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Disparities in hepatitis C testing in U.S. veterans born 1945-1965.....(51%) had HCV testing with 8.1% HCV antibody and 5.4% RNA positive.
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Jnl of Hepatology Aug 2016
Of 6,669,388 birth cohort veterans, 4,221,135 (63%) received care within the VA from 2000-2013 with two or more visits. Of this group, 2,139,935 (51%) had HCV testing with 8.1% HCV antibody and 5.4% RNA positive. Significant variation in testing was observed across centers (range: 7-83%). Older, male, African-Americans, with established risk factors and receiving care from urban centers of excellence were more likely to be tested. Among veterans free of other established risk factors (HIV negative, HBV negative, ALT ≤40 U/L, FIB-4 ≤1.45, or APRI <0.5), HCV antibody and RNA were positive in 2.8% and 0.9%, respectively, comparable to established national average. At least 2.4-4.4% of veterans had scores suggesting advanced fibrosis (APRI ≥1.5 or FIB-4 >3.25) with >30-43% having positive HCV RNA but >16-20% yet to undergo testing for HCV.
Conclusions
Significant disparities are observed in HCV testing within the United States VA health system. Examination of the predictors of testing and HCV positivity may help inform national screening policies.
Discussion
To our knowledge, this is the largest study to evaluate national HCV testing practices in the U.S. This examination of a well-characterized cohort of 4.2 million veterans born 1945-65 for whom HCV testing practices were analyzed during a 14-year period of observation (2000-2013). A previous study addressing this issue in national VA reported a 63% testing rate with 10.3% HCV RNA positivity among birth cohort veterans, but was limited to a cross-sectional analysis of one-year data [19. This study reports a significantly lower HCV testing rate (51%) and HCV RNA positivity (5.4%). Our HCV RNA positivity rate remains higher than birth cohort estimates for the U.S. general population of 2.4% [17. Of note, restriction of our analysis to individuals without identifiable risk factors for HCV reveals a lower testing rate (39%) with HCV antibody prevalence of 2.8% and HCV RNA positivity (0.9%), more akin to the broader U.S. population [28. As more than 60% of U.S. veterans are not enrolled in VA care, caution is warranted in application of these findings to U.S. veterans not enrolled in VA care [29. As previously described [30, blacks and males were associated with higher rates of HCV testing, and higher prevalence rates of positive HCV Ab and positive HCV RNA. Fewer than 5% of veterans in the birth cohort had advanced fibrosis or cirrhosis, defined as FIB-4 >3.25 or APRI >1.5, yet more than one third were positive for HCV RNA, and as a group they comprised 30-43% of all patients with chronic HCV infection. It is notable that although veterans with FIB-4 >3.25 or APRI >1.5 had higher odds of being tested for HCV compared with veterans with lower fibrosis scores, approximately one in five were never tested for HCV despite the presence of advanced liver disease. Recent NHANES data [31 confirm that a significant proportion of individuals with advanced liver disease remain unaware of their disease, and that patients who were aware or unaware of their infection had a similar proportion of cirrhosis.
Through a series of national directives and interventions, including implementation of electronic health record (EHR) clinical reminders [22, the VA has successfully tested more than half the birth cohort veterans seen in care between 2000-2013, which exceeds testing rates reported in other large health care systems [32. Incorporation of targeted testing algorithms for at-risk or birth cohort individuals within health system EHRs may potentially enhance HCV testing in other non-VA populations [[28], [30]]. However, evidence to support specific EHR-based screening strategies remains lacking. We identified significant variability in HCV testing across VA centers (7-83%) and regional VISNs (36-66%) despite national directives, and signal the potential need for region or center-specific approaches to promote testing. Patient level predictors of this variability in testing included age, gender, and race, although observations regarding race require cautious interpretation due to a significant proportion of patients assigned to undeclared race status. Other patient level predictors included elevated ALT, co-infection with HIV and HBV, and high FIB-4/APRI, all of which were associated with higher HCV testing and HCV RNA positivity rates. Center level predictors of being tested include care received at urban and higher complexity centers, as well as VAs designated as centers of excellence in primary care and HCRCs. Of note, HCRCs were associated with lower testing but higher prevalence of HCV RNA positivity.
Our analysis has important limitations. First, although we have examined key patient, provider, and system-level predictors of HCV testing, many important predictors could not be evaluated, such as provider views of testing and screening, patient preference, and community acceptance of HCV testing. Second, although the VA CDW database provides a robust, comprehensive national analysis of 4.2 million birth cohort veterans, observations regarding HCV testing patterns in this cohort may not reflect testing patterns in veterans born before or after the 1945-1965 period. Third, although the rate of HCV testing in VA centers may exceed that within the private sector, observations regarding disparities in HCV testing among veterans may not reflect patterns in the non-veteran general population. Fourth, our analysis is restricted to the period 2000-2013, and therefore does not fully reflect the effect of CDC and USPSTF screening recommendations, or the potential influence of availability of highly effective, all-oral, interferon-free treatment regimens. Future studies are needed to further examine temporal trends in HCV testing and diagnosis in response to federal screening recommendations and national VA initiatives.
National VA HCV testing rates exceed those in the general population [33. With the availability of curative and potentially cost-effective interferon-free regimens [[34], [35]], improved detection of HCV is needed to reduce the ongoing burden of chronic liver disease [9. Careful analysis of key predictors of HCV testing and regional/local variation in testing practices may help inform national HCV testing strategies within VA and non-VA settings.
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