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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
Language Barriers and LDL-C/SBP Control Among Latinos With Diabetes
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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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Another potential barrier to receiving HCV treatment may be current alcohol or illicit drug use. Certain state Medicaid programs require abstinence from illicit drug use and alcohol in order for a patient to be eligible for reimbursement for DAA HCV therapy.17,26,27 The center not reporting treatment of any patients had Medicaid restrictions that required patients to abstain from drug and alcohol use and abuse and also required fibrosis scores indicating advanced disease before treatment with interferon-free therapies25; patients with mild disease were monitored. Of the 2 treating centers, 1 center did not have requirements to abstain from drugs and alcohol but did have restrictions that required severe fibrosis before DAA treatment access.25 The state requirements of the other center were unknown.25

Medicaid restrictions may result in providers regarding active substance use as a barrier to HCV therapy.26 A recent study found that although type of insurance was not associated with HCV screening, HCV treatment rates were significantly lower for HCV-positive Medicaid patients than for HCV-positive Medicare and commercially insured patients.28 Although 20% of RNA-positive patients in our study were not treated due to physician prioritization for care, such as a competing comorbidity, most of these patients also reported current alcohol use. It is not possible to discern how alcohol use factored into decisions related to treatment.29

Treatment initiation was the largest and most important gap identified by our study. Treatment can curb morbidity and mortality due to advanced liver fibrosis or cirrhosis by preserving remaining liver function and reducing risk for liver cancer and hepatic decompensation.30 Interventional efforts may increase rates of treatment initiation. Seventeen patients were lost to follow-up after testing RNA-positive for unknown reasons. Some of these patients may have benefited from interventions to recontact them in an attempt to schedule and provide HCV care and treatment where appropriate. Other individuals may have deferred treatment due to a lack of insurance coverage. Efforts to assure coverage of DAAs by all health insurers and lower the co-pays and deductibles associated with that treatment could reduce an important barrier to treatment for some patients.31,32 Given the availability of well-tolerated all-oral treatments, virtually all patients are able to benefit from treatment, which reduces HCV-associated morbidity and mortality.

There is an ongoing need for evidence of how patients progress through the HCV care cascade within different health systems at different time points to understand where there are gaps in the cascade. This need will continue until the problem of access to HCV treatment can be resolved. This study demonstrates that when focused interventions are put in place to increase HCV testing, there is an improvement in the completion of specific steps of the care cascade, including RNA testing and linkage and referral to HCV care. However, in our study, treatment initiation remained low, so other interventions may be needed to overcome barriers to treatment initiation. Researchers of future studies may wish to examine barriers to treatment initiation among patients with HCV who completed clinical evaluation, how treatment access is affected by different payment models,33 and how specific interventions may decrease barriers to treatment initiation.


This study is limited by at least the following factors. First, the number of chronic HCV infections identified in this cohort was small and represents a convenience sample drawn from 3 health centers in the United States, which limits the generalizability of the analysis. Cascade data were not stratified by center because of the small sample size. Patients identified by the BEST-C intervention may have received clinical evaluations at a higher rate due to higher vigilance among the study investigators, although similarly high vigilance might be expected following any organized interventional effort. Second, follow-up time for included patients varied based on their HCV-positive test date. Patients testing HCV-seropositive later in the study period would have less follow-up time than patients testing HCV-seropositive earlier in the study period (although all patients were observed for at least 1 year). Third, APRI scores at diagnosis and at the time of treatment were unavailable for many patients, which limited the power of our study to detect differences in APRI scores for patients who initiated treatment compared with patients who did not. Fourth, 1 center was not able to obtain data on patient treatment from its EHR system. However, this did not limit the clinical evaluation of HCV RNA–positive patients and the majority of patients were evaluated at this center. Many restrictions on coverage for DAAs that were common in 2014-2015 were subsequently lifted or relaxed in 2016-2017. Patients included in our data may have been treated after data collection ended. Fifth, only EOT viral load data, as opposed to SVR data, were available for patients who completed treatment. Finally, at any given step of the care cascade, patients could have received care at a different center, which could lead to an underestimate of treatment rates and treatment outcomes.


Although the BEST-C study was designed to test BEST-C testing interventions to increase HCV testing, it also offered the opportunity to assess linkage to care in real-world settings; these observational data demonstrated that although linkage to care was highly successful (97% evaluated by an HCV specialist), initiation of treatment continues to be a challenge among persons born between 1945 and 1965. Reflex testing, interventions to reduce loss to follow-up, and minimizing restrictions on treatment imposed by third-party payers are potential ways to help overcome barriers to HCV RNA testing and treatment initiation for patients with HCV infection. Managed care is well positioned to help address these barriers to treatment initiation. 

Author Affiliations: NORC at the University of Chicago (JEB), Bethesda, MD; Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (CV, SH), Division of Diabetes Translation (BDS), and Center for Global Health (AKY), CDC, Atlanta, GA; The Chartis Group (DLK), Chicago, IL; Center for Health Policy and Health Services Research, Henry Ford Health System (DRN), Detroit, MI; Division of Gastroenterology, Department of Medicine, Henry Ford Hospital (KAB), Detroit, MI; Icahn School of Medicine at Mount Sinai (ADF, KK, NK), New York, NY; University of Alabama at Birmingham (OIM, JMW, TAS), Birmingham, AL; NORC at the University of Chicago (DBR), Atlanta, GA.

Source of Funding: This study was funded by the CDC Foundation. In 2015, there were 10 corporate members of the CDC Foundation, including Abbott Laboratories, AbbVie, Bristol-Myers Squibb, Gilead Sciences, Janssen, Merck Sharp & Dohme Corporation, OraSure Technologies, Quest Diagnostics, and Siemens Healthcare, Inc. The Association of State and Territorial Health Officials, the National Viral Hepatitis Roundtable, and a representative from the HHS Office of HIV/AIDS and Infectious Disease Policy continued to participate in Coalition activities. The CDC Foundation and its sponsors did not have any role in the study design; collection, analysis, or interpretation of data; writing of the report; or the decision to submit the manuscript for publication. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the CDC.

Author Disclosures: Dr Brady is currently employed by GlaxoSmithKline, but this work is unrelated to her work there and was conducted prior to her employment. Dr Nerenz is employed by an integrated healthcare system that provides screening and treatment services for hepatitis C and receives payments and incurs costs for those services. Dr Brown is a member of advisory boards discussing hepatitis C for Merck, Gilead, and AbbVie; has received grants from Merck, Gilead, AbbVie, Novartis, and Allergan; and has completed multicenter studies on hepatitis C with funding from Merck, Gilead, and AbbVie (all grant funding was to institution). Dr Rein receives grants from Gilead and Merck. The remaining 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 (DLK, DRN, KAB, KK, BDS, AKY, DBR); acquisition of data (JEB, DLK, DRN, KAB, ADF, KK, NK, OIM, JMW, TAS, AKY, DBR); analysis and interpretation of data (JEB, CV, SH, DLK, DRN, KAB, KK, BDS, DBR); drafting of the manuscript (JEB, JMW, DBR); critical revision of the manuscript for important intellectual content (JEB, CV, SH, DRN, KAB, ADF, NK, OIM, JMW, BDS, AKY, DBR); statistical analysis (JEB); provision of patients or study materials (KAB, NK, OIM); obtaining funding (OIM, AKY, DBR); administrative, technical, or logistic support (CV, SH, DLK, DRN, KAB, TAS); and supervision (KAB, TAS, BDS, DBR).

Address Correspondence to: Joanne E. Brady, PhD, NORC at the University of Chicago, 4350 East-West Hwy, 8th Fl, Bethesda, MD 20814. Email:

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