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The American Journal of Managed Care February 2019
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Impact of Hepatitis C Virus and Insurance Coverage on Mortality
Haley Bush, MSPH; James Paik, PhD; Pegah Golabi, MD; Leyla de Avila, BA; Carey Escheik, BS; and Zobair M. Younossi, MD, MPH
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Impact of Hepatitis C Virus and Insurance Coverage on Mortality

Haley Bush, MSPH; James Paik, PhD; Pegah Golabi, MD; Leyla de Avila, BA; Carey Escheik, BS; and Zobair M. Younossi, MD, MPH
The Medicaid population has significantly higher hepatitis C virus (HCV) prevalence and mortality rates than patients with private insurance. These data must be considered when policy makers assess providing additional support to Medicaid programs for HCV elimination.
Statistical Analysis

Sampling weights provided by the National Center for Health Statistics (NCHS) were used to account for survey nonresponse and sampling strategy. For national representation, original weights in our merged sample were modified using the method recommended by NCHS.25 Sampling errors were estimated by the Taylor linearization method using subpopulation (domain) analysis. Variables were expressed as weighted means or weighted percentages (standard errors). Differences between groups were evaluated using a t statistic for continuous variables and the Rao-Scott χ2 test for categorical variables. Age adjustment estimates were calculated by the direct method to the standard 2000 United States population estimates using the age groups of 18 to 44 years, 45 to 54 years, 55 to 64 years, and 65 years or older.

Among HCV-positive individuals, weighted all-cause mortality rates were stratified by types of insurance. The Cox models were implemented in the HCV-positive subjects to determine the association of insurance type with all-cause mortality adjusting for important covariates. We used 2 models: Model 1 adjusted for sociodemographics including age, gender, race, PIR, education, and marital status, and model 2 adjusted for the sociodemographic and clinical variables selected by bidirectional stepwise regression. The proportional hazards assumptions of the Cox models were examined by testing time-dependent covariates.27 All analyses were performed with SAS software, version 9.4 (SAS Institute; Cary, North Carolina).


Characteristics of Study Population

After applying exclusion criteria, 19,452 individuals from 5 NHANES cycles (2001-2010) were considered eligible for this study (eAppendix Figure). Mean age was 43.3 years, 48% were male, and 69.5% were non-Hispanic white, 11.2% were non-Hispanic black, 13.6% were Hispanic, and 5.8% were of other racial background (Table 1). Of the 19,452, 311 individuals (weighted prevalence of HCV, 1.37%; 95% CI, 1.15%-1.59%) had detectable HCV RNA. In terms of comorbidities, 33.2% were obese, 7.4% had T2D, 68.5% had hypercholesterolemia, 30.4% had HTN, and 16.6% had metabolic syndrome (Table 1). Additionally, 68.3% had private insurance, 5.8% had Medicare, 4.3% had Medicaid, and 21.7% had no insurance (Table 2). The age-adjusted prevalence of HCV was highest among individuals with Medicaid (2.58%), followed by the uninsured (2.17%), those with Medicare (1.24%), and those with private insurance (0.81%) (Figure and eAppendix Table 1).

Comparison of HCV-Positive Cohort With the HCV-Negative Controls

The results of the comparison between the HCV-positive cohort and HCV-negative controls are summarized in Table 1. The mean age of HCV-positive subjects was 48.1 years, 64.6% were non-Hispanic white, and 65.7% were male. As expected, relative to HCV-negative subjects, those with HCV were older and more likely to be male, non-Hispanic black, and unmarried. HCV-positive patients were less likely to be employed and had lower income (all P <.05). Additionally, HCV-positive participants had significantly higher prevalence of HTN and of history of arthritis, COPD, congestive heart disease, kidney failure, and stroke (P <.05) (Table 1). Compared with HCV-negative controls, HCV-positive subjects were more likely to be covered by Medicaid or be uninsured and less likely to have private insurance (Table 2).

Comparison of HCV-Positive Cohort Across Insurance Types

There were significant differences in sociodemographics and comorbid conditions according to type of insurance. Compared with HCV-positive patients with private insurance, those with Medicare or Medicaid insurance were less likely to be non-Hispanic white and more likely to be non-Hispanic black, be unmarried, and have lower income (P <.05 for each comparison) (Table 3).

As expected, HCV-positive patients with Medicare were older, more likely to be non-Hispanic black, and more likely to have comorbidities such as HTN and T2D, as well as history of arthritis, cancer, CHD, IHD, kidney failure, and stroke, compared with those with private insurance or the uninsured.

Also, HCV-positive patients with Medicaid had higher rates of obesity (41.9% vs 20.1% among Medicare and 12.0% among uninsured), T2D (27.4% vs 10.0% among private and 6.7% among uninsured), HTN (52.9% vs 34.6% among uninsured), metabolic syndrome (32.9% vs 14.9% among private and 6.6% among uninsured), arthritis (46.4% vs 27.0% among private), CHD (7.4% vs 3.8% among private and 1.9% among uninsured), and IHD (8.0% vs 1.6% among private) (Table 3).

Compared with other patients, HCV-positive patients with private insurance were more likely to have high income and to be non-Hispanic white, married, and employed.

Finally, the uninsured HCV-positive patients were younger, had lower income, and had lower rates of comorbid conditions compared with the insured HCV-positive patients (data not shown).

All-Cause Mortality Among HCV-Positive Cohort Across Insurance Types

In this subgroup analysis, only participants with HCV (n = 311) were included. Through the follow-up period (median, 58 months), there were significant differences in all-cause mortality rates across insurance types. Weighted unadjusted all-cause mortality was the highest among patients with Medicare (45.4%), followed by Medicaid (23.7%), private (7.9%), and uninsured (6.8%) (Table 4). However, after adjusting for sociodemographic variables, HCV-positive patients with Medicaid had significantly higher all-cause mortality compared with HCV-positive patients with private insurance (hazard ratio [HR], 5.81; 95% CI, 1.15-29.29) and the uninsured (HR, 5.01; 95% CI, 1.19-21.01). In fact, even after adjustments by stepwise selection, the model still indicated that those with Medicaid had an increased risk of mortality compared with those with private insurance (HR, 6.31; 95% CI, 1.22-29.94) and the uninsured (HR, 8.83; 95% CI, 1.56-49.99) (Table 4).

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