Simone Bigelow, DO

Evidence summary

Continuous glucose monitoring: Nonsignificant reductions in event rates

A 2021 multicenter RCT (N = 175) evaluated CGM effectiveness in patients with basal ­insulin–treated T2D.¹ Patients (mean age, 57 years; mean A1C, 9.1%) wore a blinded CGM device for baseline glucose measurement (minimum of 168 hours) before being randomly assigned to either CGM (n = 116) or traditional blood glucose monitoring (BGM; n = 59). At 8-month follow-up, patients in the BGM group again had blinded sensors placed. A significant reduction in hypoglycemia duration was observed for the CGM group vs the BGM group at 8 months for glucose values < 70 mg/mL (adjusted mean difference [aMD] = –0.24%; 95% CI, –0.42 to –0.05) and < 54 mg/dL (aMD = –0.10%; 95% CI, –0.15 to –0.04). A nonsignificant decrease in severe hypoglycemic events requiring resuscitative assistance occurred for BGM (2%) vs CGM (1%) patients. Study limitations included virtual visits due to COVID-19 and a short follow-­up period.

A 2022 multicenter prospective study (N = 174) examined CGM effects on hypoglycemia frequency and severity in adults with T2D.² Patients with insulin-requiring T2D (mean age, 61 years; mean A1C, 8.0%) participated in a 12-month study with 6 months of self-monitored blood glucose (SMBG) followed by 6 months of CGM use. The primary outcome was the rate of severe hypoglycemic events. A nonsignificant decrease was observed in the CGM group compared to the SMBG group for hypoglycemic event rate, per participant per 6-month period (relative risk [RR] = 0.43; 95% CI, 0.07-2.64). Four moderate hypoglycemic adverse events occurred in the SMBG phase vs 2 in the CGM phase. Financial support by the study sponsor decreases the study’s validity.

A 2021 prospective study (N = 90) evaluated the use of CGM to improve glycemic control.³ Patients younger than 66 years with insulin-treated T2D and an A1C > 7.5% participated in a 7-day blinded CGM cycle every 4 months for 1 year. A nonsignificant decrease in hypoglycemia duration was observed for glucose values < 70 mg/dL and < 54 mg/dL at 12 months. No change in hypoglycemic event rate was seen with the use of CGM. Funding by the device manufacturer was a limitation of this study.

Flash glucose monitoring: Mixed results on hypoglycemia events

A 2019 open-label RCT (N = 82) assessed the effectiveness of FGM on diabetes control.⁴ Patients with insulin-treated T2D were randomly assigned to the intervention or standard­-care groups. The intervention group (n = 46; mean age, 66 years; mean A1C, 8.3%) used the FGM system for 10 weeks, while the standard-care group (n = 36; mean age, 70 years; mean A1C, 8.9%) maintained use of their glucometers. Both groups received similar types and duration of counseling. Treatment satisfaction was the primary outcome; total hypoglycemic events was a secondary outcome. No significant difference in the number of hypoglycemic episodes was observed between the intervention and control groups at 55 to 70 mg/dL (RR = 0.79; 95% CI, 0.44-1.4) or < 54 mg/dL (RR = 1.27; 95% CI, 0.38-4.2). No adverse events of severe hypoglycemia occurred during the study. Funding by the device manufacturer was a limitation of this study.

Continuous glucose monitoring and flash glucose monitoring do not decrease symptomatic hypoglycemia episodes but do lower time in hypoglycemia.

A 2017 open-label, multicenter RCT (N = 224) assessed FGM efficacy.⁵ Adults (mean age, 59 years; mean A1C, 8.8%) with T2D on intensive insulin therapy were randomized to FGM (n = 149) or SMBG (n = 75) after a 14-day masked baseline period. The 6-month treatment phase was unblinded. The duration of hypoglycemic events (glucose values < 70 mg/dL and < 55 mg/dL) was obtained from the sensors. Compared to the SMBG group, the FGM group spent 43% less time at < 70 mg/dL (aMD = –0.47 ± 0.13 h/d; P = .0006) and 53% less time at < 55 mg/dL (aMD = –0.22 ± 0.068 h/d; P = .0014). Hypoglycemic event rates significantly decreased by 28% (aMD = –0.16 ± 0.065; P = 0.016) and 44% (aMD = –0.12 ± 0.037; P = .0017) for glucose levels < 70 mg/dL and < 55 mg/dL, respectively. A nonsignificant difference occurred in severe hypoglycemic events requiring third-party assistance for the FGM (2%) vs control (1%) groups. Involvement of the device manufacturer and unblinded group allocations are study limitations.

A 2021 single-arm, multicenter prospective study looked at the impact of FGM on glycemic control in adults with insulin-treated T2D (N = 90; mean age, 64 years; mean A1C, 7.5%).⁶ After a 14-day baseline period consisting of masked sensor readings paired with self-monitored fingerstick tests, participants were followed for 11 weeks using the sensor to monitor glucose levels. The primary outcome was amount of time spent in hypoglycemia (< 70 mg/dL), with secondary outcomes including time and events in hypoglycemia (< 70, < 55, or < 45 mg/dL). No significant decrease in hypoglycemia duration or hypoglycemic event rates at < 70, < 55, or < 45 mg/­dL was observed for FGM compared to baseline. Adverse events were observed in 64% of participants; 94% of the events were hypoglycemia related. Serious adverse events were reported for 5.3% of participants. The single-arm study format, lack of generalizability due to the single-race study population, and sponsor support were study limitations.

Editor’s takeaway

This reasonably good evidence shows a decrease in measured or monitored hypoglycemia, a disease-oriented outcome, but it did not reach statistical significance for symptomatic hypoglycemia (1% vs 2%), a patient-oriented outcome. Nevertheless, in patients reporting symptomatic hypoglycemia, a continuous or flash glucose monitor may allow for more aggressive glucose control.

Evidence summary

Continuous glucose monitoring: Nonsignificant reductions in event rates

A 2021 multicenter RCT (N = 175) evaluated CGM effectiveness in patients with basal ­insulin–treated T2D.¹ Patients (mean age, 57 years; mean A1C, 9.1%) wore a blinded CGM device for baseline glucose measurement (minimum of 168 hours) before being randomly assigned to either CGM (n = 116) or traditional blood glucose monitoring (BGM; n = 59). At 8-month follow-up, patients in the BGM group again had blinded sensors placed. A significant reduction in hypoglycemia duration was observed for the CGM group vs the BGM group at 8 months for glucose values < 70 mg/mL (adjusted mean difference [aMD] = –0.24%; 95% CI, –0.42 to –0.05) and < 54 mg/dL (aMD = –0.10%; 95% CI, –0.15 to –0.04). A nonsignificant decrease in severe hypoglycemic events requiring resuscitative assistance occurred for BGM (2%) vs CGM (1%) patients. Study limitations included virtual visits due to COVID-19 and a short follow-­up period.

A 2022 multicenter prospective study (N = 174) examined CGM effects on hypoglycemia frequency and severity in adults with T2D.² Patients with insulin-requiring T2D (mean age, 61 years; mean A1C, 8.0%) participated in a 12-month study with 6 months of self-monitored blood glucose (SMBG) followed by 6 months of CGM use. The primary outcome was the rate of severe hypoglycemic events. A nonsignificant decrease was observed in the CGM group compared to the SMBG group for hypoglycemic event rate, per participant per 6-month period (relative risk [RR] = 0.43; 95% CI, 0.07-2.64). Four moderate hypoglycemic adverse events occurred in the SMBG phase vs 2 in the CGM phase. Financial support by the study sponsor decreases the study’s validity.

A 2021 prospective study (N = 90) evaluated the use of CGM to improve glycemic control.³ Patients younger than 66 years with insulin-treated T2D and an A1C > 7.5% participated in a 7-day blinded CGM cycle every 4 months for 1 year. A nonsignificant decrease in hypoglycemia duration was observed for glucose values < 70 mg/dL and < 54 mg/dL at 12 months. No change in hypoglycemic event rate was seen with the use of CGM. Funding by the device manufacturer was a limitation of this study.

Flash glucose monitoring: Mixed results on hypoglycemia events

A 2019 open-label RCT (N = 82) assessed the effectiveness of FGM on diabetes control.⁴ Patients with insulin-treated T2D were randomly assigned to the intervention or standard­-care groups. The intervention group (n = 46; mean age, 66 years; mean A1C, 8.3%) used the FGM system for 10 weeks, while the standard-care group (n = 36; mean age, 70 years; mean A1C, 8.9%) maintained use of their glucometers. Both groups received similar types and duration of counseling. Treatment satisfaction was the primary outcome; total hypoglycemic events was a secondary outcome. No significant difference in the number of hypoglycemic episodes was observed between the intervention and control groups at 55 to 70 mg/dL (RR = 0.79; 95% CI, 0.44-1.4) or < 54 mg/dL (RR = 1.27; 95% CI, 0.38-4.2). No adverse events of severe hypoglycemia occurred during the study. Funding by the device manufacturer was a limitation of this study.

Continuous glucose monitoring and flash glucose monitoring do not decrease symptomatic hypoglycemia episodes but do lower time in hypoglycemia.

A 2017 open-label, multicenter RCT (N = 224) assessed FGM efficacy.⁵ Adults (mean age, 59 years; mean A1C, 8.8%) with T2D on intensive insulin therapy were randomized to FGM (n = 149) or SMBG (n = 75) after a 14-day masked baseline period. The 6-month treatment phase was unblinded. The duration of hypoglycemic events (glucose values < 70 mg/dL and < 55 mg/dL) was obtained from the sensors. Compared to the SMBG group, the FGM group spent 43% less time at < 70 mg/dL (aMD = –0.47 ± 0.13 h/d; P = .0006) and 53% less time at < 55 mg/dL (aMD = –0.22 ± 0.068 h/d; P = .0014). Hypoglycemic event rates significantly decreased by 28% (aMD = –0.16 ± 0.065; P = 0.016) and 44% (aMD = –0.12 ± 0.037; P = .0017) for glucose levels < 70 mg/dL and < 55 mg/dL, respectively. A nonsignificant difference occurred in severe hypoglycemic events requiring third-party assistance for the FGM (2%) vs control (1%) groups. Involvement of the device manufacturer and unblinded group allocations are study limitations.

A 2021 single-arm, multicenter prospective study looked at the impact of FGM on glycemic control in adults with insulin-treated T2D (N = 90; mean age, 64 years; mean A1C, 7.5%).⁶ After a 14-day baseline period consisting of masked sensor readings paired with self-monitored fingerstick tests, participants were followed for 11 weeks using the sensor to monitor glucose levels. The primary outcome was amount of time spent in hypoglycemia (< 70 mg/dL), with secondary outcomes including time and events in hypoglycemia (< 70, < 55, or < 45 mg/dL). No significant decrease in hypoglycemia duration or hypoglycemic event rates at < 70, < 55, or < 45 mg/­dL was observed for FGM compared to baseline. Adverse events were observed in 64% of participants; 94% of the events were hypoglycemia related. Serious adverse events were reported for 5.3% of participants. The single-arm study format, lack of generalizability due to the single-race study population, and sponsor support were study limitations.

Editor’s takeaway

This reasonably good evidence shows a decrease in measured or monitored hypoglycemia, a disease-oriented outcome, but it did not reach statistical significance for symptomatic hypoglycemia (1% vs 2%), a patient-oriented outcome. Nevertheless, in patients reporting symptomatic hypoglycemia, a continuous or flash glucose monitor may allow for more aggressive glucose control.

Evidence summary

Continuous glucose monitoring: Nonsignificant reductions in event rates

A 2021 multicenter RCT (N = 175) evaluated CGM effectiveness in patients with basal ­insulin–treated T2D.¹ Patients (mean age, 57 years; mean A1C, 9.1%) wore a blinded CGM device for baseline glucose measurement (minimum of 168 hours) before being randomly assigned to either CGM (n = 116) or traditional blood glucose monitoring (BGM; n = 59). At 8-month follow-up, patients in the BGM group again had blinded sensors placed. A significant reduction in hypoglycemia duration was observed for the CGM group vs the BGM group at 8 months for glucose values < 70 mg/mL (adjusted mean difference [aMD] = –0.24%; 95% CI, –0.42 to –0.05) and < 54 mg/dL (aMD = –0.10%; 95% CI, –0.15 to –0.04). A nonsignificant decrease in severe hypoglycemic events requiring resuscitative assistance occurred for BGM (2%) vs CGM (1%) patients. Study limitations included virtual visits due to COVID-19 and a short follow-­up period.

A 2022 multicenter prospective study (N = 174) examined CGM effects on hypoglycemia frequency and severity in adults with T2D.² Patients with insulin-requiring T2D (mean age, 61 years; mean A1C, 8.0%) participated in a 12-month study with 6 months of self-monitored blood glucose (SMBG) followed by 6 months of CGM use. The primary outcome was the rate of severe hypoglycemic events. A nonsignificant decrease was observed in the CGM group compared to the SMBG group for hypoglycemic event rate, per participant per 6-month period (relative risk [RR] = 0.43; 95% CI, 0.07-2.64). Four moderate hypoglycemic adverse events occurred in the SMBG phase vs 2 in the CGM phase. Financial support by the study sponsor decreases the study’s validity.

A 2021 prospective study (N = 90) evaluated the use of CGM to improve glycemic control.³ Patients younger than 66 years with insulin-treated T2D and an A1C > 7.5% participated in a 7-day blinded CGM cycle every 4 months for 1 year. A nonsignificant decrease in hypoglycemia duration was observed for glucose values < 70 mg/dL and < 54 mg/dL at 12 months. No change in hypoglycemic event rate was seen with the use of CGM. Funding by the device manufacturer was a limitation of this study.

Flash glucose monitoring: Mixed results on hypoglycemia events

A 2019 open-label RCT (N = 82) assessed the effectiveness of FGM on diabetes control.⁴ Patients with insulin-treated T2D were randomly assigned to the intervention or standard­-care groups. The intervention group (n = 46; mean age, 66 years; mean A1C, 8.3%) used the FGM system for 10 weeks, while the standard-care group (n = 36; mean age, 70 years; mean A1C, 8.9%) maintained use of their glucometers. Both groups received similar types and duration of counseling. Treatment satisfaction was the primary outcome; total hypoglycemic events was a secondary outcome. No significant difference in the number of hypoglycemic episodes was observed between the intervention and control groups at 55 to 70 mg/dL (RR = 0.79; 95% CI, 0.44-1.4) or < 54 mg/dL (RR = 1.27; 95% CI, 0.38-4.2). No adverse events of severe hypoglycemia occurred during the study. Funding by the device manufacturer was a limitation of this study.

Continuous glucose monitoring and flash glucose monitoring do not decrease symptomatic hypoglycemia episodes but do lower time in hypoglycemia.

A 2017 open-label, multicenter RCT (N = 224) assessed FGM efficacy.⁵ Adults (mean age, 59 years; mean A1C, 8.8%) with T2D on intensive insulin therapy were randomized to FGM (n = 149) or SMBG (n = 75) after a 14-day masked baseline period. The 6-month treatment phase was unblinded. The duration of hypoglycemic events (glucose values < 70 mg/dL and < 55 mg/dL) was obtained from the sensors. Compared to the SMBG group, the FGM group spent 43% less time at < 70 mg/dL (aMD = –0.47 ± 0.13 h/d; P = .0006) and 53% less time at < 55 mg/dL (aMD = –0.22 ± 0.068 h/d; P = .0014). Hypoglycemic event rates significantly decreased by 28% (aMD = –0.16 ± 0.065; P = 0.016) and 44% (aMD = –0.12 ± 0.037; P = .0017) for glucose levels < 70 mg/dL and < 55 mg/dL, respectively. A nonsignificant difference occurred in severe hypoglycemic events requiring third-party assistance for the FGM (2%) vs control (1%) groups. Involvement of the device manufacturer and unblinded group allocations are study limitations.

A 2021 single-arm, multicenter prospective study looked at the impact of FGM on glycemic control in adults with insulin-treated T2D (N = 90; mean age, 64 years; mean A1C, 7.5%).⁶ After a 14-day baseline period consisting of masked sensor readings paired with self-monitored fingerstick tests, participants were followed for 11 weeks using the sensor to monitor glucose levels. The primary outcome was amount of time spent in hypoglycemia (< 70 mg/dL), with secondary outcomes including time and events in hypoglycemia (< 70, < 55, or < 45 mg/dL). No significant decrease in hypoglycemia duration or hypoglycemic event rates at < 70, < 55, or < 45 mg/­dL was observed for FGM compared to baseline. Adverse events were observed in 64% of participants; 94% of the events were hypoglycemia related. Serious adverse events were reported for 5.3% of participants. The single-arm study format, lack of generalizability due to the single-race study population, and sponsor support were study limitations.

Editor’s takeaway

This reasonably good evidence shows a decrease in measured or monitored hypoglycemia, a disease-oriented outcome, but it did not reach statistical significance for symptomatic hypoglycemia (1% vs 2%), a patient-oriented outcome. Nevertheless, in patients reporting symptomatic hypoglycemia, a continuous or flash glucose monitor may allow for more aggressive glucose control.

EVIDENCE SUMMARY

Race, gender, and other factors are associated with lack of HCV Tx

A retrospective study (N = 894) assessed factors associated with direct-acting antiviral (DAA) initiation.¹ Patients who were HCV+ with at least 1 clinical visit during the study period completed a survey of psychological, behavioral, and social life assessments. The final cohort (57% male; 64% ≥ 61 years old) was divided into patients who initiated DAA treatment (n = 690) and those who did not (n = 204).

In an adjusted multivariable analysis, factors associated with lower odds of DAA initiation included Black race (adjusted odds ratio [aOR] = 0.59 vs White race; 95% CI, 0.36-0.98); perceived difficulty accessing medical care (aOR = 0.48 vs no difficulty; 95% CI, 0.27-0.83); recent intravenous (IV) drug use (aOR = 0.11 vs no use; 95% CI, 0.02-0.54); alcohol use disorder (AUD; aOR = 0.58 vs no AUD; 95% CI, 0.38-0.90); severe depression (aOR = 0.42 vs no depression; 95% CI, 0.2-0.9); recent homelessness (aOR = 0.36 vs no homelessness; 95% CI, 0.14-0.94); and recent incarceration (aOR = 0.34 vs no incarceration; 95% CI, 0.12-0.94).¹

A multicenter, observational prospective cohort study (N = 3075) evaluated receipt of HCV treatment for patients co-infected with HCV and HIV.² The primary outcome was initiation of HCV treatment with DAAs; 1957 patients initiated therapy, while 1118 did not. Significant independent risk factors for noninitiation of treatment included age younger than 50 years, a history of IV drug use, and use of opioid substitution therapy (OST). Other factors included psychiatric comorbidity (odds ratio [OR] = 0.45; 95% CI, 0.27-0.75), incarceration (OR = 0.6; 95% CI, 0.43-0.87), and female gender (OR = 0.80; 95% CI, 0.66-0.98). In a multivariate analysis limited to those with a history of IV drug use, both use of OST (aOR = 0.55; 95% CI, 0.40-0.75) and recent IV drug use (aOR = 0.019; 95% CI, 0.004-0.087) were identified as factors with low odds of treatment implementation.²

A retrospective cohort study (N = 1024) of medical charts examined the barriers to treatment in adults with chronic HCV infection.³ Of the patient population, 208 were treated and 816 were untreated. Patients not receiving DAAs were associated with poor adherence to/loss to follow-up (n = 548; OR = 36.6; 95% CI, 19.6-68.4); significant psychiatric illness (n = 103; OR = 2.02; 95% CI, 1.13-3.71); and coinfection with HIV (n = 188; OR = 4.5; 95% CI, 2.5-8.2).³

A German multicenter retrospective case-control study (N = 793) identified factors in patient and physician decisions to initiate treatment for HCV.⁴ Patients were ≥ 18 years old, confirmed to be HCV+, and had visited their physician at least 1 time during the observation period. A total of 573 patients received treatment and 220 did not. Patients and clinicians of those who chose not to receive treatment completed a survey that collected reasons for not treating. The most prevalent reason for not initiating treatment was patient wish (42%). This was further delineated to reveal that 17.3% attributed their decision to fear of treatment and 13.2% to fear of adverse events. Other factors associated with nontreatment included IV drug use (aOR = 0.31; 95% CI, 0.16-0.62); HIV coinfection (aOR = 0.19; 95% CI, 0.09-0.40); and use of OST (aOR = 0.37; 95% CI, 0.21-0.68). Patient demographics associated with wish not to be treated included older age (20.2% of those ≥ 40 years old vs 6.4% of those < 40 years old; P = .03) and female gender (51.0% of females vs 35.2% of males; P = .019).⁴

An analysis of a French insurance database (N = 22,545) evaluated the incidence of HCV treatment with DAAs in patients who inject drugs (PWID) with a diagnosis of alcohol use disorder (AUD).⁵ All participants (78% male; median age, 49 years) were chronically HCV-infected and covered by national health insurance. Individuals were grouped by AUD status: untreated (n = 5176), treated (n = 3020), and no AUD (n = 14349). After multivariate adjustment, those with untreated AUD had lower uptake of DAAs than those who did not have AUD (adjusted hazard ratio [aHR] = 0.86; 95% CI, 0.78-0.94) and those with treated AUD (aHR = 0.83; 95% CI, 0.74-0.94). There were no differences between those with treated AUD and those who did not have AUD. Other factors associated with lower DAA uptake were access to care (aHR = 0.90; 95% CI, 0.83-0.98) and female gender (aHR = 0.83; 95% CI, 0.76-0.9).⁵

A 2017 retrospective cohort study evaluated predictors and barriers to follow-up and treatment with DAAs among veterans who were HCV+.⁶ Patients (94% > 50 years old; 97% male; 48% white) had established HCV care within the US Department of Veterans Affairs system. Of those who followed up with at least 1 visit to an HCV specialty clinic (n = 47,165), 29% received DAAs. Factors associated with lack of treatment included race (Black vs White: OR = 0.77; 95% CI, 0.72-0.82; Hispanic vs White: OR = 0.88; 95% CI, 0.79-0.97); IV drug use (OR = 0.84; 95% CI, 0.80-0.88); AUD (OR = 0.73; 95% CI, 0.70-0.77); medical comorbidities (OR = 0.71; 95% CI, 0.66-0.77); and hepatocellular carcinoma (OR = 0.73; 95% CI, 0.65-0.83).⁶

Continue to: Providers identify similar barriers to treatment of HCV

Providers identify similar barriers to treatment of HCV

A 2017 prospective qualitative study (N = 24) from a Veterans Affairs health care system analyzed provider-perceived barriers to initiation of and adherence to HCV treatment.⁷ The analysis focused on differences by provider specialty. Primary care providers (PCPs; n = 12; 17% with > 40 patients with HCV) and hepatology providers (HPs; n = 12; 83% with > 40 patients with HCV) participated in a semi-structured telephone-based interview, providing their perceptions of patient-level barriers to HCV treatment. Eight patient-­level barrier themes were identified; these are outlined in the TABLE⁷ along with data for both PCPs and HPs.

Editor’s takeaway

These 7 cohort studies show us the factors we consider and the reasons we give to not initiate HCV treatment. Some of the factors seem reasonable, but many do not. We might use this list to remind and challenge ourselves to work through barriers to provide the best possible treatment.

EVIDENCE SUMMARY

Race, gender, and other factors are associated with lack of HCV Tx

A retrospective study (N = 894) assessed factors associated with direct-acting antiviral (DAA) initiation.¹ Patients who were HCV+ with at least 1 clinical visit during the study period completed a survey of psychological, behavioral, and social life assessments. The final cohort (57% male; 64% ≥ 61 years old) was divided into patients who initiated DAA treatment (n = 690) and those who did not (n = 204).

In an adjusted multivariable analysis, factors associated with lower odds of DAA initiation included Black race (adjusted odds ratio [aOR] = 0.59 vs White race; 95% CI, 0.36-0.98); perceived difficulty accessing medical care (aOR = 0.48 vs no difficulty; 95% CI, 0.27-0.83); recent intravenous (IV) drug use (aOR = 0.11 vs no use; 95% CI, 0.02-0.54); alcohol use disorder (AUD; aOR = 0.58 vs no AUD; 95% CI, 0.38-0.90); severe depression (aOR = 0.42 vs no depression; 95% CI, 0.2-0.9); recent homelessness (aOR = 0.36 vs no homelessness; 95% CI, 0.14-0.94); and recent incarceration (aOR = 0.34 vs no incarceration; 95% CI, 0.12-0.94).¹

A multicenter, observational prospective cohort study (N = 3075) evaluated receipt of HCV treatment for patients co-infected with HCV and HIV.² The primary outcome was initiation of HCV treatment with DAAs; 1957 patients initiated therapy, while 1118 did not. Significant independent risk factors for noninitiation of treatment included age younger than 50 years, a history of IV drug use, and use of opioid substitution therapy (OST). Other factors included psychiatric comorbidity (odds ratio [OR] = 0.45; 95% CI, 0.27-0.75), incarceration (OR = 0.6; 95% CI, 0.43-0.87), and female gender (OR = 0.80; 95% CI, 0.66-0.98). In a multivariate analysis limited to those with a history of IV drug use, both use of OST (aOR = 0.55; 95% CI, 0.40-0.75) and recent IV drug use (aOR = 0.019; 95% CI, 0.004-0.087) were identified as factors with low odds of treatment implementation.²

A retrospective cohort study (N = 1024) of medical charts examined the barriers to treatment in adults with chronic HCV infection.³ Of the patient population, 208 were treated and 816 were untreated. Patients not receiving DAAs were associated with poor adherence to/loss to follow-up (n = 548; OR = 36.6; 95% CI, 19.6-68.4); significant psychiatric illness (n = 103; OR = 2.02; 95% CI, 1.13-3.71); and coinfection with HIV (n = 188; OR = 4.5; 95% CI, 2.5-8.2).³

A German multicenter retrospective case-control study (N = 793) identified factors in patient and physician decisions to initiate treatment for HCV.⁴ Patients were ≥ 18 years old, confirmed to be HCV+, and had visited their physician at least 1 time during the observation period. A total of 573 patients received treatment and 220 did not. Patients and clinicians of those who chose not to receive treatment completed a survey that collected reasons for not treating. The most prevalent reason for not initiating treatment was patient wish (42%). This was further delineated to reveal that 17.3% attributed their decision to fear of treatment and 13.2% to fear of adverse events. Other factors associated with nontreatment included IV drug use (aOR = 0.31; 95% CI, 0.16-0.62); HIV coinfection (aOR = 0.19; 95% CI, 0.09-0.40); and use of OST (aOR = 0.37; 95% CI, 0.21-0.68). Patient demographics associated with wish not to be treated included older age (20.2% of those ≥ 40 years old vs 6.4% of those < 40 years old; P = .03) and female gender (51.0% of females vs 35.2% of males; P = .019).⁴

An analysis of a French insurance database (N = 22,545) evaluated the incidence of HCV treatment with DAAs in patients who inject drugs (PWID) with a diagnosis of alcohol use disorder (AUD).⁵ All participants (78% male; median age, 49 years) were chronically HCV-infected and covered by national health insurance. Individuals were grouped by AUD status: untreated (n = 5176), treated (n = 3020), and no AUD (n = 14349). After multivariate adjustment, those with untreated AUD had lower uptake of DAAs than those who did not have AUD (adjusted hazard ratio [aHR] = 0.86; 95% CI, 0.78-0.94) and those with treated AUD (aHR = 0.83; 95% CI, 0.74-0.94). There were no differences between those with treated AUD and those who did not have AUD. Other factors associated with lower DAA uptake were access to care (aHR = 0.90; 95% CI, 0.83-0.98) and female gender (aHR = 0.83; 95% CI, 0.76-0.9).⁵

A 2017 retrospective cohort study evaluated predictors and barriers to follow-up and treatment with DAAs among veterans who were HCV+.⁶ Patients (94% > 50 years old; 97% male; 48% white) had established HCV care within the US Department of Veterans Affairs system. Of those who followed up with at least 1 visit to an HCV specialty clinic (n = 47,165), 29% received DAAs. Factors associated with lack of treatment included race (Black vs White: OR = 0.77; 95% CI, 0.72-0.82; Hispanic vs White: OR = 0.88; 95% CI, 0.79-0.97); IV drug use (OR = 0.84; 95% CI, 0.80-0.88); AUD (OR = 0.73; 95% CI, 0.70-0.77); medical comorbidities (OR = 0.71; 95% CI, 0.66-0.77); and hepatocellular carcinoma (OR = 0.73; 95% CI, 0.65-0.83).⁶

Continue to: Providers identify similar barriers to treatment of HCV

Providers identify similar barriers to treatment of HCV

A 2017 prospective qualitative study (N = 24) from a Veterans Affairs health care system analyzed provider-perceived barriers to initiation of and adherence to HCV treatment.⁷ The analysis focused on differences by provider specialty. Primary care providers (PCPs; n = 12; 17% with > 40 patients with HCV) and hepatology providers (HPs; n = 12; 83% with > 40 patients with HCV) participated in a semi-structured telephone-based interview, providing their perceptions of patient-level barriers to HCV treatment. Eight patient-­level barrier themes were identified; these are outlined in the TABLE⁷ along with data for both PCPs and HPs.

Editor’s takeaway

These 7 cohort studies show us the factors we consider and the reasons we give to not initiate HCV treatment. Some of the factors seem reasonable, but many do not. We might use this list to remind and challenge ourselves to work through barriers to provide the best possible treatment.

EVIDENCE SUMMARY

Race, gender, and other factors are associated with lack of HCV Tx

A retrospective study (N = 894) assessed factors associated with direct-acting antiviral (DAA) initiation.¹ Patients who were HCV+ with at least 1 clinical visit during the study period completed a survey of psychological, behavioral, and social life assessments. The final cohort (57% male; 64% ≥ 61 years old) was divided into patients who initiated DAA treatment (n = 690) and those who did not (n = 204).

In an adjusted multivariable analysis, factors associated with lower odds of DAA initiation included Black race (adjusted odds ratio [aOR] = 0.59 vs White race; 95% CI, 0.36-0.98); perceived difficulty accessing medical care (aOR = 0.48 vs no difficulty; 95% CI, 0.27-0.83); recent intravenous (IV) drug use (aOR = 0.11 vs no use; 95% CI, 0.02-0.54); alcohol use disorder (AUD; aOR = 0.58 vs no AUD; 95% CI, 0.38-0.90); severe depression (aOR = 0.42 vs no depression; 95% CI, 0.2-0.9); recent homelessness (aOR = 0.36 vs no homelessness; 95% CI, 0.14-0.94); and recent incarceration (aOR = 0.34 vs no incarceration; 95% CI, 0.12-0.94).¹

A multicenter, observational prospective cohort study (N = 3075) evaluated receipt of HCV treatment for patients co-infected with HCV and HIV.² The primary outcome was initiation of HCV treatment with DAAs; 1957 patients initiated therapy, while 1118 did not. Significant independent risk factors for noninitiation of treatment included age younger than 50 years, a history of IV drug use, and use of opioid substitution therapy (OST). Other factors included psychiatric comorbidity (odds ratio [OR] = 0.45; 95% CI, 0.27-0.75), incarceration (OR = 0.6; 95% CI, 0.43-0.87), and female gender (OR = 0.80; 95% CI, 0.66-0.98). In a multivariate analysis limited to those with a history of IV drug use, both use of OST (aOR = 0.55; 95% CI, 0.40-0.75) and recent IV drug use (aOR = 0.019; 95% CI, 0.004-0.087) were identified as factors with low odds of treatment implementation.²

A retrospective cohort study (N = 1024) of medical charts examined the barriers to treatment in adults with chronic HCV infection.³ Of the patient population, 208 were treated and 816 were untreated. Patients not receiving DAAs were associated with poor adherence to/loss to follow-up (n = 548; OR = 36.6; 95% CI, 19.6-68.4); significant psychiatric illness (n = 103; OR = 2.02; 95% CI, 1.13-3.71); and coinfection with HIV (n = 188; OR = 4.5; 95% CI, 2.5-8.2).³

A German multicenter retrospective case-control study (N = 793) identified factors in patient and physician decisions to initiate treatment for HCV.⁴ Patients were ≥ 18 years old, confirmed to be HCV+, and had visited their physician at least 1 time during the observation period. A total of 573 patients received treatment and 220 did not. Patients and clinicians of those who chose not to receive treatment completed a survey that collected reasons for not treating. The most prevalent reason for not initiating treatment was patient wish (42%). This was further delineated to reveal that 17.3% attributed their decision to fear of treatment and 13.2% to fear of adverse events. Other factors associated with nontreatment included IV drug use (aOR = 0.31; 95% CI, 0.16-0.62); HIV coinfection (aOR = 0.19; 95% CI, 0.09-0.40); and use of OST (aOR = 0.37; 95% CI, 0.21-0.68). Patient demographics associated with wish not to be treated included older age (20.2% of those ≥ 40 years old vs 6.4% of those < 40 years old; P = .03) and female gender (51.0% of females vs 35.2% of males; P = .019).⁴

An analysis of a French insurance database (N = 22,545) evaluated the incidence of HCV treatment with DAAs in patients who inject drugs (PWID) with a diagnosis of alcohol use disorder (AUD).⁵ All participants (78% male; median age, 49 years) were chronically HCV-infected and covered by national health insurance. Individuals were grouped by AUD status: untreated (n = 5176), treated (n = 3020), and no AUD (n = 14349). After multivariate adjustment, those with untreated AUD had lower uptake of DAAs than those who did not have AUD (adjusted hazard ratio [aHR] = 0.86; 95% CI, 0.78-0.94) and those with treated AUD (aHR = 0.83; 95% CI, 0.74-0.94). There were no differences between those with treated AUD and those who did not have AUD. Other factors associated with lower DAA uptake were access to care (aHR = 0.90; 95% CI, 0.83-0.98) and female gender (aHR = 0.83; 95% CI, 0.76-0.9).⁵

A 2017 retrospective cohort study evaluated predictors and barriers to follow-up and treatment with DAAs among veterans who were HCV+.⁶ Patients (94% > 50 years old; 97% male; 48% white) had established HCV care within the US Department of Veterans Affairs system. Of those who followed up with at least 1 visit to an HCV specialty clinic (n = 47,165), 29% received DAAs. Factors associated with lack of treatment included race (Black vs White: OR = 0.77; 95% CI, 0.72-0.82; Hispanic vs White: OR = 0.88; 95% CI, 0.79-0.97); IV drug use (OR = 0.84; 95% CI, 0.80-0.88); AUD (OR = 0.73; 95% CI, 0.70-0.77); medical comorbidities (OR = 0.71; 95% CI, 0.66-0.77); and hepatocellular carcinoma (OR = 0.73; 95% CI, 0.65-0.83).⁶

Continue to: Providers identify similar barriers to treatment of HCV

Providers identify similar barriers to treatment of HCV

A 2017 prospective qualitative study (N = 24) from a Veterans Affairs health care system analyzed provider-perceived barriers to initiation of and adherence to HCV treatment.⁷ The analysis focused on differences by provider specialty. Primary care providers (PCPs; n = 12; 17% with > 40 patients with HCV) and hepatology providers (HPs; n = 12; 83% with > 40 patients with HCV) participated in a semi-structured telephone-based interview, providing their perceptions of patient-level barriers to HCV treatment. Eight patient-­level barrier themes were identified; these are outlined in the TABLE⁷ along with data for both PCPs and HPs.

Editor’s takeaway

These 7 cohort studies show us the factors we consider and the reasons we give to not initiate HCV treatment. Some of the factors seem reasonable, but many do not. We might use this list to remind and challenge ourselves to work through barriers to provide the best possible treatment.