Background: Despite emerging hepatitis C virus (HCV) treatments, barriers remain within the cascade of care (CoC) that limit impact in real world practice. Assessing breakdown in the HCV CoC will provide targets for interventions to facilitate improved access and treatment. The objective of this study was to identify factors associated with movement through the HCV CoC after referral to a multidisciplinary infectious diseases (ID) clinic, including both general and historically difficult to treat populations.
Methods: This is a single-center, retrospective, cohort study of patients receiving care at the Vanderbilt University Medical Center (VUMC) ID Clinic between July 2015 and September 2016. Data was collected from the electronic medical record used for patient care. For the purposes of this study, the defined CoC started with referral to the VUMC ID clinic and followed progression through HCV evaluation, prescription, approval, initiation, and completion of treatment, and achievement of sustained virologic response at least 12 weeks after treatment completion (SVR12). The primary endpoint was completion of treatment. Secondary endpoints were achievement of each stage in the CoC. Univariate analyses were used to identify patient groups less likely to advance through the CoC.
Results: Of the 182 patients referred to the VUMC ID clinic during our study period, 101 (55.5%) achieved the primary endpoint of treatment completion. Having Medicaid insurance was associated with a lower rate of treatment approval compared to those with other forms of insurance or no insurance (76.2% compared to 97.8%, p<0.001). The largest loss of patients in the CoC occurred from referral to an evaluation (37.7%). Of those patients completing an evaluation, 88.6% completed treatment, and 81.5% achieved an SVR12. The presence of HIV coinfection, psychiatric disorder, cirrhosis, or ongoing illicit drug use was not found to impact the primary endpoint.
Conclusion: This study shows overall high rates of HCV CoC completion within a multidisciplinary ID Clinic. The primary barrier to treatment completion identified was having Medicaid insurance. Based on our results, emphasis should be placed on improving patient engagement in care from referral to HCV evaluation.
C. Chastain, Gilead Sciences: Grant Investigator and Research Contractor , Grant recipient , Research grant and Research support