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The American Journal of Managed Care September 2018
Food Insecurity, Healthcare Utilization, and High Cost: A Longitudinal Cohort Study
Seth A. Berkowitz, MD, MPH; Hilary K. Seligman, MD, MAS; James B. Meigs, MD, MPH; and Sanjay Basu, MD, PhD
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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
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A. Mark Fendrick, MD
Health Literacy, Preventive Health Screening, and Medication Adherence Behaviors of Older African Americans at a PCMH
Anil N.F. Aranha, PhD, and Pragnesh J. Patel, MD
Early Experiences With the Acute Community Care Program in Eastern Massachusetts
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
Economic Evaluation of Patient-Centered Care Among Long-Term Cancer Survivors
JaeJin An, BPharm, PhD, and Adrian Lau, PharmD
Fragmented Ambulatory Care and Subsequent Healthcare Utilization Among Medicare Beneficiaries
Lisa M. Kern, MD, MPH; Joanna K. Seirup, MPH; Mangala Rajan, MBA; Rachel Jawahar, PhD, MPH; and Susan S. Stuard, MBA
High-Touch Care Leads to Better Outcomes and Lower Costs in a Senior Population
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
Adjusting Medicare Advantage Star Ratings for Socioeconomic Status and Disability
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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RESULTS

We identified a total of 130 individuals born between 1945 and 1965 who were newly identified with an HCV-seropositive test result (Table 1). Among the newly identified HCV-seropositive patients, 36% were born between 1950 and 1954, 56% were black, and the majority were insured by Medicare alone (42%) or private insurance (36%). Ninety-one of the 130 antibody-positive patients participated in the BEST-C study (83 intervention arm, 8 standard-of-care testing).

Using data from all 3 centers, of the 130 HCV-seropositive patients identified, 118 (91%) received a confirmatory RNA and/or genotype test, 75 (58%) had a positive RNA or genotype test result, 73 (56%) received a clinical evaluation, 22 (17% at all centers; 26% [22/84] at the 2 treating centers) initiated treatment, and 21 (16% at all centers; 25% [21/84] at the 2 treating centers) were known to have completed treatment (Figure 1). All treated patients came from the 2 treating centers. When considering the treatment cascade sequence of only the 75 patients with a positive RNA or genotype result, 97% received a clinical evaluation, 29% at all centers (43% at the 2 treating centers) initiated treatment, and 28% at all centers (41% at the 2 treating centers) were known to have completed treatment by the end of the study period. When considering only the patients identified at the 2 treating centers, 26% (22/84) of antibody-positive patients, 43% (22/51) of RNA-positive patients, and 45% (22/49) of patients receiving a clinical evaluation initiated treatment (Figure 2). At the 2 treating centers, treatment initiation for RNA-positive patients did not differ by sex, race, birth year, insurance type, or HCV genotype (Table 2).

Centers reported treatment or a reason for nontreatment for 73 (97%) of 75 RNA-positive patients. Twenty-two (29%) were treated; deferral of treatment was responsible for nearly half of the patients not treated, including 19 (25%) who chose to defer treatment for unknown reasons and 15 (20%) who were not treated due to physician assessment of prioritization for care (eg, in 1 case, treatment for brain cancer was prioritized over HCV treatment); and 17 patients were lost to follow-up for unknown reasons. Of the patients who initiated treatment, 1 (5%) did not complete treatment due to nonadherence (eg, not taking medication). Eleven patients were treated solely with direct-acting antivirals (DAAs), 9 (41%) with ledipasvir/sofosbuvir, and 2 (9%) with ombitasvir, paritaprevir, and ritonavir tablets plus dasabuvir (Table 3). RNA viral load test results were available for 14 of 21 (67%) patients who completed treatment; all 14 patients achieved an undetectable viral load at EOT.

APRI scores were available for 39 of the 75 HCV RNA–positive patients, of whom 24 (62%) had an APRI score of less than 0.55, 10 (26%) had an APRI score of 0.55 to less than 1.0, 2 (5%) had an APRI score of 1.0 to less than 2.0, and 3 (8%) had an APRI score of 2.0 or greater (Table 2; lower APRI scores indicate less advanced disease progression and the higher the value [>2.0], the greater the likelihood of cirrhosis). Rates of treatment initiation did not significantly differ by APRI score category at the 2 treating centers (P = .30) (Table 2). Of the 22 patients who initiated treatment, APRI scores were available for 21 (95%). Of these patients, 15 (71%) had an APRI score of less than 0.55, 4 (19%) had an APRI score of 0.55 to less than 1.0, and 2 (10%) had an APRI score of 2.0 or greater. Two patients with a known APRI score of 1.0 to less than 2.0 (suggesting advanced fibrosis) were not treated; 1 patient had a treatment contraindication (currently using alcohol in the period prior to interferon-free treatments) and 1 patient deferred treatment. The patient with a known APRI score of 2.0 or greater who was not treated was lost to follow-up (not shown).

DISCUSSION

Our research followed 130 newly identified HCV-seropositive patients to assess their progression through the HCV care cascade in 3 US health centers. We found that successful HCV case identification did not automatically lead to treatment initiation. At the 2 treating centers, only 45% of patients who had a clinical evaluation initiated treatment; however, treatment initiation rates following an intervention were higher than those observed in many other settings. Centers were largely successful in ensuring confirmatory RNA testing for patients who tested seropositive (91%) and in linking RNA-positive patients to clinical evaluation for treatment (97%). Ideally, all seropositive patients should receive confirmatory RNA testing; additionally, same-day HCV RNA testing and HCV RNA reflex testing, in which the same blood sample used for HCV antibody testing is used for the RNA test, may help address persistent RNA testing gaps.16,17

We also observed that a lower proportion of patients who received RNA testing were RNA-positive (64%) than observed in national estimates (75%),2 possibly because these national estimates arose from a different HCV testing protocol. Further, a positive HCV antibody test and an RNA-negative test can occur when there is natural clearance of the HCV virus, antibody cross-reactivity, or comorbid immune disorders.18,19 Due to lack of data, we were not able to determine if any of these factors led to a greater than expected number of negative RNA results following positive HCV antibody results. Another potential explanation for the lower than expected percentage of RNA-positive results is that chronic HCV infection is associated with an increased mortality risk. Therefore, it is likely that a larger proportion of people who were RNA-positive had already died, leaving a comparatively higher proportion of those who had spontaneously cleared HCV (ie, survival bias).

In our study, a high proportion of patients who had chronic HCV were clinically evaluated (97% of RNA-positive patients and 56% of antibody-positive). This proportion is higher than the 29% of antibody-positive patients reported in a recent study examining a cohort of persons born between 1945 and 1965 conducted at 3 large urban primary care clinics affiliated with a teaching hospital in the Bronx, New York.12 Unfortunately, despite high rates of clinical evaluation in our study, the overall proportion of newly identified antibody-positive patients who initiated treatment (17%) was similar to previously reported findings (7%-21% treated), although this rate was higher (26%) in the 2 treating centers.9,11-13,20

Several important factors may have contributed to the low rate of treatment initiation we observed. First, due to the timing of the study, many patients may have deferred treatment until new, all-oral, interferon-free, single-tablet regimens were approved for use beginning in October 2014.21,22 These regimens have greater effectiveness, with fewer adverse effects and a shorter treatment duration, than the interferon-based treatment available to most patients during 2013.23 Even after the approval of interferon-free treatment, lack of insurance coverage for these treatments may have led to the low percentage of patients initiating treatment.24,25 Managed care is well situated to address concerns about coverage for interferon-free HCV treatments. Second, a large proportion of HCV-infected patients in this study (65.4%) were born between 1950 and 1959, thus either just entering eligibility for Medicare or not yet eligible for Medicare, which may have limited insurance coverage for treatment.


 
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