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.
Highlights
Patients are referred to the Vanderbilt University Medical Center (VUMC) Infectious Diseases (ID) Clinic from local community providers, by self-referral, or through internal VUMC referrals, including patients seen in internal medicine clinics, screened through the emergency department, and those receiving human immunodeficiency virus (HIV) care at the Vanderbilt Comprehensive Care Clinic, Following a referral to the ID Clinic, an appointment is scheduled and a reminder letter is sent to the address listed in the electronic medical record (EMR) or provided by the referring provider
A total of 193 patients were referred to the VUMC ID Clinic for hepatitis C virus (HCV) infection that met inclusion criteria; six patients were actively progressing through the cascade of care (CoC) and were excluded from this analysis
Of the 187 patients referred to the ID clinic, 120 patients (64%) completed evaluation for treatment, 119 (64%) were prescribed treatment, 114 (61%) were approved for treatment, 113 (60%) initiated treatment, 107 (57%) completed treatment, and 100 (53%) achieved an sustained virologic response (SVR)
Summary
A single-center, ambispective cohort study of patients receiving care at the Vanderbilt University Medical Center (VUMC) Infectious Diseases (ID) Clinic was performed. The VUMC ID Clinic employs an integrated model of care for patients with HCV consisting of three physicians, one clinical pharmacist, one pharmacy technician, and one nurse. Within this program, the physician team provides clinical evaluation and assessment in preparation for DAA therapy. The pharmacist delivers comprehensive medication management, including an evaluation for regimen appropriateness, drug interaction screening and mitigation, patient education, and DAA monitoring. The pharmacist and pharmacy technician ensure ongoing access to DAA treatment from prescription to completion of prescribed therapy either through insurers or patient assistance programs (PAP)
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