BaCKgRoUND aND aIMS: Although chronic HCV infection increases mortality, thousands of patients remain diagnosed-but-untreated (DBU). We aimed to (1) develop a DBU phenotyping algorithm, (2) use it to facilitate case finding and linkage to care, and (3) identify barriers to successful treatment. appRoaCH aND ReSUltS:We developed a phenotyping algorithm using Java and SQL and applied it to ~2.5 million EPIC electronic medical records (EMRs; data entered January 2003 to December 2017). Approximately 72,000 EMRs contained an HCV International Classification of Diseases code and/or diagnostic test. The algorithm classified 10,614 cases as DBU (HCV-RNA positive and alive). Its positive and negative predictive values were 88% and 97%, respectively, as determined by manual review of 500 EMRs randomly selected from the ~72,000. Navigators reviewed the charts of 6,187 algorithm-defined DBUs and they attempted to contact potential treatment candidates by phone. By June 2020, 30% (n = 1,862) had completed an HCV-related appointment. Outcomes analysis revealed that DBU patients enrolled in our care coordination program were more likely to complete treatment (72% [n = 219] vs. 54% [n = 256]; P < 0.001) and to have a verified sustained virological response (67% vs. 46%; P < 0.001) than other patients. Fortyeight percent (n = 2,992) of DBU patients could not be reached by phone, which was a major barrier to engagement. Nearly half of these patients had Fibrosis-4 scores ≥ 2.67, indicating significant fibrosis. Multivariable logistic regression showed that DBUs who could not be contacted were less likely to have private insurance than those who could (18% vs. 50%; P < 0.001). CoNClUSIoNS:The digital DBU case-finding algorithm efficiently identified potential HCV treatment candidates, freeing resources for navigation and coordination. The algorithm is portable and accelerated HCV elimination when incorporated in our comprehensive program. (Hepatology 2021;74:2974-2987). HCV infection remains a major public health threat. Highly effective direct-acting antiviral (DAA) treatments have been available
Clinical health record data are used for HIV surveillance, but the extent to which these data are population representative is not clear. We compared age, marital status, body mass index, and pregnancy distributions in the Central Africa International Databases to Evaluate AIDS (CA-IeDEA) cohorts in Burundi and Rwanda to all people living with HIV and the subpopulation reporting receiving a previous HIV test result in the Demographic and Health Survey (DHS) data, restricted to urban areas, where CA-IeDEA sites are located. DHS uses a probabilistic sample for population-level HIV prevalence estimates. In Rwanda, the CA-IeDEA cohort and DHS populations were similar with respect to age and marital status for men and women, which was also true in Burundi among women. In Burundi, the CA-IeDEA cohort had a greater proportion of younger and single men than the DHS data, which may be a result of outreach to sexual minority populations at CA-IeDEA sites and economic migration patterns. In both countries, the CA-IeDEA cohorts had a higher proportion of underweight individuals, suggesting that symptomatic individuals are more likely to access care in these settings. Multiple sources of data are needed for HIV surveillance to interpret potential biases in epidemiological data.
Background Hepatocellular carcinoma (HCC) incidence and mortality vary by race/ethnicity and both are higher in Black patients than in Whites. For HCC surveillance, all cirrhotic patients are advised to undergo lifelong twice‐annual abdominal imaging. We investigated factors associated with surveillance and HCC incidence in a diverse HCC risk group, cirrhotic patients recently cured of hepatitis C virus (HCV) infection. Methods In this observational cohort study, all participants (n = 357) had advanced fibrosis/cirrhosis and were cured of HCV with antiviral treatment. None had Liver Imaging Reporting and Data System (LI‐RADS) 2–5 lesions prior to HCV cure. Ultrasound, computed tomography, and/or magnetic resonance imaging were used for surveillance. Results At a median follow‐up of 40 months [interquartile range (IQR) = 28–48], the median percentage of time up‐to‐date with surveillance was 49% (IQR) = 30%–71%. The likelihood of receiving a first surveillance examination was not significantly associated with race/ethnicity, but was higher for patients with more advanced cirrhosis, for example, bilirubin [odds ratio (OR) = 3.8/mg/dL, p = 0.002], private insurance (OR = 3.4, p = 0.006), and women (OR = 2.3, p = 0.008). The likelihood of receiving two or three examinations was significantly lower for non‐Hispanic Blacks and Hispanics versus non‐Hispanic Whites (OR = 0.39, and OR = 0.40, respectively, p < 0.005 for both) and for patients with higher platelet counts (OR = 0.99/10,000 cells/µl, p = 0.01), but higher for patients with private insurance (OR = 2.8, p < 0.001). Incident HCC was associated with higher bilirubin (OR = 1.7, p = 0.02) and lower lymphocyte counts (OR = 0.16, p = 0.01). Conclusions Contrary to best practices, HCC surveillance was associated with sociodemographic factors (insurance status and race/ethnicity) among patients cured of HCV. Guideline‐concordant surveillance is needed to address healthcare disparities.
Background Individuals infected with hepatitis C (HCV) often present with co-morbidities and complex socio-behavioral risk factors. Project INSPIRE was a care coordination and telementoring demonstration project which aimed to treat and cure HCV-infected patients while providing them with services and education to improve overall health outcomes and self-sufficiency. We examined changes in HCV-related health and behavior associated with completion of Project INSPIRE (the “intervention”). Methods Patients were enrolled into Project INSPIRE at clinical sites where they received HCV clinical care paired with care coordination services. Baseline and post-intervention surveys were distributed to participants in-person at a clinical site and/or via mail at two time-points, one before and one after the intervention. Surveys were mailed back to the researchers by participants, and participant-identifying information was used to link survey responses to clinical data for each respondent. Logistic models using generalized estimating equations to account for partially overlapping observations examined the association between intervention participation and changes in self-reported overall health, emergency department (ED) visits and hospitalizations in the past 6 months, drug and alcohol use in the past 6 months, HCV knowledge, and general self-efficacy, adjusting for potential demographic and sociobehavioral confounding variables. Results The response rates for complete and partial surveys were 14.0% of 883 for baseline and 9.9% of 1,552 for post-intervention. In multivariable analyses (N=269, of which 50 were paired and 219 were unpaired), INSPIRE intervention participation was associated with a decreased odds of self-reported ED visits (OR: 0.34, 95% CI: 0.20–0.57), hospitalizations (OR: 0.30, 95% CI: 0.16–0.57), alcohol use (OR: 0.35, 95% CI: 0.18–0.69), and injection drug use (OR: 0.09, 95% CI: 0.02–0.34), and a 6.8% (CI: 1.6-12.2%) increase in reported self-efficacy (p=0.01). Conclusions Survey results suggest that INSPIRE successfully improved participant health behavior and self-efficacy, indicating the intervention’s value to patients, providers, and insurance companies beyond the immediate benefits of HCV treatment and cure. Participants also had a generally positive experience working with their care teams, indicating that further research should explore how an individualized care team can improve retention and patient referral rates compared with the HCV standard of care.
List of Illustrations 4 hypothesis was dominant from the end of the war to the mid 1980s, a period during which scholars such as George Mosse, Fritz Stern, and Hans%Ulrich Wehler were wrapped up in a search for the ideological origins of Nazism. The Sonderweg theory held that Germany had undergone a unique development that set it apart from other Western nations. After 1955, a great deal of credence was placed in the American historian Otto Pflanze!s claim that one could draw a straight line through Germany!s history from the failed democratic revolution of 1848 through Bismarck!s unification of Germany in 1871 and finally to the Third Reich. 6 Initially, the Wandervogel, with its "neo%Romantic view of nature+ and its reverence for German folklore, was interpreted so as to conform to the basic Sonderweg narrative. 7 In 1946, the British historian Howard Becker contended that both the aesthetic and ideological underpinnings of the Wandervogel, among which he counted pervasive anti%Semitism, the acceptance of an *unquestioned leader,+ and eventually a *turgid chauvinism,+ made it a natural precursor to the National Socialists. 8 However, he believed the Wanderv$gel to possess only a dim awareness of their patriotic sentiment before World War One. He attributed their lack of geopolitical expansionist planning to their *irresponsible Romanticism+ and desire to rebel against the adult world, rather than to a conscious preference for non%chauvinist nationalism. 9 He claimed that later *the First World War revealed the true character of the Free German Youth and affiliated groups+ and finally exposed their latent right%wing nationalism and link to the National Socialists. 10
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