964 Patient Flow Across Physician Specialties Over the Course of the Hepatitis C Care Cascade: A Real World Analysis From the United States

Abstract

INTRODUCTION: Hepatitis C virus (HCV) infection is a major cause of hepatic and extrahepatic morbidity and mortality. In spite of recommendations for HCV screening, diagnosis, linkage to care and treatment, significant gaps remain in the cascade of care for HCV. As the role of physician specialties for closing these gaps is poorly understood, this study assesses the flow of HCV patients across physician specialties in the US, over the course of the care cascade. METHODS: This retrospective real-world study used two large de-identified national laboratory datasets (2013–2016). Screened patients had a HCV antibody (AB) test and/or HCV RNA viral load test. Diagnosed patients had a positive HCV RNA viral load test, and among this group, fibrosis assessment, genotype test and treatment were evaluated. Treatment was inferred with an algorithm based on changes in viral load. The number/proportion of patients at each step in the care cascade was calculated by physician specialty. Patient flow by physician specialty over the course of care cascade was assessed using Sankey Diagrams. RESULTS: Approximately 17 million patients received HCV screening, and 913,529 were diagnosed. Over the course of the care cascade, there was an increase in the proportion of patients switching to HCV specialists (gastroenterologist, hepatologist, and infectious disease specialist). Generalists (primary care, family practice, internal medicine) ordered 37% of the AB tests, and 15% initiated treatment. HCV specialists ordered 3% of screening tests and 37% initiated treatment. Most of the fibrosis assessment (30%) and genotype tests (29%) were ordered by HCV specialists. Obstetricians/gynecologists ordered 11% of screening tests but only 0.3% initiated treatment. Among 974,277 patients who received a positive AB test, 46% did not receive a confirmatory RNA test. Among diagnosed patients, 57% did not receive fibrosis assessment, 47% did not receive genotype test and 90% did not receive treatment. CONCLUSION: Generalists account for more than one third of all HCV screening tests, however, HCV specialists play a more prominent role in patient assessment (fibrosis status, genotype testing) and treatment. Significant gaps remain in all stages of the cascade of care for HCV, and improved efforts are needed for every physician specialty to address them. Timely screening, monitoring and linkage to care by generalists coupled with early treatment by specialists could effectively reduce the hepatic and extrahepatic burden of HCV.

Securing wider EU commitment to the elimination of hepatitis C virus

“…This may be because of the relatively high cost of the treatment or the fact that GPs are not adequately trained to treat these patients. 49 However, GPs must be seen as a valuable resource to extend screening and treatment capacities, 13,50 especially given that pangenotypic regimens have simplified HCV treatment in recent years and the fact that in most cases genotyping is not necessary. 15 Of note, one study suggested that financial incentives can improve screening rates for GPs.…”

Chronic Viral Hepatitis: Current Management and Future Directions

“…As an illustrative example, Rege et al found in an analysis of two large national laboratory databases from 2013 to 2016, that 89.4% of patients diagnosed with chronic HCV infection did not receive prescription for antiviral therapy. In this study, 46.7% of patients did not have genotype testing, and 57.3% did not have liver chemistries, suggesting that patients suffer attrition at an early phase of the care cascade . Future work to target the care cascade gaps will help to identify those for whom treatment could be offered: HCV screening, diagnosis, patient communication regarding chronic infection, care linkage, and fibrosis staging.…”

“…In this study, 46.7% of patients did not have genotype testing, and 57.3% did not have liver chemistries, suggesting that patients suffer attrition at an early phase of the care cascade. (31) Future work to target the care cascade gaps will help to identify those for whom treatment could be offered: HCV screening, diagnosis, patient communication regarding chronic infection, care linkage, and fibrosis staging. Concurrently, development of HCV vaccinations and subsequent provision implementation strategies will be important to reduce population disease burden.…”

Viral hepatitis in 2021: The challenges remaining and how we should tackle them

“…One reason for this is that care pathways have been unnecessarily complex including multiple investigations prior to treatment, which leads to patients frequently being lost to follow up and never completing treatment. Attrition appears to occur early in the treatment cascade; in one study 57.3% of patients dropped off prior to having liver enzymes checked[ 83 ]. With the advent of pangenotypic regimens and simple non-invasive fibrosis scores [ e.g., fibrosis-4 (FIB-4) and aminotransferase-platelet ratio index] pathways can effectively be simplified, which is likely to reduce attrition.…”