Disparities in Initiation of Direct-Acting Antiviral Agents for Hepatitis C Virus Infection in an Insured Population

• Published in: Public health reports (1974) Vol. 133; no. 4; pp. 452 - 460
• Main Authors: Marcus, Julia L., Hurley, Leo B., Chamberland, Scott, Champsi, Jamila H., Gittleman, Laura C., Korn, Daniel G., Lai, Jennifer B., Lam, Jennifer O., Pauly, Mary Pat, Quesenberry, Charles P., Ready, Joanna, Saxena, Varun, Seo, Suk I., Witt, David J., Silverberg, Michael J.
• Format: Journal Article
• Language: English
• Published: Los Angeles, CA ASSOCIATION OF SCHOOLS & PROGRAMS OF PUBLIC HEALTH 01-07-2018; SAGE Publications; SAGE PUBLICATIONS, INC
• Subjects: Alcohol abuse; Alcoholic beverages; Antiviral agents; Antiviral Agents - economics; Antiviral Agents - therapeutic use; Antiviral drugs; Black People - statistics & numerical data; California - epidemiology; Clinical decision making; Confidence intervals; Data analysis; Decision making; Demographics; Deprivation; Drug abuse; Fibrosis; Government programs; Health care expenditures; Health care industry; Health care policy; Health insurance; Healthcare Disparities; Hepacivirus - isolation & purification; Hepatitis; Hepatitis C; Hepatitis C - drug therapy; Hepatitis C - epidemiology; Hepatitis C - ethnology; Hispanic Americans; Hispanic or Latino - statistics & numerical data; HIV; Human immunodeficiency virus; Humans; Infections; Insurance, Health - statistics & numerical data; Liver; Medicaid; Medicare; Middle Aged; Minority & ethnic groups; Neighborhoods; Patients; Poisson density functions; Regression analysis; Regression models; Retrospective Studies; Smoking; Socioeconomic Factors; Socioeconomic status; Socioeconomics; Statistical analysis; Substance use; Substance use disorder; Trust; United States; Viruses; White People - statistics & numerical data; United States; California; racial disparities; treatment; health care delivery; hepatitis; substance abuse
• ISSN: 0033-3549; 1468-2877; 1468-2877
• DOI: 10.1177/0033354918772059

Objectives:
The cost of direct-acting antiviral agents (DAAs) for hepatitis C virus (HCV) infection may contribute to treatment disparities. However, few data exist on factors associated with DAA initiation.
Methods:
We conducted a retrospective cohort study of HCV-infected Kaiser Permanente Northern California members aged ≥18 during October 2014 to December 2016, using Poisson regression models to evaluate demographic, behavioral, and clinical factors associated with DAA initiation.
Results:
Of 14 790 HCV-infected patients aged ≥18 (median age, 60; interquartile range, 53-64), 6148 (42%) initiated DAAs. DAA initiation was less likely among patients who were non-Hispanic black (adjusted rate ratio [aRR] = 0.7; 95% confidence interval [CI], 0.7-0.8), Hispanic (aRR = 0.8; 95% CI, 0.7-0.9), and of other minority races/ethnicities (aRR = 0.9; 95% CI, 0.8-1.0) than among non-Hispanic white people and among those with lowest compared with highest neighborhood deprivation index (ie, a marker of socioeconomic status) (aRR = 0.8; 95% CI, 0.7-0.8). Having maximum annual out-of-pocket health care costs >$3000 compared with ≤$3000 (aRR = 0.9; 95% CI, 0.8-0.9) and having Medicare (aRR = 0.8; 95% CI, 0.8-0.9) or Medicaid (aRR = 0.7; 95% CI, 0.6-0.8) compared with private health insurance were associated with a lower likelihood of DAA initiation. Behavioral factors (eg, drug abuse diagnoses, alcohol use, and smoking) were also significantly associated with a lower likelihood of DAA initiation (all P < .001). Clinical factors associated with a higher likelihood of DAA initiation were advanced liver fibrosis, HCV genotype 1, previous HCV treatment (all P < .001), and HIV infection (P = .007).
Conclusions:
Racial/ethnic and socioeconomic disparities exist in DAA initiation. Substance use may also influence patient or provider decision making about DAA initiation. Strategies are needed to ensure equitable access to DAAs, even in insured populations.