the 8-week group, 7 (5%) in the 12-week group (including one death), and 2 (29%) in the > 12-week group; 4 patients (from the 12-week group) experienced serious AEs or hepatic events that were "likely attributable" to GLE/PIB treatment. CONCLUSION An 8-week regimen of GLE/PIB is well tolerated and highly effective among US patients with HCV and cirrhosis receiving routine clinical care.
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Affiliation(s)
- Mei Lu
- Department of Public Health Sciences, Henry Ford Health, One Ford Place, Detroit, MI, 48202, USA.
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing, MI, USA.
| | - Loralee B Rupp
- Department of Health Policy and Health Services Research, Henry Ford Health, Detroit, MI, USA
| | - Christina Melkonian
- Department of Public Health Sciences, Henry Ford Health, One Ford Place, Detroit, MI, 48202, USA
| | - Sheri Trudeau
- Department of Public Health Sciences, Henry Ford Health, One Ford Place, Detroit, MI, 48202, USA
| | - Yihe G Daida
- Center for Integrated Health Care Research, Kaiser Permanente Hawaii, Honolulu, HI, USA
| | - Mark A Schmidt
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
| | - Stuart C Gordon
- Department of Gastroenterology and Hepatology, Henry Ford Health, Detroit, MI, USA
- School of Medicine, Wayne State University, Detroit, MI, USA
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Gonzalez HC, Nimri FM, Lu M, Zhou Y, Rupp LB, Trudeau S, Gordon SC. Alcohol-related hepatitis admissions decline in 2021 after a 2020 surge attributed to the COVID-19 pandemic. Hepatol Int 2023; 17:1637-1644. [PMID: 37505324 DOI: 10.1007/s12072-023-10569-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 07/07/2023] [Indexed: 07/29/2023]
Abstract
OBJECTIVE We previously investigated the impact of the COVID-19 pandemic on alcohol-related liver disease (ARLD), finding that admissions for alcoholic hepatitis (AH) increased by 50% in the summer of 2020 compared to the same period in 2016-2019. We have now expanded our analysis to consider full years' data and evaluate how rates changed in 2021. We also sought to identify factors associated with ICU admissions, need for dialysis, liver transplant evaluations, and death. METHODS Using retrospective data, we identified patients admitted to our four Detroit, Michigan area hospitals for acute ARLD for three periods pre-COVID (2016-February 2020), early COVID (June-December 2020), and late COVID (2021). Clustered logistic regression was performed to study rates of AH admissions across the three eras, where the patient was defined as the cluster and the analysis accounted for multiple encounters per cluster. A similar regression approach, univariate followed by multivariable analysis, was also used to study associations between patient characteristics and outcomes during hospitalization for AH. RESULTS AH-related admissions declined significantly from the early COVID to late COVID eras (OR 0.68, 95% CL 0.52, 0.88), returning to levels similar to that of the pre- COVID period (OR 1.18, 95% CL 0.96, 1.47). In multivariable analysis, baseline MELD score was associated with ICU admission, initiation of dialysis, transplant evaluation, and death while hospitalized for AH. Female patients were at almost twice the risk of death during admission compared to male patients (aOR 1.81, 95% CL 1.1, 2.98). Increasing age was associated with slightly lower odds of transplant (aOR 0.97, 95% CL 0.94, 1) and higher odds of death (aOR 1.03, 95% CL 1.01. 1.06). CONCLUSION After a spike in AH-related admissions during the first summer of the COVID-19 pandemic, rates declined significantly in 2021, returning to pre-pandemic levels.
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Affiliation(s)
- Humberto C Gonzalez
- Department of Gastroenterology and Hepatology, Henry Ford Health, Detroit, MI, USA.
- School of Medicine, Wayne State University, Detroit, MI, USA.
- Transplant Hepatology, Henry Ford Health, 2799 West Grand Blvd, Detroit, MI, 48202, USA.
| | - Faisal M Nimri
- Department of Gastroenterology and Hepatology, Henry Ford Health, Detroit, MI, USA
| | - Mei Lu
- Department of Public Health Sciences, Henry Ford Health, Detroit, MI, USA
| | - Yueren Zhou
- Department of Public Health Sciences, Henry Ford Health, Detroit, MI, USA
| | - Loralee B Rupp
- Department of Health Policy and Health Systems Research, Henry Ford Health, Detroit, MI, USA
| | - Sheri Trudeau
- Department of Public Health Sciences, Henry Ford Health, Detroit, MI, USA
| | - Stuart C Gordon
- Department of Gastroenterology and Hepatology, Henry Ford Health, Detroit, MI, USA
- School of Medicine, Wayne State University, Detroit, MI, USA
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Lu M, Salgia R, Li J, Trudeau S, Rupp LB, Wu T, Daida YG, Schmidt MA, Gordon SC. Dynamic risk assessment for hepatocellular carcinoma in patients with chronic hepatitis C. J Viral Hepat 2023; 30:746-755. [PMID: 37415492 DOI: 10.1111/jvh.13859] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 05/27/2023] [Indexed: 07/08/2023]
Abstract
Chronic hepatitis C (HCV) is a primary cause of hepatocellular carcinoma (HCC). Although antiviral treatment reduces risk of HCC, few studies quantify the impact of treatment on long-term risk in the era of direct-acting antivirals (DAA). Using data from the Chronic Hepatitis Cohort Study, we evaluated the impact of treatment type (DAA, interferon-based [IFN], or none) and outcome (sustained virological response [SVR] or treatment failure [TF]) on risk of HCC. We then developed and validated a predictive risk model. 17186 HCV patients were followed until HCC, death or last follow-up. We used extended landmark modelling, with time-varying covariates and propensity score justification and generalized estimating equations with a link function for discrete time-to-event data. Death was considered a competing risk. We observed 586 HCC cases across 104,000 interval-years of follow-up. SVR from DAA or IFN-based treatment reduced risk of HCC (aHR 0.13, 95% CI 0.08-0.20; and aHR 0.45, 95% CI 0.31-0.65); DAA SVR reduced risk more than IFN SVR (aHR 0.29, 95% CI 0.17-0.48). Independent of treatment, cirrhosis was the strongest risk factor for HCC (aHR 3.94, 95% CI 3.17-4.89 vs. no cirrhosis). Other risk factors included male sex, White race and genotype 3. Our six-variable predictive model had 'excellent' accuracy (AUROC 0.94) in independent validation. Our novel landmark interval-based model identified HCC risk factors across antiviral treatment status and interactions with cirrhosis. This model demonstrated excellent predictive accuracy in a large, racially diverse cohort of patients and could be adapted for 'real world' HCC monitoring.
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Affiliation(s)
- Mei Lu
- Department of Public Health Sciences, Henry Ford Health, Detroit, Michigan, USA
| | - Reena Salgia
- Department of Gastroenterology and Hepatology, Henry Ford Health, Detroit, Michigan, USA
- School of Medicine, Wayne State University, Detroit, Michigan, USA
| | - Jia Li
- Department of Public Health Sciences, Henry Ford Health, Detroit, Michigan, USA
- School of Medicine, Wayne State University, Detroit, Michigan, USA
| | - Sheri Trudeau
- Department of Public Health Sciences, Henry Ford Health, Detroit, Michigan, USA
| | - Loralee B Rupp
- Department of Health Policy and Health Services Research, Henry Ford Health, Detroit, Michigan, USA
| | - Trueman Wu
- Department of Public Health Sciences, Henry Ford Health, Detroit, Michigan, USA
| | - Yihe G Daida
- Center for Integrated Health Care Research, Kaiser Permanente Hawaii, Honolulu, Hawaii, USA
| | - Mark A Schmidt
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA
| | - Stuart C Gordon
- Department of Gastroenterology and Hepatology, Henry Ford Health, Detroit, Michigan, USA
- School of Medicine, Wayne State University, Detroit, Michigan, USA
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Selim R, Gordon SC, Zhou Y, Zhang T, Lu M, Daida YG, Boscarino JA, Schmidt MA, Trudeau S, Rupp LB, Gonzalez HC. Impact of hepatitis C treatment status on risk of Parkinson's disease and secondary parkinsonism in the era of direct-acting antivirals. J Viral Hepat 2023; 30:544-550. [PMID: 36872452 DOI: 10.1111/jvh.13826] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 02/10/2023] [Accepted: 02/28/2023] [Indexed: 03/07/2023]
Abstract
Research suggests a possible link between chronic infection with hepatitis C virus (HCV) and the development of Parkinson's Disease (PD) and secondary Parkinsonism (PKM). We investigated the impact of antiviral treatment status (untreated, interferon [IFN] treated, direct-acting antiviral [DAA] treated) and outcome (treatment failure [TF] or sustained virological response [SVR]) on risk of PD/PKM among patients with HCV. Using data from the Chronic Hepatitis Cohort Study (CHeCS), we applied a discrete time-to-event approach with PD/PKM as the outcome. We performed univariate followed by a multivariable modelling that used time-varying covariates, propensity scores to adjust for potential treatment selection bias and death as a competing risk. Among 17,199 confirmed HCV patients, we observed 54 incident cases of PD/PKM during a mean follow-up period of 17 years; 3753 patients died during follow-up. There was no significant association between treatment status/outcome and risk of PD/PKM. Type 2 diabetes tripled risk (hazard ratio [HR] 3.05; 95% CI 1.75-5.32; p < .0001) and presence of cirrhosis doubled risk of PD/PKM (HR 2.13, 95% CI 1.31-3.47). BMI >30 was associated with roughly 50% lower risk of PD/PKM than BMI <25 (HR 0.43; 0.22-0.84; p = .0138). After adjustment for treatment selection bias, we did not observe a significant association between HCV patients' antiviral treatment status/outcome on risk of PD/PKM. Several clinical risk factors-diabetes, cirrhosis and BMI-were associated with PD/PKM.
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Affiliation(s)
- Ranya Selim
- Department of Gastroenterology and Hepatology, Henry Ford Health, Detroit, Michigan, United States
| | - Stuart C Gordon
- Department of Gastroenterology and Hepatology, Henry Ford Health, Detroit, Michigan, United States.,School of Medicine, Wayne State University, Detroit, Michigan, United States
| | - Yueren Zhou
- Department of Public Health Sciences, Henry Ford Health, Detroit, Michigan, United States
| | - Talan Zhang
- Center on Aging & Health, Johns Hopkins University, Baltimore, Maryland, United States
| | - Mei Lu
- Center on Aging & Health, Johns Hopkins University, Baltimore, Maryland, United States
| | - Yihe G Daida
- Center for Integrated Health Care Research, Kaiser Permanente Hawaii, Honolulu, Hawaii, United States
| | | | - Mark A Schmidt
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, United States
| | - Sheri Trudeau
- Center on Aging & Health, Johns Hopkins University, Baltimore, Maryland, United States
| | - Loralee B Rupp
- Department of Health Policy and Health Systems Research, Henry Ford Health, Detroit, Michigan, United States
| | - Humberto C Gonzalez
- Department of Gastroenterology and Hepatology, Henry Ford Health, Detroit, Michigan, United States.,School of Medicine, Wayne State University, Detroit, Michigan, United States
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Li J, Lu M, Zhou Y, Bowlus CL, Lindor K, Rodriguez-Watson C, Romanelli RJ, Haller IV, Anderson H, VanWormer JJ, Boscarino JA, Schmidt MA, Daida YG, Sahota A, Vincent J, Wu KHH, Trudeau S, Rupp LB, Melkonian C, Gordon SC. Dynamic Risk Prediction of Response to Ursodeoxycholic Acid Among Patients with Primary Biliary Cholangitis in the USA. Dig Dis Sci 2022; 67:4170-4180. [PMID: 34499271 DOI: 10.1007/s10620-021-07219-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 08/05/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Ursodeoxycholic acid (UDCA) remains the first-line therapy for primary biliary cholangitis (PBC); however, inadequate treatment response (ITR) is common. The UK-PBC Consortium developed the modified UDCA Response Score (m-URS) to predict ITR (using alkaline phosphatase [ALP] > 1.67 times the upper limit of normal [*ULN]) at 12 months post-UDCA initiation). Using data from the US-based Fibrotic Liver Disease Consortium, we assessed the m-URS in our multi-racial cohort. We then used a dynamic modeling approach to improve prediction accuracy. METHODS Using data collected at the time of UDCA initiation, we assessed the m-URS using the original formula; then, by calibrating coefficients to our data, we also assessed whether it remained accurate when using Paris II criteria for ITR. Next, we developed and validated a dynamic risk prediction model that included post-UDCA initiation laboratory data. RESULTS Among 1578 patients (13% men; 8% African American, 9% Asian American/American Indian/Pacific Islander; 25% Hispanic), the rate of ITR was 27% using ALP > 1.67*ULN and 45% using Paris II criteria. M-URS accuracy was "very good" (AUROC = 0.87, sensitivity = 0.62, and specificity = 0.82) for ALP > 1.67*ULN and "moderate" (AUROC = 0.74, sensitivity = 0.57, and specificity = 0.70) for Paris II. Our dynamic model significantly improved accuracy for both definitions of ITR (ALP > 1.67*ULN: AUROC = 0.91; Paris II: AUROC = 0.81); specificity approached 100%. Roughly 9% of patients in our cohort were at the highest risk of ITR. CONCLUSIONS Early identification of patients who will not respond to UDCA treatment using a dynamic prediction model based on longitudinal, repeated risk factor measurements may facilitate earlier introduction of adjuvant treatment.
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Affiliation(s)
- Jia Li
- Department of Public Health Sciences, Henry Ford Health System, 3E One Ford Place, Detroit, MI, 48202, USA.
| | - Mei Lu
- Department of Public Health Sciences, Henry Ford Health System, 3E One Ford Place, Detroit, MI, 48202, USA
| | - Yueren Zhou
- Department of Public Health Sciences, Henry Ford Health System, 3E One Ford Place, Detroit, MI, 48202, USA
| | | | - Keith Lindor
- College of Health Solutions, Arizona State University, Phoenix, AZ, USA
| | - Carla Rodriguez-Watson
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, MD, USA
- Innovation in Medical Evidence Development and Surveillance, The Reagan-Udall Foundation for the FDA, Washington, DC, USA
| | | | - Irina V Haller
- Essentia Institute of Rural Health, Essentia Health, Duluth, MN, USA
| | - Heather Anderson
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO, USA
| | | | - Joseph A Boscarino
- Department of Epidemiology and Health Services Research, Geisinger Clinic, Danville, PA, USA
| | - Mark A Schmidt
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
| | - Yihe G Daida
- Center for Integrated Health Care Research, Kaiser Permanente Hawaii, Honolulu, HI, USA
| | - Amandeep Sahota
- Department of Research and Evaluation, Kaiser Permanente Southern California, Los Angeles, CA, USA
| | | | - Kuan-Han Hank Wu
- Department of Public Health Sciences, Henry Ford Health System, 3E One Ford Place, Detroit, MI, 48202, USA
| | - Sheri Trudeau
- Department of Public Health Sciences, Henry Ford Health System, 3E One Ford Place, Detroit, MI, 48202, USA
| | - Loralee B Rupp
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, MI, USA
| | - Christina Melkonian
- Department of Public Health Sciences, Henry Ford Health System, 3E One Ford Place, Detroit, MI, 48202, USA
| | - Stuart C Gordon
- Department of Gastroenterology and Hepatology, Henry Ford Health System, and Wayne State University School of Medicine, Detroit, MI, USA
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Gonzalez HC, Rupp LB, Trudeau S, Gordon SC. Response to: 'No impact of Covid-19 pandemic on decompensation of alcoholic liver disease: Results from a single Center in Milan'. Liver Int 2022; 42:1910-1911. [PMID: 35670429 PMCID: PMC9348101 DOI: 10.1111/liv.15333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 06/04/2022] [Indexed: 02/13/2023]
Affiliation(s)
- Humberto C. Gonzalez
- Department of Gastroenterology and HepatologyHenry Ford Health SystemDetroitMichiganUSA,School of MedicineWayne State UniversityDetroitMichiganUSA
| | - Loralee B. Rupp
- Department of Health Policy and Health Systems ResearchHenry Ford Health SystemDetroitMichiganUSA
| | - Sheri Trudeau
- Department of Public Health SciencesHenry Ford Health SystemDetroitMichiganUSA
| | - Stuart C. Gordon
- Department of Gastroenterology and HepatologyHenry Ford Health SystemDetroitMichiganUSA,School of MedicineWayne State UniversityDetroitMichiganUSA
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Gonzalez HC, Zhou Y, Nimri FM, Rupp LB, Trudeau S, Gordon SC. Alcohol-related hepatitis admissions increased 50% in the first months of the COVID-19 pandemic in the USA. Liver Int 2022; 42:762-764. [PMID: 35094494 DOI: 10.1111/liv.15172] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 12/03/2021] [Accepted: 01/12/2022] [Indexed: 02/13/2023]
Abstract
Early reports suggest that alcohol misuse increased in 2020 as a result of the COVID-19 pandemic. Using retrospective data from Henry Ford Health System in Detroit MI-an area that experienced an early and severe COVID-19 outbreak-we investigated the impact of the pandemic on alcohol-related liver disease (ARLD) in the summer of 2020 compared with the same period in 2016-2019. Both the number of ARLD admissions and the proportion of total admissions represented by ARLD patients increased significantly in 2020 compared with previous years. The number of ARLD admissions as a proportion of all hospitalizations was 50% higher in 2020 than in 2016-2019 (0.31% vs 0.21%; P = .0013); by September 2020, the number of admissions was 66% higher than previous years. Despite racial and geographical disparities in direct and indirect COVID-related stressors across the Detroit metropolitan area, the demographic profile of ARLD patients did not change compared with previous years.
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Affiliation(s)
- Humberto C Gonzalez
- Department of Gastroenterology and Hepatology, Henry Ford Health System, Detroit, Michigan, USA.,School of Medicine, Wayne State University, Detroit, Michigan, USA
| | - Yueren Zhou
- Department of Public Health Sciences, Henry Ford Health System, Detroit, Michigan, USA
| | - Faisal M Nimri
- Department of Gastroenterology and Hepatology, Henry Ford Health System, Detroit, Michigan, USA
| | - Loralee B Rupp
- Department of Health Policy and Health Systems Research, Henry Ford Health System, Detroit, Michigan, USA
| | - Sheri Trudeau
- Department of Public Health Sciences, Henry Ford Health System, Detroit, Michigan, USA
| | - Stuart C Gordon
- Department of Gastroenterology and Hepatology, Henry Ford Health System, Detroit, Michigan, USA.,School of Medicine, Wayne State University, Detroit, Michigan, USA
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11
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Zhou Y, Li J, Gordon SC, Trudeau S, Rupp LB, Boscarino JA, Daida YG, Schmidt MA, Lu M. Laboratory monitoring and antiviral treatment for chronic hepatitis B among routine care patients in the United States. J Viral Hepat 2022; 29:189-195. [PMID: 34905259 DOI: 10.1111/jvh.13639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 11/22/2021] [Accepted: 11/30/2021] [Indexed: 12/09/2022]
Abstract
We investigated factors associated with rates of recommended monitoring of chronic hepatitis B (HBV) patients for viral DNA and alanine aminotransferase (ALT), and initiation of antiviral treatment among eligible patients, in a US cohort of patients under routine care. Patients were categorised by treatment indication: definite, equivocal or ineligible. Baseline covariates included demographics, clinical characteristics and specialist care status. 'Recommended monitoring' was defined ≥1 ALT or HBV DNA test per year. Logit models, univariate then multivariable, were used to evaluate factors associated with monitoring and treatment. Among 3,830 patients, treatment was received by 67.5% (788/1168 patients) in the 'definite' category, and 34.1% (208/610 patients) in the 'equivocal' category, of whom 109 moved up to 'definite' status at some point during follow-up. Sex, age and specialist care were independently associated with receipt of treatment in 'definite' patients. Routine monitoring rates were high prior to treatment in 'definite/ treated' patients (ALT: 77%; DNA: 85%) but declined afterwards (ALT 63%; DNA 36%). Rates of monitoring were lower in 'definite/ untreated' patients (ALT: 48%; DNA: 32%). Among 'equivocal/ treated' patients, lower age and comorbidity scores were associated with receipt of treatment; ALT monitoring rates were similar before and after treatment initiation (41% and 46%, respectively), while rates of DNA monitoring declined (55% and 29%). Monitoring among 'treatment ineligible' patients was similar to those in the 'equivocal' and untreated 'definite' groups. A large proportion of US HBV patients under routine care did not receive recommended annual laboratory monitoring, especially after initiation of antiviral treatment, and nearly one-third of patients with 'definite' indications for antiviral therapy remained untreated.
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Affiliation(s)
- Yueren Zhou
- Department of Public Health Sciences, Henry Ford Health System, Detroit, Michigan, USA
| | - Jia Li
- Department of Public Health Sciences, Henry Ford Health System, Detroit, Michigan, USA
| | - Stuart C Gordon
- Division of Gastroenterology and Hepatology, Henry Ford Health System, Detroit, Michigan, USA.,School of Medicine, Wayne State University, Detroit, Michigan, USA
| | - Sheri Trudeau
- Department of Public Health Sciences, Henry Ford Health System, Detroit, Michigan, USA
| | - Loralee B Rupp
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, Michigan, USA
| | - Joseph A Boscarino
- Department of Population Health Sciences, Geisinger Clinic, Danville, Pennsylvania, USA
| | - Yihe G Daida
- Center for Integrated Health Care Research, Kaiser Permanente-Hawai'i, Honolulu, Hawaii, USA
| | - Mark A Schmidt
- Center for Health Research, Kaiser Permanente-Northwest, Portland, Oregon, USA
| | - Mei Lu
- Department of Public Health Sciences, Henry Ford Health System, Detroit, Michigan, USA
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12
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Lu M, Li J, Zhou Y, Rupp LB, Moorman AC, Spradling PR, Teshale EH, Boscarino JA, Daida YG, Schmidt MA, Trudeau S, Gordon SC. Trends in Cirrhosis and Mortality by Age, Sex, Race, and Antiviral Treatment Status Among US Chronic Hepatitis B Patients (2006-2016). J Clin Gastroenterol 2022; 56:273-279. [PMID: 33780209 PMCID: PMC10257940 DOI: 10.1097/mcg.0000000000001522] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 01/31/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND Changing US demographics and evolving chronic hepatitis B (CHB) treatments may affect longitudinal trends in CHB-related complications. We studied trends in the prevalence of cirrhosis (past or present) and incidence of all-cause mortality, stratified by patient age, sex, race, and antiviral treatment status, in a sample from US health care systems. METHODS Joinpoint and Poisson regression (univariate and multivariable) were used to estimate the annual percent change in each outcome from 2006 to 2016. RESULTS Among 5528 CHB patients, cirrhosis prevalence (including decompensated cirrhosis) rose from 6.7% in 2006 to 13.7% in 2016; overall mortality was unchanged. Overall rates of cirrhosis and mortality were higher among treated patients, but adjusted annual percent changes (aAPC) were significantly lower among treated than untreated patients (cirrhosis: aAPC +2.4% vs. +6.2%, mortality: aAPC -3.9% vs. +4.0%). Likewise, among treated patients, the aAPC for mortality declined -3.9% per year whereas among untreated patients, mortality increased +4.0% per year. CONCLUSIONS From 2006 to 2016, the prevalence of cirrhosis among CHB patients doubled. Notably, all-cause mortality increased among untreated patients but decreased among treated patients. These results suggest that antiviral treatment attenuates the progression of cirrhosis and the risk of death among patients with CHB.
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Affiliation(s)
- Mei Lu
- Department of Public Health Sciences
| | - Jia Li
- Department of Public Health Sciences
| | | | - Loralee B. Rupp
- Center for Health Policy and Health Services Research, Henry Ford Health System
| | - Anne C. Moorman
- Division of Viral Hepatitis, National Center for HIV, Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Philip R. Spradling
- Division of Viral Hepatitis, National Center for HIV, Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Eyasu H. Teshale
- Division of Viral Hepatitis, National Center for HIV, Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Joseph A. Boscarino
- Department of Epidemiology and Health Research, Geisinger Clinic, Danville, PA
| | - Yihe G. Daida
- Center for Health Research, Kaiser Permanente—Hawaii, Honolulu, HI
| | - Mark A. Schmidt
- Center for Health Research, Kaiser Permanente—Northwest, Portland, OR
| | | | - Stuart C. Gordon
- Division of Gastroenterology and Hepatology, Henry Ford Health System and Wayne State University School of Medicine, Detroit, MI
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13
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Gordon SC, Teshale EH, Spradling PR, Moorman AC, Boscarino JA, Schmidt MA, Daida YG, Rupp LB, Trudeau S, Zhang J, Lu M. Lower rates of emergency visits and hospitalizations among chronic hepatitis C patients with sustained virological response to interferon-free direct-acting antiviral therapy (2014-2018). Clin Infect Dis 2022; 75:1453-1456. [PMID: 35147184 DOI: 10.1093/cid/ciac124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Indexed: 12/09/2022] Open
Abstract
We compared rates of emergency department (ED) visits and hospitalizations between HCV patients who achieved sustained virological response (SVR) after direct-acting antiviral (DAA) therapy (cases) to matched controls. Among 3049 pairs, cases demonstrated lower rates of liver-related ED visits (P=.01) than controls; all-cause and liver-related hospitalization rates and hospitalized days were also lower in cases (P<.0001).
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Affiliation(s)
- Stuart C Gordon
- Department of Hepatology and Gastroenterology, Henry Ford Health System; and Wayne State University School of Medicine, Detroit MI
| | - Eyasu H Teshale
- Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Philip R Spradling
- Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Anne C Moorman
- Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | | | - Mark A Schmidt
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR
| | - Yihe G Daida
- Center for Integrated Health Care Research, Kaiser Permanente Hawaii, Honolulu, HI
| | - Loralee B Rupp
- Center for Health Policy and Health Systems Research, Henry Ford Health System, Detroit MI
| | - Sheri Trudeau
- Department of Public Health Sciences, Henry Ford Health System, Detroit MI
| | - Jiaqi Zhang
- Department of Public Health Sciences, Henry Ford Health System, Detroit MI
| | - Mei Lu
- Department of Public Health Sciences, Henry Ford Health System, Detroit MI
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14
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Selim R, Zhou Y, Rupp LB, Trudeau S, Naffouj S, AlShamaa O, Ahmed A, Jafri SM, Gordon SC, Segal A, Gonzalez HC. Availability of PEth testing is associated with reduced eligibility for liver transplant among patients with alcohol-related liver disease. Clin Transplant 2022; 36:e14595. [PMID: 35041223 DOI: 10.1111/ctr.14595] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 12/20/2021] [Accepted: 01/04/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Serum phosphatidylethanol (PEth) is a highly sensitive test to detect alcohol use. We evaluated whether the availability of PEth testing impacted rates of liver transplant evaluation terminations and delistings. METHODS Medical record data were collected for patients who initiated transplant evaluation due to alcohol-related liver disease in the pre-PEth (2017) or PEth (2019) eras. Inverse probability weighting (IPW) was used to balance baseline patient characteristics. Outcomes included termination of evaluation or delisting due to alcohol use; patients were censored at receipt of transplant; death was considered a competing risk. The Fine-Gray method was performed to determine whether PEth testing affected risk of evaluation termination/ delisting due to alcohol use. RESULTS 375 patients with alcohol-related indications for transplant (157 in 2017; 210 in 2019) were included. The final IPW-adjusted model for the composite outcome of terminations/delisting due to alcohol use retained two significant variables (p<0.05): PEth era and BMI category. Patients evaluated during the PEth era were almost three times more likely to experience an alcohol-related termination/delisting than those in the pre-PEth era (sHR = 2.86; 95%CI 1.67-4.97) CONCLUSION: We found that availability of PEth testing at our institution was associated with a higher rate of exclusion of patients from eligibility for liver transplant. Use of PEth testing has significant potential to inform decisions regarding transplant candidacy for patients with alcohol-related liver disease. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Ranya Selim
- Department of Gastroenterology and Hepatology, Henry Ford Health System, Detroit, MI
| | - Yueren Zhou
- Department of Public Health Sciences, Henry Ford Health System, Detroit, MI
| | - Loralee B Rupp
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, MI
| | - Sheri Trudeau
- Department of Public Health Sciences, Henry Ford Health System, Detroit, MI
| | - Sandra Naffouj
- Department of Internal Medicine, Henry Ford Health System, Detroit, MI
| | - Omar AlShamaa
- Department of Internal Medicine, Henry Ford Health System, Detroit, MI
| | | | - Syed-Mohammed Jafri
- Department of Gastroenterology and Hepatology, Henry Ford Health System, Detroit, MI.,Wayne State University School of Medicine, Detroit, MI
| | - Stuart C Gordon
- Department of Gastroenterology and Hepatology, Henry Ford Health System, Detroit, MI.,Wayne State University School of Medicine, Detroit, MI
| | - Antu Segal
- Wayne State University School of Medicine, Detroit, MI.,Transplant Institute, Henry Ford Health System, Detroit, MI
| | - Humberto C Gonzalez
- Department of Gastroenterology and Hepatology, Henry Ford Health System, Detroit, MI.,Wayne State University School of Medicine, Detroit, MI
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15
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Spradling PR, Xing J, Zhong Y, Rupp LB, Moorman AC, Lu M, Teshale EH, Schmidt MA, Daida YG, Boscarino JA, Gordon SC. Incidence of malignancies among patients with chronic hepatitis B in US health care organizations, 2006-2018. J Infect Dis 2022; 226:896-900. [PMID: 35039863 DOI: 10.1093/infdis/jiac011] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 01/13/2022] [Indexed: 12/09/2022] Open
Abstract
Hepatitis B virus (HBV) infection causes hepatocellular carcinoma but its association with other cancers is not well established. We compared age-adjusted incidence of primary cancers among 5,773 HBV-infected persons with US cancer registries during 2006-2018. Compared with the US population, substantially higher incidence among HBV-infected persons was observed for hepatocellular carcinoma (Standardized rate ratio [SRR] 30.79), gastric (SRR 7.95), neuroendocrine (SRR 5.88), cholangiocarcinoma (SRR 4.62), and ovarian (SRR 3.72) cancers, and non-Hodgkin lymphoma (SRR 2.52). Clinicians should be aware of a heightened potential for certain non-hepatic malignancies among hepatitis B patients, as earlier diagnosis favors improved survival.
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Affiliation(s)
- Philip R Spradling
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Jian Xing
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Y Zhong
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Anne C Moorman
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Mei Lu
- Henry Ford Health System, Detroit, MI, USA
| | - Eyasu H Teshale
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Mark A Schmidt
- The Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
| | - Yihe G Daida
- The Center for Integrated Health Care Research, Kaiser Permanente Hawaii, Honolulu, HI, USA
| | - Joseph A Boscarino
- Department of Population Health Sciences, Geisinger Clinic, Danville, PA, USA
| | - Stuart C Gordon
- Henry Ford Health System, Detroit, MI, USA.,Wayne State University School of Medicine, Detroit, MI, USA
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16
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Spradling PR, Zhong Y, Moorman AC, Rupp LB, Lu M, Teshale EH, Schmidt MA, Daida YG, Boscarino JA, Gordon SC. The Persistence of Underreporting of Hepatitis C as an Underlying or Contributing Cause of Death, 2011-2017. Clin Infect Dis 2021; 73:891-894. [PMID: 33561187 DOI: 10.1093/cid/ciab108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Indexed: 11/14/2022] Open
Abstract
Using electronic health records, we found that hepatitis C virus (HCV) reporting on death certificates of 2901 HCV-infected decedents from 4 US healthcare organizations during 2011-2017 was documented in only 50% of decedents with hepatocellular carcinoma and less than half with decompensated cirrhosis. National figures likely underestimate the US HCV mortality burden.
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Affiliation(s)
- Philip R Spradling
- Division of Viral Hepatitis, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA
| | - Yuna Zhong
- Division of Viral Hepatitis, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA
| | - Anne C Moorman
- Division of Viral Hepatitis, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA
| | | | - Mei Lu
- Henry Ford Health System, Detroit, Michigan, USA
| | - Eyasu H Teshale
- Division of Viral Hepatitis, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA
| | - Mark A Schmidt
- The Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA
| | - Yihe G Daida
- The Center for Integrated Health Research, Kaiser Permanente Hawaii, Honolulu, Hawaii, USA
| | - Joseph A Boscarino
- Department of Population Health Sciences, Geisinger Clinic, Danville, Pennsylvania, USA
| | - Stuart C Gordon
- Henry Ford Health System, Detroit, Michigan, USA.,Wayne State University School of Medicine, Detroit, Michigan, USA
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17
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Spradling PR, Zhong Y, Moorman AC, Rupp LB, Lu M, Gordon SC, Teshale EH, Schmidt MA, Daida YG, Boscarino JA. Psychosocial Obstacles to Hepatitis C Treatment Initiation Among Patients in Care: A Hitch in the Cascade of Cure. Hepatol Commun 2021; 5:400-411. [PMID: 33681675 PMCID: PMC7917278 DOI: 10.1002/hep4.1632] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 09/25/2020] [Accepted: 10/12/2020] [Indexed: 12/14/2022] Open
Abstract
There are limited data examining the relationship between psychosocial factors and receipt of direct-acting antiviral (DAA) treatment among patients with hepatitis C in large health care organizations in the United States. We therefore sought to determine whether such factors were associated with DAA initiation. We analyzed data from an extensive psychological, behavioral, and social survey (that incorporated several health-related quality of life assessments) coupled with clinical data from electronic health records of patients with hepatitis C enrolled at four health care organizations during 2017-2018. Of 2,681 patients invited, 1,051 (39.2%) responded to the survey; of 894 respondents eligible for analysis, 690 (77.2%) initiated DAAs. Mean follow-up among respondents was 9.2 years. Compared with DAA recipients, nonrecipients had significantly poorer standardized scores for depression, anxiety, and life-related stressors as well as poorer scores related to physical and mental function. Lower odds of DAA initiation in multivariable analysis (adjusted by age, race, sex, study site, payment provider, cirrhosis status, comorbidity status, and duration of follow-up) included Black race (adjusted odds ratio [aOR], 0.59 vs. White race), perceived difficulty getting medical care in the preceding year (aOR, 0.48 vs. no difficulty), recent injection drug use (aOR, 0.11 vs. none), alcohol use disorder (aOR, 0.58 vs. no alcohol use disorder), severe depression (aOR, 0.42 vs. no depression), recent homelessness (aOR, 0.36 vs. no homelessness), and recent incarceration (aOR, 0.34 vs. no incarceration). Conclusion: In addition to racial differences, compared with respondents who initiated DAAs, those who did not were more likely to have several psychological, behavioral, and social impairments. Psychosocial barriers to DAA initiation among patients in care should also be addressed to reduce hepatitis C-related morbidity and mortality.
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Affiliation(s)
- Philip R Spradling
- Division of Viral HepatitisCenters for Disease Control and PreventionAtlantaGAUSA
| | - Yuna Zhong
- Division of Viral HepatitisCenters for Disease Control and PreventionAtlantaGAUSA
| | - Anne C Moorman
- Division of Viral HepatitisCenters for Disease Control and PreventionAtlantaGAUSA
| | | | - Mei Lu
- Henry Ford Health SystemDetroitMIUSA
| | - Stuart C Gordon
- Henry Ford Health SystemDetroitMIUSA.,Wayne State University School of MedicineDetroitMIUSA
| | - Eyasu H Teshale
- Division of Viral HepatitisCenters for Disease Control and PreventionAtlantaGAUSA
| | - Mark A Schmidt
- Center for Health ResearchKaiser Permanente NorthwestPortlandORUSA
| | - Yihe G Daida
- Center for Integrated Health Care ResearchKaiser Permanente HawaiiHonoluluHIUSA
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18
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Spradling PR, Xing J, Rupp LB, Moorman AC, Gordon SC, Lu M, Teshale EH, Boscarino JA, Schmidt MA, Daida YG, Holmberg SD. Low Uptake of Direct-acting Antiviral Therapy Among Hepatitis C Patients With Advanced Liver Disease and Access to Care, 2014-2017. J Clin Gastroenterol 2021; 55:77-83. [PMID: 32250999 PMCID: PMC10711731 DOI: 10.1097/mcg.0000000000001344] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
GOALS To determine the proportion and characteristics of adults with hepatitis C at health care organizations in 4 US states who initiated direct-acting antivirals (DAAs). BACKGROUND There are almost no data to assess the penetrance of treatment of the hepatitis C population in general US health care settings. STUDY We conducted a prospective observational study using electronic clinical, pharmacy, and mortality data to determine the fraction of patients who initiated DAAs between January 2014 and December 2017, by start date and regimen. We used stepwise multivariate logistic regression analysis to identify sociodemographic and clinical characteristics associated with receipt of DAAs. RESULTS Of 8823 patients, 2887 (32.7%) received DAAs. Quarterly (Q) uptake ranged from 1.1% in Q3 2014 to a high of 5.6% in Q2 2015. Characteristics associated with receipt of DAAs included age 51 to 70 years, higher income, pre-2014 treatment failure, and higher noninvasive fibrosis score (FIB4); however, over one half of patients with FIB4 scores >3.25, consistent with severe liver disease, were not treated. A lower likelihood of initiation was associated with Medicaid coverage. Of 5936 patients who did not initiate treatment, 911 (15.3%) had died and 2774 (46.7%) had not had a clinical encounter in ≥12 months by the end of the study. Fewer than 1% of DAA prescriptions originated from nonspecialty providers. CONCLUSIONS During 4 calendar years of follow-up, one third of patients initiated DAAs. Large fractions of untreated patients had advanced liver disease, died, or were lost to follow-up. Even among patients in integrated health care systems, receipt of DAAs was limited.
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Affiliation(s)
- Philip R. Spradling
- Division of Viral Hepatitis, National Centers for HIV, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Jian Xing
- Division of Viral Hepatitis, National Centers for HIV, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | | | - Anne C. Moorman
- Division of Viral Hepatitis, National Centers for HIV, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Stuart C. Gordon
- Henry Ford Health System, Detroit, Michigan
- Wayne State University School of Medicine, Detroit, MI
| | - Mei Lu
- Henry Ford Health System, Detroit, Michigan
| | - Eyasu H. Teshale
- Division of Viral Hepatitis, National Centers for HIV, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | | | - Mark A. Schmidt
- The Center for Health Research, Kaiser Permanente-Northwest, Portland, Oregon
| | - Yihe G. Daida
- The Center for Health Research, Kaiser Permanente-Hawaii, Honolulu, Hawaii
| | - Scott D. Holmberg
- Division of Viral Hepatitis, National Centers for HIV, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
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19
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Lu M, Bowlus CL, Lindor K, Rodriguez-Watson CV, Romanelli RJ, Haller IV, Anderson H, VanWormer JJ, Boscarino JA, Schmidt MA, Daida YG, Sahota A, Vincent J, Li J, Trudeau S, Rupp LB, Gordon SC. Validity of an Automated Algorithm to Identify Cirrhosis Using Electronic Health Records in Patients with Primary Biliary Cholangitis. Clin Epidemiol 2020; 12:1261-1267. [PMID: 33204167 PMCID: PMC7666983 DOI: 10.2147/clep.s262558] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 09/23/2020] [Indexed: 11/23/2022] Open
Abstract
Background Biopsy remains the gold standard for determining fibrosis stage in patients with primary biliary cholangitis (PBC), but it is unavailable for most patients. We used data from the 11 US health systems in the FibrOtic Liver Disease Consortium to explore a combination of biochemical markers and electronic health record (EHR)-based diagnosis/procedure codes (DPCs) to identify the presence of cirrhosis in PBC patients. Methods Histological fibrosis staging data were obtained from liver biopsies. Variables considered for the model included demographics (age, gender, race, ethnicity), total bilirubin, alkaline phosphatase, albumin, aspartate aminotransferase (AST) to platelet ratio index (APRI), Fibrosis 4 (FIB4) index, AST to alanine aminotransferase (ALT) ratio, and >100 DPCs associated with cirrhosis/decompensated cirrhosis, categorized into ten clusters. Using least absolute shrinkage and selection operator regression (LASSO), we derived and validated cutoffs for identifying cirrhosis. Results Among 4328 PBC patients, 1350 (32%) had biopsy data; 121 (9%) were staged F4 (cirrhosis). DPC clusters (including codes related to cirrhosis and hepatocellular carcinoma diagnoses/procedures), Hispanic ethnicity, ALP, AST/ALT ratio, and total bilirubin were retained in the final model (AUROC=0.86 and 0.83 on learning and testing data, respectively); this model with two cutoffs divided patients into three categories (no cirrhosis, indeterminate, and cirrhosis) with specificities of 81.8% (for no cirrhosis) and 80.3% (for cirrhosis). A model excluding DPCs retained ALP, AST/ALT ratio, total bilirubin, Hispanic ethnicity, and gender (AUROC=0.81 and 0.78 on learning and testing data, respectively). Conclusion An algorithm using laboratory results and DPCs can categorize a majority of PBC patients as cirrhotic or noncirrhotic with high accuracy (with a small remaining group of patients' cirrhosis status indeterminate). In the absence of biopsy data, this EHR-based model can be used to identify cirrhosis in cohorts of PBC patients for research and/or clinical follow-up.
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Affiliation(s)
- Mei Lu
- Department of Public Health Sciences, Henry Ford Health System, Detroit, MI, USA
| | | | - Keith Lindor
- College of Health Solutions, Arizona State University, Phoenix, AZ, USA
| | - Carla V Rodriguez-Watson
- Center for Health Research Kaiser Permanente Mid-Atlantic Research Institute, Rockville, MD; Reagan-Udall Foundation for the FDA, Washington, DC, USA
| | | | - Irina V Haller
- Essentia Institute of Rural Health, Essentia Health, Duluth, MN, USA
| | - Heather Anderson
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | | | - Joseph A Boscarino
- Department of Population Health Sciences, Geisinger Clinic, Danville, PA, USA
| | - Mark A Schmidt
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
| | - Yihe G Daida
- Center for Integrated Health Care Research, Kaiser Permanente Hawai'i, Honolulu, HI, USA
| | - Amandeep Sahota
- Department of Research and Evaluation, Kaiser Permanente Southern California, Los Angeles, CA, USA
| | | | - Jia Li
- Department of Public Health Sciences, Henry Ford Health System, Detroit, MI, USA
| | - Sheri Trudeau
- Department of Public Health Sciences, Henry Ford Health System, Detroit, MI, USA
| | - Loralee B Rupp
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, MI, USA
| | - Stuart C Gordon
- Division of Gastroenterology and Hepatology, Henry Ford Health System; and Wayne State University School of Medicine, Detroit, MI, USA
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Lu M, Wu KH, Li J, Moorman AC, Spradling PR, Teshale EH, Boscarino JA, Daida YG, Schmidt MA, Rupp LB, Zhang T, Trudeau S, Gordon SC. Adjuvant ribavirin and longer direct-acting antiviral treatment duration improve sustained virological response among hepatitis C patients at risk of treatment failure. J Viral Hepat 2019; 26:1210-1217. [PMID: 31197910 PMCID: PMC6764853 DOI: 10.1111/jvh.13162] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 05/06/2019] [Accepted: 05/15/2019] [Indexed: 12/13/2022]
Abstract
The role of ribavirin (RBV) in the era of direct-acting antivirals (DAA) is not clear, and DAA studies have been largely genotype- and regimen-specific. Using data from the Chronic Hepatitis Cohort Study, we evaluated the role of RBV and increased DAA treatment duration among patients with chronic hepatitis C (HCV) in routine clinical care. We performed multivariable analysis of data from 4133 patients receiving any of the following: sofosbuvir (SOF); daclatasvir + SOF; grazoprevir + elbasvir; paritaprevir/ritonavir + ombitasvir; simeprevir + SOF; and SOF + ledipasvir; SOF + velpatasvir ± voxilaprevir; and glecaprevir + pibrentasvir-all with/ without RBV. Inverse probability treatment weighting was used to adjust for treatment selection bias. Sustained virological response (SVR) was defined by undetectable HCV RNA 12 weeks after end of therapy. The overall SVR rate was 95%. Mean treatment duration was 12 ± 4.5 weeks. The final model included treatment duration and diabetes, as well as the interaction of RBV with previous treatment status (treatment naïve, interferon treatment failure [TF] or previous DAA TF), cirrhosis status, and HCV genotype (GT). Each one-month increment of treatment duration increased odds of SVR by 99% (aOR = 1.99). Diabetes, previous DAA TF, and decompensated cirrhosis significantly reduced odds of SVR. RBV significantly increased the likelihood of SVR among patients with decompensated cirrhosis (aOR = 5.05), previous DAA treatment failure (aOR = 5.43), and GT3 (aOR = 13.28). Among RBV-free regimens, patients with GT3 were less likely to achieve SVR than those with GT1 or 2 (aOR 0.07). Diabetes, decompensated cirrhosis, and prior DAA TF independently reduced the likelihood of SVR. Longer treatment duration increased likelihood of SVR. Conclusion: RBV increased likelihood of SVR among patients with GT3, previous DAA TF, or decompensated cirrhosis.
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Affiliation(s)
- Mei Lu
- Department of Public Health Sciences, Henry Ford Health System, Detroit, Michigan
| | - Kuan-Han Wu
- Department of Public Health Sciences, Henry Ford Health System, Detroit, Michigan
| | - Jia Li
- Department of Public Health Sciences, Henry Ford Health System, Detroit, Michigan
| | - Anne C. Moorman
- Division of Viral Hepatitis, National Center for HIV, Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Philip R. Spradling
- Division of Viral Hepatitis, National Center for HIV, Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Eyasu H. Teshale
- Division of Viral Hepatitis, National Center for HIV, Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Joseph A. Boscarino
- Department of Epidemiology and Health Services Research, Geisinger Clinic, Danville, Pennsylvania
| | - Yihe G. Daida
- Center for Health Research, Kaiser Permanente-Hawai’i, Waipahu, Hawaii
| | - Mark A. Schmidt
- Center for Health Research, Kaiser Permanente-Northwest, Portland, Oregon
| | - Loralee B. Rupp
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, Michigan
| | - Talan Zhang
- Department of Public Health Sciences, Henry Ford Health System, Detroit, Michigan
| | - Sheri Trudeau
- Department of Public Health Sciences, Henry Ford Health System, Detroit, Michigan
| | - Stuart C. Gordon
- Division of Gastroenterology and Hepatology, Henry Ford Health System, Detroit, Michigan,Wayne State University School of Medicine, Detroit, Michigan
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Moorman AC, Xing J, Rupp LB, Gordon SC, Lu M, Spradling PR, Boscarino JA, Schmidt MA, Daida YG, Teshale EH. Late diagnosis of hepatitis C virus infection, 2014-2016: continuing missed intervention opportunities. Am J Manag Care 2019; 25:369-374. [PMID: 31419094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVES Chronic hepatitis C virus (HCV) infection is typically asymptomatic until severe liver disease occurs and even then can remain undiagnosed for some time; thus, screening and treatment of asymptomatic persons are needed to prevent poor outcomes. In a previous analysis of data from between 2006 and 2011, we found that 17% of newly diagnosed HCV infections in 4 large health systems were among persons with cirrhosis and/or end-stage liver disease, termed "late diagnosis." We sought to determine the proportion with late diagnosis during 2014-2016, after release of CDC baby boomer (1945-1965 birth cohort) testing guidelines in 2012. STUDY DESIGN The cohort was based on analysis of electronic health records and administrative data of about 2.7 million patients visiting the same healthcare systems during 2014-2016. METHODS Among persons with newly diagnosed chronic HCV infection during 2014-2016, we analyzed data collected up to January 1, 2017. RESULTS Among 2695 patients with newly diagnosed HCV infection, 576 (21.4%) had late diagnosis. Most were born between 1945 and 1965 (n = 1613 [59.9%]), and among these, 27.6% had late diagnosis. Patients with versus without late diagnosis had equally lengthy prediagnosis observation in the health systems (mean and median, 9.1 and 9.1 vs 8.3 and 7.8 years, respectively) but were more likely to have a postdiagnosis hospitalization (32.5% vs 12.5%; P <.001) with greater number of hospital days (358.8 vs 78.5 per 100 person-years; P <.001). CONCLUSIONS More than one-fifth of patients with newly diagnosed HCV infection during 2014-2016-and more than a quarter of those born between 1945 and 1965-had late diagnosis despite many years of in-system care, an increase of 5 percentage points since 2006-2011, after the interim initiation of age-based screening recommendations. Our data highlight missed opportunities for diagnosis and therapeutic intervention before the onset of severe liver disease, which is associated with high cost and diminished outcomes.
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Affiliation(s)
- Anne C Moorman
- Division of Viral Hepatitis, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, CDC, Mailstop G-37, Atlanta, GA 30329.
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Lu M, Zhou Y, Holmberg SD, Moorman AC, Spradling PR, Teshale EH, Boscarino JA, Daida YG, Schmidt MA, Li J, Rupp LB, Trudeau S, Gordon SC. Trends in Diagnosed Chronic Hepatitis B in a US Health System Population, 2006-2015. Open Forum Infect Dis 2019; 6:ofz286. [PMID: 31341929 PMCID: PMC6641786 DOI: 10.1093/ofid/ofz286] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 06/13/2019] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Trends in the epidemiology of chronic hepatitis B (CHB) among routine clinical care patients in the United States are not well documented. We used data from the Chronic Hepatitis Cohort Study to investigate changes in prevalence and newly recorded cases of CHB from 2006 to 2015. METHODS Annual percentage changes (APCs) were estimated using join point Poisson regression. Analyses were adjusted by study site; when an interaction with the trend was observed, APCs were estimated by subgroups. Differences in rates based on race, age, and sex were calculated with rate ratios. RESULTS We identified 5492 patients with CHB within select health systems with total populations that ranged from 1.9 to 2.4 million persons. From 2006 to 2014, the prevalence of diagnosed CHB increased from 181.3 to 253.0 per 100 000 persons in the health system population; from 2014 to 2015, it declined to 237.0 per 100 000 persons. APC was +3.7%/y through 131 December 2014 (P < .001) and -15.0%/y (P < .001) thereafter. The rate of newly reported cases of CHB did not change significantly across the study period (APC, -1.1%/y; P = .07). The rates of newly reported cases were 20.5 times higher among patients in the Asian American/American Indian/Pacific Islander (ASINPI) category, compared with white patients, and 2.8 times higher among African American patients. The ratio of male to female patients was roughly 3:2. CONCLUSIONS The prevalence of diagnosed CHB in this US patient population increased from 2006 to 2014, after which it decreased significantly. Rates declined most rapidly among patients ≤40 or 61-70 years old, as well as among ASINPI patients. The rate of newly reported cases remained steady over the study period.
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Affiliation(s)
- Mei Lu
- Department of Public Health Sciences, Wayne State University School of Medicine, Detroit, Michigan
| | - Yueren Zhou
- Department of Public Health Sciences, Wayne State University School of Medicine, Detroit, Michigan
| | - Scott D Holmberg
- Division of Viral Hepatitis, National Center for HIV, Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta Georgia
| | - Anne C Moorman
- Division of Viral Hepatitis, National Center for HIV, Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta Georgia
| | - Philip R Spradling
- Division of Viral Hepatitis, National Center for HIV, Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta Georgia
| | - Eyasu H Teshale
- Division of Viral Hepatitis, National Center for HIV, Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta Georgia
| | - Joseph A Boscarino
- Department of Epidemiology and Health Services Research, Geisinger Clinic, Danville, Pennsylvania
| | - Yihe G Daida
- Center for Health Research, Kaiser Permanente Hawaii, Honolulu, Hawai’i
| | - Mark A Schmidt
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Jia Li
- Department of Public Health Sciences, Wayne State University School of Medicine, Detroit, Michigan
| | - Loralee B Rupp
- Center for Health Policy and Health Services Research, Wayne State University School of Medicine, Detroit, Michigan
| | - Sheri Trudeau
- Department of Public Health Sciences, Wayne State University School of Medicine, Detroit, Michigan
| | - Stuart C Gordon
- Division of Gastroenterology and Hepatology, Henry Ford Health System, and Wayne State University School of Medicine, Detroit, Michigan
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Li J, Gordon SC, Rupp LB, Zhang T, Trudeau S, Holmberg SD, Moorman AC, Spradling PR, Teshale EH, Boscarino JA, Schmidt MA, Daida YG, Lu M. Sustained virological response does not improve long-term glycaemic control in patients with type 2 diabetes and chronic hepatitis C. Liver Int 2019; 39:1027-1032. [PMID: 30570808 PMCID: PMC6628708 DOI: 10.1111/liv.14031] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 10/25/2018] [Accepted: 12/11/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Sustained virological response to treatment for chronic hepatitis C virus may improve short-term glucose control among patients with type 2 diabetes, but the long-term impact remains largely unknown. We used data from the Chronic Hepatitis Cohort Study to investigate the impact of sustained virological response on long-term trends in haemoglobin A1c in patients with type 2 diabetes. METHODS "Index date" was defined as the date of treatment initiation (treated patients) or hepatitis C virus diagnosis (untreated patients). To address treatment selection bias, we used a propensity score approach. We used a piecewise, linear spline, mixed-effects model to evaluate changes in haemoglobin A1c over a 5-year period. RESULTS Our sample included 384 hepatitis C virus patients with type 2 diabetes (192 untreated, 192 treated, with sustained virological response or treatment failure). After adjusting for body mass index, haemoglobin A1c was stable among untreated and treatment failure patients. In sustained virological response patients, Hb1Ac trajectories evolved in three phases: (a) index through 6 months post-index, average haemoglobin A1c decreased significantly from 7.7% to 5.4% per 90 days (P < 0.001); (b) 6-30 months post-index, haemoglobin A1c rebounded at a rate of 1.5% every 90 days (P = 0.003); and (c) from 30 months onward, haemoglobin A1c stabilized at an average level of 7.9 (P-value = 0.34). Results from an analysis restricted to patients receiving direct-acting antivirals were consistent with the main findings. CONCLUSION Successful hepatitis C virus treatment among patients with type 2 diabetes significantly reduces HbA1c shortly after treatment, but these decreases are not sustained long-term. Less than three years after sustained virological response, haemoglobin A1c rebounds to levels similar to untreated/treatment failure patients, and higher than recommended for type 2 diabetic maintenance.
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Affiliation(s)
- Jia Li
- Department of Public Health Sciences, Henry Ford Health System, Detroit, Michigan
| | - Stuart C. Gordon
- Division of Gastroenterology and Hepatology, Henry Ford Health System and Wayne State University School of Medicine, Detroit, Michigan
| | - Loralee B. Rupp
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, Michigan
| | - Talan Zhang
- Department of Public Health Sciences, Henry Ford Health System, Detroit, Michigan
| | - Sheri Trudeau
- Department of Public Health Sciences, Henry Ford Health System, Detroit, Michigan
| | - Scott D. Holmberg
- Division of Viral Hepatitis, National Center for HIV, Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Anne C. Moorman
- Division of Viral Hepatitis, National Center for HIV, Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Philip R. Spradling
- Division of Viral Hepatitis, National Center for HIV, Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Eyasu H. Teshale
- Division of Viral Hepatitis, National Center for HIV, Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Joseph A. Boscarino
- Department of Epidemiology & Health Services Research, Geisinger Clinic, Danville, Pennsylvania
| | - Mark A. Schmidt
- Center for Health Research, Kaiser Permanente–Northwest, Portland, Oregon
| | - Yihe G. Daida
- Center for Health Research, Kaiser Permanente–Hawai’i, Honolulu, Hawaii
| | - Mei Lu
- Department of Public Health Sciences, Henry Ford Health System, Detroit, Michigan
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Li J, Gordon SC, Rupp LB, Zhang T, Trudeau S, Holmberg SD, Moorman AC, Spradling PR, Teshale EH, Boscarino JA, Schmidt MA, Daida YG, Lu M. Sustained virological response to hepatitis C treatment decreases the incidence of complications associated with type 2 diabetes. Aliment Pharmacol Ther 2019; 49:599-608. [PMID: 30650468 PMCID: PMC6599612 DOI: 10.1111/apt.15102] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 09/12/2018] [Accepted: 11/28/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND The role of hepatitis C (HCV) eradication on the long-term complications of type 2 diabetes mellitus remains incompletely studied. AIM To investigate whether antiviral treatment impacted risk of acute coronary syndrome, end-stage renal disease, ischaemic stroke, and retinopathy among diabetic patients from the four US health systems comprising the Chronic Hepatitis Cohort Study (CHeCS). METHODS We included CHeCS HCV patients with diagnosis codes for type 2 diabetes who were on antidiabetic medications. Patients were followed until an outcome of interest, death, or last health system encounter. The effect of treatment on outcomes was estimated using the competing risk analysis (Fine-Gray subdistribution hazard ratio [sHR]), with death as a competing event. RESULTS Among 1395 HCV-infected patients with type 2 diabetes, 723 (52%) were treated with either interferon-based or direct-acting antivirals (DAAs); 539 (75% of treated) achieved sustained virological response (SVR). After propensity score adjustment to address treatment selection bias, patients with SVR demonstrated significantly decreased risk of acute coronary syndrome (sHR = 0.36; P < 0.001), end-stage renal disease (sHR = 0.46; P < 0.001), stroke (sHR = 0.34; P < 0.001), and retinopathy (sHR = 0.24; P < 0.001) compared to untreated patients. Results were consistent in subgroup analyses of DAA-treated patients and interferon-treated patients, an analysis of cirrhotic patients, as well as in sensitivity analyses considering cause-specific hazards, exclusion of patients with on-treatment retinopathy, and treatment status as a time-varying covariate. CONCLUSION Successful HCV treatment among patients with type 2 diabetes significantly reduces incidence of acute coronary syndrome, end-stage renal disease, ischaemic stroke, and retinopathy, regardless of cirrhosis. Our findings support the importance of HCV antiviral therapy among patients with type 2 diabetes to reduce the risk of these extrahepatic outcomes.
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Affiliation(s)
- Jia Li
- Department of Public Health Sciences, Henry Ford Health System, Detroit, Michigan
| | - Stuart C. Gordon
- Division of Gastroenterology and Hepatology, Henry Ford Health System, and Wayne State University School of Medicine, Detroit, Michigan
| | - Loralee B. Rupp
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, Michigan
| | - Talan Zhang
- Department of Public Health Sciences, Henry Ford Health System, Detroit, Michigan
| | - Sheri Trudeau
- Department of Public Health Sciences, Henry Ford Health System, Detroit, Michigan
| | - Scott D. Holmberg
- Division of Viral Hepatitis, National Center for HIV, Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Anne C. Moorman
- Division of Viral Hepatitis, National Center for HIV, Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Philip R. Spradling
- Division of Viral Hepatitis, National Center for HIV, Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Eyasu H. Teshale
- Division of Viral Hepatitis, National Center for HIV, Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Joseph A. Boscarino
- Department of Epidemiology & Health Services Research, Geisinger Clinic, Danville, Pennsylvania
| | - Mark A. Schmidt
- Center for Health Research, Kaiser Permanente-Northwest, Portland, Oregon
| | - Yihe G. Daida
- Center for Health Research, Kaiser Permanente-Hawai’i, Honolulu, Hawaii
| | - Mei Lu
- Department of Public Health Sciences, Henry Ford Health System, Detroit, Michigan
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Spradling PR, Xing J, Rupp LB, Moorman AC, Gordon SC, Lu M, Teshale EH, Boscarino JA, Schmidt MA, Daida YG, Holmberg SD. Uptake of and Factors Associated With Direct-acting Antiviral Therapy Among Patients in the Chronic Hepatitis Cohort Study, 2014 to 2015. J Clin Gastroenterol 2018; 52:641-647. [PMID: 28590325 PMCID: PMC6427915 DOI: 10.1097/mcg.0000000000000857] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Limited information is available describing the uptake of direct-acting antiviral (DAA) therapy for hepatitis C virus (HCV) infection among patients in general US health care settings. We determined the proportion of HCV-infected patients in the Chronic Hepatitis Cohort Study prescribed DAAs in 2014, who initiated treatment and identified characteristics associated with treatment initiation. METHODS Uptake was defined as the proportion of HCV-infected patients with at least 1 clinical encounter in 2013 who were prescribed a DAA regimen during 2014 and initiated the regimen by August 2015. Using multivariable analysis, we examined demographic and clinical characteristics associated with receipt of DAAs. RESULTS The cohort comprised 9508 patients; 544 (5.7%) started a DAA regimen. Higher annual income [adjusted odds ratios (aOR) 2.3 for income>$50K vs. <$30K], higher Fibrosis-4 score (aORs, 2.1, 2.0, and 1.4 for Fibrosis-4, >5.88, 3.25 to 5.88, 2.0 to 3.25, respectively, vs. <2.0), genotype 2 infection (aOR 2.2 vs. genotype 1), pre-2014 treatment failure (aOR 2.0 vs. treatment-naive), and human immunodeficiency virus (HIV) coinfection (aOR 1.8 vs. HCV monoinfection) were associated with DAA initiation. Black race/ethnicity (aOR 0.7 vs. whites) and Medicaid coverage (aOR 0.5 vs. private insurance) were associated with noninitiation. Sex, age, comorbidity, previous liver transplant, and duration of follow-up were not associated with receipt of DAAs. CONCLUSIONS Among patients in these general US health care settings, uptake of DAA therapy was low in 2014, and especially so among minority and Medicaid patients. Systemic efforts to improve access to DAAs for all patients are essential to reduce morbidity and mortality from HCV infection.
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Affiliation(s)
- Philip R. Spradling
- National Centers for HIV, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), Centers for Disease Control and Prevention (CDC), Division of Viral Hepatitis, Atlanta, GA
| | - Jian Xing
- National Centers for HIV, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), Centers for Disease Control and Prevention (CDC), Division of Viral Hepatitis, Atlanta, GA
| | | | - Anne C. Moorman
- National Centers for HIV, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), Centers for Disease Control and Prevention (CDC), Division of Viral Hepatitis, Atlanta, GA
| | | | - Mei Lu
- Henry Ford Health System, Detroit, MI
| | - Eyasu H. Teshale
- National Centers for HIV, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), Centers for Disease Control and Prevention (CDC), Division of Viral Hepatitis, Atlanta, GA
| | | | - Mark A. Schmidt
- The Center for Health Research, Kaiser Permanente-Northwest, Portland, OR
| | - Yihe G. Daida
- The Center for Health Research, Kaiser Permanente-Hawaii, Honolulu, HI
| | - Scott D. Holmberg
- National Centers for HIV, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), Centers for Disease Control and Prevention (CDC), Division of Viral Hepatitis, Atlanta, GA
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Lu M, Zhou Y, Haller IV, Romanelli RJ, VanWormer JJ, Rodriguez CV, Anderson H, Boscarino JA, Schmidt MA, Daida YG, Sahota A, Vincent J, Bowlus CL, Lindor K, Zhang T, Trudeau S, Li J, Rupp LB, Gordon SC. Increasing Prevalence of Primary Biliary Cholangitis and Reduced Mortality With Treatment. Clin Gastroenterol Hepatol 2018; 16:1342-1350.e1. [PMID: 29277621 DOI: 10.1016/j.cgh.2017.12.033] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 12/08/2017] [Accepted: 12/12/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS There are few data from longitudinal studies of trends in primary biliary cholangitis (PBC) among patients under routine clinical care in the United States. We collected data from the Fibrotic Liver Disease consortium to investigate changes in the incidence and prevalence of PBC and the effects of patient demographics, clinical features, and treatment on mortality. METHODS We collected demographic and clinical data for the general patient population as well as PBC patients receiving care from 11 health systems in different regions of the United States (Northeast, Midwest, Northwest, and South) from January 1, 2003, through December 31, 2014. Annual percentage changes in PBC prevalence and incidence were estimated using join-point Poisson regression. Differences based on race, age, and gender were calculated with rate ratios. All-cause mortality was estimated using Cox regression with adjustment for patient characteristics and treatment with ursodeoxycholic acid (UDCA). Propensity scores were used to adjust for treatment selection bias. Analyses were adjusted by geographic regions. RESULTS In our racially diverse cohort of 3488 patients with PBC (21% Hispanic, 8% African American, 7% Asian American), 70% had ever received UDCA. From 2006 through 2014, the prevalence of PBC increased from 21.7 to 39.2 per 100,000 persons. Adjusted annual percentage changes in prevalence differed among age groups (≤40 y, 41-50 y, 51-60 y, 61-70 y, and >70 y), ranging from 3.0% to 7.5% (P < .05). Incidence did not change significantly during the study period (4.2 vs 4.3 per 100,000 person-years in 2006 and 2014, respectively; P = .98). Ratios of prevalence for women vs men (3.9:1) and incidence for women vs men (3.2:1) were consistent over the study period. Among African Americans, the prevalence of PBC increased from 16.9 to 30.8 per 100,000 during the study period, and annual incidence ranged from 2.6 to 6.6 per 100,000 person-years. In adjusted analyses, an increased level of alkaline phosphatase at baseline was associated with significantly higher mortality (adjusted hazard ratios [aHR], 1.24; 95% CI, 1.04-1.48 for patients with levels 1-2 times the upper limit of normal and aHR, 2.27; 95% CI, 1.88-2.73 for patients with levels more than 3 times the upper limit of normal). UDCA treatment was associated with significantly reduced mortality (aHR, 0.57; 95% CI, 0.52-0.64). CONCLUSIONS In an analysis of data from patients receiving routine clinical care in Fibrotic Liver Disease Consortium health systems, we found that the prevalence of PBC increased from 2004 through 2014, despite steady incidence. Patient demographic and clinical characteristics, as well as UDCA treatment, affected mortality.
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Affiliation(s)
- Mei Lu
- Department of Public Health Sciences, Henry Ford Health System, Detroit, Michigan.
| | - Yueren Zhou
- Department of Public Health Sciences, Henry Ford Health System, Detroit, Michigan
| | - Irina V Haller
- Essentia Institute of Rural Health, Essentia Health, Duluth, Minnesota
| | | | | | - Carla V Rodriguez
- Center for Health Research, Kaiser Permanente Mid-Atlantic Research Institute, Rockville, Maryland
| | - Heather Anderson
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, Colorado
| | - Joseph A Boscarino
- Department of Epidemiology and Health Services Research, Geisinger Clinic, Danville, Pennsylvania
| | - Mark A Schmidt
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Yihe G Daida
- Center for Health Research Hawai'i, Kaiser Permanente, Honolulu, Hawaii
| | - Amandeep Sahota
- Department of Research and Evaluation, Kaiser Permanente Southern California, Los Angeles, California
| | | | | | - Keith Lindor
- College of Health Solutions, Arizona State University, Phoenix, Arizona
| | - Talan Zhang
- Department of Public Health Sciences, Henry Ford Health System, Detroit, Michigan
| | - Sheri Trudeau
- Department of Public Health Sciences, Henry Ford Health System, Detroit, Michigan
| | - Jia Li
- Department of Public Health Sciences, Henry Ford Health System, Detroit, Michigan
| | - Loralee B Rupp
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, Michigan
| | - Stuart C Gordon
- Department of Gastroenterology and Hepatology, Henry Ford Health System, Detroit, Michigan
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Bixler D, Zhong Y, Ly KN, Moorman AC, Spradling PR, Teshale EH, Rupp LB, Gordon SC, Boscarino JA, Schmidt MA, Daida YG, Holmberg SD, Holmberg SD, Teshale EH, Spradling PR, Moorman AC, Xing J, Zhong Y, Gordon SC, Nerenz DR, Lu M, Lamerato L, Li J, Rupp LB, Akkerman N, Zhang T, Trudeau S, Zhou Y, Wu KH, Boscarino JA, Daar ZS, Smith RE, Daida YG, Trinacty CM, Lai JW, Wong CP, Schmidt MA, Donald JL. Mortality Among Patients With Chronic Hepatitis B Infection: The Chronic Hepatitis Cohort Study (CHeCS). Clin Infect Dis 2018; 68:956-963. [DOI: 10.1093/cid/ciy598] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 07/24/2018] [Indexed: 02/07/2023] Open
Affiliation(s)
- Danae Bixler
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Yuna Zhong
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Kathleen N Ly
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Anne C Moorman
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Philip R Spradling
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Eyasu H Teshale
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | | | | | | | | | - Scott D Holmberg
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia
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Moorman AC, Rupp LB, Gordon SC, Zhong Y, Xing J, Lu M, Boscarino JA, Schmidt MA, Daida YG, Teshale EH, Spradling PR, Holmberg SD. Long-Term Liver Disease, Treatment, and Mortality Outcomes Among 17,000 Persons Diagnosed with Chronic Hepatitis C Virus Infection: Current Chronic Hepatitis Cohort Study Status and Review of Findings. Infect Dis Clin North Am 2018; 32:253-268. [PMID: 29778254 PMCID: PMC6211170 DOI: 10.1016/j.idc.2018.02.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Chronic Hepatitis Cohort Study (CHeCS) publications using data from "real-world" patients with hepatitis C virus (HCV) have described demographic disparities in access to care; rates of advanced liver disease, morbidity, and mortality (2.5%-3.5% per year during 2006-10, although only 19% of all CHeCS decedents, and just 30% of those with deaths attributed to liver disease, had HCV listed on death certificate); substantial comorbidities, such as diabetes, advanced liver fibrosis (29% prevalence), renal disease, and depression, and partial reversal of all these with successful antiviral therapy; patient risk behaviors; and use of noninvasive markers to assess liver disease.
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Affiliation(s)
- Anne C Moorman
- Division of Viral Hepatitis, Centers for Disease Control and Prevention (CDC), Mailstop G-37, Atlanta, GA 30329, USA.
| | - Loralee B Rupp
- Division of Gastroenterology and Hepatology, Henry Ford Health System, 2799 West Grand Boulevard, Detroit, MI 48202, USA
| | - Stuart C Gordon
- Division of Gastroenterology and Hepatology, Henry Ford Health System, 2799 West Grand Boulevard, Detroit, MI 48202, USA
| | - Yuna Zhong
- Division of Viral Hepatitis, Centers for Disease Control and Prevention (CDC), Mailstop G-37, Atlanta, GA 30329, USA
| | - Jian Xing
- Division of Viral Hepatitis, Centers for Disease Control and Prevention (CDC), Mailstop G-37, Atlanta, GA 30329, USA
| | - Mei Lu
- Public Health Sciences, Henry Ford Health System, 1 Ford Place -3A, Detroit, MI 48202, USA
| | - Joseph A Boscarino
- Department of Epidemiology and Health Services Research, Geisinger Clinic, 100 North Academy Avenue, Danville, PA 17822, USA
| | - Mark A Schmidt
- Kaiser Permanente-Center for Health Research, Northwest, Kaiser Permanente Northwest, 3800 North Interstate Avenue, Portland, OR 97227-1098, USA
| | - Yihe G Daida
- Kaiser Permanente-Center for Health Research, Hawaii, Kaiser Permanente Hawaii, 501 Alakawa Street, Suite 201, Honolulu, HI 9681, USA
| | - Eyasu H Teshale
- Division of Viral Hepatitis, Centers for Disease Control and Prevention (CDC), Mailstop G-37, Atlanta, GA 30329, USA
| | - Philip R Spradling
- Division of Viral Hepatitis, Centers for Disease Control and Prevention (CDC), Mailstop G-37, Atlanta, GA 30329, USA
| | - Scott D Holmberg
- Division of Viral Hepatitis, Centers for Disease Control and Prevention (CDC), Mailstop G-37, Atlanta, GA 30329, USA
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Moorman AC, Xing J, Rupp LB, Gordon SC, Spradling PR, Boscarino JA, Schmidt MA, Daida YG, Teshale EH, Holmberg SD. Hepatitis B Virus Infection and Hepatitis C Virus Treatment in a Large Cohort of Hepatitis C-Infected Patients in the United States. Gastroenterology 2018; 154:754-758. [PMID: 29360428 PMCID: PMC5850951 DOI: 10.1053/j.gastro.2017.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 10/10/2017] [Accepted: 12/06/2017] [Indexed: 12/09/2022]
Affiliation(s)
- Anne C Moorman
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jian Xing
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | | | - Philip R Spradling
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | | | | | - Eyasu H Teshale
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Scott D Holmberg
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia
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Lu M, Li J, Rupp LB, Zhou Y, Holmberg SD, Moorman AC, Spradling PR, Teshale EH, Boscarino JA, Daida YG, Schmidt MA, Trudeau S, Gordon SC. Changing trends in complications of chronic hepatitis C. Liver Int 2018; 38. [PMID: 28636782 PMCID: PMC5777910 DOI: 10.1111/liv.13501] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND & AIMS Chronic hepatitis C virus (HCV)-related complications have increased over the past decade. METHODS We used join-point regression modelling to investigate trends in these complications from 2006 to 2015, and the impact of demographics on these trends. Using data from the Chronic Hepatitis Cohort Study (CHeCS), we identified points at which the trend significantly changed, and estimated the annual percent change (APC) in rates of cirrhosis, decompensated cirrhosis and all-cause mortality, adjusted by race, sex and age. RESULTS Among 11,167 adults with chronic HCV infection, prevalence of cirrhosis increased from 20.8% to 27.6% from 2006 to 2015, with adjusted annual percentage change (aAPC) of 1.2 (p <. 01). Although incidence of all-cause mortality increased from 1.8% in 2006 to 2.9% in 2015, a join-point was identified at 2010, with aAPCs of 9.6 before (2006 < 2010; p < .01) and -5.2 after (2010 ≤ 2015; p < .01), indicating a decrease in mortality from 2010 and onward. Likewise, overall prevalence of decompensated cirrhosis increased from 9.3% in 2006 to 10.4% in 2015, but this increase was confined to patients 60 or older (aAPC = 1.5; p = .023). Asian American and Black/African American patients demonstrated significantly higher rates of cirrhosis than White patients, while older patients and men demonstrated higher rates of cirrhosis and mortality. CONCLUSIONS Although cirrhosis and mortality among HCV-infected patients in the US have increased over the past decade, all-cause mortality has decreased in recent years.
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Affiliation(s)
- Mei Lu
- Department of Public Health Sciences, Henry Ford Health System, Detroit MI
| | - Jia Li
- Department of Public Health Sciences, Henry Ford Health System, Detroit MI
| | - Loralee B. Rupp
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit MI
| | - Yueren Zhou
- Department of Public Health Sciences, Henry Ford Health System, Detroit MI
| | - Scott D. Holmberg
- Division of Viral Hepatitis, National Center for HIV, Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta GA
| | - Anne C. Moorman
- Division of Viral Hepatitis, National Center for HIV, Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta GA
| | - Philip R. Spradling
- Division of Viral Hepatitis, National Center for HIV, Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta GA
| | - Eyasu H. Teshale
- Division of Viral Hepatitis, National Center for HIV, Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta GA
| | - Joseph A. Boscarino
- Department of Epidemiology and Health Services Research, Geisinger Health System, Danville PA
| | - Yihe G. Daida
- Center for Health Research, Kaiser Permanente–Hawai’i, Honolulu HI
| | - Mark A. Schmidt
- Center for Health Research, Kaiser Permanente–Northwest, Portland OR
| | - Sheri Trudeau
- Department of Public Health Sciences, Henry Ford Health System, Detroit MI
| | - Stuart C. Gordon
- Division of Gastroenterology and Hepatology, Henry Ford Health System, Detroit MI
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Xing J, Spradling PR, Moorman AC, Holmberg SD, Teshale EH, Rupp LB, Gordon SC, Lu M, Boscarino JA, Schmidt MA, Trinacty CM, Xu F. A Point System to Forecast Hepatocellular Carcinoma Risk Before and After Treatment Among Persons with Chronic Hepatitis C. Dig Dis Sci 2017; 62:3221-3234. [PMID: 28965221 DOI: 10.1007/s10620-017-4762-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 09/11/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND Risk of hepatocellular carcinoma (HCC) may be difficult to determine in the clinical setting. AIM Develop a scoring system to forecast HCC risk among patients with chronic hepatitis C. METHODS Using data from the Chronic Hepatitis Cohort Study collected during 2005-2014, we derived HCC risk scores for males and females using an extended Cox model with aspartate aminotransferase-to-platelet ratio index (APRI) as a time-dependent variables and mean Kaplan-Meier survival functions from patient data at two study sites, and used data collected at two separate sites for external validation. For model calibration, we used the Greenwood-Nam-D'Agostino goodness-of-fit statistic to examine differences between predicted and observed risk. RESULTS Of 12,469 patients (1628 with a history of sustained viral response [SVR]), 504 developed HCC; median follow-up was 6 years. Final predictors in the model included age, alcohol abuse, interferon-based treatment response, and APRI. Point values, ranging from -3 to 14 (males) and -3 to 12 (females), were established using hazard ratios of the predictors aligned with 1-, 3-, and 5-year Kaplan-Meier survival probabilities of HCC. Discriminatory capacity was high (c-index 0.82 males and 0.84 females) and external calibration demonstrated no differences between predicted and observed HCC risk for 1-, 3-, and 5-year forecasts among males (all p values >0.97) and for 3- and 5-year risk among females (all p values >0.87). CONCLUSION This scoring system, based on age, alcohol abuse history, treatment response, and APRI, can be used to forecast up to a 5-year risk of HCC among hepatitis C patients before and after SVR.
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Affiliation(s)
- Jian Xing
- Division of Viral Hepatitis, National Center for HIV, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), Centers for Disease Control and Prevention (CDC), Mailstop G37, 1600 Clifton Road NE, Atlanta, GA, 30333, USA
| | - Philip R Spradling
- Division of Viral Hepatitis, National Center for HIV, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), Centers for Disease Control and Prevention (CDC), Mailstop G37, 1600 Clifton Road NE, Atlanta, GA, 30333, USA.
| | - Anne C Moorman
- Division of Viral Hepatitis, National Center for HIV, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), Centers for Disease Control and Prevention (CDC), Mailstop G37, 1600 Clifton Road NE, Atlanta, GA, 30333, USA
| | - Scott D Holmberg
- Division of Viral Hepatitis, National Center for HIV, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), Centers for Disease Control and Prevention (CDC), Mailstop G37, 1600 Clifton Road NE, Atlanta, GA, 30333, USA
| | - Eyasu H Teshale
- Division of Viral Hepatitis, National Center for HIV, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), Centers for Disease Control and Prevention (CDC), Mailstop G37, 1600 Clifton Road NE, Atlanta, GA, 30333, USA
| | | | | | - Mei Lu
- Henry Ford Health System, Detroit, MI, USA
| | | | - Mark A Schmidt
- The Center for Health Research, Kaiser Permanente-Northwest, Portland, OR, USA
| | - Connie M Trinacty
- The Center for Health Research, Kaiser Permanente-Hawaii, Honolulu, HI, USA
| | - Fujie Xu
- Division of Viral Hepatitis, National Center for HIV, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), Centers for Disease Control and Prevention (CDC), Mailstop G37, 1600 Clifton Road NE, Atlanta, GA, 30333, USA
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Lu M, Chacra W, Rabin D, Rupp LB, Trudeau S, Li J, Gordon SC. Validity of an automated algorithm using diagnosis and procedure codes to identify decompensated cirrhosis using electronic health records. Clin Epidemiol 2017; 9:369-376. [PMID: 28744162 PMCID: PMC5513832 DOI: 10.2147/clep.s136134] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Viral hepatitis-induced cirrhosis can progress to decompensated cirrhosis. Clinical decompensation represents a milestone event for the patient with cirrhosis, yet there remains uncertainty regarding precisely how to define this important phenomenon. With the development of broader treatment options for cirrhotic hepatitis patients, efficient identification of liver status before evolving to decompensated cirrhosis could be life-saving, but research on the topic has been limited by inconsistencies across studies, populations, and case-confirmation methods. We sought to determine whether diagnosis/procedure codes drawn from electronic health records (EHRs) could be used to identify patients with decompensated cirrhosis. In our first step, chart review was used to determine liver status (compensated cirrhosis, decompensated cirrhosis, non-cirrhotic) in patients from the Chronic Hepatitis Cohort Study. Next, a hybrid approach between Least Absolute Shrinkage and Selection Operator regression and Classification Regression Trees models was used to optimize EHR-based identification of decompensated cirrhosis, based on 41 diagnosis and procedure codes. These models were validated using tenfold cross-validation; method accuracy was evaluated by positive predictive values (PPVs) and area under receiver operating characteristic (AUROC) curves. Among 296 patients (23 with hepatitis B, 268 with hepatitis C, and 5 co-infected) with a 2:1 ratio of biopsy-confirmed cirrhosis to noncirrhosis, chart review identified 127 cases of decompensated cirrhosis (Kappa=0.88). The algorithm of five liver-related conditions—liver transplant, hepatocellular carcinoma, esophageal varices complications/procedures, ascites, and cirrhosis—yielded a PPV of 85% and an AUROC of 92%. A hierarchical subset of three conditions (hepatocellular carcinoma, ascites, and esophageal varices) demonstrated a PPV of 81% and an AUROC of 86%. Given the excellent predictive ability of our model, this EHR-based automated algorithm may be used to successfully identify patients with decompensated cirrhosis. This algorithm may contribute to timely identification and treatment of viral hepatitis patients who have progressed to decompensated cirrhosis.
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Affiliation(s)
- Mei Lu
- Department of Public Health Sciences, Henry Ford Health System, Detroit, MI, USA
| | - Wadih Chacra
- Division of Gastroenterology and Hepatology, University of Illinois College of Medicine, Chicago, IL, USA
| | - David Rabin
- Atlanta Gastroenterology Associates, Atlanta, GA, USA
| | - Loralee B Rupp
- Center for Health Policy & Health Services Research, Henry Ford Health System, Detroit MI, USA
| | - Sheri Trudeau
- Department of Public Health Sciences, Henry Ford Health System, Detroit, MI, USA
| | - Jia Li
- Department of Public Health Sciences, Henry Ford Health System, Detroit, MI, USA
| | - Stuart C Gordon
- Division of Gastroenterology and Hepatology, Henry Ford Health System, Detroit, MI, USA
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Li J, Gordon SC, Rupp LB, Zhang T, Trudeau S, Holmberg SD, Moorman AC, Spradling PR, Teshale EH, Boscarino JA, Daida YG, Schmidt MA, Lu M. Long-term progression of viral load and serum markers of fibrosis among treated and untreated patients with chronic hepatitis B. J Gastroenterol Hepatol 2017; 32:1250-1257. [PMID: 27888529 PMCID: PMC5674987 DOI: 10.1111/jgh.13667] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 11/04/2016] [Accepted: 11/22/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIMS Antiviral therapy for patients with hepatitis B (HBV) infection is generally deferred for "immune inactive" patients, although longitudinal changes in viral load and liver fibrosis remain understudied in this population. Likewise, in treated patients, the temporal relationship between changes in viral load and liver fibrosis is not well characterized. Using data from the chronic hepatitis cohort study, the study investigated viral load and the Fibrosis-4 index (FIB4, a serum-based marker of liver fibrosis) trajectories in both untreated and treated HBV patients. MATERIALS AND METHODS We applied a bivariate, piecewise, linear spline, mixed-effects modeling approach to data from 766 HBV patients (342 untreated, 424 treated). Treatment selection bias was adjusted using propensity scores. Multiple sensitivity analyses were used to confirm results in untreated patients. RESULTS Among all untreated patients, FIB4 began to increase by 0.9% per month (11% per year; P < 0.05) at 28 months post-index date, suggesting fibrosis progression. Significant FIB4 progression was also observed in a subgroup analysis of "immune inactive" untreated patients. In treated patients, viral load declined 31.8% per month (P < 0.05) for the first 5 months after treatment initiation, and 1.4-1.7% per month (P < 0.05) thereafter. At 5 months after treatment initiation, FIB4 began to decline 0.5% per month (P < 0.05), stabilizing at 28 months. CONCLUSION Among untreated HBV patients, FIB4 gradually increases over time, suggesting fibrosis progression, even in those patients designated as immune inactive. In treated patients, antiviral therapy results in a rapid decline in viral load followed by a delayed decline in markers of liver fibrosis.
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Affiliation(s)
- Jia Li
- Department of Public Health Sciences
| | | | - Loralee B Rupp
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, Michigan
| | | | | | - Scott D Holmberg
- Division of Viral Hepatitis, National Center for HIV, Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Anne C Moorman
- Division of Viral Hepatitis, National Center for HIV, Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Philip R Spradling
- Division of Viral Hepatitis, National Center for HIV, Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Eyasu H Teshale
- Division of Viral Hepatitis, National Center for HIV, Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Joseph A Boscarino
- Center for Health Research, Geisinger Health System, Danville, Pennsylvania
| | - Yihe G Daida
- Center for Health Research, Kaiser Permanente-Hawai’i, Waipahu, Hawaii
| | - Mark A Schmidt
- Center for Health Research, Kaiser Permanente-Northwest, Portland, Oregon, USA
| | - Mei Lu
- Department of Public Health Sciences
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Spradling PR, Xing J, Rupp LB, Moorman AC, Gordon SC, Teshale ET, Lu M, Boscarino JA, Schmidt MA, Trinacty CM, Holmberg SD. Distribution of disease phase, treatment prescription and severe liver disease among 1598 patients with chronic hepatitis B in the Chronic Hepatitis Cohort Study, 2006-2013. Aliment Pharmacol Ther 2016; 44:1080-1089. [PMID: 27640985 DOI: 10.1111/apt.13802] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 07/07/2016] [Accepted: 08/25/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND Limited information exists regarding the distribution of disease phases, treatment prescription and severe liver disease among patients with chronic hepatitis B (CHB) in US general healthcare settings. AIM To determine the distribution of disease phases, treatment prescription and severe liver disease among patients with CHB in general US healthcare settings. METHODS We analysed demographic and clinical data collected during 2006-2013 from patients with confirmed CHB in the Chronic Hepatitis Cohort Study, an observational cohort study involving patients from healthcare organisations in Michigan, Pennsylvania, Oregon and Hawaii. CHB phases were classified according to American Association for the Study of Liver Disease guidelines. RESULTS Of 1598 CHB patients with ≥12 months of follow-up (median 6.3 years), 457 (29%) were immune active during follow-up [11% hepatitis B e antigen (HBeAg)-positive, 16% HBeAg-negative, and 2% HBeAg status unknown], 10 (0.6%) were immune tolerant, 112 (7%) were inactive through the duration of follow-up and 886 (55%) were phase indeterminate. Patients with cirrhosis were identified within each group (among 21% of immune active, 3% of inactive and 9% of indeterminate phase patients) except among those with immune-tolerant CHB. Prescription of treatment was 59% among immune active patients and 84% among patients with cirrhosis and hepatitis B virus (HBV) DNA >2000 IU/mL. CONCLUSIONS Approximately, one-third of the cohort had active disease during follow-up; 60% of eligible patients were prescribed treatment. Our findings underscore the importance of ascertainment of fibrosis status in addition to regular assessment of ALT and HBV DNA levels.
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Affiliation(s)
- P R Spradling
- Division of Viral Hepatitis, National Centers for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - J Xing
- Division of Viral Hepatitis, National Centers for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - L B Rupp
- Henry Ford Health System, Detroit, MI, USA
| | - A C Moorman
- Division of Viral Hepatitis, National Centers for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - S C Gordon
- Henry Ford Health System, Detroit, MI, USA
| | - E T Teshale
- Division of Viral Hepatitis, National Centers for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - M Lu
- Henry Ford Health System, Detroit, MI, USA
| | - J A Boscarino
- Center for Health Research, Geisinger Health System, Danville, PA, USA
| | - M A Schmidt
- The Center for Health Research, Kaiser Permanente-Northwest, Portland, OR, USA
| | - C M Trinacty
- The Center for Health Research, Kaiser Permanente-Hawaii, Honolulu, Hawaii
| | - S D Holmberg
- Division of Viral Hepatitis, National Centers for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Teshale EH, Xing J, Moorman A, Holmberg SD, Spradling PR, Gordon SC, Rupp LB, Lu M, Boscarino JA, Trinacity CM, Schmidt MA, Xu F. Higher all-cause hospitalization among patients with chronic hepatitis C: the Chronic Hepatitis Cohort Study (CHeCS), 2006-2013. J Viral Hepat 2016; 23:748-54. [PMID: 27186944 DOI: 10.1111/jvh.12548] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 04/04/2016] [Indexed: 01/28/2023]
Abstract
In the United States, hospitalization among patients with chronic hepatitis C virus (HCV) infection is high. The healthcare burden associated with hospitalization is not clearly known. We analysed data from the Chronic Hepatitis Cohort Study, an observational cohort of patients receiving care at four integrated healthcare systems, collected from 2006 to 2013 to determine all-cause hospitalization rates of patients with chronic HCV infection and the other health system patients. To compare the hospitalization rates, we selected two health system patients for each chronic HCV patient using their propensity score (PS). Propensity score matching was conducted by site, gender, race, age and household income to minimize differences attributable to these characteristics. We also compared primary reason for hospitalization between chronic HCV patients and the other health system patients. Overall, 10 131 patients with chronic HCV infection and 20 262 health system patients were selected from the 1 867 802 health system patients and were matched by PS. All-cause hospitalization rates were 27.4 (27.0-27.8) and 7.4 (7.2-7.5) per 100 persons-year (PY) for chronic HCV patients and for the other health system patients, respectively. Compared to health system patients, hospitalization rates were significantly higher by site, gender, age group, race and household income among chronic HCV patients (P < 0.001). Compared to health system patients, chronic HCV patients were more likely to be hospitalized from liver-related conditions (RR = 24.8, P < 0.001). Hence, patients with chronic HCV infection had approximately 3.7-fold higher all-cause hospitalization rate than other health system patients. These findings highlight the incremental costs and healthcare burden of patients with chronic HCV infection associated with hospitalization.
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Affiliation(s)
- E H Teshale
- Division of Viral Hepatitis, CDC, Atlanta, GA, USA.
| | - J Xing
- Division of Viral Hepatitis, CDC, Atlanta, GA, USA
| | - A Moorman
- Division of Viral Hepatitis, CDC, Atlanta, GA, USA
| | - S D Holmberg
- Division of Viral Hepatitis, CDC, Atlanta, GA, USA
| | | | | | - L B Rupp
- Henry Ford Hospital, Detroit, MI, USA
| | - M Lu
- Henry Ford Hospital, Detroit, MI, USA
| | | | | | - M A Schmidt
- Kaiser Permanente Northwest, Portland, OR, USA
| | - F Xu
- Division of Viral Hepatitis, CDC, Atlanta, GA, USA
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Lu M, Li J, Rupp LB, Holmberg SD, Moorman AC, Spradling PR, Teshale EH, Zhou Y, Boscarino JA, Schmidt MA, Lamerato LE, Trinacty C, Trudeau S, Gordon SC. Hepatitis C treatment failure is associated with increased risk of hepatocellular carcinoma. J Viral Hepat 2016; 23:718-29. [PMID: 27028626 PMCID: PMC5724043 DOI: 10.1111/jvh.12538] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Accepted: 02/18/2016] [Indexed: 12/11/2022]
Abstract
Sustained virological response (SVR) to antiviral therapy for hepatitis C (HCV) reduces risk of hepatocellular carcinoma (HCC), but there is little information regarding how treatment failure (TF) compares to lack of treatment. We evaluated the impact of treatment status on risk of HCC using data from the Chronic Hepatitis Cohort Study (CHeCS-an observational study based in four large US health systems, with up to 7 years of follow-up on patients). Multivariable analyses were used to adjust for bias in treatment selection, as well as other covariates, followed by sensitivity analyses. Among 10 091 HCV patients, 3681 (36%) received treatment, 2099 (57%) experienced treatment failure (TF), and 1582 (43%) of these achieved sustained virological response (SVR). TF patients demonstrated almost twice the risk of HCC than untreated patients [adjusted hazard ratio (aHR) = 1.95, 95% confidence interval (CI) 1.50-2.53]; this risk persisted across all stages of fibrosis. Several sensitivity analyses validated these results. Although African Americans were at increased risk of treatment failure, they were at lower risk for HCC and all-cause mortality compared to White patients. SVR patients had lower risk of HCC than TF patients (aHR = 0.48, CI 0.31-0.73), whereas treatment - regardless of outcome - reduced all-cause mortality (aHR = 0.45, CI 0.34-0.60 for SVR patients; aHR = 0.78, CI 0.65-0.93 for TF patients).
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Affiliation(s)
- Mei Lu
- Department of Public Health Sciences, Henry Ford Health System, Detroit, MI, USA
| | - Jia Li
- Department of Public Health Sciences, Henry Ford Health System, Detroit, MI, USA
| | - Loralee B. Rupp
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, MI, USA
| | - Scott D. Holmberg
- Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Anne C. Moorman
- Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Philip R. Spradling
- Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Eyasu H. Teshale
- Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Yueren Zhou
- Department of Public Health Sciences, Henry Ford Health System, Detroit, MI, USA
| | | | - Mark A. Schmidt
- Center for Health Research, Kaiser Permanente–Northwest, Portland, OR, Portland
| | - Lois E. Lamerato
- Department of Public Health Sciences, Henry Ford Health System, Detroit, MI, USA
| | - Connie Trinacty
- Center for Health Research, Kaiser Permanente–Hawai’i, Waipahu, HI, USA
| | - Sheri Trudeau
- Department of Public Health Sciences, Henry Ford Health System, Detroit, MI, USA
| | - Stuart C. Gordon
- Division of Gastroenterology and Hepatology, Henry Ford Health System, Detroit, MI, USA
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Spradling PR, Xing J, Rupp LB, Moorman AC, Gordon SC, Teshale ET, Lu M, Boscarino JA, Trinacty CM, Schmidt MA, Holmberg SD. Infrequent Clinical Assessment of Chronic Hepatitis B Patients in United States General Healthcare Settings. Clin Infect Dis 2016; 63:1205-1208. [PMID: 27486115 DOI: 10.1093/cid/ciw516] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 07/03/2016] [Indexed: 01/05/2023] Open
Abstract
Among 2338 chronic hepatitis B patients followed during 2006-2013 in the Chronic Hepatitis Cohort Study, 78% had ≥1 alanine aminotransferase and 37% had ≥1 hepatitis B virus DNA level assessed annually. Among cirrhotic patients, 46% never had hepatic imaging. Patients in this cohort were insufficiently monitored for disease activity and hepatocellular carcinoma.
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Affiliation(s)
- Philip R Spradling
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jian Xing
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Loralee B Rupp
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Anne C Moorman
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Stuart C Gordon
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Eyasu T Teshale
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Mei Lu
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Joseph A Boscarino
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Connie M Trinacty
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Mark A Schmidt
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Scott D Holmberg
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia
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Moorman AC, Tong X, Spradling PR, Rupp LB, Gordon SC, Lu M, Teshale EH, Boscarino JA, Trinacty CM, Schmidt MA, Xu F, Holmberg SD. Prevalence of Renal Impairment and Associated Conditions Among HCV-Infected Persons in the Chronic Hepatitis Cohort Study (CHeCS). Dig Dis Sci 2016; 61:2087-93. [PMID: 27216163 PMCID: PMC5675517 DOI: 10.1007/s10620-016-4199-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Accepted: 05/10/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND Guidelines for the treatment of HCV-infected persons were updated in August 2015 with new recommendations for patients with renal impairment. Treatment is imperative for patients with severe, renal-associated extrahepatic manifestations of HCV infection. AIMS We sought to describe the prevalence of these conditions among current HCV-infected patients in a population-based prospective, observational cohort study at four large US health systems. METHODS Data from cohort patients with chronic HCV infection during 2012 were analyzed for the period from 2006 to 2013. We determined the prevalence of mild to moderately impaired renal function defined as having the most recent estimated glomerular filtration rate [eGFR] ≤ 80 ml/min/1.73 m(2), with severe impairment defined as eGFR < 30 ml/min/1.73 m(2), based on the treatment guidelines. Prevalence of extrahepatic conditions was ascertained using ICD9-codes. RESULTS Among 5772 persons, the prevalence of eGFR ≤ 80 was 33 % and eGFR < 30 was 2 %, including among patients with hepatic fibrosis. Diagnosed extrahepatic renal manifestations were rare: vasculitis- 0.2 %, nephrotic syndrome- 0.3 %, and cryoglobulinemia- 0.9 %. CONCLUSIONS While the prevalence of severe renal impairment and diagnosed extrahepatic manifestations was low, mild-to-moderate renal impairment was common in HCV patients, including those with advanced liver fibrosis for whom the need for treatment is urgent.
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Affiliation(s)
- Anne C Moorman
- Division of Viral Hepatitis, CDC, Mailstop G-37, Atlanta, GA, 30329, USA.
| | - Xin Tong
- Division of Viral Hepatitis, CDC, Mailstop G-37, Atlanta, GA, 30329, USA
| | - Philip R Spradling
- Division of Viral Hepatitis, CDC, Mailstop G-37, Atlanta, GA, 30329, USA
| | - Loralee B Rupp
- Henry Ford Health System, 2799 West Grand Blvd., Detroit, MI, USA
| | - Stuart C Gordon
- Henry Ford Health System, 2799 West Grand Blvd., Detroit, MI, USA
| | - Mei Lu
- Henry Ford Health System, 2799 West Grand Blvd., Detroit, MI, USA
| | - Eyasu H Teshale
- Division of Viral Hepatitis, CDC, Mailstop G-37, Atlanta, GA, 30329, USA
| | - Joseph A Boscarino
- Geisinger Center for Health Research, Geisinger Health System, 100 N. Academy Avenue, Danville, PA, 17822, USA
| | - Connie M Trinacty
- Kaiser Permanente-Center for Health Research, Kaiser Permanente Hawaii, 501 Alakawa Street, Suite 201, Honolulu, HI, 96817, USA
| | - Mark A Schmidt
- Center for Health Research Northwest, Kaiser Permanente Northwest, 3800 N. Interstate Avenue, Portland, OR, 97227-1098, USA
| | - Fujie Xu
- Division of Viral Hepatitis, CDC, Mailstop G-37, Atlanta, GA, 30329, USA
| | - Scott D Holmberg
- Division of Viral Hepatitis, CDC, Mailstop G-37, Atlanta, GA, 30329, USA
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Xu F, Moorman AC, Tong X, Gordon SC, Rupp LB, Lu M, Teshale EH, Spradling PR, Boscarino JA, Trinacty CM, Schmidt MA, Holmberg SD, Holmberg SD, Teshale EH, Spradling PR, Moorman AC, Xing J, Tong X, Xu F, Gordon SC, Nerenz DR, Lu M, Lamerato L, Wang Y, Rupp LB, Akkerman N, Oja-Tebbe N, Zhang T, Li J, Sitarik A, Larkin D, Boscarino JA, Daar ZS, Curry PJ, Smith RE, Vijayadeva V, Parker JV, Schmidt MA, Donald JL, Keast EM. All-Cause Mortality and Progression Risks to Hepatic Decompensation and Hepatocellular Carcinoma in Patients Infected With Hepatitis C Virus. Clin Infect Dis 2015; 62:289-297. [PMID: 26417034 DOI: 10.1093/cid/civ860] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 09/22/2015] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND A key question in care of patients with chronic hepatitis C virus (HCV) infection is beginning treatment immediately vs delaying treatment. Risks of mortality and disease progression in "real world" settings are important to assess the implications of delaying HCV treatment. METHODS This was a cohort study of HCV patients identified from 4 integrated health systems in the United States who had liver biopsies during 2001-2012. The probabilities of death and progression to hepatocellular carcinoma, hepatic decompensation (hepatic encephalopathy, esophageal varices, ascites, or portal hypertension) or liver transplant were estimated over 1, 2, or 5 years by fibrosis stage (Metavir F0-F4) determined by biopsy at beginning of observation. RESULTS Among 2799 HCV-monoinfected patients who had a qualifying liver biopsy, the mean age at the time of biopsy was 50.7 years. The majority were male (58.9%) and non-Hispanic white (66.9%). Over a mean observation of 5.0 years, 261 (9.3%) patients died and 34 (1.2%) received liver transplants. At 5 years after biopsy, the estimated risk of progression to hepatic decompensation or hepatocellular carcinoma was 37.2% in stage F4, 19.6% in F3, 4.7% in F2, and 2.3% in F0-F1 patients. Baseline biopsy stage F3 or F4 and platelet count below normal were the strongest predictors of progression to hepatic decompensation or hepatocellular carcinoma. CONCLUSIONS The risks of death and progression to liver failure varied greatly by fibrosis stage. Clinicians and policy makers could use these progression risk data in prioritization and in determining the timing of treatment for patients in early stages of liver disease.
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Affiliation(s)
- Fujie Xu
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Anne C Moorman
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Xin Tong
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | | | - Mei Lu
- Henry Ford Health System, Detroit, Michigan
| | - Eyasu H Teshale
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Philip R Spradling
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | | | | | - Scott D Holmberg
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia
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Gordon SC, Lamerato LE, Rupp LB, Holmberg SD, Moorman AC, Spradling PR, Teshale E, Xu F, Boscarino JA, Vijayadeva V, Schmidt MA, Oja-Tebbe N, Lu M. Prevalence of cirrhosis in hepatitis C patients in the Chronic Hepatitis Cohort Study (CHeCS): a retrospective and prospective observational study. Am J Gastroenterol 2015; 110. [PMID: 26215529 PMCID: PMC5731242 DOI: 10.1038/ajg.2015.203] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES The severity of liver disease in the hepatitis C virus (HCV)-infected population in the United States remains uncertain. We estimated the prevalence of cirrhosis in adults with chronic hepatitis C (CHC) using multiple parameters including liver biopsy, diagnosis/procedure codes, and a biomarker. METHODS Patients enrolled in the Chronic Hepatitis Cohort Study (CHeCS) who received health services during 2006-2010 were included. Cirrhosis was identified through liver biopsy reports, diagnosis/procedure codes for cirrhosis or hepatic decompensation, and Fibrosis-4 (FIB-4) scores ≥5.88. Demographic and clinical characteristics associated with cirrhosis were identified through multivariable logistic modeling. RESULTS Among 9,783 patients, 2,788 (28.5%) were cirrhotic by at least one method. Biopsy identified cirrhosis in only 661 (7%) patients, whereas FIB-4 scores and diagnosis/procedure codes for cirrhosis and hepatic decompensation identified cirrhosis in 2,194 (22%), 557 (6%), and 482 (5%) patients, respectively. Among 661 patients with biopsy-confirmed cirrhosis, only 356 (54%) had an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code for cirrhosis. Older age, male gender, Asian race, Hispanic ethnicity, genotype 3 infection, HIV coinfection, diabetes, history of antiviral therapy, and history of alcohol abuse were independently associated with higher odds of cirrhosis (all, P<0.05). Conversely, private health insurance coverage, black race, and HCV genotype 2 were associated with lower odds of cirrhosis. CONCLUSIONS A high proportion of patients with biopsy-confirmed cirrhosis are not assigned ICD-9 codes for cirrhosis. Consequently, ICD-9 codes may not be reliable as the sole indicator of the prevalence of cirrhosis in cohort studies. Use of additional parameters suggests a fourfold higher prevalence of cirrhosis than is revealed by biopsy alone. These findings suggest that cirrhosis in CHC patients may be significantly underdocumented and underdiagnosed.
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Affiliation(s)
- Stuart C. Gordon
- Division of Gastroenterology and Hepatology, Henry Ford Health System, Detroit, Michigan, USA
| | - Lois E. Lamerato
- Department of Public Health Sciences, Henry Ford Health System, Detroit, Michigan, USA
| | - Loralee B. Rupp
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, Michigan, USA
| | - Scott D. Holmberg
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Anne C. Moorman
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Philip R. Spradling
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Eyasu Teshale
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Fujie Xu
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Joseph A. Boscarino
- Center for Health Research, Geisinger Health System, Danville, Pennsylvania, USA
| | - Vinutha Vijayadeva
- Center for Health Research, Kaiser Permanente-Hawaii, Honolulu, Hawaii, USA
| | - Mark A. Schmidt
- Center For Health Research, Kaiser Permanente-Northwest, Portland, Oregon, USA
| | - Nancy Oja-Tebbe
- Department of Public Health Sciences, Henry Ford Health System, Detroit, Michigan, USA
| | - Mei Lu
- Department of Public Health Sciences, Henry Ford Health System, Detroit, Michigan, USA
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Moorman AC, Xing J, Ko S, Rupp LB, Xu F, Gordon SC, Lu M, Spradling PR, Teshale EH, Boscarino JA, Vijayadeva V, Schmidt MA, Holmberg SD. Late diagnosis of hepatitis C virus infection in the Chronic Hepatitis Cohort Study (CHeCS): Missed opportunities for intervention. Hepatology 2015; 61:1479-84. [PMID: 25131217 PMCID: PMC5675516 DOI: 10.1002/hep.27365] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Accepted: 08/07/2014] [Indexed: 01/08/2023]
Abstract
UNLABELLED To determine the stage of liver disease at initial diagnosis of hepatitis C virus (HCV) infection, we analyzed data from the Chronic Hepatitis Cohort Study (CHeCS), a large U.S. observational study. We examined the temporal relationships of initial HCV infection diagnosis with cirrhosis-defined by liver biopsy or mean FIB-4 score >5.88-and time to onset of cirrhotic decompensation in electronic medical records. We determined time in the health system prior to HCV diagnosis and rates of hospitalization and death following HCV diagnosis. Of 14,717 patients with chronic HCV seen during 2006-2011, 6,166 (42%) had a definable time of initial HCV diagnosis. Of these, 1,056 (17%) patients met our definition for "late diagnosis" with either cirrhosis concurrent with initial HCV diagnosis (n = 550), a first diagnosis of hepatic decompensation before or within 12 months after initial HCV diagnosis (n = 506), or both (n = 314). Patients with late diagnosis had an average of 6 years in the health system before their HCV diagnosis. In a comparison with patients without late diagnosis, hospitalization (59% versus 35%) and death (33% versus 9%) were more frequent among patients with late diagnosis. Among all who died, mean (median) time from initial HCV diagnosis to death was 4.8 (4.2) years. CONCLUSION Many CHeCS patients had advanced liver disease concurrent with their initial HCV diagnosis despite many years of engagement with the healthcare system, and these patients had high rates of hospitalization and mortality.
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Affiliation(s)
| | - Jian Xing
- Division of Viral Hepatitis, CDC, Atlanta, GA
| | - Stephen Ko
- Division of Viral Hepatitis, CDC, Atlanta, GA
| | | | - Fujie Xu
- Division of Viral Hepatitis, CDC, Atlanta, GA
| | | | - Mei Lu
- Henry Ford Health System, Detroit, MI
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Boscarino JA, Lu M, Moorman AC, Gordon SC, Rupp LB, Spradling PR, Teshale EH, Schmidt MA, Vijayadeva V, Holmberg SD. Predictors of poor mental and physical health status among patients with chronic hepatitis C infection: the Chronic Hepatitis Cohort Study (CHeCS). Hepatology 2015; 61:802-11. [PMID: 25203533 PMCID: PMC5675518 DOI: 10.1002/hep.27422] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Accepted: 09/05/2014] [Indexed: 12/14/2022]
Abstract
UNLABELLED Our objective was to assess the extent and risk factors for depression and poor physical health among patients with chronic hepatitis C virus (HCV) infection. We surveyed HCV-infected patients seen at four large healthcare systems participating in the Chronic Hepatitis Cohort Study (CHeCS). Survey data included demographics, depression and physical health measures, substance use history, current social support, recent stressor exposures, and, from the electronic medical record, treatment history, and Charlson Comorbidity Index scores. There were 4,781 respondents, who were a mean of 56.7 years old, 71% White, and 57% male. Altogether, 51.4% reported past injection drug use, 33.9% were current smokers, and 17.7% had abused alcohol in the previous year. Additionally, 47.4% had been previously treated for HCV and 14.8% had a 12-week sustained viral response (SVR) following HCV therapy. Overall, 29.7% of patients met criteria for current depression and 24.6% were in poor physical health. In multivariate analyses, significant predictors of depression and poor health included: male gender (versus female, odds ratios [ORs], 0.70 and 0.81), Black race (versus white, ORs, 0.60 and 0.61), having education less than high school (versus college, ORs, 1.81 and 1.54), being employed (versus not, ORs, 0.36 and 0.25), having high life stressors (versus low, ORs, 2.44 and 1.64), having low social support (versus high, ORs=2.78 and 1.40), and having high Charlson scores (versus none, ORs=1.58 and 2.12). Achieving a 12-week SVR was found to be protective for depression. CONCLUSION This large survey of U.S. HCV patients indicates the extent of adverse health behaviors and mental and physical comorbidities among these patients.
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Affiliation(s)
| | - Mei Lu
- Henry Ford Health System, Detroit, MI
| | - Anne C. Moorman
- Division of Viral Hepatitis National Center for HIV, Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | | | | | - Philip R. Spradling
- Division of Viral Hepatitis National Center for HIV, Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Eyasu H. Teshale
- Division of Viral Hepatitis National Center for HIV, Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | | | | | - Scott D. Holmberg
- Division of Viral Hepatitis National Center for HIV, Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
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Teshale E, Lu M, Rupp LB, Holmberg SD, Moorman AC, Spradling P, Vijayadeva V, Boscarino JA, Schmidt MA, Gordon SC. APRI and FIB-4 are good predictors of the stage of liver fibrosis in chronic hepatitis B: the Chronic Hepatitis Cohort Study (CHeCS). J Viral Hepat 2014; 21:917-20. [PMID: 25131445 DOI: 10.1111/jvh.12279] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2014] [Accepted: 06/01/2014] [Indexed: 02/06/2023]
Abstract
We aim to determine the predictive ability of APRI, FIB-4 and AST/ALT ratio for staging of liver fibrosis and to differentiate significant fibrosis (F2-F4) from none to minimal fibrosis (F0-F1) in chronic hepatitis B (CHB). Liver biopsy results were mapped to an F0-4 equivalent fibrosis stage. Mean APRI and FIB-4 scores were significantly higher for each successive fibrosis level from F1 to F4 (P < 0.05). Based on optimized cut-offs, the AUROCs in distinguishing F2-F4 from F0 to F1 were 0.81 (0.76-0.87) for APRI, 0.81 (0.75-0.86) for FIB-4 and 0.56 (0.49-0.64) for AST/ALT ratio. APRI and FIB-4 distinguished F2-F4 from F0 to F1 with good sensitivity and specificity and can be useful for treatment decisions and monitoring progression of fibrosis.
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Affiliation(s)
- E Teshale
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Lu M, Rupp LB, Moorman AC, Li J, Zhang T, Lamerato LE, Holmberg SD, Spradling PR, Teshale EH, Vijayadeva V, Boscarino JA, Schmidt MA, Nerenz DR, Gordon SC. Comparative effectiveness research of chronic hepatitis B and C cohort study (CHeCS): improving data collection and cohort identification. Dig Dis Sci 2014; 59:3053-61. [PMID: 25030940 PMCID: PMC5719869 DOI: 10.1007/s10620-014-3272-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 06/26/2014] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIMS The Chronic Hepatitis Cohort Study (CHeCS) is a longitudinal observational study of risks and benefits of treatments and care in patients with chronic hepatitis B (HBV) and C (HCV) infection from four US health systems. We hypothesized that comparative effectiveness methods-including a centralized data management system and an adaptive approach for cohort selection-would improve cohort selection while controlling data quality and reducing the cost. METHODS Cohort selection and data collection were performed primarily via the electronic health record (EHR); cases were confirmed via chart abstraction. Two parallel sources fed data to a centralized data management system: direct EHR data collection with common data elements, and chart abstraction via electronic data capture. An adaptive Classification and Regression Tree (CART) identified a set of electronic variables to improve case ascertainment accuracy. RESULTS Over 16 million patient records were collected on 23 case report forms in 2006-2008. The vast majority of data (99.2%) were collected electronically from EHR; only 0.8% was collected via chart abstraction. Initial electronic criteria identified 12,144 chronic hepatitis patients; 10,098 were confirmed via chart abstraction with positive predictive values (PPV) 79 and 83% for HBV and HCV, respectively. CART-optimized models significantly increased PPV to 88 for HBV and 95% for HCV. CONCLUSIONS CHeCS is a comparative effectiveness research project that leverages electronic centralized data collection and adaptive cohort identification approaches to enhance study efficiency. The adaptive CART model significantly improved the positive predictive value of cohort identification methods.
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Affiliation(s)
- Mei Lu
- Departments of Public Health Sciences, Center for Health Services Research, and Gastroenterology, Henry Ford Health System, One Ford Place, 3E, Detroit, MI 48202, USA
| | - Loralee B. Rupp
- Departments of Public Health Sciences, Center for Health Services Research, and Gastroenterology, Henry Ford Health System, One Ford Place, 3E, Detroit, MI 48202, USA
| | - Anne C. Moorman
- Division of Viral Hepatitis National Center for HIV, Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Jia Li
- Departments of Public Health Sciences, Center for Health Services Research, and Gastroenterology, Henry Ford Health System, One Ford Place, 3E, Detroit, MI 48202, USA
| | - Talan Zhang
- Departments of Public Health Sciences, Center for Health Services Research, and Gastroenterology, Henry Ford Health System, One Ford Place, 3E, Detroit, MI 48202, USA
| | - Lois E. Lamerato
- Departments of Public Health Sciences, Center for Health Services Research, and Gastroenterology, Henry Ford Health System, One Ford Place, 3E, Detroit, MI 48202, USA
| | - Scott D. Holmberg
- Division of Viral Hepatitis National Center for HIV, Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Philip R. Spradling
- Division of Viral Hepatitis National Center for HIV, Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Eyasu H. Teshale
- Division of Viral Hepatitis National Center for HIV, Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Vinutha Vijayadeva
- The Center for Health Research, Kaiser Permanente Hawaii, Honolulu, HI, USA
| | | | - Mark A. Schmidt
- The Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
| | - David R. Nerenz
- Departments of Public Health Sciences, Center for Health Services Research, and Gastroenterology, Henry Ford Health System, One Ford Place, 3E, Detroit, MI 48202, USA
| | - Stuart C. Gordon
- Departments of Public Health Sciences, Center for Health Services Research, and Gastroenterology, Henry Ford Health System, One Ford Place, 3E, Detroit, MI 48202, USA
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Li J, Gordon SC, Rupp LB, Zhang T, Boscarino JA, Vijayadeva V, Schmidt MA, Lu M. The validity of serum markers for fibrosis staging in chronic hepatitis B and C. J Viral Hepat 2014; 21:930-7. [PMID: 24472062 DOI: 10.1111/jvh.12224] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Accepted: 10/30/2013] [Indexed: 12/16/2022]
Abstract
Assessment of liver fibrosis is critical for successful individualized disease management in persons with chronic hepatitis B (CHB) or chronic hepatitis C (CHC). We expanded and validated serum marker indices to provide accurate, reproducible and easily applied methods of fibrosis assessment. Liver biopsy results from over 284 CHB and 2304 CHC patients in the Chronic Hepatitis Cohort Study ('CHeCS') were mapped to a F0-F4 equivalent scale. APRI and FIB-4 scores within a 6-month window of biopsy were mapped to the same scale. A novel algorithm was applied to derive and validate optimal cut-offs for differentiating fibrosis levels. For the prediction of advanced fibrosis and cirrhosis, the FIB-4 score outperformed the other serum marker indices in the CHC cohort and was similar to APRI in the CHB cohort. The area under the receiver operating characteristic curves (AUROC) for FIB-4 in differentiating F3-F4 from F0-F2 was 0.86 (95% CI: 0.80-0.92) for CHB and 0.83 (95% CI: 0.81-0.85) for CHC. The suggested cut-offs based on FIB-4 model produced high positive predictive values [CHB: 90.0% for F0-F2, 100.0% for cirrhosis (F4); CHC: 89.7% for F0-F2; 82.9% for cirrhosis (F4)]. In this large observational cohort, FIB-4 predicted the upper and lower end of liver fibrosis stage (cirrhosis and F0-F2, respectively) with a high degree of accuracy in both CHB and CHC patients.
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Affiliation(s)
- J Li
- Henry Ford Health System, Detroit, MI, USA
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Spradling PR, Tong X, Rupp LB, Moorman AC, Lu M, Teshale EH, Gordon SC, Vijayadeva V, Boscarino JA, Schmidt MA, Holmberg SD. Trends in HCV RNA testing among HCV antibody-positive persons in care, 2003-2010. Clin Infect Dis 2014; 59:976-81. [PMID: 24991025 PMCID: PMC6463879 DOI: 10.1093/cid/ciu509] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND A test for hepatitis C virus (HCV) RNA is essential to identify persons with active, or current, HCV infection. We assessed trends in HCV RNA testing following a positive HCV antibody result among persons in 4 large healthcare organizations. METHODS Data collected from adults with ≥2 clinical encounters during 2003-2010 were analyzed to determine the frequency of, interval between, and factors associated with having an RNA test after a first positive HCV antibody test. RESULTS From 2003-2010, 5860 persons had a positive antibody test, of whom 3570 (60.9%) had a follow-up RNA test. During this period, the annual frequency of persons with an eventual RNA test did not change significantly; however, the fraction of persons who had the follow-up RNA test within 6 months improved significantly, from 45% in 2003 to 57% in 2010 (P < .001, for trend). Persons born during 1945-1965, men, and those with annual income <$30 000 (by census geocode) were less likely to have had a follow-up RNA test done within 6 months of a positive antibody test. CONCLUSIONS Less than two-thirds of persons with a positive HCV antibody test had a follow-up RNA test. Rapid ascertainment of HCV infection status with reflex testing to RNA is critical to identify persons eligible for treatment.
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Affiliation(s)
- Philip R. Spradling
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Xin Tong
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Anne C. Moorman
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Mei Lu
- Henry Ford Health System, Detroit, Michigan
| | - Eyasu H. Teshale
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | | | | | | | - Scott D. Holmberg
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia
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Gerbi GB, Rupp LB, Ko SC, Moorman AC, Holmberg SD, Xu F. Reported reasons for testing among hepatitis B virus-infected patients - Chronic Hepatitis Cohort Study (CHeCS), United States, 2006-2010. Liver Int 2014; 34:e162-3. [PMID: 24589333 DOI: 10.1111/liv.12509] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Accepted: 02/19/2014] [Indexed: 02/13/2023]
Affiliation(s)
- Gemechu B Gerbi
- Centers for Disease Control and Prevention, 1600 Clifton Rd, Mailstop G-37, Atlanta, GA, 30333, USA
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Vijayadeva V, Spradling PR, Moorman AC, Rupp LB, Lu M, Gordon SC, Henkle E, Boscarino JA, Teshale EH, Nakasato C. Hepatitis B virus infection testing and prevalence among Asian and Pacific Islanders. Am J Manag Care 2014; 20:e98-e104. [PMID: 24884958 PMCID: PMC6542464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVES Asian and Pacific Islanders (APIs) constitute less than 6% of the US population, but account for more than half of Americans with chronic hepatitis B virus (HBV) infection. We sought to examine the effect of country of origin on HBV testing and chronic HBV infection prevalence among APIs. METHODS We analyzed demographic and clinical data collected for adults from Kaiser Permanente Hawaii with 1 or more healthcare encounters during 2006 to 2008, 12 months or more of follow-up before 2009, and no HBV-related diagnosis within 6 months of enrollment. Persons who received a test and a positive test result for HBV surface antigen or HBV DNA were classified "tested" and with "chronic HBV infection," respectively. RESULTS Of 92,687 eligible APIs, 53,573 (58%) had country-of-origin data available. Among those, 41,263 were US born; 28.3% were tested; and 1.8% of those tested had chronic HBV infection. Of 12,310 foreign-born APIs, 30.5% were tested and 7.4% of those tested had chronic HBV infection. Foreignborn APIs had higher odds of being tested (odds ratio [OR] = 1.15) and testing positive (OR = 4.18) compared with US-born APIs. Persons with 2 or more abnormal tests for alanine aminotransferase (ALT) levels had higher odds of getting tested (OR = 6.12) and of testing positive (OR = 1.86) compared with persons with other ALT levels. CONCLUSIONS Less than one-third of this managed care API population (29% of 53,573) was tested, yet the prevalence of chronic HBV infection (3.2%) was 12 times higher than that of the general US population. These findings underscore the importance of adherence to HBV testing guidelines to identify persons with infection so they may be linked to care.
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Affiliation(s)
- Vinutha Vijayadeva
- Kaiser Permanente Center for Health Research Hawaii, 501 Alakawa St, Ste 201, Honolulu, HI 96817. E-mail:
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Boscarino JA, Sitarik A, Gordon SC, Rupp LB, Nerenz DR, Vijayadeva V, Schmidt MA, Henkle E, Lu M. Risk Factors for Hepatitis C Infection Among Vietnam Era Veterans Versus Nonveterans: Results from the Chronic Hepatitis Cohort Study (CHeCS). J Community Health 2014; 39:914-21. [DOI: 10.1007/s10900-014-9863-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Holmberg SD, Lu M, Rupp LB, Lamerato LE, Moorman AC, Vijayadeva V, Boscarino JA, Henkle EM, Gordon SC. Noninvasive serum fibrosis markers for screening and staging chronic hepatitis C virus patients in a large US cohort. Clin Infect Dis 2013; 57:240-6. [PMID: 23592832 DOI: 10.1093/cid/cit245] [Citation(s) in RCA: 106] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Liver biopsy remains critical for staging liver disease in hepatitis C virus (HCV)-infected persons, but is a bottleneck to evaluation, follow-up, and treatment of HCV. Our analysis sought to validate APRI (aspartate aminotransferase [AST]-to-platelet ratio index) and FIB-4, an index from serum fibrosis markers (alanine aminotransferase [ALT], AST, and platelets plus patient age) to stage liver disease. METHODS Biopsy results from HCV patients in the Chronic Hepatitis Cohort Study were mapped to an F0-F4 equivalent scale; APRI and FIB-4 scores at the time of biopsy were then mapped to the same scale. RESULTS We identified 2372 liver biopsies from HCV-infected patients with contemporaneous laboratory values for imputing APRI and FIB-4. Fibrosis stage distributions by the equivalent biopsy scale were 267 (11%) F0; 555 (23%) F1; 648 (27%) F2; 394 (17%) F3; and 508 (21%) F4. Mean APRI and FIB-4 values significantly increased with successive fibrosis levels (P < .05). The areas under the receiver operating characteristic curve (AUROC) analysis distinguishing severe (F3-F4) from mild-to-moderate fibrosis (F0-F2) were 0.80 (95% confidence interval [CI], .78-.82) for APRI and 0.83 (95% CI, .81-.85) for FIB-4. There was a significant difference between the AUROCs of FIB-4 and APRI (P < .001); 88% of persons who had a FIB-4 score ≥2.0 were at stage F2 or higher. CONCLUSIONS In a large observational cohort, FIB-4 was good at differentiating 5 stages of chronic HCV infection. It can be useful in screening patients who need biopsy and therapy, for monitoring patients with less advanced disease, and for longitudinal studies.
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Affiliation(s)
- Scott D Holmberg
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA.
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