The hepatitis C cascade of care in a 1945-1965 birth cohort in Southern United States Open Access

Abstract

Background: Chronic hepatitis C (HCV) affects an estimated 2-2.8 million people living in the United States, most of whom were born between 1945-1965. Left untreated, HCV can contribute to complications, such as cirrhosis, liver cancer, and death. The recent introduction of direct-acting antiviral (DAA) medications provides effective treatment with minimal side effects, and public health organizations have called for HCV elimination by 2030. The cascade of care is a useful model to assist efforts toward elimination by tracking patients through steps of clinical care required for cure.

Methods: Clinical and demographic data were extracted from a database of electronic health record data for persons who: were born during 1945-1965, received outpatient care on or after January 1, 2014, and were screened for HCV between January 1, 2014-June 1, 2017. Laboratory test results and records of DAA prescriptions were used to determine seropositivity, confirmatory testing, linkage to care, antiviral treatment initiation, and virologic cure. Decision tree and random forest models were used to identify sociodemographic and clinical predictors of progression through the cascade of care.

Results: Only 3,399 of the 121,807 patients in the 1945-1965 birth cohort who received outpatient care during the study period were screened for HCV. 540 patients were seropositive, and 442 had detectable HCV RNA. Of the 442 patients with HCV, 237 were linked to care, and predictive variables included: age at first HCV screening, insurance at first HCV screening, race, fibrosis and/or cirrhosis, other liver disease, ascites, and transplanted liver. Of those linked to care, 65 initiated antiviral treatment, and insurance at first HCV screening, gender, other liver cancer, steatosis, and liver cell carcinoma were predictive variables. Only 32 patients achieved virologic cure, and insurance at first HCV screening, transplanted liver, and ethnicity were predictive variables. 

Conclusion: HCV screening rates were low, and seroprevalence in the screened population was high. There were low rates of progression through the cascade of care with less than 10% of patients with HCV being cured. Many sociodemographic and clinical variables were related to progression through the cascade of care, and more work is needed to improve HCV care.

Table of Contents

Introduction .................................................................................................................................. 1

Statement of the problem ................................................................................................... 1

Background ........................................................................................................................ 2

           Chronic hepatitis C (HCV) .................................................................................... 2

           1945-1965 birth cohort .......................................................................................... 2

           Cascade of care ...................................................................................................... 3

Screening and confirmatory testing ....................................................................... 4

Linkage to care ....................................................................................................... 4

Initiation of antiviral treatment .............................................................................. 4

Virologic cure ........................................................................................................ 5

           Specific aims ...................................................................................................................... 5

                       Aim 1 ..................................................................................................................... 5

                       Aim 2 ..................................................................................................................... 6

Introduction to manuscripts ............................................................................................... 6

           Summary ............................................................................................................................ 6

           References .......................................................................................................................... 8

Manuscript 1: Hepatitis C cascade of care in the United States: Systematic review of current applications ................................................................................................................... 15

           Abstract ............................................................................................................................ 15

           Background ...................................................................................................................... 16

Methods ............................................................................................................................ 17

Results .............................................................................................................................. 19

                       General study characteristics ............................................................................... 27

                       Study sample characteristics ................................................................................ 28

Study setting characteristics ................................................................................. 29

Cascade of care steps ........................................................................................... 30

           Pre-treatment ............................................................................................ 30

           Antiviral treatment ................................................................................... 32

           Post-treatment .......................................................................................... 32

           Discussion ........................................................................................................................ 33

           Conclusion ....................................................................................................................... 37

References ........................................................................................................................ 39

Manuscript 2: Hepatitis C cascade of care in a 1945-1965 birth cohort in the Southern United States ............................................................................................................................... 46

           Abstract ............................................................................................................................ 46

           Background ...................................................................................................................... 47

Methods ............................................................................................................................ 49

           Data source and analytic strategy ........................................................................ 49

           Sample .................................................................................................................. 50

           Cascade of care .................................................................................................... 50

                       Screening and confirmatory testing ......................................................... 50

                       Linkage to care ......................................................................................... 51

                       Initiation of antiviral treatment ................................................................ 52

Virologic cure .......................................................................................... 52

Drop-offs between steps .......................................................................... 53

Results .............................................................................................................................. 53

Discussion ........................................................................................................................ 55

Conclusion ....................................................................................................................... 57

References ........................................................................................................................ 59

Manuscript 3: Predictors of progression through the hepatitis C cascade of care in a 1945-1965 birth cohort using decision trees and random forests ................................................... 68

Abstract ............................................................................................................................ 68

           Background ...................................................................................................................... 69

Methods ............................................................................................................................ 71

Results .............................................................................................................................. 75

           Linkage to care ..................................................................................................... 75

           Initiation of antiviral treatment ............................................................................ 78

Virologic cure ...................................................................................................... 81

Discussion ........................................................................................................................ 84

Conclusion ....................................................................................................................... 88

References ........................................................................................................................ 90

Conclusion .................................................................................................................................. 98

Summary of results .......................................................................................................... 98

           Implications for practice and research ........................................................................... 101

           Strengths and limitations ................................................................................................ 101

Conclusion ..................................................................................................................... 102

References ...................................................................................................................... 104

About this Dissertation

Rights statement

• Permission granted by the author to include this thesis or dissertation in this repository. All rights reserved by the author. Please contact the author for information regarding the reproduction and use of this thesis or dissertation.

School	Laney Graduate School
Department	Nursing
Degree	Ph.D.
Submission	Dissertation
Language	English
Research Field	Health Sciences, Public Health Health Sciences, Nursing
Keyword	hepatitis C cascade of care machine learning
Committee Chair / Thesis Advisor	Hertzberg, Vicki, Emory University
Committee Members	Cartwright, Emily, Emory University Simpson, Roy, Emory University Ho, Joyce, Emory University

Last modified

Primary PDF

Thumbnail	Title	Date Uploaded	Actions
	The hepatitis C cascade of care in a 1945-1965 birth cohort in Southern United States ()	2020-03-23 15:36:38 -0400	Press to Select an action Download

Supplemental Files

Thumbnail	Title	Date Uploaded	Actions