Hepatitis C Within a Single Health System: Progression Along the Cascade to Cure Is Higher for Those With Substance Misuse When Linked to a Clinic With Embedded Support Services

Abstract

BackgroundHepatitis C is now curable for most individuals, and national goals for elimination have been established. Transmission persists, however, particularly in nonurban regions affected by the opioid epidemic. To reach goals of elimination, barriers to treatment must be identified.MethodsIn this open cohort of all individuals diagnosed with active hepatitis C from 2010 to 2016 at a large medical center, we identified patient and clinic characteristics associated with our primary outcome, sustained virologic response (SVR). We performed a subgroup analysis for those with documented substance misuse.ResultsSVR was achieved in 1544 (41%) of 3790 people with active hepatitis C. In a multivariable Poisson regression model, SVR was more likely in individuals diagnosed outpatient (incident rate ratio [IRR], 1.7; 95% confidence interval [CI], 1.5–2.0), living in close proximity to the medical center (IRR, 1.2; 95% CI, 1.1–1.3), with private insurance (IRR, 1.1; 95% CI, 1.0–1.3), and with cirrhosis (IRR, 1.4; 95% CI, 1.3–1.5). Achieving SVR was less likely in those qualifying as indigent (IRR, 0.8; 95% CI, 0.8–0.9) and those with substance misuse (IRR, 0.8; 95% CI, 0.7–0.9). In the subgroup analysis of those with substance misuse, SVR rates were higher in those linked to the infectious diseases clinic, which has embedded support services, than those linked to the gastroenterology clinic, which does not (IRR, 1.4; 95% CI, 1.1–1.9).ConclusionsSocial determinants of health including proximity to care and poverty impacted achievement of SVR. Those with substance misuse, a high-priority population for treatment of hepatitis C, had better outcomes when receiving care in a clinic with embedded support services.

Disparities in Hepatitis C Linkage to Care in the Direct Acting Antiviral Era: Findings From a Referral Clinic With an Embedded Nurse Navigator Model

“…Telehealth, such as the ECHO model and collaborations between HCV specialists and general practitioners have expanded access to treatment, with a focus on rural regions (14). For those with a history of substance use, linkage to a clinic with embedded support services improves outcomes (28).…”

Cost‐effectiveness of scaling‐up HCV prevention and treatment in the United States for people who inject drugs

“…(7) To account for the possibility of higher treatment rates for diagnosed people who formerly injected drugs, we assumed that 53.8% of diagnosed people who formerly injected drugs would be treated (Yea‐Hung Chen, personal communication 2019), instead of the base‐case assumptions of only 10–20% . (8) To account for a possible lower HCV prevalence in San Francisco, for those older than 50 we changed the base‐case value of 96 to 75.6% (64.6–86.6%), based on the results of rapid testing from the latest 2018 NHBS round , which reported prevalence using voluntary testing. (9) Finally, we assessed the impact of accounting for an increased risk of death in the 4 weeks before and after starting MAT .…”

A qualitative study of perceived barriers to hepatitis C care among people who did not attend appointments in the non-urban US South

“…In the HBM, perceived barriers to care are one of the strongest predictors of health behavior [36]. Housing instability, unreliable transportation, drug and alcohol use, and lack of insurance have all been previously identified to be barriers to care [12][13][14][15][16][17][18][19]37] and were common in our population. Lack of insurance and financial status were commonly perceived to be barriers, despite our clinic's ability to access treatment for all patients, regardless of insurance status.…”