Currently Viewing:
The American Journal of Managed Care May 2018
Impact of Emergency Physician–Provided Patient Education About Alternative Care Venues
Pankaj B. Patel, MD; David R. Vinson, MD; Marla N. Gardner, BA; David A. Wulf, BS; Patricia Kipnis, PhD; Vincent Liu, MD, MS; and Gabriel J. Escobar, MD
Currently Reading
Monitoring the Hepatitis C Care Cascade Using Administrative Claims Data
Cheryl Isenhour, DVM, MPH; Susan Hariri, PhD; and Claudia Vellozzi, MD, MPH
Impact of Formulary Restrictions on Medication Intensification in Diabetes Treatment
Bruce C. Stuart, PhD; Julia F. Slejko, PhD; Juan-David Rueda, MD; Catherine E. Cooke, PharmD; Xian Shen, PhD; Pamela Roberto, PhD; Michael Ciarametaro, MBA; and Robert Dubois, MD
Characteristics and Medication Use of Veterans in Medicare Advantage Plans
Talar W. Markossian, PhD, MPH; Katie J. Suda, PharmD, MS; Lauren Abderhalden, MS; Zhiping Huo, MS; Bridget M. Smith, PhD; and Kevin T. Stroupe, PhD
Rural Hospital Transitional Care Program Reduces Medicare Spending
Keith Kranker, PhD; Linda M. Barterian, MPP; Rumin Sarwar, MS; G. Greg Peterson, PhD; Boyd Gilman, PhD; Laura Blue, PhD; Kate Allison Stewart, PhD; Sheila D. Hoag, MA; Timothy J. Day, MSHP; and Lorenzo Moreno, PhD
Understanding Factors Associated With Readmission Disparities Among Delta Region, Delta State, and Other Hospitals
Hsueh-Fen Chen, PhD; Adrienne Nevola, MPH; Tommy M. Bird, PhD; Saleema A. Karim, PhD; Michael E. Morris, PhD; Fei Wan, PhD; and J. Mick Tilford, PhD
Changes in Specialty Care Use and Leakage in Medicare Accountable Care Organizations
Michael L. Barnett, MD, MS, and J. Michael McWilliams, MD, PhD
Increasing Hepatitis C Screening in a Large Integrated Health System: Science and Policy in Concert
Carla V. Rodriguez, PhD; Kevin B. Rubenstein, MS; Benjamin Linas, MD; Haihong Hu, MS; and Michael Horberg, MD
Nevada's Medicaid Expansion and Admissions for Ambulatory Care–Sensitive Conditions
Olena Mazurenko, MD, PhD; Jay Shen, PhD; Guogen Shan, PhD; and Joseph Greenway, MPH
Introduction of Cost Display Reduces Laboratory Test Utilization
Kim Ekblom, MD, PhD, and Annika Petersson, MSc, PhD

Monitoring the Hepatitis C Care Cascade Using Administrative Claims Data

Cheryl Isenhour, DVM, MPH; Susan Hariri, PhD; and Claudia Vellozzi, MD, MPH
Development, validation, and application of hepatitis C case-finding algorithms to describe the care cascade among a commercially insured population in the United States.

Algorithm Validation

We identified 6983 eligible enrollees in the laboratory test results dataset with at least 1 HCV RNA test result between January 1, 2011, and June 30, 2014; 3037 (43%) were HCV RNA–positive. Algorithm 9, an HCV RNA test followed by 3 or more chronic HCV ICD-9-CM diagnosis codes on different service dates, yielded a PPV of 90%. Algorithms 7 and 8, an HCV RNA CPT code followed by 2 or more chronic HCV ICD-9-CM codes separated by more than 60 days, and an HCV RNA CPT code followed by 2 or more chronic HCV ICD-9-CM codes separated by more than 90 days, respectively, each yielded a PPV of 89% (Table 1). We elected to apply algorithms 7 and 9 to the full claims database to maximize the number of cases identified.

HCV Care Cascade

From January 1, 2013, through June 30, 2014, we identified 88,509 unique enrollees with an HCV RNA test who met our study criteria. Of these, 5791 enrollees with chronic HCV were identified by 1 or both of the algorithms (Table 3). Half (51%; n = 2981) of this population was aged 50 to 59 years, with 4816 (83%) included in the birth cohort and 55% enrolled in preferred provider organization plans. Males made up 64% of the population, which was also geographically diverse.

Engagement in HCV-specific care. Among the 5791 enrollees with HCV, 5360 met at least 1 definition of engagement in HCV-specific care (Figure 2). We also included 145 enrollees who were prescribed HCV treatment but did not meet any of our 13 definitions of engagement as engaged in HCV-specific care. These individuals were likely to have been evaluated prior to receiving HCV treatment, but their evaluation events were not captured in these claims data. Therefore, 5505 enrollees within our cohort of chronic HCV cases (95%) were engaged in HCV-specific care following HCV RNA testing. The most common definitions for engagement in care were through the identification of a gastrointestinal or infectious disease specialist provider type (77%), abdominal ultrasound (44%), hepatic function panel (36%), and genotyping (30%) (Table 2).

Initiation of HCV treatment and follow-up RNA testing. Of those enrollees identified as having chronic HCV, 2843 (49%) had a claim for HCV treatment, with 2633 of those patients (93%) receiving a DAA medication as part of their treatment regimen. Among those prescribed DAAs, 75% received sofosbuvir, 10% received sofosbuvir and ledipasvir, 11% received telaprevir, 4% received boceprevir, and 1 enrollee received ombitasvir, paritaprevir, and ritonavir (data not shown). Among those who initiated HCV treatment, 2475 (87%) had at least 1 follow-up HCV RNA test 30 or more days after their first HCV treatment claim. Among those prescribed DAAs, 1489 (57%) had at least 1 HCV RNA test 20 or more weeks after initiating treatment (data not shown).


This is the first study to validate algorithms for identifying individuals living with HCV that utilized a large insurance claims database and HCV RNA laboratory test results linked to claims. Two of the 9 algorithms we tested had high PPVs, 90% and 89%, respectively, for detecting cases of HCV. The ability to correctly identify individuals with current HCV infection in administrative data is an important first step toward understanding the quality of clinical management and treatment and supporting strategic changes for quality improvement. Among those identified by the algorithms, we found that 95% of enrollees with chronic HCV were engaged in HCV-specific care and 49% initiated HCV treatment. Although the relatively high proportion engaged in HCV-specific care is encouraging, our findings highlight that even individuals with commercial insurance coverage may find it challenging to access HCV treatment.37-39 Increased access can be demonstrated over time through monitoring the cascade at a national level using large administrative databases, including Medicare and Medicaid.

Algorithm Validation

Administrative healthcare data have been used to develop algorithms for identifying persons diagnosed with HCV among patients with cirrhosis.30,31 Kramer et al and Niu et al found that identifying 1 to 3 HCV ICD-9-CM codes of any type resulted in PPVs as high as 93% and 97%, respectively, among HCV-infected enrollees with cirrhosis compared with electronic health record data. We did not limit our analysis to enrollees diagnosed with cirrhosis, and we observed an improvement in PPV when we tested algorithms including only codes for chronic HCV (070.44 or 070.54). Although the sole use of these 2 codes resulted in reduced sensitivity, our aim was to identify the algorithms with the highest PPVs so that we could increase the probability of identifying true cases for describing the chronic HCV care cascade.

HCV Care Cascade

Engagement in HCV-specific care. Insurance claims data provide an opportunity to identify several laboratory tests, diagnostic procedures, or specialty provider visits that can be used to demonstrate that enrollees are engaged in HCV-specific care. We elected to use 13 definitions in an attempt to identify as many engaged enrollees as possible. Other investigators have defined engagement in different ways, such as referral for HCV care,18,20,22 1 or more visits with a healthcare provider or specialist,12,13,16,21,23-25,27 and a certain number of HCV tests within a specified time period.23,26

Although 95% of enrollees with chronic HCV were engaged in HCV-specific care in our study, the observed or estimated proportion of engaged study participants varies widely among other published cascades, from as low as 6% up to 89%,21,23 demonstrating potential effects of variation in study setting, population, and methodology on observed estimations of engagement. In addition, we found that 77% of enrollees with chronic HCV were engaged in HCV-specific care through a visit with either a gastrointestinal or infectious disease specialist. Among previously published cascades, the highest reported proportion of enrollees positive for HCV attending a specialty visit for HCV care was 52%.15 The relatively higher proportion we observed may reflect better access to, and retention in, care among a commercially insured population.

HCV genotype testing is recommended for all individuals chronically infected with HCV to guide providers in selecting the most appropriate treatment regimen.40 We found that just 30% of enrollees with HCV received a genotype test after their HCV RNA CPT index date. However, we used this metric to define engagement in care after diagnosis of HCV infection, and genotype tests are often done on the same date as the HCV RNA test; therefore, 30% is a minimum estimate of the true proportion that were ever genotype-tested. That proportion has been reported to be as low as 6.1% and as high as 75.4% in previously published cascades.14,16

Initiation of HCV treatment and follow-up RNA testing. Just less than half of the enrollees in the cascade study group initiated HCV treatment by the end of the study period. As we only required a minimum of 6 months of continuous enrollment following the HCV RNA CPT index date, we may not have captured all treatment events for enrollees in this population who had less observation time. However, our minimum estimate is higher than values reported in other published cascades, which range from 3% to 46%.12,13,15,16,18-27 This may reflect the advantage of studying a commercially insured population in care in the era of DAA treatment regimens.

Our finding that 75% of those who initiated HCV treatment were prescribed sofosbuvir is not unexpected considering the timing of our study period and the FDA approval of sofosbuvir in December 2013. Additionally, although we do not have laboratory results to determine who among our care cascade study group ultimately achieved virologic cure, we did determine that 87% of treated enrollees continued to be engaged in care through follow-up RNA testing 30 or more days after initiating treatment.

Copyright AJMC 2006-2019 Clinical Care Targeted Communications Group, LLC. All Rights Reserved.
Welcome the the new and improved, the premier managed market network. Tell us about yourself so that we can serve you better.
Sign Up