Disparities in hepatitis C testing in U.S. veterans born 1945–1965

Abstract

Background/Aims Universal one-time antibody testing for hepatitis C virus (HCV) infection has been recommended by the Centers for Disease Control (CDC) and the United States Preventive Services Task Force (USPSTF) for Americans born 1945-1965 (birth cohort). Limited data exists addressing national HCV testing practices. We studied patterns and predictors of HCV testing across the U.S. within the birth cohort utilizing data from the national corporate data warehouse (CDW) of the U.S. Veterans Administration (VA) health system. Method Testing was defined as any HCV test including antibody, RNA or genotype performed during 2000-2013. Result Of 6,669,388 birth cohort veterans, 4,221,135 (63%) received care within the VA from 2000-2013 with two or more visits. Of this group, 2,139,935 (51%) had HCV testing with 8.1% HCV antibody and 5.4% RNA positive. Significant variation in testing was observed across centers (Range: 7-83%). Older, male, African-Americans, with established risk factors and receiving care from urban centers of excellence were more likely to be tested. Among veterans free of other established risk factors (HIV negative, HBV negative, ALT≤40 U/L, FIB-4≤1.45, or APRI<0.5), HCV antibody and RNA were positive in 2.8% and 0.9%, respectively, comparable to established national average. At least 2.4-4.4% of veterans had scores suggesting advanced fibrosis (APRI≥1.5 or FIB-4>3.25) with >30-43% having positive HCV RNA but >16-20% yet to undergo testing for HCV. Conclusion Significant disparities are observed in HCV testing within the U.S. VA health system. Examination of the predictors of testing and HCV positivity may help inform national screening policies. Lay Summary Analysis of United States Veterans Administration data show significant disparities in Hepatitis C Virus (HCV) testing of veterans born 1945-1965 (birth cohort). A fifth of those not tested had evidence of advanced liver fibrosis. Our data suggests some predictors for this disparity and will potentially help inform future policy measures in the era of universal birth cohort testing for HCV.

Hepatitis C Testing Increased Among Baby Boomers Following The 2012 Change To CDC Testing Recommendations

“…We found no disparities based on sex in the change in screening rates following the intervention, which is consistent with a previous study that found only slightly higher screening rates among female veterans than males (58.2 percent versus 54.5 percent). 11 However, another study found that male veterans were more likely than females to be tested for hepatitis C. 28 Both studies reported screening rates that were considerably higher than the national screening rates we found. These differences may be a result of the effective programs that the Department of Veterans Affairs has implemented to reduce barriers to implementation of the testing recommendation.…”

“…29,30 Additionally, Sourik Sarkar and coauthors found significant regional variability in hepatitis C testing. 28 Taken together, these findings suggest the need for region-specific programs to augment guidelines to further improve screening.…”

The end of the hepatitis C burden: Really?

“…Approximately half were HCV RNA positive, the majority of whom were referred to care . However, among 4,221,135 birth cohort veterans receiving care within the Veterans Administration health system between 2000 and 2013, significant variation in testing (7%‐83%) was observed, suggesting that implementation of birth cohort testing for HCV failed to be “universal” as initially planned . The model presented by Chhatwal et al further emphasizes the limitations of the birth cohort strategy, estimating that, under the current standard of care, 597,000 (95% confidence interval [CI], 542,000‐891,000) of an estimated 834,000 remaining viremic subjects (72%) will be unaware of their infection in 2020 in the United States …”

Evaluation of a Multifaceted Intervention to Reduce Health Disparities in Hepatitis C Screening: A Pre‐Post Analysis

“…Similarly, another study demonstrated increased HCV screening from 1.09 to 2.53 per 100,000 person‐years after release of US Preventive Service Task Force (USPSTF) guidelines, with the most dramatic increase occurring in the Northeast compared to other regions of the country . Despite these increases in HCV screening among baby boomer patients, disparities exist with some subgroups based on age, racial/ethnic minority status, gender, primary care visits, and comorbidities …”