Integrated Care Increases Treatment and Improves Outcomes of Patients With Chronic Hepatitis C Virus Infection and Psychiatric Illness or Substance Abuse.
OBJECTIVE
Patients with hepatitis C virus (HCV) infection with psychiatric disorders and/or substance abuse face significant barriers to antiviral treatment. New strategies are needed to improve treatment rates and outcomes. We investigated whether an integrated care (IC) protocol, which includes multidisciplinary care coordination and patient case management, could increase the proportion of patients with chronic HCV infection who receive antiviral treatment (a combination of interferon-based and direct-acting antiviral agents) and achieve a sustained virologic response (SVR).


METHODS
We performed a prospective randomized trial at 3 medical centers in the United States. Participants (n = 363 patients attending HCV clinics) had been screened and tested positive for depression, post-traumatic stress disorder, and/or substance use; they were assigned randomly to groups that received IC or usual care (controls) from March 2009 through February 2011. A midlevel mental health practitioner was placed at each HCV clinic to provide IC with brief mental health interventions and case management, according to formal protocol. The primary end point was SVR.


RESULTS
Of the study participants, 63% were non-white, 51% were homeless in the past 5 years, 64% had psychiatric illness, 65% were substance abusers within 1 year before enrollment, 57% were at risk for post-traumatic stress disorder, 71% had active depression, 80% were infected with HCV genotype 1, and 23% had advanced fibrosis. Over a mean follow-up period of 28 months, a greater proportion of patients in the IC group began receiving antiviral therapy (31.9% vs 18.8% for controls; P = .005) and achieved a SVR (15.9% vs 7.7% of controls; odds ratio, 2.26; 95% confidence interval, 1.15-4.44; P = .018). There were no differences in serious adverse events between groups.


CONCLUSIONS
Integrated care increases the proportion of patients with HCV infection and psychiatric illness and/or substance abuse who begin antiviral therapy and achieve SVRs, without serious adverse events. ClinicalTrials.gov # NCT00722423.
Gastroenterology Section, Medicine Service, VA San Diego Healthcare System, San Diego, California; Division of Gastroenterology, Department of Medicine, University of California, San Diego, San Diego, California. Electronic address: samuel.ho2@va.gov.
Samuel B
SB
Ho
Infectious Disease Section, James J. Peters VA Medical Center, Bronx, New York; Divisions of Infectious Disease and Liver Disease, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.
Norbert
N
Bräu
Gastroenterology Section, Medicine Service, VA Palo Alto Healthcare System, Palo Alto, California; Division of Gastroenterology and Hepatology, Stanford University, Stanford, California.
Ramsey
R
Cheung
Division of Biostatistics, Department of Family Medicine and Public Health, University of California, San Diego, San Diego, California.
Lin
L
Liu
Research Service, VA San Diego Healthcare System, San Diego, California.
Courtney
C
Sanchez
Research Service, VA San Diego Healthcare System, San Diego, California.
Marisa
M
Sklar
Gastroenterology Section, Medicine Service, VA Palo Alto Healthcare System, Palo Alto, California.
Tyler E
TE
Phelps
Research Service, James J. Peters VA Medical Center, Bronx, New York.
Sonja G
SG
Marcus
Research Service, VA San Diego Healthcare System, San Diego, California.
Michelene M
MM
Wasil
Research Service, James J. Peters VA Medical Center, Bronx, New York.
Amelia
A
Tisi
Research Service, VA Palo Alto Healthcare System, Palo Alto, California.
Lia
L
Huynh
Department of Psychiatry, VA San Diego Healthcare System, San Diego, California; Department of Psychiatry, University of California, San Diego, San Diego, California.
Shannon K
SK
Robinson
Infectious Disease Section, Medicine Service, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts; Departments of Health Policy and Management and Medicine, Boston University, Boston, Massachusetts.
Allen L
AL
Gifford
Research Service, VA Palo Alto Healthcare System, Palo Alto, California; Division of General Medical Disciplines, Department of Medicine, Stanford University, Stanford, California.
Steven M
SM
Asch
Division of Health Services Research & Development, Research Service, VA San Diego Healthcare System, San Diego, California; Division of Behavioral Medicine, Department of Family Medicine and Public Health, University of California, San Diego, San Diego, California.
Erik J
EJ
Groessl
D000328:Adult; D000368:Aged; D019090:Case Management / Q000458:organization & administration; D019033:Delivery of Health Care, Integrated / Q000379:methods*; D005260:Female; D019698:Hepatitis C, Chronic / Q000150:complications* / Q000188:drug therapy*; D006801:Humans; D008297:Male; D001523:Mental Disorders / Q000150:complications* / Q000188:drug therapy*; D008875:Middle Aged; D011446:Prospective Studies; D019966:Substance-Related Disorders / Q000150:complications* / Q000188:drug therapy*; D016896:Treatment Outcome; D014481:United States
Care Integration; Hepatitis C; PTSD; Substance Use Disorders