Increasing success and evolving barriers in the hepatitis C cascade of care during the direct acting antiviral era

Abstract

Barriers remain in the hepatitis C virus (HCV) cascade of care (CoC), limiting the overall impact of direct acting antivirals. This study examines movement between the stages of the HCV CoC and identifies reasons why patients and specific patient populations fail to advance through care in a real world population. We performed a single-center, ambispective cohort study of patients receiving care in an outpatient infectious diseases clinic between October 2015 and September 2016. Patients were followed from treatment referral through sustained virologic response. Univariate and multivariate analyses were performed to identify factors related to completion of each step of the CoC. Of 187 patients meeting inclusion criteria, 120 (64%) completed an evaluation for HCV treatment, 119 (64%) were prescribed treatment, 114 (61%) were approved for treatment, 113 (60%) initiated treatment, 107 (57%) completed treatment, and 100 (53%) achieved a sustained virologic response. In univariate and multivariate analyses, patients with Medicaid insurance were less likely to complete an evaluation and were less likely to be approved for treatment. Treatment completion and SVR rates are much improved from historical CoC reports. However, linkage to care following referral continues to be a formidable challenge for the HCV CoC in the DAA era. Ongoing efforts should focus on linkage to care to capitalize on DAA treatment advances and improving access for patients with Medicaid insurance.

Fig 1. Cascade of care and reasons for lack of progression.

Of 187 patients meeting inclusion criteria, 120 (64%) completed an evaluation for HCV treatment, 119 (64%) were prescribed treatment, 114 (61%) were approved for treatment, 113 (60%) initiated treatment, 107 (57%) completed treatment, and 100 (53%) achieved a SVR. The largest lack of progression was seen from a referral to an evaluation with 51 patients never attending a scheduled clinic appointment. After an evaluation was completed, the most common reason for lack of progression was losing a patient to follow-up, defined as ≥5 attempts to contact the patient were made by phone as well as a letter sent to the patient’s most recent address with no response over at least three months.

Fig 2. Time-to-approval analysis.

Insurance type was a significant predictor of the rate in days to approval of direct acting antiviral therapy. The rate in days to approval decreased by 73% in patients with Medicaid compared with non-Medicaid (HR = 0.27, 95% CI = 0.15 to 0.48, p<0.001), reflecting a longer time to treatment approval in this population.