Prescribing trends in direct-acting antivirals for the treatment of hepatitis C in Ontario, Canada

Abstract

BACKGROUND: Direct-acting antivirals (DAA) offer an opportunity to cure hepatitis C. Reimbursement for DAAs has changed on two occasions since their inclusion on the Ontario public formulary. Whether these changes have appreciably modified prescribing patterns and increased access to DAAs is unknown. METHODS: We conducted a repeated cross-sectional study of DAA reimbursement by the Ontario Public Drug Programs from January 1, 2012, to December 31, 2018, to summarize the use of DAAs in Ontario and describe changes in DAA prescribing physician specialties over this period. We measured the total number of users quarterly. Results are reported overall and by prescriber type. RESULTS: A total of 27,116 individuals received a publicly funded prescription for a DAA from the first quarter (Q1) of 2012 to the fourth quarter (Q4) of 2018. Nearly two-thirds (n = 17,813; 65.7%) of all DAAs were prescribed by gastroenterologists, hepatologists, or infectious disease specialists. Use of DAAs over time appears to have had three major phases in uptake: (1) the introduction of DAA treatments on the Ontario public drug formulary as a prior authorization benefit in Q1 2015, (2) expanded listing of all DAAs as limited-use products on the formulary in Q1 2017, and (3) the introduction of newer DAAs in Q2 2018. CONCLUSIONS: Changes in listing of these agents had a direct impact on the use of DAAs overall. Generally, broader listing expanded access but did not appear to shift utilization patterns to primary care prescribers. Further understanding of who is not receiving treatment is needed.

Characterizing the cascade of care for hepatitis C virus infection among Status First Nations peoples in Ontario: a retrospective cohort study

“…Our time-to-event estimates and uptake rates also likely reflect changes in treatment availability over the study period, including the expanded eligibility for public funding of DAAs for HCV in 2017 in Ontario. 28 The long time from testing positive for HCV RNA to treatment in some individuals may have reflected the documented warehousing effect, with a backlog of treatment-eligible individuals who deferred treatment in anticipation of the wider availability of DAAs. 42 However, crude analyses of ODB records up to 2020 were not indicative of higher prescribing trends after 2017 (Appendix 5).…”

“… 47 , 48 Therefore, allowing other health care professionals such as nurse practitioners to prescribe DAA treatment may increase access. 28 In addition, as the efficacy of treatment relies on adherence, HCV elimination efforts will need to provide services that emphasize peer and community supports, as well as trust between provider and patient, which have been shown to increase adherence and treatment completion among Indigenous peoples. 49 Broader efforts to promote and implement antiracism and cultural safety training for health care providers will be critical to fostering and restoring trust between Indigenous Peoples and the health care system to encourage them to seek HCV testing and care.…”

“…Second-generation DAA treatments were launched in Canada in 2014, 27 followed by changes in reimbursement criteria in Ontario after 2015. 28 To identify potential improvements in care from wider availability and use of DAA treatments, we examined the cascade of care for people alive and in the province on Dec. 31, 2013 (hereby referred to as the “pre-DAA era”).…”

Impact of COVID-19 on Prescribing Trends of Direct-Acting Antivirals for the Treatment of Hepatitis C in Ontario, Canada

“…HCV testing is a requirement for diagnosis and subsequent treatment, and reduced testing is likely to have also contributed to decreases in prescribing. Prescribing by infectious disease specialists surpassed gastroenterologists/hepatologists in Q3-2019 as infectious disease specialists are more likely to work with marginalized populations and often have established partnerships with public health programs (5). Decreases in prescribing by infectious disease physicians in Q1-2020 may be attributed to these physicians, in particular, having increased duties associated with the pandemic, resulting in rescheduled appointments.…”

Time Costs and Out-of-Pocket Costs in Patients With Chronic Hepatitis C in a Publicly Funded Health System

“…At the time of this study, DAAs were new treatments that had not been included in the Ontario publicly funded drug formulary; patients had to apply for reimbursement through special authorization and would be reimbursed if they are eligible. 27,28 The objective of this study was to estimate the OOP and time costs associated with CHC healthcare for patients and their caregivers. We recruited patients with CHC from a tertiary care hospital setting and a community care setting that provided services to individuals who are marginalized by poverty or substance use.…”