Disparities in Initiation of Direct-Acting Antiviral Agents for Hepatitis C Virus Infection in an Insured Population
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 Norther...
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| Published in: | Public health reports (1974) Vol. 133; no. 4; pp. 452 - 460 |
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| Language: | English |
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Los Angeles, CA
ASSOCIATION OF SCHOOLS & PROGRAMS OF PUBLIC HEALTH
01-07-2018
SAGE Publications SAGE PUBLICATIONS, INC |
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| Abstract | 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. |
|---|---|
| AbstractList | 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. 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. 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. 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. 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). 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. 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.OBJECTIVESThe 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.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.METHODSWe 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.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).RESULTSOf 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).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.CONCLUSIONSRacial/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. |
| Author | Quesenberry, Charles P. Seo, Suk I. Korn, Daniel G. Pauly, Mary Pat Chamberland, Scott Lam, Jennifer O. Ready, Joanna Saxena, Varun Champsi, Jamila H. Gittleman, Laura C. Marcus, Julia L. Hurley, Leo B. Lai, Jennifer B. Witt, David J. Silverberg, Michael J. |
| AuthorAffiliation | 9 Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA, USA 4 Kaiser Permanente South San Francisco Medical Center, South San Francisco, CA, USA 8 Kaiser Permanente Sacramento Medical Center, Sacramento, CA, USA 5 Medical Group Support Services, Kaiser Permanente Northern California, Oakland, CA, USA 7 Kaiser Permanente San Rafael Medical Center, San Rafael, CA, USA 2 Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA 11 Kaiser Permanente Walnut Creek Medical Center, Walnut Creek, CA, USA 3 Regional Pharmacy, Kaiser Permanente Northern California, Oakland, CA, USA 10 Kaiser Permanente Antioch Medical Center, Antioch, CA, USA 6 Kaiser Permanente Oakland Medical Center, Oakland, CA, USA 1 Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA |
| AuthorAffiliation_xml | – name: 2 Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA – name: 3 Regional Pharmacy, Kaiser Permanente Northern California, Oakland, CA, USA – name: 4 Kaiser Permanente South San Francisco Medical Center, South San Francisco, CA, USA – name: 8 Kaiser Permanente Sacramento Medical Center, Sacramento, CA, USA – name: 6 Kaiser Permanente Oakland Medical Center, Oakland, CA, USA – name: 11 Kaiser Permanente Walnut Creek Medical Center, Walnut Creek, CA, USA – name: 5 Medical Group Support Services, Kaiser Permanente Northern California, Oakland, CA, USA – name: 9 Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA, USA – name: 1 Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA – name: 7 Kaiser Permanente San Rafael Medical Center, San Rafael, CA, USA – name: 10 Kaiser Permanente Antioch Medical Center, Antioch, CA, USA |
| Author_xml | – sequence: 1 givenname: Julia L. surname: Marcus fullname: Marcus, Julia L. organization: Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA – sequence: 2 givenname: Leo B. surname: Hurley fullname: Hurley, Leo B. organization: Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA – sequence: 3 givenname: Scott surname: Chamberland fullname: Chamberland, Scott organization: Regional Pharmacy, Kaiser Permanente Northern California, Oakland, CA, USA – sequence: 4 givenname: Jamila H. surname: Champsi fullname: Champsi, Jamila H. organization: Kaiser Permanente South San Francisco Medical Center, South San Francisco, CA, USA – sequence: 5 givenname: Laura C. surname: Gittleman fullname: Gittleman, Laura C. organization: Medical Group Support Services, Kaiser Permanente Northern California, Oakland, CA, USA – sequence: 6 givenname: Daniel G. surname: Korn fullname: Korn, Daniel G. organization: Kaiser Permanente Oakland Medical Center, Oakland, CA, USA – sequence: 7 givenname: Jennifer B. surname: Lai fullname: Lai, Jennifer B. organization: Kaiser Permanente San Rafael Medical Center, San Rafael, CA, USA – sequence: 8 givenname: Jennifer O. surname: Lam fullname: Lam, Jennifer O. organization: Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA – sequence: 9 givenname: Mary Pat surname: Pauly fullname: Pauly, Mary Pat organization: Kaiser Permanente Sacramento Medical Center, Sacramento, CA, USA – sequence: 10 givenname: Charles P. surname: Quesenberry fullname: Quesenberry, Charles P. organization: Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA – sequence: 11 givenname: Joanna surname: Ready fullname: Ready, Joanna organization: Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA, USA – sequence: 12 givenname: Varun surname: Saxena fullname: Saxena, Varun organization: Kaiser Permanente South San Francisco Medical Center, South San Francisco, CA, USA – sequence: 13 givenname: Suk I. surname: Seo fullname: Seo, Suk I. organization: Kaiser Permanente Walnut Creek Medical Center, Walnut Creek, CA, USA – sequence: 14 givenname: David J. surname: Witt fullname: Witt, David J. organization: Kaiser Permanente San Rafael Medical Center, San Rafael, CA, USA – sequence: 15 givenname: Michael J. surname: Silverberg fullname: Silverberg, Michael J. organization: Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA |
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| References | Daskalopoulou, Rodger, Phillips 2014; 1 Muir, Bornstein, Killenberg 2004; 350 Marcus, Hurley, Hare 2016; 73 Karter, Parker, Solomon 2018; 53 Canary, Klevens, Holmberg 2015; 163 Wilder, Jeffers, Ravendhran 2016; 63 Spradling, Xing, Rupp Mahajan, Xing, Liu 2014; 58 Aspinall, Corson, Doyle 2013; 57 Kowdley, Gordon, Reddy 2014; 370 Kanwal, Hoang, Spiegel 2007; 46 Boulware, Cooper, Ratner, LaVeist, Powe 2003; 118 Mehta, Lucas, Mirel 2006; 20 Van Houtven, Voils, Oddone 2005; 20 Grebely, Page, Sacks-Davis 2014; 59 Patel, Nelson, Id-Deen, Caldwell 2014; 51 Sulkowski, Naggie, Lalezari 2014; 312 Calvaruso, Craxi 2016; 36 Messer, Laraia, Kaufman 2006; 83 Hezode 2016; 36 Janjua, Islam, Wong 2017; 24 Rogal, McCarthy, Reid 2017; 62 King, Bornschlegel, Johnson, Rude, Laraque 2016; 131 Chak, Talal, Sherman, Schiff, Saab 2011; 31 Rousseau, Ioannou, Todd-Stenberg 2008; 98 Afdhal, Reddy, Nelson 2014; 370 Jayasekera, Arora, Ahmed 2016; 315 Manns, Wedemeyer, Cornberg 2006; 55 Castera, Vergniol, Foucher 2005; 128 Mehta, Genberg, Astemborski 2008; 33 Dimova, Zeremski, Jacobson, Hagan, Des Jarlais, Talal 2013; 56 Kanwal, Kramer, El-Serag 2016; 63 Feld, Kowdley, Coakley 2014; 370 Holmberg, Lu, Rupp 2013; 57 bibr6-0033354918772059 bibr23-0033354918772059 bibr31-0033354918772059 bibr10-0033354918772059 bibr1-0033354918772059 bibr36-0033354918772059 bibr14-0033354918772059 bibr40-0033354918772059 bibr27-0033354918772059 bibr44-0033354918772059 bibr7-0033354918772059 bibr30-0033354918772059 bibr22-0033354918772059 bibr35-0033354918772059 bibr39-0033354918772059 bibr4-0033354918772059 bibr26-0033354918772059 bibr13-0033354918772059 bibr8-0033354918772059 bibr43-0033354918772059 bibr17-0033354918772059 bibr12-0033354918772059 bibr25-0033354918772059 bibr34-0033354918772059 bibr20-0033354918772059 bibr38-0033354918772059 bibr21-0033354918772059 bibr3-0033354918772059 bibr33-0033354918772059 bibr18-0033354918772059 Spradling PR (bibr29-0033354918772059) bibr16-0033354918772059 bibr42-0033354918772059 bibr9-0033354918772059 bibr5-0033354918772059 bibr11-0033354918772059 bibr2-0033354918772059 bibr37-0033354918772059 bibr19-0033354918772059 bibr32-0033354918772059 bibr41-0033354918772059 bibr28-0033354918772059 bibr15-0033354918772059 SAS Institute (bibr24-0033354918772059) 2013 |
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The cost of direct-acting antiviral agents (DAAs) for hepatitis C virus (HCV) infection may contribute to treatment disparities. However, few data... The cost of direct-acting antiviral agents (DAAs) for hepatitis C virus (HCV) infection may contribute to treatment disparities. However, few data exist on... Objectives:The cost of direct-acting antiviral agents (DAAs) for hepatitis C virus (HCV) infection may contribute to treatment disparities. However, few data... |
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| SubjectTerms | 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 |
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| Title | Disparities in Initiation of Direct-Acting Antiviral Agents for Hepatitis C Virus Infection in an Insured Population |
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