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Monitoring the Hepatitis C Care Cascade Using Administrative Claims Data
Cheryl Isenhour, DVM, MPH; Susan Hariri, PhD; and Claudia Vellozzi, MD, MPH
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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.

Our study is subject to certain limitations. First, these analyses were conducted among a subset of commercially insured enrollees and are not generalizable to all HCV-infected individuals in the United States. Second, it is possible that enrollees included in the validation study were misclassified by HCV RNA test result if enrollees we classified as always negative had a positive test result prior to January 1, 2011. Third, because we selected algorithms based on PPV to maximize accuracy, our algorithms may not be suitable for other evaluations, such as estimating HCV prevalence.

Finally, we were not able to describe the care cascade for HCV-infected enrollees in MarketScan who were not identified by the algorithms. However, among 1098 enrollees testing positive for HCV RNA identified in the MarketScan laboratory test results subset, during the same time period, we found that 79% were engaged in HCV-specific care and just 30% initiated treatment (data not shown). It is not surprising that fewer enrollees in the RNA-positive subset were engaged and subsequently treated, as our algorithms selected individuals based on chronic HCV diagnosis codes documented at healthcare encounters; individuals not having chronic HCV-related encounters will not be selected. It is possible that we have selected enrollees who were already exhibiting signs of advanced liver disease and prioritized for treatment. Additional analyses are under way to further examine the differences between the cascades developed using the validated algorithms and the subset of enrollees with laboratory test results.


We have successfully validated 2 algorithms to identify cases of chronic HCV in claims data and described the HCV care cascade among those identified by the algorithms. In addition to utilizing these algorithms to identify cases of HCV in other sources of claims data, analyses are under way to identify predictors of progression along the cascade. Although 95% of enrollees chronically infected with HCV were engaged in HCV care and 49% initiated HCV treatment, our findings indicate that commercially insured enrollees in care may still find it challenging to access HCV treatment. Additionally, a previous analysis of trends in HCV antibody testing among MarketScan enrollees demonstrated that just 3% of individuals born from 1945 to 1965 and 2% of persons born in other years received an antibody test in 2014,28 highlighting a clear need for improved uptake of national testing recommendations.6 It will be important to continue to monitor the HCV care cascade over time to ensure that all individuals living with HCV receive recommended care and treatment. 


The authors would like to acknowledge the contributions of Lauren Canary, Liesl Hagan, Dr Aaron Harris, and Dr Alexander Millman, who assisted with the creation of an inclusive list of ways insured enrollees could be engaged in HCV-specific care.

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the CDC.

Author Affiliations: Partnerships and Evaluation Branch, Division of Health Informatics and Surveillance (CI), and Meningitis and Vaccine Preventable Diseases Branch, Division of Bacterial Diseases (SH), and Prevention Branch, Division of Viral Hepatitis (CV), CDC, Atlanta, GA.

Source of Funding: None.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (CI, SH, CV); analysis and interpretation of data (CI, SH, CV); drafting of the manuscript (CI, CV); critical revision of the manuscript for important intellectual content (CI, SH, CV); statistical analysis (CI); and supervision (SH, CV).

Address Correspondence to: Cheryl Isenhour, DVM, MPH, Mailstop E-91, Division of Health Informatics and Surveillance, CDC, 1600 Clifton Rd, Atlanta, GA 30329. Email:

1. Edlin BR, Eckhardt BJ, Shu MA, Holmberg SD, Swan T. Toward a more accurate estimate of the prevalence of hepatitis C in the United States. Hepatology. 2015;62(5):1353-1363. doi: 10.1002/hep.27978.

2. Denniston MM, Klevens RM, McQuillan GM, Jiles RB. Awareness of infection, knowledge of hepatitis C, and medical follow-up among individuals testing positive for hepatitis C: National Health and Nutrition Examination Survey 2001-2008. Hepatology. 2012;55(6):1652-1661. doi: 10.1002/hep.25556.

3. Kuniholm MH, Jung M, Del Amo J, et al. Awareness of hepatitis C virus seropositivity and chronic infection in the Hispanic Community Health Study/Study of Latinos (HCHS/SOL). J Immigr Minor Health. 2016;18(6):1257-1265. doi: 10.1007/s10903-016-0350-1.

4. Denniston MM, Jiles RB, Drobeniuc J, et al. Chronic hepatitis C virus infection in the United States, National Health and Nutrition Examination Survey 2003 to 2010. Ann Intern Med. 2014;160(5):293-300. doi: 10.7326/M13-1133.

5. Surveillance for viral hepatitis – United States, 2014: hepatitis C. CDC website. Updated June 22, 2016. Accessed November 9, 2016.

6. Smith BD, Morgan RL, Beckett GA, et al; CDC. Recommendations for the identification of chronic hepatitis C virus infection among persons born during 1945-1965. MMWR Recomm Rep. 2012;61(RR-4):1-32.

7. Kanwal F, Hoang T, Kramer JR, et al. Increasing prevalence of HCC and cirrhosis in patients with chronic hepatitis C virus infection. Gastroenterology. 2011;140(4):1182-1188.e1. doi: 10.1053/j.gastro.2010.12.032.

8. El-Serag HB, Kanwal F. Epidemiology of hepatocellular carcinoma in the United States: where are we? where do we go? Hepatology. 2014;60(5):1767-1775. doi: 10.1002/hep.27222.

9. Ly KN, Hughes EM, Jiles RB, Holmberg SD. Rising mortality associated with hepatitis C virus in the United States, 2003-2013. Clin Infect Dis. 2016;62(10):1287-1288. doi: 10.1093/cid/ciw111.

10. Smith-Palmer J, Cerri K, Valentine W. Achieving sustained virologic response in hepatitis C: a systematic review of the clinical, economic and quality of life benefits. BMC Infect Dis. 2015;15:19. doi: 10.1186/s12879-015-0748-8.

11. Walker DR, Pedrosa MC, Manthena SR, Patel N, Marx SE. Early view of the effectiveness of new direct-acting antiviral (DAA) regimens in patients with hepatitis C virus (HCV). Adv Ther. 2015;32(11):1117-1127. doi: 10.1007/s12325-015-0258-5.

12. Cachay ER, Hill L, Wyles D, et al. The hepatitis C cascade of care among HIV infected patients: a call to address ongoing barriers to care. PLoS One. 2014;9(7):e102883. doi: 10.1371/journal.pone.0102883.

13. Hawks L, Norton BL, Cunningham CO, Fox AD. The hepatitis C virus treatment cascade at an urban postincarceration transitions clinic. J Viral Hepat. 2016;23(6):473-478. doi: 10.1111/jvh.12512.

14. Jonas MC, Rodriguez CV, Redd J, Sloane DA, Winston BJ, Loftus BC. Streamlining screening to treatment: the hepatitis C cascade of care at Kaiser Permanente Mid-Atlantic States. Clin Infect Dis. 2016;62(10):1290-1296. doi: 10.1093/cid/ciw086.

15. Linas BP, Barter DM, Leff JA, et al. The hepatitis C cascade of care: identifying priorities to improve clinical outcomes. PLoS One. 2014;9(5):e97317. doi: 10.1371/journal.pone.0097317.

16. Maier MM, Ross DB, Chartier M, Belperio PS, Backus LI. Cascade of care for hepatitis C virus infection within the US Veterans Health Administration. Am J Public Health. 2016;106(2):353-358. doi: 10.2105/AJPH.2015.302927.

17. Meyer JP, Moghimi Y, Marcus R, Lim JK, Litwin AH, Altice FL. Evidence-based interventions to enhance assessment, treatment, and adherence in the chronic hepatitis C care continuum. Int J Drug Policy. 2015;26(10):922-935. doi: 10.1016/j.drugpo.2015.05.002.

18. Norton BL, Southern WN, Steinman M, et al. No differences in achieving hepatitis C virus care milestones between patients identified by birth cohort or risk-based screening. Clin Gastroenterol Hepatol. 2016;14(9):1356-1360. doi: 10.1016/j.cgh.2016.04.017.

19. Yehia BR, Schranz AJ, Umscheid CA, Lo Re V 3rd. The treatment cascade for chronic hepatitis C virus infection in the United States: a systematic review and meta-analysis. PLoS One. 2014;9(7):e101554. doi: 10.1371/journal.pone.0101554.

20. Holmberg SD, Spradling PR, Moorman AC, Denniston MM. Hepatitis C in the United States. N Engl J Med. 2013;368(20):1859-1861. doi: 10.1056/NEJMp1302973.

21. Falade-Nwulia O, Mehta SH, Lasola J, et al. Public health clinic-based hepatitis C testing and linkage to care in Baltimore. J Viral Hepat. 2016;23(5):366-374. doi: 10.1111/jvh.12507.

22. Trooskin SB, Poceta J, Towey CM, et al. Results from a geographically focused, community-based HCV screening, linkage-to-care and patient navigation program. J Gen Intern Med. 2015;30(7):950-957. doi: 10.1007/s11606-015-3209-6.

23. Viner K, Kuncio D, Newbern EC, Johnson CC. The continuum of hepatitis C testing and care. Hepatology. 2015;61(3):783-789. doi: 10.1002/hep.27584.

24. Anderson ES, Galbraith JW, Deering LJ, et al. Continuum of care for HCV among patients diagnosed in the emergency department setting. Clin Infect Dis. 2017;64(11):1540-1546. doi: 10.1093/cid/cix163.

25. Ford MM, Jordan AE, Johnson N, et al. Check Hep C: a community-based approach to hepatitis C diagnosis and linkage to care in high-risk populations. J Public Health Manag Pract. 2018;24(1):41-48. doi: 10.1097/PHH.0000000000000519.

26. Noska AJ, Belperio PS, Loomis TP, O’Toole TP, Backus LI. Engagement in the hepatitis C care cascade among homeless veterans, 2015. Public Health Rep. 2017;132(2):136-139. doi: 10.1177/0033354916689610.

27. Norton BL, Beitin A, Glenn M, DeLuca J, Litwin AH, Cunningham CO. Retention in buprenorphine treatment is associated with improved HCV care outcomes. J Subst Abuse Treat. 2017;75:38-42. doi: 10.1016/j.jsat.2017.01.015.

28. Isenhour CJ, Hariri SH, Hales CM, Vellozzi CJ. Hepatitis C antibody testing in a commercially insured population, 2005-2014. Am J Prev Med. 2017;52(5):625-631. doi: 10.1016/j.amepre.2016.12.016.

29. O’Malley KJ, Cook KF, Price MD, Wildes KR, Hurdle JF, Ashton CM. Measuring diagnoses: ICD code accuracy. Health Serv Res. 2005;40(5 pt 2):1620-1639. doi: 10.1111/j.1475-6773.2005.00444.x.

30. Kramer JR, Davila JA, Miller ED, Richardson P, Giordano TP, El-Serag HB. The validity of viral hepatitis and chronic liver disease diagnoses in Veterans Affairs administrative databases. Aliment Pharmacol Ther. 2008;27(3):274-282. doi: 10.1111/j.1365-2036.2007.03572.x.

31. Niu B, Forde KA, Goldberg DS. Coding algorithms for identifying patients with cirrhosis and hepatitis B or C virus using administrative data. Pharmacoepidemiol Drug Saf. 2015;24(1):107-111. doi: 10.1002/pds.3721.

32. MarketScan. Truven Health website. Accessed October 11, 2016.

33. LOINC website. Accessed February 1, 2016.

34. Wiesmann F, Naeth G, Sarrazin C, et al. Variation analysis of six HCV viral load assays using low viremic HCV samples in the range of the clinical decision points for HCV protease inhibitors. Med Microbiol Immunol. 2015;204(4):515-525. doi: 10.1007/s00430-014-0364-z.

35. National drug code directory. FDA website. Accessed April 26, 2016.

36. Monitoring patients who are starting HCV treatment, are on treatment, or have completed therapy. website. Updated September 21, 2017. Accessed August 1, 2016.

37. King A, Bornschlegel K, Johnson N, Rude E, Laraque F. Barriers to treatment among New York City residents with chronic hepatitis C virus infection, 2014. Public Health Rep. 2016;131(3):430-437. doi: 10.1177/003335491613100309.

38. Edlin BR. Access to treatment for hepatitis C virus infection: time to put patients first. Lancet Infect Dis. 2016;16(9):e196-e201. doi: 10.1016/S1473-3099(16)30005-6.

39. Saab S, Jimenez M, Fong T, et al. Accessibility to oral antiviral therapy for patients with chronic hepatitis C in the United States. J Clin Transl Hepatol. 2016;4(2):76-82. doi: 10.14218/JCTH.2016.00011.

40. Initial treatment of HCV infection. website. Updated September 21, 2017. Accessed November 10, 2016.
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