Obstacles to successful treatment of hepatitis C in uninsured patients from a minority population

Abstract

BackgroundHepatitis C virus (HCV) treatment regimens (DAAs) are well tolerated, efficacious but costly. Their high cost and restricted availability, raises concerns about the outcome of treatment in uninsured patients. This study investigated sustained virologic response (SVR) outcomes in a predominately uninsured patient population and completion of four steps along the HCV treatment cascade.MethodsA retrospective chart review was conducted to characterize the patient population and analyze covariates to determine association with insurance status, attainment of SVR and progression through the HCV treatment cascade.ResultsOut of a total of 216 patients, 154 (71%) were uninsured. Approximately 50% of patients (109 of 216 patients) were male and 57% were Hispanic (123 of 216 patients). Sex, race, ethnicity, treatment compliance, and rates of complications were not associated with insurance status. Insured patients were older (median 60 years vs 57 years, p-value < 0.001) and had higher rates of cirrhosis: 32 out of 62 patients (52%) vs 48 out of 154 patients (31%) (p-value = 0.005). Insured patients were tested for SVR at similar rates as uninsured patients: 84% (52 of 62 patients) vs 81% (125 of 154 patients), respectively. Of those tested for SVR, the cure rate for insured patients was 98% (51 out of 52 patients) compared to 97% (121 out of 125 patients) in the uninsured. Out of those who completed treatment, 177 of 189 (94%) were tested for attainment of SVR. Compliance rates were significantly different between tested and untested patients: 88% (156 of 177 patients) vs 0% (0 of 12 patients), respectively (p-value < 0.001). However, insurance status, race ethnicity, cirrhosis, and complications were not associated with being tested for SVR.ConclusionsThese results demonstrate that insured and uninsured patients with chronic HCV infection, with access to patient assistance programs, can be treated and have comparable clinical outcomes. In addition, testing for SVR remains an important obstacle in completion of the HCV treatment cascade. Nevertheless, patient assistance programs remove a significant barrier for treatment access in real-world HCV infected populations.Electronic supplementary materialThe online version of this article (10.1186/s12967-018-1555-y) contains supplementary material, which is available to authorized users.

Underserved Does Not Mean Undeserved: Unfurling the HCV Care in the Safety Net

“…Stewart, et al evaluated an urban public hospital cohort of 435 HCV patients to assess real-world SVR rates in an underserved safety-net setting 3 . In this study, the investigators utilized multiple imputation statistical methods to account for the 28% missing SVR values and reported an overall SVR rate of 89%, which is comparable to that reported in other safety-net settings 6,7 . While using multiple imputation technique enhances validity of findings, the assumption that the missing data are from random subjects may be erroneous 8 .…”

“…The three studies in this issue highlight different approaches in enhancing treatment success: 1) an on-site specialty pharmacy program that systematically streamlines the process of initiating and monitoring HCV therapy along with patient education 2 ; 2) an individualized patient education and counseling on the importance of adherence to treatment completion and monitoring during a pre-treatment nurse visit 2 ; and 3) advanced practice provider-based on-treatment monitoring of compliance, adverse events, and treatment response 3 . In these studies and in others 7 ‘ 10–13 , it is clear that structured and integrated multidisciplinary models, patient navigation services, and access to patient assistance programs, particularly among safety-net populations, do improve all aspects of the HCV care cascade. Furthermore, utilization of multiple strategies, including enhanced integration of already existing safety-net health care services, tailored patient and interprofessional care team education, and broad dissemination of HCV guidelines may enhance adherence to post-treatment monitoring and HCC surveillance.…”

Predicting Treatment Failure for Initiators of Hepatitis C Virus Treatment in the era of Direct-Acting Antiviral Therapy

“…Studies have also found that the presence of HCC at the initiation of DAA therapy is significantly associated with treatment failure in patients with HCV, for reasons that are not entirely clear (Prenner et al, 2017;Konjeti and John, 2018;Kushner et al, 2018). Finally, insurance status may be a significant predictor of treatment failure as patients who are denied HCV therapy have a higher risk of developing more severe HCV-related symptoms and complications, such as cirrhosis and HCC, making them more difficult to cure (DeBose-Scarlett et al, 2018). Given that the incidence of absolute denial of DAA therapy has been found to be substantially higher among patients with private insurance vs. Medicaid or Medicare (Gowda et al, 2018), it is possible that the commercially-insured patients in our sample encountered more barriers to accessing HCV treatment.…”

“…Currently, validated tools to identify patients at high risk of HCV treatment failure do not exist and although barriers to HCV treatment initiation have been explored, factors associated with unsuccessful treatment completion have not been elucidated (Morrill et al, 2005;Kattakuzhy et al, 2017). In light of evidence that a large loss of patients throughout the HCV treatment cascade occurs after treatment initiation, early identification and intervention of these patients who initiate but fail treatment may have significant positive economic and public health impact (DeBose-Scarlett et al, 2018). Therefore, in alignment with a broader movement toward cost-effective personalized HCV therapy and identification of valid predictors of response for a given patient (Ferenci, 2004;Ochi et al, 2012;Beinhardt et al, 2013;Petta and Craxi, 2013;Andriulli et al, 2014;Ansaldi et al, 2014;Mathes et al, 2014;Petta et al, 2014;Thompson et al, 2014;Iannazzo et al, 2015;Backus et al, 2016;Jansen et al, 2017;Su et al, 2017;Kouris et al, 2018), our aim was to develop and evaluate a prediction model of treatment failure in patients initiating DAA therapy using demographic and clinical characteristics measured before treatment initiation.…”

"Sell an Ox" - The Price of Cure for Hepatitis C in Two Countries

“…21 Yet, not surprisingly, when treatment is offered to the uninsured in financial assistance programs which cover both pharmaceutical costs and testing, compliance and treatment outcomes were found to be similar to those of insured patients. 22 For many Americans, costs of medications and illness can be major determinants of personal bankruptcy and home foreclosures. 23 In a recent survey of a representative sample of the US population, when asked to "choose between two treatments, identical in every way except for their probability of a cure and their risk of driving the individual into bankruptcy, " the majority (70.5%) stated that they would choose cure "at all costs, " even at risk of bankruptcy, 21% weighted cure and financial protection equally and a surprising 8.5% chose financial solvency over cure.…”