Factors Associated with Delay in Therapy for Chronic Hepatitis C

Background: Direct acting antiviral (DAA) therapy is safe, cost-effective, and recommended by joint IDSA/AASLD guidelines for treatment of hepatitis C virus (HCV) infection. However, variability in drug payment rules may represent a barrier to treatment disproportionately affecting certain populations.

Methods: Retrospective review of all patients with HCV infection treated with DAA therapy at the University of Connecticut Health Center from 1/1/2014 to 2/1/2016 was performed to record time from prescription to delivery of DAA agents and patient factors. Time to treatment was compared between groups using the log-rank test and ANOVA. Factors achieving significance (p<0.10) along with age and race were included in multivariable analysis by Cox proportional hazards. Analyses performed with SPSS software version 22.

Results: Mean age at prescription was 53.1 years (median 55.5, IQR 48.8-61). Mean time to treatment was 30.9 days (median 22.5, IQR 14-35). Age, gender, race, HIV infection, referral source (internal or external), viral genotype, fibrosis level, Child-Pugh score, substance abuse history, choice of DAA regimen, drug compliance, and sustained virologic response at 12 weeks were not statistically significant (p>0.05). Factors associated with prompt treatment were Infectious Diseases Clinic management (27.5 v. 44.5 days, p=0.04), absence of other liver disease (28.4 v. 61.0 days, p=0.05), public insurance payer (27.5 v. 50.4 days, p=0.03), and initial approval of requested regimen (25.6 v. 101.6 days, p<0.001).

Multivariable Analysis	Adjusted Hazard Ratio	Sig (p-value)
Age	1.216 (0.733-2.018)	0.45
Race	1.132 (0.713-1.796)	0.59
Office setting	1.521 (0.852-2.718)	0.16
Other liver disease	0.264 (0.084-0.831)	0.02
Approval	0.136 (0.045-0.414)	<0.001
Insurance	0.613 (0.293-1.283)	0.19

Conclusion: Current Connecticut Medicare and Medicaid Practices resulted in more rapid delivery of medication compared to private payers in univariate analysis. Fibrosis level, Child-Pugh score, and HIV status did not significantly change time to treatment. The presence of concomitant liver disease not related to HCV infection and denial of initial requested regimen were associated with significant delay in therapy in multivariable analysis.