Introduction
The advent of direct-acting antiviral agents for treating hepatitis C virus infection
has made hepatitis C virus elimination possible. Rural patients with hepatitis C virus
infection may be less likely to access direct-acting antiviral agents, but the real-world
evidence is scarce on urban–rural disparities in direct-acting antiviral agent utilization.
Methods
This retrospective cohort study was conducted in 2019–2020 using Medicare data to
examine urban–rural disparities in direct-acting antiviral agent utilization among
newly diagnosed patients with hepatitis C virus infection in 2014–2016. Direct-acting
antiviral agent use was defined as filling ≥1 prescription for direct-acting antiviral
agents during 2014–2017, and patient's urban–rural status was classified on the basis
of their ZIP code of residence. This study evaluated the associations between multilevel
factors and direct-acting antiviral agent use with a focus on urban–rural disparities.
It also assessed changes over time in urban–rural disparities in direct-acting antiviral
agent utilization using multivariable cause-specific Cox regression analyses with
time-varying hazard ratios.
Results
Among 204,018 new patients with hepatitis C virus infection, about 30% received direct-acting
antiviral agents during 2014–2017. Cumulative direct-acting antiviral agent use gradually
increased over time in both urban and rural patients. However, the increase was greater
in urban patients than in rural patients. In the first year of follow-up, rural patients
had a similar rate of receiving direct-acting antiviral agents (adjusted hazard ratio=1.03,
95% CI=1.00, 1.07), but they were less likely to use direct-acting antiviral agents
in later years than urban patients (adjusted hazard ratio=0.85, 95% CI=0.81, 0.90
in the second year, adjusted hazard ratio=0.82, 95% CI=0.76, 0.89 in the third year,
and adjusted hazard ratio=0.76, 95% CI=0.64, 0.90 in the fourth year of follow-up).
Conclusions
This study reveals important gaps in hepatitis C virus treatment and suggests increasing
urban–rural disparities in direct-acting antiviral agent utilization. Enhancing direct-acting
antiviral agent uptake in rural populations with hepatitis C virus infection will
help reduce hepatitis C virus‒related health disparities and reach the national goal
of eliminating hepatitis C virus infection.
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to American Journal of Preventive MedicineAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
REFERENCES
- The increasing burden of mortality from viral hepatitis in the United States between 1999 and 2007 [published correction appears in Ann Intern Med. 2012;156(11):840].Ann Intern Med. 2012; 156: 271-278https://doi.org/10.7326/0003-4819-156-4-201202210-00004
- Extrahepatic manifestations of hepatitis C: a meta-analysis of prevalence, quality of life, and economic burden.Gastroenterology. 2016; 150: 1599-1608https://doi.org/10.1053/j.gastro.2016.02.039
- Estimating prevalence of hepatitis C virus infection in the United States, 2013-2016.Hepatology. 2019; 69: 1020-1031https://doi.org/10.1002/hep.30297
- Recommendations for the identification of chronic hepatitis C virus infection among persons born during 1945-1965 [published correction appears in MMWR Recomm Rep. 2012;61(43):886].MMWR Recomm Rep. 2012; 61: 1-32
- Direct-acting antivirals: the endgame for hepatitis C?.Curr Opin Virol. 2017; 24: 31-37https://doi.org/10.1016/j.coviro.2017.03.017
WHO. Combating hepatitis B and C to reach elimination by 2030: advocacy brief. Geneva, Switzerland: WHO.https://www.who.int/hepatitis/publications/hep-elimination-by-2030-brief/en/. Published May 2016. Accessed 13 September 2019.
- Hepatitis C guidance: AASLD-IDSA recommendations for testing, managing, and treating adults infected with hepatitis C virus.Hepatology. 2015; 62: 932-954https://doi.org/10.1002/hep.27950
Patients with HIV/HCV coinfection. American Association for the Liver Diseases, Infectious Diseases Society of America.https://www.hcvguidelines.org/unique-populations/hiv-hcv. Updated August 27, 2020. Accessed April 23, 2019.
HHS. National viral hepatitis action plan 2017–2020. Washington, DC: HHS https://www.hhs.gov/sites/default/files/National%20Viral%20Hepatitis%20Action%20Plan%202017-2020.pdf. Published January. Accessed December 12, 2019.
- Coverage for hepatitis C drugs in Medicare part D.Am J Manag Care. 2016; 22: SP220-SP226
- Hepatitis C virus: a review of treatment guidelines, cost-effectiveness, and access to therapy.J Clin Transl Hepatol. 2016; 4: 310-319https://doi.org/10.14218/JCTH.2016.00027
- Disparities in initiation of direct-acting antiviral agents for hepatitis C virus infection in an insured population.Public Health Rep. 2018; 133: 452-460https://doi.org/10.1177/0033354918772059
- Uptake of and factors associated with direct-acting antiviral therapy among patients in the Chronic Hepatitis Cohort Study, 2014 to 2015.J Clin Gastroenterol. 2018; 52: 641-647https://doi.org/10.1097/MCG.0000000000000857
- Regional and rural-urban differences in the use of direct-acting antiviral agents for hepatitis C virus: the Veteran Birth Cohort.Med Care. 2019; 57: 279-285https://doi.org/10.1097/MLR.0000000000001071
- Racial/ethnic and socioeconomic disparities in use of direct-acting antivirals among Medicare beneficiaries with chronic hepatitis C, 2014-2016.J Manag Care Spec Pharm. 2019; 25: 1236-1242https://doi.org/10.18553/jmcp.2019.25.11.1236
- Aging of hepatitis C virus (HCV)-infected persons in the United States: a multiple cohort model of HCV prevalence and disease progression.Gastroenterology. 2010; 138 (e5216): 513-521https://doi.org/10.1053/j.gastro.2009.09.067
- Treatment of chronic hepatitis C in the aged - does it impact life expectancy? A decision analysis.PLoS One. 2016; 11e0157832https://doi.org/10.1371/journal.pone.0157832
- Impact of rural residence and health system structure on quality of liver care.PLoS One. 2013; 8: e84826https://doi.org/10.1371/journal.pone.0084826
- Contextual analysis of determinants of late diagnosis of hepatitis C virus infection in Medicare patients.Hepatology. 2015; 62: 68-78https://doi.org/10.1002/hep.27775
- Provider workforce assessment in a rural hepatitis C epidemic: implications for scale-up of antiviral therapy.J Prim Care Community Health. 2015; 6: 215-217https://doi.org/10.1177/2150131914560229
- Primary care and hepatology provider-perceived barriers to and facilitators of hepatitis C treatment candidacy and adherence.Dig Dis Sci. 2017; 62: 1933-1943https://doi.org/10.1007/s10620-017-4608-9
- Hepatitis C virus detection and treatment in rural communities.Gastroenterol Hepatol (N Y). 2018; 14: 720-722
- Challenges facing a rural opioid epidemic: treatment and prevention of HIV and hepatitis C.Curr HIV/AIDS Rep. 2018; 15: 245-254https://doi.org/10.1007/s11904-018-0393-0
- Strategies for the elimination of hepatitis C virus infection as a public health threat in the United States.Curr Hepatol Rep. 2018; 17: 111-120https://doi.org/10.1007/s11901-018-0394-x
- Hepatitis C management simplification from test to cure: a framework for primary care providers.Clin Ther. 2018; 40: 1234-1245https://doi.org/10.1016/j.clinthera.2018.05.010
- Expanding access to hepatitis C virus treatment–extension for Community Healthcare Outcomes (ECHO) project: disruptive innovation in specialty care.Hepatology. 2010; 52: 1124-1133https://doi.org/10.1002/hep.23802
- Outcomes of treatment for hepatitis C virus infection by primary care providers.N Engl J Med. 2011; 364: 2199-2207https://doi.org/10.1056/NEJMoa1009370
- Hepatitis C treatment delivery mandates optimizing available health care human resources: a case for task shifting.JAMA. 2016; 315: 1947-1948https://doi.org/10.1001/jama.2016.1993
- Evaluating a collaborative approach to improve prior authorization efficiency in the treatment of hepatitis C virus.Qual Manag Health Care. 2017; 26: 136-139https://doi.org/10.1097/QMH.0000000000000137
- Expanding treatment access for chronic hepatitis C with task-shifting in the era of direct-acting antivirals.J Clin Transl Hepatol. 2017; 5: 130-133https://doi.org/10.14218/JCTH.2016.00059
- Polypharmacy and comorbidity are associated with a lower early virologic response in hepatitis C patients treated with first generation protease inhibitor triple therapy: a preliminary analysis.Dig Dis Sci. 2013; 58: 3348-3358https://doi.org/10.1007/s10620-013-2812-9
- Medicines use and spending in the U.S.: a review of 2016 and outlook to 2021.QuintilesIMS Institute, Parsippany, NJ2017https://structurecms-staging-psyclone.netdna-ssl.com/client_assets/dwonk/media/attachments/590c/6aa0/6970/2d2d/4182/0000/590c6aa069702d2d41820000.pdf(Published May)Date accessed: September 13, 2019
- Effect of Medicare payment on rural health care systems.J Rural Health. 2002; 18: 147-163https://doi.org/10.1111/j.1748-0361.2002.tb00927.x
- Absolute insurer denial of direct-acting antiviral therapy for hepatitis C: a national specialty pharmacy cohort study.Open Forum Infect Dis. 2018; 5: ofy076https://doi.org/10.1093/ofid/ofy076
- Disparities in absolute denial of modern hepatitis C therapy by type of insurance.Clin Gastroenterol Hepatol. 2016; 14: 1035-1043https://doi.org/10.1016/j.cgh.2016.03.040
- CCW chronic condition algorithms.2019https://www2.ccwdata.org/web/guest/condition-categories(Published)Date accessed: September 24, 2020
- Early treatment uptake and cost burden of hepatitis C therapies among newly diagnosed hepatitis C patients with a particular focus on HIV coinfection.Dig Dis Sci. 2020; 65: 3159-3174https://doi.org/10.1007/s10620-019-06037-z
- HHS, Health Resources and Services Administration, Bureau of Health Workforce.2019https://data.hrsa.gov/topics/health-workforce/ahrf(Updated July 31)Date accessed: October 7, 2019
- WWAMI, RUCA, Rural Health Research Center.2007http://depts.washington.edu/uwruca/ruca-download.php(Updated November 13)Date accessed: October 31, 2019
- EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis [published correction appears in J Hepatol. 2018;69(5):1207].J Hepatol. 2018; 69: 406-460https://doi.org/10.1016/j.jhep.2018.03.024
- A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.J Chronic Dis. 1987; 40: 373-383https://doi.org/10.1016/0021-9681(87)90171-8
- A class of K-sample tests for comparing the cumulative incidence of a competing risk.Ann Statist. 1988; 16: 1141-1154https://doi.org/10.1214/aos/1176350951
- Competing risk regression models for epidemiologic data.Am J Epidemiol. 2009; 170: 244-256https://doi.org/10.1093/aje/kwp107
- Clinicians’ views of hepatitis C virus treatment candidacy with direct-acting antiviral regimens for people who inject drugs.Subst Use Misuse. 2016; 51: 1218-1223https://doi.org/10.3109/10826084.2016.1161054
- Access to care for rural Medicare beneficiaries.J Rural Health. 2000; 16: 31-42https://doi.org/10.1111/j.1748-0361.2000.tb00434.x
- A public health approach to hepatitis C in an urban setting.Am J Public Health. 2017; 107: 922-926https://doi.org/10.2105/AJPH.2017.303718
- Increasing access to hepatitis C virus medications: a program model using patient navigators and specialty pharmacy to obtain prior authorization approval.J Manag Care Spec Pharm. 2018; 24: 329-333https://doi.org/10.18553/jmcp.2018.24.4.329
- Emerging epidemic of hepatitis C virus infections among young nonurban persons who inject drugs in the United States, 2006-2012.Clin Infect Dis. 2014; 59: 1411-1419https://doi.org/10.1093/cid/ciu643
- How to eliminate HCV in people who inject drugs in the USA.Lancet Infect Dis. 2018; 18: 134-135https://doi.org/10.1016/S1473-3099(17)30678-3
Article Info
Publication History
Published online: November 19, 2020
Identification
Copyright
© 2020 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.
