Study Suggests Need for More HCV Treatment Delivery in Primary Care Settings

David Goodman-Meza, MD

Credit: UCLA Health

Primary care providers (PCP) are encouraged to provide hepatitis C virus (HCV) treatment to infected patients to improve service delivery and alleviate the burden placed on specialists, but findings from a recent study suggest treatment has been on the decline in recent years among both PCPs and specialists.¹

The single-center, retrospective study examined adult patients who received HCV treatment through the University of California, Los Angeles (UCLA) health system between 2015 and 2022 and found the overall proportion of new cases treated for HCV declined, suggesting changes in payor restrictions and requirements did little to shift new treatments to the primary care space in this specific medical system.¹

The World Health Organization (WHO) recommends therapy with pan-genotypic direct-acting antivirals (DAAs) for all adults, adolescents, and children down to 3 years of age with chronic HCV infection. Given the lack of side effects and short course of treatment, the WHO recommends that testing, care, and treatment for persons with HCV can be provided by trained non-specialist doctors and nurses in primary care.²

“It is unclear if changes in rates of PCP prescribing are increasing at a health system level in the absence of targeted campaigns aimed at increasing HCV treatment rates,” David Goodman-Meza, MD, assistant professor in the division of infectious diseases at the David Geffen School of Medicine at UCLA, and colleagues wrote.¹ “Further, little research exists examining patient characteristics among those who receive DAAs from PCPs versus those who are referred to specialists.”

To examine the proportion of DAAs prescribed by PCPs and specialists and to describe the population receiving treatment in a single health system from 2015 - 2022, investigators obtained electronic health record data from UCLA’s Office of Health Informatics and Analytics Data Repository and Dashboard for patients ≥ 18 years of age for patients who were prescribed HCV treatment through the UCLA health system. The Data Repository and Dashboard includes de-identified, system-wide patient encounters including demographic information, diagnosis codes, laboratory results, and prescription information for all UCLA health system hospitals and outpatient offices.¹

Investigators described the number of prescriptions for HCV medication prescribed by PCPs and specialists by year, medication type, and physician specialty, additionally considering patient demographics and comorbidities. HCV treatment was defined as receiving a single prescription for a DAA medication and included ledipasvir-sofosbuvir; sofosbuvir-velpatasvir; glecaprevir-pibrentasvir; elbasvir-grazoprevir; sofosbuvir-velpatasvir-voxilaprevir; simeprevir-sofosbuvir; sofosbuvir-daclatasvir; and paritaprevir-ritonavir-ombitasvir plus dasabuvir.¹

Provider characteristics were assessed based on the encounter for the initial prescription of DAAs. Investigators categorized providers as a specialist or PCP based on their listed specialty as included in outpatient clinic visit data.¹

From 2015 - 2022, 2315 cases received ≥ 1 prescription for an HCV medication. Of these, 800 cases were excluded due to being less than 18 years of age (n = 5), initiating HCV medication as an inpatient (n = 308), or receiving ribavirin (n = 538) or pegylated interferon (n = 5). Thus, the final sample included 1515 cases.¹

Results showed PCPs prescribed DAAs to 203 (13.4%) cases and specialists prescribed DAAs to 1312 (86.6%) cases. Of note, the number of patients who received prescriptions for HCV treatment decreased in each year of the study period, declining from 379 in 2015 to 88 in 2022. Investigators pointed out the proportion of patients who received prescriptions from PCPs peaked at 19% in 2016 and decreased to 5.7% in 2022.¹

Of patients who received HCV treatment from any provider type, 61% were male and the median age was 60 (Interquartile range [IQR], 52-66) years. The majority of patients who received treatment had commercial insurance as the primary payer (56%), regardless of provider type, with no significant differences found between patient insurance type and prescribing provider type.¹

Among patients who received treatment from specialists, 33% had a diagnosis of cirrhosis compared to 21% of patients treated by a PCP (P <.001). Similarly, investigators noted 14% of patients in specialist care had hepatocellular carcinoma compared to 3.4% of patients treated by PCPs (P <.001).¹

The majority of patients received prescriptions for ledipasvir-sofosbuvir, sofosbuvir-velpatasvir , or glecaprevir-pibrentasvir regardless of provider specialty. More than half (53.2%) of the patients treated by PCPs received prescriptions for ledipasvir-sofosbuvir, while specialists prescribed 92% of sofosbuvir-velpatasvir prescriptions (P <.01) and 87% of glecaprevir-pibrentasvir prescriptions (P = .98).¹

Investigators described the single-center study design, inability to account for patients who were linked to care outside of the UCLA health system, and missing race, ethnicity, and HCV risk factor data as potential limitations to these findings.¹

“Increasing access to DAAs through PCP prescribing could increase treatment, decreasing morbidity and transmission of HCV within the community,” investigators concluded.¹

References:

1. ^{Scialli A, Saab S, Salimian A, et al. Hepatitis C Treatment Among Primary Care and Specialty Providers: A Single Center Study, 2015 to 2022. Journal of Primary Care & Community Health. 2024;15. doi:10.1177/21501319241253521}
2. ^{World Health Organization. Hepatitis C. Newsroom. April 9, 2024. Accessed May 15, 2024. https://www.who.int/news-room/fact-sheets/detail/hepatitis-c}