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The American Journal of Managed Care September 2018
The American Journal of Managed Care September 2018
CLINICAL
Seth A. Berkowitz, MD, MPH; Hilary K. Seligman, MD, MAS; James B. Meigs, MD, MPH; and Sanjay Basu, MD, PhD
Alicia Fernandez, MD; E. Margaret Warton, MPH; Dean Schillinger, MD; Howard H. Moffet, MPH; Jenna Kruger, MPH; Nancy Adler, PhD; and Andrew J. Karter, PhD
Currently Reading
Hepatitis C Care Cascade Among Persons Born 1945-1965: 3 Medical Centers
Joanne E. Brady, PhD; Claudia Vellozzi, MD, MPH; Susan Hariri, PhD; Danielle L. Kruger, BA; David R. Nerenz, PhD; Kimberly Ann Brown, MD; Alex D. Federman, MD, MPH; Katherine Krauskopf, MD, MPH; Natalie Kil, MPH; Omar I. Massoud, MD; Jenni M. Wise, RN, MSN; Toni Ann Seay, MPH, MA; Bryce D. Smith, PhD; Anthony K. Yartel, MPH; and David B. Rein, PhD
COMMENTARY
Dhruv Khullar, MD, MPP, and Rainu Kaushal, MD, MPH
From The Editorial Board
A. Mark Fendrick, MD
TRENDS FROM THE FIELD
Anil N.F. Aranha, PhD, and Pragnesh J. Patel, MD
WEB EXCLUSIVE
Lisa I. Iezzoni, MD, MSc; Amy J. Wint, MSc; W. Scott Cluett III; Toyin Ajayi, MD, MPhil; Matthew Goudreau, BS; Bonnie B. Blanchfield, CPA, SM, ScD; Joseph Palmisano, MA, MPH; and Yorghos Tripodis, PhD
JaeJin An, BPharm, PhD, and Adrian Lau, PharmD
Lisa M. Kern, MD, MPH; Joanna K. Seirup, MPH; Mangala Rajan, MBA; Rachel Jawahar, PhD, MPH; and Susan S. Stuard, MBA
Reyan Ghany, MD; Leonardo Tamariz, MD, MPH; Gordon Chen, MD; Elissa Dawkins, MS; Alina Ghany, MD; Emancia Forbes, RDCS; Thiago Tajiri, MBA; and Ana Palacio, MD, MPH
Melony E. Sorbero, PhD, MS, MPH; Susan M. Paddock, PhD; Cheryl L. Damberg, PhD; Ann Haas, MS, MPH; Mallika Kommareddi, MPH; Anagha Tolpadi, MS; Megan Mathews, MA; and Marc N. Elliott, PhD
Hepatitis C Care Cascade Among Persons Born 1945-1965: 3 Medical Centers
Joanne E. Brady, PhD; Claudia Vellozzi, MD, MPH; Susan Hariri, PhD; Danielle L. Kruger, BA; David R. Nerenz, PhD; Kimberly Ann Brown, MD; Alex D. Federman, MD, MPH; Katherine Krauskopf, MD, MPH; Natalie Kil, MPH; Omar I. Massoud, MD; Jenni M. Wise, RN, MSN; Toni Ann Seay, MPH, MA; Bryce D. Smith, PhD; Anthony K. Yartel, MPH; and David B. Rein, PhD
In this analysis of patients with newly diagnosed hepatitis C, linkage to care was largely successful in the 1945-1965 birth cohort, but treatment initiation remained low.
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ABSTRACT
Objectives: Effective screening, diagnosis, and treatment are needed to reduce chronic hepatitis C virus (HCV) infection–associated morbidity and mortality. In order to successfully increase HCV treatment, it is necessary to identify and understand gaps in linkage of antibody-positive patients with newly identified HCV to subsequent HCV RNA testing, clinical evaluation, and treatment.
Study Design: To estimate attainment of HCV care cascade steps among antibody-positive patients with newly identified HCV, we conducted chart reviews of patients with a new positive HCV antibody test at 3 academic medical centers participating in the Birth-Cohort Evaluation to Advance Screening and Testing of Hepatitis C (BEST-C) study.
Methods: We tracked receipt of RNA testing, clinical evaluation, treatment initiation, and treatment completion among individuals born between 1945 and 1965 who were newly diagnosed as HCV antibody–positive between December 2012 and October 2015 at 3 BEST-C centers, predominantly from the participating medical centers’ primary care practices and emergency departments.
Results: Of the 130 HCV-seropositive individuals identified, 118 (91%) had an RNA or genotype test, 75 (58%) were RNA-positive, 73 (56%) were linked to care, 22 (17% overall; 29% among RNA-positive) started treatment, and 21 (16%; 28% among RNA-positive) completed treatment.
Conclusions: This analysis showed that although linkage to care was largely successful in the target birth cohort, the largest gap in the HCV care cascade was seen in initiating treatment. Greater emphasis on linking patients to clinical evaluation and treatment is necessary in order to achieve the public health benefits promised by birth-cohort testing.
Am J Manag Care. 2018;24(9):421-427Takeaway Points
In this analysis of patients with newly diagnosed hepatitis C between December 2012 and October 2015, linkage to care was largely successful in the 1945-1965 birth cohort, but treatment initiation remained low.
Studying attainment of "care cascade" steps among patients identified at BEST-C medical centers is instructive in understanding the possible impact of future HCV testing interventions, especially in managed care settings. These settings have a long history of proactive health promotion activities, such as patient education and care coordination, that may be effective in addressing gaps in care experienced by patients with newly diagnosed HCV.
In this paper, we used electronic health records (EHRs) to examine HCV care and treatment among antibody-positive patients identified at BEST-C study centers during the study period.
METHODS
Study Population
Patients included in this analysis were those who tested HCV antibody–positive during the BEST-C study period (December 2012-October 2015) at any of the 3 participating healthcare systems (“centers”) as an enrolled participant of the BEST-C study or as an unenrolled patient who was identified during the same study period. All evaluated patients were born between 1945 and 1965 and had no previous record of being tested for HCV in the EHR.5,6,14 Information about BEST-C has previously been described.5,14 This study received institutional review board approval from the University of Alabama, Henry Ford Health System, Mount Sinai Hospital, and NORC at the University of Chicago.
Measures
We defined the care cascade as consisting of the following 7 consecutive steps: (1) a positive HCV antibody test; (2) a confirmatory test, defined as a qualitative or quantitative RNA or HCV genotype test; (3) receipt of a positive RNA result or genotype; (4) clinical evaluation (either concurrently with receipt of confirmatory RNA test result or at a subsequent encounter), defined as a visit with a specialty provider (hepatologist, gastroenterologist, or infectious disease specialist) or other HCV treatment provider (primary care provider trained to treat HCV); (5) initiation of antiviral therapy as indicated in the EHR; (6) treatment completion as indicated in the EHR by a provider; and (7) EOT virologic response, defined as an undetectable viral load at treatment completion (within 2 weeks of the end of intended course of treatment). Only 1 patient received a liver biopsy. Sustained viral load 12 weeks following EOT was not available at the end of the study; we therefore do not report on this step or the final outcome of the cascade.
Data Collection and Analysis
Using a standardized abstraction form, center coordinators collected data from the EHR of each patient from the date of his or her first positive HCV antibody test from December 1, 2012, through October 31, 2015. Coordinators identified relevant laboratory orders, encounters, and pharmacy records associated with each step of the HCV care cascade and sent deidentified person-level data to the coordinating center (NORC at the University of Chicago). Because of small sample sizes, the care cascade steps were not stratified by center. Data were analyzed using Microsoft Excel 2013 and SAS version 9.4 (SAS Institute, Inc; Cary, North Carolina).
We calculated the proportion of persons who progressed along the HCV care cascade as the number of individuals who completed each step (numerator) divided by the number of individuals with a positive HCV antibody test (denominator). We also calculated the proportion of individuals completing each step (numerator) divided by the number of individuals completing the previous step. Due to problems extracting pharmacy information from their EHR systems, 1 center did not report treatment of any patients. Therefore, we also calculated the care cascade and the percent of patients initiating treatment using data from the 2 centers with accessible treatment records (“treating centers”).
We estimated patients’ liver disease stage at initial evaluation using their first recorded AST (aspartate aminotransferase) to Platelet Ratio Index (APRI) scores. Disease stage was categorized using the following values: 0.0 to 0.54, 0.55 to less than 1.0, 1.0 to less than 2.0, and 2.0 or greater (ranging from no liver disease at 0.0 to advanced fibrosis/cirrhosis).15 Using χ2 tests and Fisher’s exact tests and data from the 2 treating centers, we compared differences in treatment initiation by sex, race, birth year, insurance type, APRI score categories, and HCV genotype. A P value ≤.05 was considered statistically significant.
Objectives: Effective screening, diagnosis, and treatment are needed to reduce chronic hepatitis C virus (HCV) infection–associated morbidity and mortality. In order to successfully increase HCV treatment, it is necessary to identify and understand gaps in linkage of antibody-positive patients with newly identified HCV to subsequent HCV RNA testing, clinical evaluation, and treatment.
Study Design: To estimate attainment of HCV care cascade steps among antibody-positive patients with newly identified HCV, we conducted chart reviews of patients with a new positive HCV antibody test at 3 academic medical centers participating in the Birth-Cohort Evaluation to Advance Screening and Testing of Hepatitis C (BEST-C) study.
Methods: We tracked receipt of RNA testing, clinical evaluation, treatment initiation, and treatment completion among individuals born between 1945 and 1965 who were newly diagnosed as HCV antibody–positive between December 2012 and October 2015 at 3 BEST-C centers, predominantly from the participating medical centers’ primary care practices and emergency departments.
Results: Of the 130 HCV-seropositive individuals identified, 118 (91%) had an RNA or genotype test, 75 (58%) were RNA-positive, 73 (56%) were linked to care, 22 (17% overall; 29% among RNA-positive) started treatment, and 21 (16%; 28% among RNA-positive) completed treatment.
Conclusions: This analysis showed that although linkage to care was largely successful in the target birth cohort, the largest gap in the HCV care cascade was seen in initiating treatment. Greater emphasis on linking patients to clinical evaluation and treatment is necessary in order to achieve the public health benefits promised by birth-cohort testing.
Am J Manag Care. 2018;24(9):421-427Takeaway Points
In this analysis of patients with newly diagnosed hepatitis C between December 2012 and October 2015, linkage to care was largely successful in the 1945-1965 birth cohort, but treatment initiation remained low.
- The largest gap in the hepatitis C virus care cascade was initiating treatment.
- Greater emphasis on linking patients to clinical evaluation and treatment is needed.
- Managed care is well poised to address barriers to initiating treatment.
Studying attainment of "care cascade" steps among patients identified at BEST-C medical centers is instructive in understanding the possible impact of future HCV testing interventions, especially in managed care settings. These settings have a long history of proactive health promotion activities, such as patient education and care coordination, that may be effective in addressing gaps in care experienced by patients with newly diagnosed HCV.
In this paper, we used electronic health records (EHRs) to examine HCV care and treatment among antibody-positive patients identified at BEST-C study centers during the study period.
METHODS
Study Population
Patients included in this analysis were those who tested HCV antibody–positive during the BEST-C study period (December 2012-October 2015) at any of the 3 participating healthcare systems (“centers”) as an enrolled participant of the BEST-C study or as an unenrolled patient who was identified during the same study period. All evaluated patients were born between 1945 and 1965 and had no previous record of being tested for HCV in the EHR.5,6,14 Information about BEST-C has previously been described.5,14 This study received institutional review board approval from the University of Alabama, Henry Ford Health System, Mount Sinai Hospital, and NORC at the University of Chicago.
Measures
We defined the care cascade as consisting of the following 7 consecutive steps: (1) a positive HCV antibody test; (2) a confirmatory test, defined as a qualitative or quantitative RNA or HCV genotype test; (3) receipt of a positive RNA result or genotype; (4) clinical evaluation (either concurrently with receipt of confirmatory RNA test result or at a subsequent encounter), defined as a visit with a specialty provider (hepatologist, gastroenterologist, or infectious disease specialist) or other HCV treatment provider (primary care provider trained to treat HCV); (5) initiation of antiviral therapy as indicated in the EHR; (6) treatment completion as indicated in the EHR by a provider; and (7) EOT virologic response, defined as an undetectable viral load at treatment completion (within 2 weeks of the end of intended course of treatment). Only 1 patient received a liver biopsy. Sustained viral load 12 weeks following EOT was not available at the end of the study; we therefore do not report on this step or the final outcome of the cascade.
Data Collection and Analysis
Using a standardized abstraction form, center coordinators collected data from the EHR of each patient from the date of his or her first positive HCV antibody test from December 1, 2012, through October 31, 2015. Coordinators identified relevant laboratory orders, encounters, and pharmacy records associated with each step of the HCV care cascade and sent deidentified person-level data to the coordinating center (NORC at the University of Chicago). Because of small sample sizes, the care cascade steps were not stratified by center. Data were analyzed using Microsoft Excel 2013 and SAS version 9.4 (SAS Institute, Inc; Cary, North Carolina).
We calculated the proportion of persons who progressed along the HCV care cascade as the number of individuals who completed each step (numerator) divided by the number of individuals with a positive HCV antibody test (denominator). We also calculated the proportion of individuals completing each step (numerator) divided by the number of individuals completing the previous step. Due to problems extracting pharmacy information from their EHR systems, 1 center did not report treatment of any patients. Therefore, we also calculated the care cascade and the percent of patients initiating treatment using data from the 2 centers with accessible treatment records (“treating centers”).
We estimated patients’ liver disease stage at initial evaluation using their first recorded AST (aspartate aminotransferase) to Platelet Ratio Index (APRI) scores. Disease stage was categorized using the following values: 0.0 to 0.54, 0.55 to less than 1.0, 1.0 to less than 2.0, and 2.0 or greater (ranging from no liver disease at 0.0 to advanced fibrosis/cirrhosis).15 Using χ2 tests and Fisher’s exact tests and data from the 2 treating centers, we compared differences in treatment initiation by sex, race, birth year, insurance type, APRI score categories, and HCV genotype. A P value ≤.05 was considered statistically significant.
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