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Studies Look at Hepatitis C Care Cascade and Healthcare Utilization


Half of people with hepatitis C in the U.S. are aware of their infection, but fewer than 10% have been successfully treated and achieved sustained virological response (SVR), according to a meta-analysis published July 2 in the open-access journal PLoS ONE. Despite these gaps in testing, care, and treatment, hepatitis C accounts for a substantial share of healthcare utilization, especially among baby boomers, a related study found.

The concept of a "cascade of care" was developed to describe gaps in care for people with HIV. A similar continuum is now also being used for hepatitis C.

Baligh Yehia and Vincent Lo Re from the University of Pennsylvania Perelman School of Medicine and colleagues analyzed gaps in hepatitis C care, performing a medical literature review to estimate the number of people who completed each step along the continuum of care. Study findings were previously presented in part at the 2014 Conference on Retroviruses and Opportunistic Infections (CROI) in March.

The researchers searched MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews for English-language articles published between January 2003 and July 2013. Relevant articles addressed the total number of people with chronic hepatitis C virus (HCV) infection and proportions who were diagnosed and aware of their infection, had access to outpatient care, had a confirmed HCV RNA viral load measurement, underwent liver biopsy for fibrosis staging, were prescribed HCV treatment, and achieved SVR, or a lasting cure after finishing treatment.

Out of more than 9500 articles reviewed, 10 met the inclusion criteria. Studies were excluded if they focused on specific populations, involved only a single site, were conducted outside the U.S., or only included data collected prior to 2000.


  • Overall, 3.5 million people are estimated have chronic hepatitis C in the U.S.
  • 50% (1.7 million people  were diagnosed and aware of their infection, according to the meta-analysis.
  • 43% (1.5 million people) had access to outpatient care.
  • 27% (950,000 people) received confirmatory HCV RNA testing.
  • 17% (580,000 people) underwent fibrosis staging.
  • However, just 16% (550,000 people) were prescribed antiviral treatment.
  • Only 9% (330,000 people) achieved SVR.

"Continued efforts are needed to improve HCV care in the U.S.," the researchers concluded. "The proposed HCV treatment cascade provides a framework for evaluating the delivery of HCV care over time and within subgroups, and will be useful in monitoring the impact of new screening efforts and advances in antiviral therapy."

These findings will prove useful as the U.S. healthcare system continues to see an influx of people with hepatitis C due to expanded screening and the advent of highly effective direct-acting antiviral drugs such as sofosbuvir (Sovaldi) and simeprevir (Olysio), according to a University of Pennsylvania press release.

"There are many people who don't know that they have the infection, don't have access to hepatitis C care and medications, and who haven't been treated," said Yehia. "This information will be useful for ensuring better access to hepatitis C care and treatment in the coming years."

The Centers for Disease Control and Prevention (CDC) and U.S. Preventive Services Task Force recommend that all baby boomers born between 1945 and 1965, as well as people with risk factors on other age groups, should be screened for hepatitis C. Medicare and Medicaid will now cover such screening, which is expected to bring more people into care.

One factor contributing to the low proportion of people receiving treatment is that the former standard of care -- pegylated interferon plus ribavirin -- had difficult side effects, required 6 to 12 months of therapy, and only cured about half of treated patients. Many people with hepatitis C and their providers have been waiting for new drugs to use in interferon-free regimens, which have demonstrated cure rates of more than 90% in as little as 6 to 12 weeks in clinical trials.

Previously, due to the challenges and suboptimal effectiveness of interferon-based therapy, treatment was generally limited to people with progressive liver disease. With the new options, however, a growing number of experts think everyone infected with HCV should be eligible for treatment. But the new drugs are expensive -- $84,000 for a 12-week course of sofosbuvir -- which could present an ongoing barrier to treatment expansion.

"The new regimens will be game changers in the treatment of chronic hepatitis C," Lo Re stated in the press release. "Given the high prevalence of this infection, particularly in baby boomers who didn't know they were infected, having new, highly-effective treatment options to eradicate the virus will be a tremendous benefit to patients that will ultimately help us to reduce liver-related complications and re-infection rates."

"The advent of new antiviral agents for hepatitis C will shorten treatment duration, likely increasing the number of people offered treatment, and improving cure rates, which are the final two steps of the hepatitis C treatment cascade," Yehia added. "However, educating providers and the general public about prevention, care, and treatment, ensuring access to providers skilled in the treatment of hepatitis C, and addressing the high cost of these agents will be critical to maximizing the benefits of these new therapies."

Healthcare Utilization

A related study by James Galbraith from theUniversity of Alabama at Birmingham and colleagues analyzed health services used by adults with hepatitis C. They looked at data from the National Ambulatory Medical Care Survey, the National Hospital Ambulatory Medical Care Survey, and the Nationwide Inpatient Sample to characterize healthcare utilization during 2001-2010, divided by age group.

As described in the in the June 9 advance edition of Clinical Infectious Diseases, people with hepatitis C accounted for 2.29 million outpatient visits (0.28% of the 824 million total visits for all reasons), 475,224 inpatient visits (1.48% of 31.8 million total), and 72,138 emergency department visits (0.08% of 90 million total) annually. Baby boomers accounted for 73%, 71%, and 68% of these visits, respectively.

Out of all hepatitis C inpatient admissions, 35% among baby boomers and 14% among younger patients were due to liver-related complications. A substantial proportion of visits for other reasons were due to mental health conditions. "These findings highlight the burden of mental health disorders, which includes substance abuse and psychiatric illness, within this HCV-infected population," the study authors wrote.

While the number of outpatient visits remained stable during the study period, inpatient admissions among baby boomers with hepatitis C increased by more than 60%. Inpatient stays totaled 2.8 million days and cost more than $15 billion annually, the researchers calculated.

"Individuals with HCV infection are large users of outpatient, [emergency department], and inpatient health services," the authors concluded. "Resource use is highest and increasing in the 'baby boomer' generation," they added, while "[n]on-whites, uninsured individuals, and individuals receiving publicly funded health insurance were disproportionately affected in all healthcare settings."



BR Yehia, AJ Schranz, CA Umscheid, and V Lo Re. The Treatment Cascade for Chronic Hepatitis C Virus Infection in the United States: A Systematic Review and Meta-Analysis. PLoS ONE9(7):e101554. July 2, 2014.

JW Galbraith, JP Donnelly, R Franco, et al. National Estimates of Healthcare Utilization by Individuals with Hepatitis C Virus Infection in the United States. Clinical Infectious Diseases. June 9, 2014 (Epub ahead of print).

Other Source

University of Pennsylvania Perelman School of Medicine. Major Gaps in Hepatitis C Care Identified As New Drugs and Screening Efforts Emerge, Penn Study Finds. Press release. July 2, 2014.