title: Determinants of Treatment Eligibility in Veterans With Hepatitis C Viral Infection.
abstract: The objective of this study was to determine the percentage of veterans with active hepatitis C virus (HCV) infection who were deemed to be candidates for treatment and to identify factors associated with treatment ineligibility.
  
  
  
  This was a multisite, retrospective cohort analysis of veterans with HCV infection within the Veteran Integrated Service Network 21. Patients evaluated between August and November 2015 who were viremic and not receiving HCV treatment were included in the analysis. Reasons for treatment exclusion were determined by an experienced clinician and recorded into a regional population management dashboard. Descriptive statistics were used to describe the population. The t test for normally distributed data, the Mann-Whitney rank sum test for data that failed normality testing, or the χ2test were used to examine differences between the treatment eligible and ineligible cohorts. Generalized linear mixed-effects models were conducted to estimate patient outcomes relevant to various disease states and characteristics while controlling for interfacility variability.
  
  
  
  The cohort included 1,003 veterans within 5 medical centers; 988 (98.5%) were male, and 625 (62%) had a fibrosis 4 score >3.25, indicating the presence of ALD. According to clinician classification, 478 (48%) were considered HCV treatment candidates, whereas 525 (52%) were determined to be treatment ineligible. The most common reasons documented by clinicians for treatment ineligibility included unstable or uncontrolled comorbidities (n = 118 [22.4%]), excessive alcohol use (n = 116 [22.1%]), and treatment refusal by the patient (n = 69 [13%]). On the basis of statistical modeling and reporting odds ratios (ORs) and 95% CIs, diagnoses of active alcohol use disorder (OR = 0.68; 95% CI, 0.47-0.98; P = 0.038), hepatocellular carcinoma (OR = 0.24; 95% CI, 0.13-0.47; P < 0.001), and palliative care status (OR = 0.21; 95% CI, 0.05-0.99; P = 0.049) were statistically associated with treatment ineligibility, whereas posttraumatic stress disorder (OR = 1.48; 95% CI, 1.01-2.18; P = 0.046) was associated with treatment eligibility. There were no statistically significant differences found for other psychiatric diagnoses or an encounter for homelessness.
  
  
  
  Results of this study indicate that a high percentage of patients may not be considered treatment eligible at initial clinical review. Within this veteran population, the presence of uncontrolled comorbidities and excessive alcohol use were the most commonly reported reasons for treatment ineligibility. On the basis of this analysis, processes could be established to address modifiable barriers to treatment, thus expanding the number of individuals receiving potentially curative therapy for HCV infection.
authors.affiliation: Veterans Affairs Sierra Pacific Network, Reno, Nevada. Electronic address: Janice.Sanders2@va.gov.
authors.forename: Janice
authors.initials: J
authors.lastname: Taylor
authors.affiliation: Veterans Affairs Northern California Healthcare System, Mather, California; University of the Pacific, Stockton, California.
authors.forename: Sian
authors.initials: S
authors.lastname: Carr-Lopez
authors.affiliation: Veterans Affairs Sierra Pacific Network, Mountain View, California.
authors.forename: Amy
authors.initials: A
authors.lastname: Robinson
authors.affiliation: Veterans Affairs Northern California Healthcare System, Martinez, California.
authors.forename: Robert
authors.initials: R
authors.lastname: Malmstrom
authors.affiliation: Veterans Affairs Northern California Healthcare System, Mather, California.
authors.forename: Karsten
authors.initials: K
authors.lastname: Duncan
authors.affiliation: Veterans Affairs Northern California Healthcare System, Mather, California; University of California Healthcare System, Sacramento, California.
authors.forename: Archana
authors.initials: A
authors.lastname: Maniar
authors.affiliation: Center for Innovation Implementation Veterans Affairs Palo Alto Healthcare System, Menlo Park, California.
authors.forename: A C Del
authors.initials: ACD
authors.lastname: Re
authors.affiliation: Veterans Affairs Sierra Pacific Network, Reno, Nevada.
authors.forename: Jannet M
authors.initials: JM
authors.lastname: Carmichael
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000998:Antiviral Agents / Q000627:therapeutic use*; D015897:Comorbidity; D005260:Female; D016174:Hepacivirus; D006526:Hepatitis C / Q000188:drug therapy*; D006801:Humans; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D012189:Retrospective Studies; D014728:Veterans
chemical_list: D000998:Antiviral Agents
keywords: direct-acting antivirals; hepatitis C; population management; pretreatment assessment; treatment candidate