Addressing Unmet PrEP Needs in Women: Impact of a Laboratory-Driven Protocol at an Urban, Essential Hospital

Background

HIV pre-exposure prophylaxis (PrEP) uptake in women remains low. We developed a laboratory result-driven protocol to link women with a positive bacterial sexually transmitted infection (STI) to HIV PrEP at an urban safety-net hospital.

Methods

Electronic health records of women with positive chlamydia, gonorrhea, and/or syphilis tests were reviewed, and those eligible for PrEP were referred for direct or primary care provider-driven outreach. We assessed the proportion of women with STIs who received PrEP offers, acceptance, and prescriptions before (July 1, 2018-December 31, 2018) and after (January 1, 2019-June 30, 2020) implementation to evaluate changes in the delivery of key elements of the PrEP care cascade (ie, PrEP offers, acceptance, and prescribing) for women with STIs after protocol implementation.

Results

The proportion of women who received PrEP offers increased from 7.6% to 17.6% (P < .001). After multivariable adjustment, only the postintervention period was associated with PrEP offers (odds ratio [OR], 2.49; 95% CI, 1.68-3.68). In subgroup analyses, PrEP offers increased significantly among non-Hispanic Black (OR, 2.75; 95% CI, 1.65-4.58) and Hispanic (OR, 5.34; 95% CI, 1.77-16.11) women but not among non-Hispanic White women (OR, 1.49; 95% CI, 0.54-4.05). Significant changes in PrEP acceptance and prescriptions were not observed in the sample overall.

Conclusions

A laboratory result-driven protocol was associated with a significant increase in PrEP offers to Black and Hispanic women with STI. These results provide concrete suggestions for health systems seeking to increase PrEP access and equity among women.

Racial differences in testing for infectious diseases: An analysis of jail intake data

HIV and hepatitis C virus (HCV) testing for all people in jail is recommended by the CDC. In the community, there are barriers to HIV and HCV testing for minoritized people. We examined the relationship between race and infectious diseases (HIV, HCV, syphilis) testing in one Massachusetts jail, Middlesex House of Corrections (MHOC). This is a retrospective analysis of people incarcerated at MHOC who opted-in to infectious diseases testing between 2016-2020. Variables of interest were race/ethnicity, self-identified history of psychiatric illness, and ever having experienced restrictive housing. Twenty-three percent (1,688/8,467) of people who were incarcerated requested testing at intake. Of those, only 38% received testing. Black non-Hispanic (25%) and Hispanic people (30%) were more likely to request testing than white people (19%). Hispanic people (16%, AOR 1.69(1.24-2.29) were more likely to receive a test result compared to their white non-Hispanic (8%, AOR 1.54(1.10-2.15)) counterparts. Black non-Hispanic and Hispanic people were more likely to opt-in to and complete infectious disease testing than white people. These findings could be related to racial disparities in access to care in the community. Additionally, just over one-third of people who requested testing received it, underscoring that there is room for improvement in ensuring testing is completed. We hope our collaborative efforts with jail professionals can encourage other cross-disciplinary investigations.

A study protocol for Project I-Test: a cluster randomized controlled trial of a practice coaching intervention to increase HIV testing in substance use treatment programs

BACKGROUND

People with substance use disorders are vulnerable to acquiring HIV. Testing is fundamental to diagnosis, treatment, and prevention; however, in the past decade, there has been a decline in the number of substance use disorder (SUD) treatment programs offering on-site HIV testing. Fewer than half of SUDs in the USA offer on-site HIV testing. In addition, nearly a quarter of newly diagnosed cases have AIDS at the time of diagnosis. Lack of testing is one of the main reasons that annual HIV incidences have remained constant over time. Integration of HIV testing with testing for HCV, an infection prevalent among persons vulnerable to HIV infection, and in settings where they receive health services, including opioid treatment programs (OTPs), is of great public health importance.

METHODS/DESIGN

In this 3-arm cluster-RCT of opioid use disorders treatment programs, we test the effect of two evidence-based "practice coaching" (PC) interventions on the provision and sustained implementation of on-site HIV testing, on-site HIV/HCV testing, and linkage to care. Using the National Survey of Substance Abuse Treatment Services data available from SAMHSA, 51 sites are randomly assigned to one of the three conditions: practice coach facilitated structured conversations around implementing change, with provision of resources and documents to support the implementation of (1) HIV testing only, or (2) HIV/HCV testing, and (3) a control condition that provides a package with information only. We collect quantitative (e.g., HIV and HCV testing at 6-month-long intervals) and qualitative site data near the time of randomization, and again approximately 7-12 months after randomization.

DISCUSSION

Innovative and comprehensive approaches that facilitate and promote the adoption and sustainability of HIV and HCV testing in opioid treatment programs are important for addressing and reducing HIV and HCV infection rates. This study is one of the first to test organizational approaches (practice coaching) to increase HIV and HIV/HCV testing and linkage to care among individuals receiving treatment for opioid use disorder. The study may provide valuable insight and knowledge on the multiple levels of intervention that, if integrated, may better position OTPs to improve and sustain testing practices and improve population health.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03135886. Registered on 2 May 2017.

Economic Evaluation of Extended-Release Buprenorphine for Persons With Opioid Use Disorder

Importance

In 2017, the US Food and Drug Administration (FDA) approved a monthly injectable form of buprenorphine, extended-release buprenorphine; published data show that extended-release buprenorphine is effective compared with no treatment, but its current cost is higher and current retention is lower than that of transmucosal buprenorphine. Preliminary research suggests that extended-release buprenorphine may be an important addition to treatment options, but the cost-effectiveness of extended-release buprenorphine compared with transmucosal buprenorphine remains unclear.

Objective

To evaluate the cost-effectiveness of extended-release buprenorphine compared with transmucosal buprenorphine.

Design, Setting, and Participants

This economic evaluation used a state transition model starting in 2019 to simulate the lifetime of a closed cohort of individuals with OUD presenting for evaluation for opioid agonist treatment with buprenorphine. The data sources used to estimate model parameters included cohort studies, clinical trials, and administrative data. The model relied on pharmaceutical costs from the Federal Supply Schedule and health care utilization costs from published studies. Data were analyzed from September 2021 to January 2023.

Interventions

No treatment, treatment with transmucosal buprenorphine, or treatment with extended-release buprenorphine.

Main Outcomes and Measures

Mean lifetime costs per person, discounted quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs).

Results

The simulated cohort included 100 000 patients with OUD receiving (61% male; mean [SD] age, 38 [11] years) or not receiving medication treatment (58% male, mean [SD] age, 48 [18] years). Compared with no medication treatment, treatment with transmucosal buprenorphine yielded an ICER of $19 740 per QALY. Compared with treatment with transmucosal buprenorphine, treatment with extended-release buprenorphine yielded lower effectiveness by 0.03 QALYs per person at higher cost, suggesting that treatment with extended-release buprenorphine was dominated and not preferred. In probabilistic sensitivity analyses, treatment with transmucosal buprenorphine was the preferred strategy 60% of the time. Treatment with extended-release buprenorphine was cost-effective compared with treatment with transmucosal buprenorphine at a $100 000 per QALY willingness-to-pay threshold only after substantial changes in key parameters.

Conclusions and Relevance

In this economic evaluation of extended-release buprenorphine compared with transmucosal buprenorphine for the treatment of OUD, extended-release buprenorphine was not associated with efficient allocation of limited resources when transmucosal buprenorphine was available. Future initiatives should aim to improve retention rates or decrease costs associated with extended-release buprenorphine.

A study protocol for Project I-Test: a cluster randomized controlled trial of a practice coaching intervention to increase HIV testing in substance use treatment programs

Background People with substance use disorders are vulnerable to acquiring HIV. Testing is fundamental to diagnosis, treatment, and prevention; however, in the past decade, there has been a decline in the number of substance use disorder (SUD) treatment programs offering on-site HIV testing. Fewer than half of SUDs in the United States offer on-site HIV testing. In addition, nearly a quarter of newly diagnosed cases have AIDS at the time of diagnosis. Lack of testing is one of the main reasons that annual HIV incidences have remained constant over time. Integration of HIV testing with testing for HCV, an infection prevalent among persons vulnerable to HIV infection, and in settings where they receive health services, including opioid treatment programs (OTPs), is of great public health importance. Methods/Design In this 3-arm cluster-RCT of opioid use disorders treatment programs, we test the effect of two evidence-based "practice coaching" (PC) interventions on: the provision and sustained implementation of on-site HIV testing, on-site HIV/HCV testing, and linkage to care. Using the National Survey of Substance Abuse Treatment Services data available from SAMHSA, 51 sites are randomly assigned to one of the three conditions: practice coach facilitated structured conversations around implementing change, with provision of resources and documents to support the implementation of (1) HIV testing only, or (2) HIV/HCV testing, and (3) a control condition that provides a package with information only. We collect quantitative (e,g., HIV and HCV testing at six-month-long intervals) and qualitative site data near the time of randomization, and again approximately 7-12 months after randomization. Discussion Innovative and comprehensive approaches that facilitate and promote the adoption and sustainability of HIV and HCV testing in opioid treatment programs are important for addressing and reducing HIV and HCV infection rates. This study is one of the first to test organizational approaches (practice coaching) to increase HIV and HIV/HCV testing and linkage to care among individuals receiving treatment for opioid use disorder. The study may provide valuable insight and knowledge on the multiple levels of intervention that, if integrated, may better position OTPs to improve and sustain testing practices and improve population health. Trial registration ClinicalTrials.gov: NCT03135886. (02 05 2017).

Research Compensation and Enhanced Contacts in Studies With Persons Who Use Drugs: Lessons From the COVID-19 Pandemic Demand a Reset

Policy changes resulting from the coronavirus 2019 (COVID-19) pandemic have had a substantial and positive impact on the clinical care of persons with opioid use disorder. These innovative paradigm shifts created a ripe environment for re-evaluating traditional approaches to recruiting and retaining persons who use drugs into research studies. For example, changes to methadone prescribing requirements and authorization of buprenorphine prescriptions via telehealth have both increased access to medications. In this commentary, we contribute to ongoing conversations about the ethics of compensation for participants in addiction-related clinical research and share methods of payment that proved successful in research performed during the pandemic. We also discuss approaches to enrollment and follow-up that were implemented during the height of COVID restrictions. These approaches may mutually benefit both participants and researchers in a post-pandemic era.

Peer recovery coaching for comprehensive HIV, hepatitis C, and opioid use disorder management: The CHORUS pilot study

Introduction

Amidst a surge in HIV and hepatitis C virus (HCV) infections in persons who use drugs, medications that effectively prevent HIV and treat opioid use disorder and HCV remain underutilized.

Methods

We developed a 6-month peer recovery coaching intervention (brief motivational interviewing followed by weekly virtual or in-person coaching) and collected data on uptake of medications for opioid use disorder (MOUD), HIV pre-exposure prophylaxis (PrEP), and HCV treatment. The primary outcomes were intervention acceptability and feasibility.

Results

At a Boston substance use disorder bridge clinic, we enrolled 31 HIV-negative patients who used opioids. Participants reported high intervention satisfaction at 6 months (95% "satisfied" or "very satisfied"). At study completion, 48% of the participants were on MOUD, 43% who met CDC guidelines were on PrEP, and 22% with HCV were engaged with treatment.

Conclusions

A peer recovery coaching intervention is feasible and acceptable, with positive preliminary findings regarding MOUD, PrEP and HCV treatment uptake.

"I've been 95% safe": perspectives on HIV pre-exposure prophylaxis at a drug detoxification center: a qualitative study

Pre-exposure prophylaxis (PrEP) decreases human immunodeficiency virus (HIV) acquisition among persons who inject drugs (PWID); however, its uptake has been suboptimal. We explored HIV risk perceptions and PrEP interest among drug detoxification center patients in the context of the ongoing opioid overdose epidemic. We conducted in-depth interviews of patients (n = 24) and professional key informants (n = 10 physicians, case managers, nurses, and harm reduction educators), and thematic analysis of coded data. The mean age of participants (patients) was 37 years; 54% identified as male and 67% as White. Although 71% reported injecting drugs and 62% had condomless sex in the past 6 months, participants had mixed HIV risk perceptions, and some viewed PrEP as an undesirable indicator of elevated HIV risk. Nevertheless, many participants viewed drug detoxification as a first step towards embarking on a "healthier lifestyle," with some narratives identifying opportunities for delivering PrEP information and services in this setting. Opportunities exist to expand PrEP at drug detoxification centers, but initiatives are needed to educate patients and staff on indications and benefits of this prevention tool. Interventions are also needed to determine the best strategies for implementing PrEP adoption in this setting.

Comparing COVID-19-related Morbidity and Mortality Between Patients With and Without Substance Use Disorders: A Retrospective Cohort Study

Objectives:

People with substance use disorders (SUD) are suggested to have higher risk of hospitalization, intubation, or death from coronavirus disease 2019 (COVID-19), although data are mixed. Little is known about other COVID-19-related complications in this group. We compared morbidity and mortality among individuals with and without SUD who were admitted to an urban safety net hospital with COVID-19 early in the pandemic, contemporaneous to other published studies on this subject.

Methods:

We performed a retrospective study of patients ⩾18 years old admitted with COVID-19 from March 16th to April 8th, 2020. SUD included alcohol, opioid, cocaine, amphetamine, and benzodiazepine use disorders and was identified using diagnostic codes, free text clinical documentation, and urine drug screens. The primary outcome was inpatient mortality. Secondary outcomes included clinical complications (eg, secondary infections, venous thromboembolism) and resource utilization (eg, mechanical ventilation, length of stay). We used multivariable regression to assess the relationship between SUD and mortality.

Results:

Of 409 patients, the mean age was 56 years and 13.7% had SUD. Those with SUD were more likely to be male, have experienced homelessness, have pulmonary disease or hepatitis C, or use tobacco or cannabis. After multivariable analysis, SUD was not associated with mortality (aOR 1.03; 95% CI, 0.31-3.10). Secondary outcomes were also similar between groups.

Conclusions:

Our findings suggest that persons with and without SUD have similar COVID-19-related outcomes. Previously reported increased COVID-19 complications may be from medical comorbidities.

At the intersection of trust and mistrust: A qualitative analysis of motivators and barriers to research participation at a safety-net hospital

INTRODUCTION

The underrepresentation of Black, Indigenous, and People of Color (BIPOC) individuals in healthcare research limits generalizability and contributes to healthcare inequities. Existing barriers and attitudes toward research participation must be addressed to increase the representation of safety net and other underserved populations.

METHODS

We conducted semi-structured qualitative interviews with patients at an urban safety net hospital, focusing on facilitators, barriers, motivators, and preferences for research participation. We conducted direct content analysis guided by an implementation framework and used rapid analysis methods to generate final themes.

RESULTS

We completed 38 interviews and identified six major themes related to preferences for engagement in research participation: (1) wide variation in research recruitment preferences; (2) logistical complexity negatively impacts willingness to participate; (3) risk contributes to hesitation toward research participation; (4) personal/community benefit, interest in study topic, and compensation serve as motivators for research participation; (5) continued participation despite reported shortcomings of informed consent process; and (6) mistrust could be overcome by relationship or credibility of information sources.

CONCLUSION

Despite barriers to participation in research studies among safety-net populations, there are also facilitators that can be implemented to increase knowledge and comprehension, ease of participation, and willingness to join research studies. Study teams should vary recruitment and participation methods to ensure equal access to research opportunities.

PATIENT/PUBLIC CONTRIBUTION

Our analysis methods and study progress were presented to individuals within the Boston Medical Center healthcare system. Through this process community engagement specialists, clinical experts, research directors, and others with significant experience working with safety-net populations supported data interpretation and provided recommendations for action following the dissemination of data.

"Community members have more impact on their neighbors than celebrities": leveraging community partnerships to build COVID-19 vaccine confidence

BACKGROUND

Vaccines are a strong public health tool to protect against severe disease, hospitalization, and death from COVID-19. Still, inequities in COVID-19 vaccination rates and health outcomes continue to exist among Black and Latino populations. Boston Medical Center (BMC) has played a significant role in vaccinating medically underserved populations, and organized a series of community-engaged conversations to better understand community concerns regarding the COVID-19 vaccine. This paper describes the themes which resulted from these community-engaged conversations and proposes next steps for healthcare leaders.

METHODS

We accessed nine publicly available recordings of the community-engaged conversations which were held between March 2021 and September 2021 and ranged from 8 to 122 attendees. Six conversations prioritized specific groups: the Haitian-Creole community, the Cape Verdean community, the Latino community, the Black Christian Faith community, guardians who care for children living with disabilities, and individuals affected by systemic lupus erythematosus. Remaining conversations targeted the general public of the Greater Boston Area. We employed a Consolidated Framework for Implementation Research-driven codebook to code our data. Our analysis utilized a modified version of qualitative rapid analysis methods.

RESULTS

Five main themes emerged from these community-engaged conversations: (1) Structural factors are important barriers to COVID-19 vaccination; (2) Mistrust exists due to the negative impact of systemic oppression and perceived motivation of the government; (3) There is a desire to learn more about biological and clinical characteristics of the COVID-19 vaccine as well as the practical implications of being vaccinated; (4) Community leaders emphasize community engagement for delivering COVID-19 information and education and; (5) Community leaders believe that the COVID-19 vaccine is a solution to address the pandemic.

CONCLUSION

This study illustrates a need for community-engaged COVID-19 vaccine messaging which reflects the nuances of the COVID-19 vaccine and pandemic without oversimplifying information. In highlighting common concerns of the Greater Boston Area which contribute to a lack of confidence in the COVID-19 vaccine, we underscore important considerations for public health and healthcare leadership in the development of initiatives which work to advance health equity.

Development and Validation of the HIV-CARDIO-PREDICT Score to Estimate the Risk of Cardiovascular Events in HIV-Infected Patients

IMPORTANCE

Commonly used risk assessment tools for cardiovascular disease might not be accurate for HIV-infected patients.

OBJECTIVE

We aimed to develop a model to accurately predict the 10-year cardiovascular disease (CV) risk of HIV-infected patients.

DESIGN

In this retrospective cohort study, adult HIV-infected patients seen at Boston Medical Center between March 2012 and January 2017 were divided into model development and validation cohorts.

SETTING

Boston Medical Center, a tertiary, academic medical center.

PARTICIPANTS

Adult HIV-infected patients, seen in inpatient and outpatient setting.

MAIN OUTCOMES AND MEASURES

We used logistic regression to create a prediction risk model for cardiovascular events using data from the development cohort. Using a point-based risk-scoring system, we summarized the relationship between risk factors and cardiovascular disease (CVD) risk. We then used the area under the receiver operating characteristics curve (AUC) to evaluate model discrimination. Finally, we tested the model using a validation cohort.

RESULTS

1914 individuals met the inclusion criteria. The model had excellent discrimination for CVD risk [AUC 0.989; (95% CI: 0.986-0.993)] and included the following 11 variables: male sex (95% CI: 2.53-3.99), African American race/ethnicity (95% CI: 1.50-3.13), current age (95% CI: 0.07-0.13), age at HIV diagnosis (95% CI: -0.10-(-0.02)), peak HIV viral load (95% CI: 9.89 × 10^-7-3.00 × 10^-6), nadir CD4 lymphocyte count (95% CI: -0.03-(-0.02)), hypertension (95% CI: 0.20-1.54), hyperlipidemia (95% CI: 3.03-4.60), diabetes (95% CI: 0.61-1.89), chronic kidney disease (95% CI: 1.26-2.62), and smoking (95% CI: 0.12-2.39). The eleven-parameter multiple logistic regression model had excellent discrimination [AUC 0.957; (95% CI: 0.938-0.975)] when applied to the validation cohort.

CONCLUSIONS AND RELEVANCE

Our novel HIV-CARDIO-PREDICT Score may provide a rapid and accurate evaluation of CV disease risk among HIV-infected patients and inform prevention measures.

Retaining Faculty from Underrepresented Groups in Academic Medicine: Results from a Needs Assessment

OBJECTIVES

Academic medical centers can improve the quality of care and address health inequities by recruiting and retaining faculty from underrepresented in medicine (URiM) groups; however, the retention of URiM faculty is a barrier to reaching equity-related goals because URiM faculty are less likely to remain in academia and be promoted compared with their peers. As such, the objective of this study was to determine factors that influence the retention of URiM faculty at large academic centers.

METHODS

One-time, semistructured stay interviews were conducted to assess the experiences of URiM faculty at a large academic hospital in Boston, Massachusetts between October 2016 and April 2017. A qualitative researcher coded the transcripts and identified central themes.

RESULTS

The participants (N = 17) were 65% Black/African American and 35% Hispanic/Latinx. The median number of years on faculty was 3 years (range 1-33). The themes identified through the stay interviews were grouped into three domains: areas of strength, challenges to advancement, and suggestions for improvement of support. Participants voiced leadership support in their development, the community of patients, URiM networking opportunities, and mentorship as strengths. The barriers to retention included the lack of transparency and trust in their work, a sense of tokenism, organizational management issues, and implicit biases. The suggested ways to improve support included the expanding of initiatives to include all members of groups URiM, continuing URiM faculty development programs, and increasing funding to support advancement.

CONCLUSIONS

This study underscored the importance of supportive leadership, URiM-specific faculty development programs, networking opportunities, and the recognition of achievements as factors that influence the retention of faculty at a large academic medical center. In addition, participants highlighted the need for strong mentor networks and emphasizing sponsorship.

Laboratory test trends within 72 hours of hospital admission associated with death among COVID-19 patients

Early identification of patients at risk for severe coronavirus disease 2019 (COVID-19) is crucial for appropriate triage and determination of need for closer monitoring. Few studies have examined laboratory trends in COVID-19 infection and sought to quantify the degree to which laboratory values affect mortality. We conducted a retrospective cohort (n = 407) study of hospitalized patients with COVID-19 early in the course of the pandemic, from March 16th to April 8th, 2020 and compared baseline to repeat laboratory testing 72 hours into admission. The primary outcome was death. We found that rises of 25 mg/L C-reactive protein, 50 units/L lactate dehydrogenase, and 100 ng/mL ferritin were associated with 23%, 28%, and 1% increased odds of death, respectively. In contrast, changes in fibrinogen, D-dimer, white blood cell count, and creatinine in the first few days of hospital admission were not associated with mortality. These quantitative findings may assist clinicians in determining the risk of potential clinical decline in patients with COVID-19 and influence early management.

Barriers to accessing treatment for substance use after inpatient managed withdrawal (Detox): A qualitative study

INTRODUCTION

Access to and uptake of evidence-based treatment for substance use disorder, specifically opioid use disorder (OUD), are limited despite the high death toll from drug overdose in the United States in recent years. Patient perceived barriers to evidence-based treatment after completion of short-term inpatient medically managed withdrawal programs (detox) have not been well studied. The purpose of the current study is to elicit patients' perspectives on challenges to transition to treatment, including medications for OUD (MOUD), after detox and potential solutions.

METHODS

We conducted semi-structured interviews (N = 24) at a detox center (2018-2019) to explore patients' perspectives on obstacles to treatment. The study managed the data in NVivo and we used content analysis to identify themes.

RESULTS

Patients' characteristics included the following: 54 % male; mean age 37 years; self-identified as White 67 %, Black 13 %, Latinx 8 %, Native Hawaiian/Pacific Islander 4 %, and other 8 %; heroin use in the past 3 months 67 %; and ever injecting drugs 71 %. Patients identified the following barriers: 1) lack of continuity of care; 2) limited number of detox and residential treatment program beds; 3) unstable housing; and 4) lack of options when choosing a treatment pathway. Solutions proposed by participants included: 1) increase low-barrier access to community MOUD; 2) add case managers at the detox center to establish continuity of care after discharge; 3) increase assistance with housing; and 4) encourage patient participation in treatment decisions.

CONCLUSIONS

Patients identified lack of continuity of care, especially care coordination, as a major barrier to substance use treatment. Increasing treatment utilization, including MOUD, necessitates a multimodal approach to continuity of care, low-barrier access to MOUD, and support to address unstable housing. Patients want care that incorporates options and respect for. individualized preferences and needs.

Estimating Absenteeism Related to Nonalcohol Substance Use in a US National Cohort of Full-Time Employees

OBJECTIVE

We aimed to estimate absenteeism due to substance use disorder among full-time employees.

METHODS

We used the 2018 National Survey on Drug Use and Health to identify a sample of individuals employed full time. We used a survey-weighted multivariable negative binomial model to evaluate the association between absenteeism and type of substance use disorder controlling for available demographic information.

RESULTS

In the adjusted model, we estimated that opioid use without a disorder had the highest absenteeism for use, and polysubstance use disorder had the highest absenteeism among use disorders. In a hypothetical firm of 10,000 employees, we estimate $232,000 of lost wage value annually.

CONCLUSIONS

Substance use is associated with absenteeism and presents a compelling argument for employers to promote programs that support treatment for employees and reduce downstream costs associated with absenteeism and turnover.

Metamodeling for Policy Simulations with Multivariate Outcomes

PURPOSE

Metamodels are simplified approximations of more complex models that can be used as surrogates for the original models. Challenges in using metamodels for policy analysis arise when there are multiple correlated outputs of interest. We develop a framework for metamodeling with policy simulations to accommodate multivariate outcomes.

METHODS

We combine 2 algorithm adaptation methods-multitarget stacking and regression chain with maximum correlation-with different base learners including linear regression (LR), elastic net (EE) with second-order terms, Gaussian process regression (GPR), random forests (RFs), and neural networks. We optimize integrated models using variable selection and hyperparameter tuning. We compare the accuracy, efficiency, and interpretability of different approaches. As an example application, we develop metamodels to emulate a microsimulation model of testing and treatment strategies for hepatitis C in correctional settings.

RESULTS

Output variables from the simulation model were correlated (average ρ = 0.58). Without multioutput algorithm adaptation methods, in-sample fit (measured by R2) ranged from 0.881 for LR to 0.987 for GPR. The multioutput algorithm adaptation method increased R2 by an average 0.002 across base learners. Variable selection and hyperparameter tuning increased R2 by 0.009. Simpler models such as LR, EE, and RF required minimal training and prediction time. LR and EE had advantages in model interpretability, and we considered methods for improving the interpretability of other models.

CONCLUSIONS

In our example application, the choice of base learner had the largest impact on R2; multioutput algorithm adaptation and variable selection and hyperparameter tuning had a modest impact. Although advantages and disadvantages of specific learning algorithms may vary across different modeling applications, our framework for metamodeling in policy analyses with multivariate outcomes has broad applicability to decision analysis in health and medicine.

Population-level impact of initiating pharmacotherapy and linking to care people with opioid use disorder at inpatient medically managed withdrawal programs: an effectiveness and cost-effectiveness analysis

BACKGROUND AND AIMS

Medications for opioid use disorder (MOUD) are shown to reduce opioid use and the risk of overdose. People with opioid use disorder (OUD) who exit inpatient medically managed withdrawal programs (detox) without initiating MOUD and linking to outpatient care have high rates of overdose. While detox encounters provide a theoretical opportunity for MOUD initiation, this is not ubiquitous in the United States. We used simulation modeling to estimate the population-level health effects and cost-effectiveness of a policy encouraging MOUD initiation during inpatient detox encounters.

DESIGN, SETTING AND PARTICIPANTS

We employed a dynamic population state-transition model to evaluate the effectiveness and cost-effectiveness of using detox programs as venues for initiating MOUD in Massachusetts, United States. We compared standard of care, where no detox patients initiate MOUD or link to outpatient MOUD providers, to strategies of offering MOUD to detox patients and linking those patients to outpatient MOUD.

MEASURES

Budgetary impact to the Massachusetts health-care sector, incremental cost-effectiveness ratios (ICER) and total counts and percentage differences of fatal overdoses prevented.

FINDINGS

Initiating MOUD in detox with perfect linkage to outpatient MOUD would reduce fatal overdoses by 4.5% [95% confidence interval (CI) = 2.3-5.9], at an ICER of $56 000 per quality-adjusted life-year (QALY) gained, compared with the standard of care. With moderate linkage, fatal overdoses would be reduced by 2.3% (95% CI= 1.2-3.1) with an ICER of $78 500 per QALY gained, compared with standard of care. Budgetary increase to Massachusetts health-care spending ranged from 0.5-1%.

CONCLUSION

A simulation model indicates that initiation of medications for opioid use disorder and linkage policies among detox patients in Massachusetts, USA could prevent fatal opioid overdoses in the opioid use disorder population and would be cost-effective from a health-care sector perspective.

Factors associated with inpatient complications among patients with obesity and COVID-19 at an urban safety-net hospital: A retrospective cohort study

Objective

Obesity increases morbidity and mortality from Coronavirus disease 2019 (COVID-19). This study characterized inpatient complications among patients with obesity and COVID-19-including myocardial infarction, renal failure requiring dialysis, stroke, secondary bacterial infection, and venous thromboembolism-and identified factors associated with developing at least one inpatient complication at a safety-net hospital with a diverse cohort.

Methods

A retrospective review was performed of all patients admitted for ≥3 days with COVID-19 between 16 March 2020, and 8 April 2020. Logistic regression identified factors associated with developing at least one COVID-19-related complication among patients with obesity (body mass index ≥30 kg/m2).

Results

374 patients were included; 53.7% were classified as having obesity, 43.9% identified as Black, and 38.5% identified as Latino or Hispanic. Obesity was not associated with having at least one inpatient complication on multivariable analysis, but increased age (aOR 1.02, [95% CI 1.01-1.04], p = 0.010) and obstructive sleep apnea (aOR 2.25, [1.08-4.85], p = 0.034) were associated with this outcome.

Conclusions

Obesity was not associated with specified inpatient complications among patients with COVID-19 admitted to a health system caring for diverse patients. Future studies should incorporate larger cohorts and reflect newer treatment protocols.

Addressing Inequities in SARS-CoV-2 Vaccine Uptake: The Boston Medical Center Health System Experience

Academic medical centers could play an important role in increasing access to and uptake of SARS-CoV-2 vaccines, especially in Black and Latino communities that have been disproportionately affected by the pandemic. This article describes the vaccination program developed by the Boston Medical Center (BMC) health system (New England's largest safety-net health system), its affiliated community health centers (CHCs), and community partners. The program was based on a conceptual framework for community interventions and aimed to increase equitable access to vaccination in the hardest-hit communities through community-based sites in churches and community centers, mobile vaccination events, and vaccination on the BMC campus. Key strategies included a communication campaign featuring trusted messengers, a focus on health equity, established partnerships with community leaders and CHCs, and strong collaboration with local health departments and the Commonwealth of Massachusetts to ensure equitable allocation of the vaccine supply. Process factors involved the use of robust analytics relying on the Centers for Disease Control and Prevention's Social Vulnerability Index (SVI). The vaccination program administered 109 938 first doses, with 94 703 (86%) given at community sites and 2466 (2%) given at mobile sites. Mobile vaccination events were key in reaching younger people living in locations with the highest SVIs. Challenges included the need for a robust operational infrastructure and mistrust of the health system given the long history of economic disinvestment in the surrounding community. The BMC model could serve as a blueprint for other medical centers interested in implementing programs aimed at increasing vaccine uptake during a pandemic and in developing an infrastructure to address other health-related disparities.

OUP accepted manuscript

Objective

To develop predictive models of coronavirus disease 2019 (COVID-19) outcomes, elucidate the influence of socioeconomic factors, and assess algorithmic racial fairness using a racially diverse patient population with high social needs.

Materials and Methods

Data included 7,102 patients with positive (RT-PCR) severe acute respiratory syndrome coronavirus 2 test at a safety-net system in Massachusetts. Linear and nonlinear classification methods were applied. A score based on a recurrent neural network and a transformer architecture was developed to capture the dynamic evolution of vital signs. Combined with patient characteristics, clinical variables, and hospital occupancy measures, this dynamic vital score was used to train predictive models.

Results

Hospitalizations can be predicted with an area under the receiver-operating characteristic curve (AUC) of 92% using symptoms, hospital occupancy, and patient characteristics, including social determinants of health. Parsimonious models to predict intensive care, mechanical ventilation, and mortality that used the most recent labs and vitals exhibited AUCs of 92.7%, 91.2%, and 94%, respectively. Early predictive models, using labs and vital signs closer to admission had AUCs of 81.1%, 84.9%, and 92%, respectively.

Discussion

The most accurate models exhibit racial bias, being more likely to falsely predict that Black patients will be hospitalized. Models that are only based on the dynamic vital score exhibited accuracies close to the best parsimonious models, although the latter also used laboratories.

Conclusions

This large study demonstrates that COVID-19 severity may accurately be predicted using a score that accounts for the dynamic evolution of vital signs. Further, race, social determinants of health, and hospital occupancy play an important role.

333. Comparing COVID-19-related Morbidity and Mortality between Patients with and without Substance Use Disorder: A Retrospective Cohort Study

Background

Early data suggest that people with substance use disorder (SUD) who develop coronavirus disease 2019 (COVID-19) have increased intubation and mortality rates when compared to those without SUD. Information on other COVID-19-related complications in this population is limited. We evaluated COVID-19 outcomes in patients with and without SUD.

Methods

We created a retrospective cohort of patients with COVID-19 admitted to an urban safety net hospital from 3/16/2020 to 4/8/2020. Inclusion criteria were admission with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 and age greater than 18 years. SUD included alcohol use disorder or heavy alcohol use as defined by the National Institute on Alcohol Abuse and Alcoholism, use of cocaine, non-prescribed opioids or amphetamines. Primary outcome was inpatient mortality. Secondary outcomes were clinical complications (intubation, secondary infections, renal failure, venous thromboembolism, stroke, hepatitis, myocardial infarct, multisystem organ failure) and resource utilization (length of stay, intensive care unit [ICU] admission, ICU days, readmission). We used multivariable regression to assess factors associated with mortality and length of stay, and univariate analyses for other outcomes.

Results

Of 409 included patients, 70 (17.1%) had SUD. Those with SUD were more likely to be male and have pulmonary disease or hepatitis C. There were no differences in other comorbidities, mean age or race/ethnicity. After multivariable analysis, SUD was not associated with mortality (aOR 1.60; 95% CI, 0.60-3.81). Similarly baseline oxygenation defined as the ratio of oxygen saturation to fraction of inspired oxygen (aOR 1.57; 0.11-13.0) and administration of immunomodulatory therapy (tocilizumab, sarilumab or anakinra) (aOR 1.41; 0.65-3.01) did not affect mortality. In contrast, age (aOR 1.06; 1.03-1.09), sex (aOR 2.30; 1.04-5.47) and obstructive sleep apnea (aOR 4.07; 1.64-9.66) were associated with mortality. We did not find any associations with secondary outcomes.

Conclusion

Our findings suggest that substance use alone may not increase COVID-19 adverse outcomes. Future studies should evaluate these results in the current period of improved COVID-19 therapy.

Disclosures

All Authors: No reported disclosures

HIV Pre-exposure Prophylaxis and Buprenorphine at a Drug Detoxification Center During the Opioid Epidemic: Opportunities and Challenges

Human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) and buprenorphine decrease HIV acquisition. Between November, 2016 and July, 2017, we surveyed persons (N = 200) at a drug detoxification center to assess their interest in PrEP and in buprenorphine, and to examine factors associated with such interests. Over the previous 6 months, 58% (117/200) injected drugs, 87% (173/200) used opioids, 50% (85/171) had condomless sex. Only 22% (26/117) of persons who injected drugs were aware of PrEP, yet 74% (86/116) and 72% (84/116) were interested in oral or injectable PrEP, respectively. Thirty-eight percent (47/125) of persons not receiving buprenorphine or methadone expressed interest in buprenorphine. After multivariable adjustment, Latinx ethnicity was associated with interest in PrEP (aOR 3.80; 95% CI 1.37-10.53), while male gender (aOR 2.76; 95% CI 1.21-6.34) was associated with interest in buprenorphine. Opportunities exist to implement PrEP and buprenorphine within drug detoxification centers.Clinical trial registration NCT02869776. Clinicaltrials.gov https://clinicaltrials.gov/ct2/show/NCT02869776?term=Sabrina+Assoumou&cond=HIV+HCV&rank=1 .

Partnering With State Health Departments to Address Injection-Related Infections During the Opioid Epidemic: Experience at a Safety Net Hospital

Massachusetts is one of the epicenters of the opioid epidemic and has been severely impacted by injection-related viral and bacterial infections. A recent increase in newly diagnosed human immunodeficiency virus (HIV) infections among persons who inject drugs in the state highlights the urgent need to address and bridge the overlapping epidemics of opioid use disorder (OUD) and injection-related infections. Building on an established relationship between the Massachusetts Department of Public Health and Boston Medical Center, the Infectious Diseases section has contributed to the development and implementation of a cohesive response involving ambulatory, inpatient, emergency department, and community-based services. We describe this comprehensive approach including the rapid delivery of antimicrobials for the prevention and treatment of HIV, sexually transmitted diseases, systemic infections such as endocarditis, bone and joint infections, as well as curative therapy for chronic hepatitis C virus in a manner that is accessible to patients on the addiction-recovery continuum. We also provide an overview of programs that provide access to medications for OUD, harm reduction services including overdose education, and distribution of naloxone. Finally, we outline lessons learned to inform initiatives in other settings.

Characterizing initiation, use, and discontinuation of extended-release buprenorphine in a nationally representative United States commercially insured cohort

BACKGROUND AND AIMS

While the United States is in the midst of an overdose epidemic, effective treatments are underutilized and commonly discontinued. Innovations in medication delivery, including an extended-release formulations, have the potential to improve treatment access and reduce discontinuation. We sought to assess extended-release buprenorphine discontinuation among individuals with opioid use disorder (OUD) in a real-world, nationally representative cohort.

SETTING

United States PARTICIPANTS: Commercially insured individuals initiating one of four FDA-approved medications for opioid use disorder (MOUD) in 2018: extended-release buprenorphine, extended-release naltrexone, mucosal buprenorphine (mono- or co-formulated with naloxone), or methadone.

MEASUREMENTS

Our primary outcome was medication discontinuation, defined as a gap of more than 14 days between the end of one prescription or administration and the subsequent dose.

FINDINGS

We identified 14,358 individuals initiating MOUD in 2018, including 204 (1%) extended-release buprenorphine, 1,173 (8%) extended-release naltrexone, 12,171 (85%) mucosal buprenorphine, and 810 (6%) methadone initiations. Three months after initiation, 50% (95% confidence interval [CI] 40%-60%) of extended-release buprenorphine, 64% (95% CI 61%-69%) of extended-release naltrexone, 34% (95% CI 33%-35%) of mucosal buprenorphine, and 58% (95% CI 54%-62%) of methadone initiators had discontinued treatment.

CONCLUSIONS

Across all treatment groups, medication discontinuation was high, and in this sample of early adopters with limited follow-up time, we found no evidence that extended-release buprenorphine offered a retention advantage compared to other MOUD in real-world settings. Retention continues to represent a major obstacle to treatment effectiveness, and interventions are needed to address this challenge even as new MOUD formulations become available.

Rapid Versus Laboratory-Based Testing for HIV and Hepatitis C at a Drug Detoxification Treatment Center: A Randomized Trial

BACKGROUND

A health department survey revealed nearly half employ laboratory-based HIV and HCV testing (LBT) over rapid testing (RT) in nonhospital settings such as drug detoxification centers. LBT has higher sensitivity for acute HIV infection compared to RT but LBT is not point of care and may result in fewer diagnoses due to loss to follow-up before result delivery.

METHODS

We conducted a randomized trial comparing real-world case notification of RT (Orasure) vs LBT (HIV Combo Ag/Ab EIA, HCV EIA) for HIV and HCV at a drug detoxification center. Primary outcome was receipt of test results within 2 weeks.

RESULTS

Among 341 individuals screened (11/2016-7/2017), 200 met inclusion criteria; 58% injected drugs and 31% shared needles in the previous 6 months. Of the 200 randomized, 98 received RT and 102 LBT. Among all participants, 0.5% were positive for HIV and 48% for HCV; 96% received test results in the RT arm and 42% in the LBT arm (odds ratio, 28.72; 95% confidence interval, 10.27-80.31). Real-world case notification was 95% and 93% for HIV and HCV RT, respectively, compared to 42% for HIV and HCV LBT.

CONCLUSIONS

RT has higher real-world case notification than LBT at drug detoxification centers.Clinical trials registration: NCT02869776.

The Effect of IL-6 Inhibitors on Mortality Among Hospitalized COVID-19 Patients: A Multicenter Study

BACKGROUND

The effectiveness of interleukin-6 inhibitors (IL-6i) in ameliorating coronavirus disease 2019 (COVID-19) remains uncertain.

METHODS

We analyzed data for patients aged ≥18 years admitted with a positive severe acute respiratory syndrome coronavirus 2 polymerase chain reaction test at 4 safety-net hospital systems with diverse populations and high rates of medical comorbidities in 3 US regions. We used inverse probability of treatment weighting via machine learning for confounding adjustment by demographics, comorbidities, and disease severity markers. We estimated the average treatment effect, the odds of IL-6i effect on in-hospital mortality from COVID-19, using a logistic marginal structural model.

RESULTS

Of 516 patients, 104 (20.1%) received IL-6i. Estimate of the average treatment effect adjusted for confounders suggested a 37% reduction in odds of in-hospital mortality in those who received IL-6i compared with those who did not, although the confidence interval included the null value of 1 (odds ratio = 0.63; 95% confidence interval, .29-1.38). A sensitivity analysis suggested that potential unmeasured confounding would require a minimum odds ratio of 2.55 to nullify our estimated IL-6i effect size.

CONCLUSIONS

Despite low precision, our findings suggested a relatively large effect size of IL-6i in reducing the odds of COVID-19-related in-hospital mortality.

Projected Estimates of Opioid Mortality After Community-Level Interventions

Importance

The United States is experiencing a crisis of opioid overdose. In response, the US Department of Health and Human Services has defined a goal to reduce overdose mortality by 40% by 2022.

Objective

To identify specific combinations of 3 interventions (initiating more people to medications for opioid use disorder [MOUD], increasing 6-month retention with MOUD, and increasing naloxone distribution) associated with at least a 40% reduction in opioid overdose in simulated populations.

Design, Setting, and Participants

This decision analytical model used a dynamic population-level state-transition model to project outcomes over a 2-year horizon. Each intervention scenario was compared with the counterfactual of no intervention in simulated urban and rural communities in Massachusetts. Simulation modeling was used to determine the associations of community-level interventions with opioid overdose rates. The 3 examined interventions were initiation of more people to MOUD, increasing individuals' retention with MOUD, and increasing distribution of naloxone. Data were analyzed from July to November 2020.

Main Outcomes and Measures

Reduction in overdose mortality, medication treatment capacity needs, and naloxone needs.

Results

No single intervention was associated with a 40% reduction in overdose mortality in the simulated communities. Reaching this goal required use of MOUD and naloxone. Achieving a 40% reduction required that 10% to 15% of the estimated OUD population not already receiving MOUD initiate MOUD every month, with 45% to 60%% retention for at least 6 months, and increased naloxone distribution. In all feasible settings and scenarios, attaining a 40% reduction in overdose mortality required that in every month, at least 10% of the population with OUD who were not currently receiving treatment initiate an MOUD.

Conclusions and Relevance

In this modeling study, only communities with increased capacity for treating with MOUD and increased MOUD retention experienced a 40% decrease in overdose mortality. These findings could provide a framework for developing community-level interventions to reduce opioid overdose death.

Cost-effectiveness and Budgetary Impact of Hepatitis C Virus Testing, Treatment, and Linkage to Care in US Prisons

BACKGROUND

Hepatitis C virus (HCV) testing and treatment uptake in prisons remains low. We aimed to estimate clinical outcomes, cost-effectiveness (CE), and budgetary impact (BI) of HCV testing and treatment in United States (US) prisons or linkage to care at release.

METHODS

We used individual-based simulation modeling with healthcare and Department of Corrections (DOC) perspectives for CE and BI analyses, respectively. We simulated a US prison cohort at entry using published data and Washington State DOC individual-level data. We considered permutations of testing (risk factor based, routine at entry or at release, no testing), treatment (if liver fibrosis stage ≥F3, for all HCV infected or no treatment), and linkage to care (at release or no linkage). Outcomes included quality-adjusted life-years (QALY); cases identified, treated, and cured; cirrhosis cases avoided; incremental cost-effectiveness ratios; DOC costs (2016 US dollars); and BI (healthcare cost/prison entrant) to generalize to other states.

RESULTS

Compared to "no testing, no treatment, and no linkage to care," the "test all, treat all, and linkage to care at release" model increased the lifetime sustained virologic response by 23%, reduced cirrhosis cases by 54% at a DOC annual additional cost of $1440 per prison entrant, and would be cost-effective. At current drug prices, targeted testing and liver fibrosis-based treatment provided worse outcomes at higher cost or worse outcomes at higher cost per QALY gained. In sensitivity analysis, fibrosis-based treatment restrictions were cost-effective at previous higher drug costs.

CONCLUSIONS

Although costly, widespread testing and treatment in prisons is considered to be of good value at current drug prices.

Hepatitis C Management at Federally Qualified Health Centers during the Opioid Epidemic: A Cost-Effectiveness Study

BACKGROUND

The opioid epidemic has been associated with an increase in hepatitis C virus (HCV) infections. Federally qualified health centers (FQHCs) have a high burden of hepatitis C disease and could serve as venues to enhance testing and treatment.

METHODS

We estimated clinical outcomes and the cost-effectiveness of hepatitis C testing and treatment at US FQHCs using individual-based simulation modeling. We used individual-level data from 57 FQHCs to model 9 strategies, including permutations of HCV antibody testing modality, person initiating testing, and testing approach. Outcomes included life expectancy, quality-adjusted life-years (QALY), hepatitis C cases identified, treated and cured; and incremental cost-effectiveness ratios.

RESULTS

Compared with current practice (risk-based with laboratory-based testing), routine rapid point-of-care testing initiated and performed by a counselor identified 68% more cases after (nonreflex) RNA testing in the first month of the intervention and led to a 17% reduction in cirrhosis cases and a 22% reduction in liver deaths among those with cirrhosis over a lifetime. Routine rapid testing initiated by a counselor or a clinician provided better outcomes at either lower total cost or at lower cost per QALY gained, when compared with all other strategies. Findings were most influenced by the proportion of patients informed of their anti-HCV test results.

CONCLUSIONS

Routine anti-HCV testing followed by prompt RNA testing for positives is recommended at FQHCs to identify infections. If using dedicated staff or point-of-care testing is not feasible, then measures to improve immediate patient knowledge of antibody status should be considered.

Early administration of interleukin-6 inhibitors for patients with severe COVID-19 disease is associated with decreased intubation, reduced mortality, and increased discharge

•

Observational data on interleukin-6 receptor inhibitors (IL6ri) for COVID-19 disease are reported.

•

IL6ri therapy was found to be associated with improved COVID-19 outcomes.

•

The treatment benefit was greatest when therapy was initiated early during the disease course.

•

IL6ri therapy appears to be superior to remdesivir and dexamethasone.

Objective

The aim of this observational study was to determine the optimal timing of interleukin-6 receptor inhibitor (IL6ri) administration for coronavirus disease 2019 (COVID-19).

Methods

Patients with COVID-19 were given an IL6ri (sarilumab or tocilizumab) based on iteratively reviewed guidelines. IL6ri were initially reserved for critically ill patients, but after review, treatment was liberalized to patients with lower oxygen requirements. Patients were divided into two groups: those requiring ≤45% fraction of inspired oxygen (FiO₂) (termed stage IIB) and those requiring >45% FiO₂ (termed stage III) at the time of IL6ri administration. The main outcomes were all-cause mortality, discharge alive from hospital, and extubation.

Results

A total of 255 COVID-19 patients were treated with IL6ri (149 stage IIB and 106 stage III). Patients treated in stage IIB had lower mortality than those treated in stage III (adjusted hazard ratio (aHR) 0.24, 95% confidence interval (CI) 0.08–0.74). Overall, 218 (85.5%) patients were discharged alive. Patients treated in stage IIB were more likely to be discharged (aHR 1.43, 95% CI 1.06–1.93) and were less likely to be intubated (aHR 0.43, 95% CI 0.24–0.79).

Conclusions

IL6ri administration prior to >45% FiO₂ requirement was associated with improved COVID-19 outcomes. This can guide clinical management pending results from randomized controlled trials.

HCV Testing and Treatment in a National Sample of US Federally Qualified Health Centers during the Opioid Epidemic

BACKGROUND

Federally qualified health centers (FQHCs) serve diverse communities in the United States (U.S.) and could function as important venues to diagnose and treat hepatitis C virus (HCV) infections.

OBJECTIVE

To determine HCV testing proportion and factors associated with treatment initiation, and treatment outcomes in a large sample of FQHCs around the U.S.

DESIGN

Retrospective cohort study using electronic health records of three hundred and forty-one FQHC clinical sites participating in the OCHIN network in 19 U.S. states.

PARTICIPANTS

Adult patients (≥ 18 years of age) seen between January 01, 2012, and June 30, 2017.

MAIN MEASURES

HCV testing proportion, stratified by diagnosis of opioid use disorder (OUD); treatment initiation rates; and sustained virologic response (SVR), defined as undetectable HCV RNA 6 months after treatment initiation.

KEY RESULTS

Of the 1,508,525 patients meeting inclusion criteria, 88,384 (5.9%) were tested for HCV, and 8694 (9.8%) of individuals tested had reactive results. Of the 6357 with HCV RNA testing, 4092 (64.4%) had detectable RNA. Twelve percent of individuals with chronic HCV and evaluable data initiated treatment. Of those, 87% reached SVR. Having commercial insurance (aOR, 2.11; 95% CI, 1.46-3.05), older age (aOR, 1.07; 95% CI, 1.06-1.09), and being Hispanic/Latino (aOR, 1.87; 95% CI, 1.38-2.53) or Asian/Pacific Islander (aOR, 2.47; 95% CI, 1.46-4.19) were independently associated with higher odds of treatment initiation after multivariable adjustment. In contrast, women (aOR, 0.76; 95% CI, 0.60-0.97) and the uninsured (aOR, 0.15; 95% CI, 0.09-0.25) were less likely to initiate treatment. Only 8% of individuals with chronic HCV were tested for HIV, and 15% of individuals with identified OUD were tested for HCV.

CONCLUSIONS

Fewer than 20% of individuals with identified OUD were tested for HCV. SVR was lower than findings in other real-world cohorts. Measures to improve outcomes should be considered with the expansion of HCV management into community clinics.

Hepatitis C Virus Antibody Testing Among 13- to 21-Year-Olds in a Large Sample of US Federally Qualified Health Centers

This study characterizes hepatitis C virus (HCV) testing and the HCV care cascade among 13- to 21-year-olds accessing US federally qualified health centers.

302. HCV Care in Federally Qualified Health Centers During the Opioid Epidemic: A Retrospective Cohort Study

Background

Federally qualified health centers (FQHCs) serve diverse communities in the United States (US) and could function as important venues to manage hepatitis C virus (HCV) infections. Little is known on HCV outcomes in underserved communities as most of the current data are derived from clinical trials, commercially insured patients, or small health center samples. We aimed to determine the proportion of HCV testing, factors associated with treatment initiation, and real-world treatment outcomes in a large, national diverse sample of US FQHCs during the opioid epidemic.

Methods

We created a retrospective cohort of adults seen at 341 participating FQHCs in 19 US states. Inclusion criteria were: (1) clinical visit between January 01, 2012 and June 30, 2017; (2) ≥18 years of age. Outcomes included HCV testing proportion, stratified by diagnosis of opioid use disorder (OUD); treatment initiation rates; and sustained virologic response (SVR), defined as undetectable HCV RNA 3 months after treatment completion. We identified factors associated with testing, treatment initiation, and SVR using logistic regression.

Results

Of the 1,508,525 patients meeting inclusion criteria, 88,384 (5.9%) were tested for HCV, and 8,694 (9.8%) of individuals tested had reactive results. Of the 6,357 with HCV RNA testing, 4,092 (64.4%) had detectable RNA. Twelve percent of individuals with chronic HCV and evaluable data initiated treatment. Of those, 86% reached SVR. Having commercial insurance (aOR, 2.10, 95% CI, 1.45–3.02), older age (aOR, 1.07, 95% CI, 1.06–1.09) and being Hispanic/Latino (aOR, 1.35, 95% CI, 1.33–1.38) or Asian/Pacific Islander (aOR, 1.84, 95% CI, 1.79–1.90) were independently associated with higher odds of treatment initiation after multivariable adjustment. Only 8% of individuals with chronic HCV were tested for HIV, and 15% of individuals with identified OUD were tested for HCV.

Conclusion

During the opioid epidemic, fewer than 20% of individuals with identified OUD were tested for HCV at evaluated FQHCs. In addition, approximately 10% of patients initiated treatment and SVR was lower than expected. Expansion of HCV management into community clinics must consider measures to monitor and evaluate treatment effectiveness, and to improve outcomes if cure rates are low.

Disclosures

All authors: No reported disclosures.

976. Development and Validation of a Risk Score for Predicting Cardiovascular Events in HIV-Infected Patients

Background

HIV-infected individuals are at higher risk for developing cardiovascular disease (CVD). We aimed to develop a model to predict 10-year cardiovascular (CV) risk given that commonly used CVD risk assessment tools might not be accurate for HIV-infected patients.

Methods

We conducted a retrospective cohort study of HIV-infected patients seen at Boston Medical Center between March 2012 and January 2017. Exclusion criteria are shown in Figure 1. Patients were divided into model development and validation cohorts. Logistic regression was used to create a risk model for CV events using data from the development cohort. The relationship between risk factors and CVD risk was summarized using a point-based risk-scoring system. Areas under the receiver-operating-characteristics curve (AUC) were used to evaluate model discrimination. The model was subsequently tested using the validation cohort.

Results

Of 3,867 eligible HIV-infected patients, 1,914 individuals met inclusion criteria (Figure 1). There were 256 CV events in the development cohort. Ten independent prognostic factors were incorporated into the prediction function (P_model < 0.001). The model had excellent discrimination for CVD risk [AUC 0.94; (95% CI:0.93–0.96)] (Figure 2) and included the following variables: male sex (P < 0.001), African-American ethnicity (P = 0.023), current age (P = 0.020), age at HIV diagnosis (P = 0.006), peak HIV viral load (P = 0.012), nadir CD4 lymphocyte count (P < 0.001), hypertension (P < 0.001), hyperlipidemia (P = 0.001), diabetes (P < 0.001), and chronic kidney disease (P < 0.001). Scoring system and score sheets of risk estimates were developed to predict CV events in a 10-year follow-up period (Figures 3 and 4). The 10-parameter multiple logistic regression model also had excellent discrimination [AUC 0.96; (95% CI: 0.89–0.99)] when applied to the validation cohort.

Conclusion

We developed and validated a risk-scoring system based on 10 clinical factors that accurately predict the 10-year risk for CV events in an HIV-infected population. This assessment tool may provide clinicians with a rapid assessment of cardiovascular disease risk among HIV-infected patients and inform prevention measures during the era of effective antiretroviral therapy.

Disclosures

All Authors: No reported Disclosures.

Evidence-based and guideline-concurrent responses to narratives deferring HCV treatment among people who inject drugs

BACKGROUND

Hepatitis C virus (HCV) infection is increasingly prevalent among people who inject drugs (PWID) in the context of the current US opioid crisis. Although curative therapy is available and recommended as a public health strategy, few PWID have been treated. We explore PWID narratives that explain why they have not sought HCV treatment or decided against starting it. We then compare these narratives to evidence-based and guideline-concordant information to better enable health, social service, harm reduction providers, PWID, and other stakeholders to dispel misconceptions and improve HCV treatment uptake in this vulnerable population.

METHODS

We recruited HIV-uninfected PWID (n = 33) through community-based organizations (CBOs) to participate in semi-structured, in-depth qualitative interviews on topics related to overall health, access to care, and knowledge and interest in specific HIV prevention methods.

RESULTS

In interviews, HCV transmission and delaying or forgoing HCV treatment emerged as important themes. We identified three predominant narratives relating to delaying or deferring HCV treatment among PWID: (1) lacking concern about HCV being serious or urgent enough to require treatment, (2) recognizing the importance of treatment but nevertheless deciding to delay treatment, and (3) perceiving that clinicians and insurance companies recommend that patients who currently use or inject drugs should delay treatment.

CONCLUSIONS

Our findings highlight persistent beliefs among PWID that hinder HCV treatment utilization. Given the strong evidence that treatment improves individual health regardless of substance use status while also decreasing HCV transmission in the population, efforts are urgently needed to counter the predominant narratives identified in our study. We provide evidence-based, guideline-adherent information that counters the identified narratives in order to help individuals working with PWID to motivate and facilitate treatment access and uptake. An important strategy to improve HCV treatment initiation among PWID could involve disseminating guideline-concordant counternarratives to PWID and the providers who work with and are trusted by this population.

Hepatitis C Testing and Patient Characteristics in Washington State's Prisons Between 2012 and 2016

INTRODUCTION

There is no widely accepted testing approach for hepatitis C virus infection in correctional settings, and many U.S. prisons do not provide routine testing. The aim of this study was to determine the most effective hepatitis C virus testing strategy in one U.S. state prison and describe the population with reactive testing.

METHODS

A retrospective analysis was performed using individuals entering the Washington State prison system, which routinely offers hepatitis C virus testing, to compare routine opt-out with current recommendations for risk-based and one-time testing for individuals born between 1945 and 1965. Additionally, liver fibrosis stage was characterized using aspartate aminotransferase to platelet ratio index and Fibrosis-4 index. Analyses were conducted in 2017.

RESULTS

Between 2012 and 2016, a total of 24,567 (83%) individuals were tested for the hepatitis C virus antibody and 4,921 (20%) were reactive (test was positive). There were 2,403 (49%) that had hepatitis C virus RNA testing, with 1,727 (72%) showing chronic infection. Reactive antibody was more prevalent in individuals born between 1945 and 1965 compared with other years (44% vs 17%); however, most cases (72%) were outside of this cohort. Up to 35% of positive reactive tests would be missed with testing targeted by birth cohort and risk behavior. Of chronically infected individuals, 23% had at least moderate liver fibrosis.

CONCLUSIONS

Targeted testing in the Washington State prison system missed a substantial proportion of hepatitis C virus cases; of those with reactive testing, a sizeable proportion of people had at least moderate liver disease, placing them at risk for complications. Routine testing at entry should be considered by U.S. state prisons.

340. Clinical Use of a Multiplex PCR Meningitis/Encephalitis Panel at an Urban Tertiary Care Center

Background

The FilmArray® Meningitis/Encephalitis (ME) Panel (BioFire Diagnostics, Salt Lake City, Utah) is the first multiplex polymerase chain reaction (PCR) test for detection of 14 pathogens in cerebrospinal fluid (CSF) that are commonly associated with meningitis and encephalitis. Its impact on clinical management has not been well evaluated. Our aim was to describe the experience using the ME panel since its implementation at an urban tertiary care center.

Methods

We conducted a retrospective chart review of all patients aged >21 who had CSF samples analyzed by the ME panel from January 1 to July 31, 2017. We abstracted demographic, clinical, laboratory, and imaging data to assess ME panel results and their influence on clinical management.

Results

We reviewed the charts of 93 patients aged 21 to 85 who had the ME panel performed. Forty-nine (53%) were males and eight (9%) were immunosuppressed. Eight (9%) patients had a positive test for at least one target pathogen: four for a bacterial target (S. pneumoniae, N. meningitidis, or H. influenza), three for a viral target (HSV-2 or VZV), and one for both a bacterial and a viral target (S. pneumoniae and HSV-2). CSF cultures were negative for all five cases with bacteria detected. Confirmatory uniplex PCR was not performed for the positive viral results. Four of the five patients with positive results for a bacterial pathogen had received broad-spectrum antibiotics prior to lumbar puncture. In all five, antibiotics were modified (either started or de-escalated) based on the pathogen identified on the ME panel. All four patients with a positive result for a viral target received anti-viral therapy—in one case this was started empirically, while in the remaining three treatment was started only after the ME panel had resulted. Antibiotic management in the 85 patients with a negative ME panel varied widely based on clinical suspicion and other laboratory data. Three (3%) of the 93 patients had positive cultures for pathogens that are not ME panel targets (S. aureus and S. hominis).

Conclusion

The ME panel yielded positive results in cases where conventional tests did not, including when antibiotics had been initiated prior to CSF sampling. While a positive ME panel prompted changes in therapy, negative results, in the majority of cases, did not supersede clinical suspicion.

Disclosures

N. Miller, BioFire Diagnostics: Paid speaker, single day event (1 time only): 4/6/2017, BioFire Diagnostics, Syndromic Testing Symposium, Burlington, MA, Speaker honorarium.

2570. HCV Screening Practices Among Adolescents and Young Adults in a National Sample of Federally Qualified Health Centers in the United States

Background

The opioid crisis has been associated with an increase in hepatitis C virus (HCV) infections among 15–30 year olds. Federally Qualified Health Centers (FQHCs) provide comprehensive healthcare to diverse and underserved communities. However, little is known about HCV screening practices among adolescents and young adults seen at FQHCs across the United States.

Objective. To characterize the continuum of HCV testing and care among adolescents and emerging adults in a large national sample of US FQHCs.

Methods

We used the OCHIN electronic medical record to create a retrospective cohort of 13 to 21 year olds who had a least 1 outpatient visit at any of 98 participating US FQHCs across 19 states from 2012 to 2017. Primary outcome was HCV testing during this timeframe. We also identified predictors of HCV screening using multivariable logistic regression adjusting for age, sex, race/ethnicity, and substance use.

Results

Among 269,287 youth who met inclusion criteria, 54.7% were female, 37.6% White, 33.5% Hispanic, 17.6% Black, and 11.3% other. Mean [SD] age at first HCV screening was 18.5 [2.2] years. Over the study period, 2.5% (6849/269,287) were tested for HCV and 153 (2.2%) had reactive HCV testing. Of those, 117 (76.5%) had confirmatory RNA testing and 65 (55.6%) had detectable RNA. Thirty-five percent (325/933) with ICD-9 codes for opioid-use disorder (OUD) and 8.9% (2080/23,345) with any ICD-9 code for drug use were tested for HCV. Only 10.6% (728/6,849) of individuals tested for HCV had also been tested for human immunodeficiency virus (HIV). Older age (19–21 vs. 13–15 years old at study end, aOR 5.64, 95% CI 5.13–6.19), Black race (aOR 1.88, 95% CI 1.76–2.00), and ICD-9 codes for substance-use disorder, in particular amphetamine (aOR 5.82, 5.10–6.64), opioids (aOR 3.50, 2.92–4.19), cocaine (aOR 2.90, 2.43–3.47), or cannabis (aOR 2.46, 2.31–2.62) were independently associated with HCV testing in multivariable analysis.

Conclusion

During the current opioid crisis, only a third of adolescents/young adults diagnosed with OUD in a large national sample of FQHCs were tested for HCV. In addition, only 10% of those tested for HCV were also screened for HIV. Initiatives are needed to increase HCV and HIV screening among at-risk youth at FQHCs.

Disclosures

All authors: No reported disclosures.

Real-world Outcomes of Hepatitis C Treatment during the Interferon-free Era at an Urban Safety-net Hospital

BACKGROUND

Little is known about real-world outcomes for new interferon-free treatment for hepatitis C virus (HCV) among underserved and diverse communities.

OBJECTIVE

To identify predictors of treatment prescription and evaluate outcomes as measured by sustained virologic response (SVR) with HCV RNA testing three months after therapy completion.

DESIGN

Retrospective cohort at a safety-net health care system.

PARTICIPANTS

Patients with (1) at least one clinical visit between December 6, 2013, and December 31st 2014; and (2) at least three months follow-up.

KEY RESULTS

Predominantly non-White cohort (61%). Of 1,284 HCV-infected patients 121 prescribed sofosbuvir-based therapy. Severe liver fibrosis (OR 1.66, 95% CI 1.05, 2.64) independently associated with treatment prescription. In those with evaluable HCV RNA, SVR was 99%.

CONCLUSION

Cure rates similar to clinical trial data can be achieved in diverse underserved communities.

Cost-Effectiveness of One-Time Hepatitis C Screening Strategies Among Adolescents and Young Adults in Primary Care Settings

Background

High hepatitis C virus (HCV) rates have been reported in young people who inject drugs (PWID). We evaluated the clinical benefit and cost-effectiveness of testing among youth seen in communities with a high overall number of reported HCV cases.

Methods

We developed a decision analytic model to project quality-adjusted life years (QALYs), costs (2016 US$), and incremental cost-effectiveness ratios (ICERs) of 9 strategies for 1-time testing among 15- to 30-year-olds seen at urban community health centers. Strategies differed in 3 ways: targeted vs routine testing, rapid finger stick vs standard venipuncture, and ordered by physician vs by counselor/tester using standing orders. We performed deterministic and probabilistic sensitivity analyses (PSA) to evaluate uncertainty.

Results

Compared to targeted risk-based testing (current standard of care), routine testing increased the lifetime medical cost by $80 and discounted QALYs by 0.0013 per person. Across all strategies, rapid testing provided higher QALYs at a lower cost per QALY gained and was always preferred. Counselor-initiated routine rapid testing was associated with an ICER of $71000/QALY gained. Results were sensitive to offer and result receipt rates. Counselor-initiated routine rapid testing was cost-effective (ICER <$100000/QALY) unless the prevalence of PWID was <0.59%, HCV prevalence among PWID was <16%, reinfection rate was >26 cases per 100 person-years, or reflex confirmatory testing followed all reactive venipuncture diagnostics. In PSA, routine rapid testing was the optimal strategy in 90% of simulations.

Conclusions

Routine rapid HCV testing among 15- to 30-year-olds may be cost-effective when the prevalence of PWID is >0.59%.

Cost Effectiveness and Cost Containment in the Era of Interferon-Free Therapies to Treat Hepatitis C Virus Genotype 1

Background

Interferon-free regimens to treat hepatitis C virus (HCV) genotype 1 are effective but costly. At this time, payers in the United States use strategies to control costs including (1) limiting treatment to those with advanced disease and (2) negotiating price discounts in exchange for exclusivity.

Methods

We used Monte Carlo simulation to investigate budgetary impact and cost effectiveness of these treatment policies and to identify strategies that balance access with cost control. Outcomes included nondiscounted 5-year payer cost per 10000 HCV-infected patients and incremental cost-effectiveness ratios.

Results

We found that the budgetary impact of HCV treatment is high, with 5-year undiscounted costs of $1.0 billion to 2.3 billion per 10000 HCV-infected patients depending on regimen choices. Among noncirrhotic patients, using the least costly interferon-free regimen leads to the lowest payer costs with negligible difference in clinical outcomes, even when the lower cost regimen is less convenient and/or effective. Among cirrhotic patients, more effective but costly regimens remain cost effective. Controlling costs by restricting treatment to those with fibrosis stage 2 or greater disease was cost ineffective for any patient type compared with treating all patients.

Conclusions

Treatment strategies using interferon-free therapies to treat all HCV-infected persons are cost effective, but short-term cost is high. Among noncirrhotic patients, using the least costly interferon-free regimen, even if it is not single tablet or once daily, is the cost-control strategy that results in best outcomes. Restricting treatment to patients with more advanced disease often results in worse outcomes than treating all patients, and it is not preferred.

Quality of hepatitis C care at an urban tertiary care medical center

BACKGROUND

More effective treatment for hepatitis C virus (HCV) creates an opportunity to improve health outcomes.

OBJECTIVE

To use Centers for Medicare and Medicaid Services (CMS)-defined HCV quality indicators (QI) as a framework to assess the quality of care at an urban safety net hospital.

DESIGN

Retrospective cohort.

PARTICIPANTS

Patients engaged in care (at least two outpatient visits, and minimum six-month follow-up time) between 2005 and 2011. Outcomes measures. 1) HCV ribonucleic acid (RNA); 2) genotyping; 3) treatment; and 4) Hepatitis A and B vaccination. Study time was divided into three periods: 1) 2005-2006, 2) 2007-2008, 3) 2009-2011. Key results. Number who met inclusion criteria: 3,018; 13% were human immunodeficiency virus co-infected. Only 1% completed the care recommended in the CMS quality indicators that were evaluated. Later time periods were independently associated with greater rates (aHR for HCV testing, 1.15; 95% CI, 1.04-1.28).

CONCLUSIONS

Quality of care is improving, but it remains suboptimal. Initiatives are needed to increase QI completion.

Eighteen- to 30-year-olds more likely to link to hepatitis C virus care: an opportunity to decrease transmission

Hepatitis C virus (HCV) infection incidence among 18- to 30-year-olds is increasing and guidelines recommend treatment of active injection drug users to limit transmission. We aimed to : measure linkage to HCV care among 18- to 30-year-olds and identify factors associated with linkage; compare linkage among 18- to 30-year-olds to that of patients >30 years. We used the electronic medical record at an urban safety net hospital to create a retrospective cohort with reactive HCV antibody between 2005 and 2010. We report seroprevalence and demographics of seropositive patients, and used multivariable logistic regression to identify factors associated with linkage to HCV care. We defined linkage as having evidence of HCV RNA testing after reactive antibody. Thirty two thousand four hundred and eighteen individuals were tested, including 8873 between 18 and 30 years. The seropositivity rate among those ages 18-30 was 10%. In multivariate analysis, among those 18-30, diagnosis location (Outpatient vs Inpatient/ED) (OR 1.78, 95% CI 1.28-2.49) and number of visits after diagnosis (OR 5.30, 95% CI 3.91-7.19) were associated with higher odds of linking to care. When we compared linkage in patients ages 18-30 to that among those older than 30, patients in the 18-30 years age group were more likely to link to HCV care than those in the older cohort even when controlling for gender, ethnicity, socioeconomic status, birthplace, diagnosis location and duration of follow-up. Eighteen- to 30-year-olds are more likely to link to HCV care than their older counterparts. During the interferon-free treatment era, there is an opportunity to prevent further HCV transmission in this population.

The cost-effectiveness of sofosbuvir-based regimens for treatment of hepatitis C virus genotype 2 or 3 infection

BACKGROUND

Chronic infection with hepatitis C virus (HCV) genotype 2 or 3 can be treated with sofosbuvir without interferon. Because sofosbuvir is costly, its benefits should be compared with the additional resources used.

OBJECTIVE

To estimate the cost-effectiveness of sofosbuvir-based treatments for HCV genotype 2 or 3 infection in the United States.

DESIGN

Monte Carlo simulation, including deterministic and probabilistic sensitivity analyses.

DATA SOURCES

Randomized trials, observational cohorts, and national health care spending surveys.

TARGET POPULATION

8 patient types defined by HCV genotype (2 vs. 3), treatment history (naive vs. experienced), and cirrhosis status (noncirrhotic vs. cirrhotic).

TIME HORIZON

Lifetime.

PERSPECTIVE

Payer.

INTERVENTION

Sofosbuvir-based therapies, pegylated interferon-ribavirin, and no therapy.

OUTCOME MEASURES

Discounted quality-adjusted life-years (QALYs), costs, and incremental cost-effectiveness ratios (ICERs).

RESULTS OF BASE-CASE ANALYSIS

The ICER of sofosbuvir-based treatment was less than $100,000 per QALY in cirrhotic patients (genotype 2 or 3 and treatment-naive or treatment-experienced) and in treatment-experienced noncirrhotic patients but was greater than $200,000 per QALY in treatment-naive noncirrhotic patients.

RESULTS OF SENSITIVITY ANALYSIS

The ICER of sofosbuvir-based therapy for treatment-naive noncirrhotic patients with genotype 2 or 3 infection was less than $100,000 per QALY when the cost of sofosbuvir was reduced by approximately 40% and 60%, respectively. In probabilistic sensitivity analyses, cost-effectiveness conclusions were robust to uncertainty in treatment efficacy.

LIMITATION

The analysis did not consider possible benefits of preventing HCV transmission.

CONCLUSION

Sofosbuvir provides good value for money for treatment-experienced patients with HCV genotype 2 or 3 infection and those with cirrhosis. At their current cost, sofosbuvir-based regimens for treatment-naive noncirrhotic patients exceed willingness-to-pay thresholds commonly cited in the United States.

PRIMARY FUNDING SOURCE

National Institute on Drug Abuse and National Institute of Allergy and Infectious Diseases.

The hepatitis C cascade of care: identifying priorities to improve clinical outcomes

BACKGROUND

As highly effective hepatitis C virus (HCV) therapies emerge, data are needed to inform the development of interventions to improve HCV treatment rates. We used simulation modeling to estimate the impact of loss to follow-up on HCV treatment outcomes and to identify intervention strategies likely to provide good value for the resources invested in them.

METHODS

We used a Monte Carlo state-transition model to simulate a hypothetical cohort of chronically HCV-infected individuals recently screened positive for serum HCV antibody. We simulated four hypothetical intervention strategies (linkage to care; treatment initiation; integrated case management; peer navigator) to improve HCV treatment rates, varying efficacies and costs, and identified strategies that would most likely result in the best value for the resources required for implementation.

MAIN MEASURES

Sustained virologic responses (SVRs), life expectancy, quality-adjusted life expectancy (QALE), costs from health system and program implementation perspectives, and incremental cost-effectiveness ratios (ICERs).

RESULTS

We estimate that imperfect follow-up reduces the real-world effectiveness of HCV therapies by approximately 75%. In the base case, a modestly effective hypothetical peer navigator program maximized the number of SVRs and QALE, with an ICER compared to the next best intervention of $48,700/quality-adjusted life year. Hypothetical interventions that simultaneously addressed multiple points along the cascade provided better outcomes and more value for money than less costly interventions targeting single steps. The 5-year program cost of the hypothetical peer navigator intervention was $14.5 million per 10,000 newly diagnosed individuals.

CONCLUSIONS

We estimate that imperfect follow-up during the HCV cascade of care greatly reduces the real-world effectiveness of HCV therapy. Our mathematical model shows that modestly effective interventions to improve follow-up would likely be cost-effective. Priority should be given to developing and evaluating interventions addressing multiple points along the cascade rather than options focusing solely on single points.

Relationship between hepatitis C clinical testing site and linkage to care

When compared to those diagnosed in the outpatient, patients with reactive HCV testing in the Emergency Department or in the inpatient setting were less likely to link to care as measured by HCV RNA testing.

Background.

 The Centers for Disease Control and Prevention recommends one-time hepatitis C virus (HCV) testing of the population born between 1945 and 1965 with follow-up RNA testing for those with reactive serology. To increase the rate of diagnosis, testing may be considered in settings other than outpatient clinics (OC), such as inpatient wards (IP) or emergency department (ED).

Methods.

 We used electronic medical records to create a retrospective cohort with reactive HCV serology between 2005 and 2010 at an urban safety net hospital. We determined factors associated with linkage to HCV care as measured by HCV RNA testing, and we evaluated the rate of linkage to care according to diagnosis location (OC, IP, or ED).

Results.

 Individuals, 37 828, were tested and 5885 (16%) were reactive. Seropositivity was similar across all sites. Of the 4466 patients who met inclusion criteria, 3400 (76%) were diagnosed in the OC, whereas 967 (22%) and 99 (2%) were tested in the IP and the ED, respectively. A total of 2135 (48%) underwent HCV RNA testing. Using multivariable regression modeling, the following factors were independently associated with HCV RNA testing: diagnosis in the OC (odds ratio [OR], 1.64; 95% confidence interval [CI], 1.42–1.90); age at diagnosis in decades (OR, 0.98; 95% CI, 0.98–0.99); private insurance (OR, 1.17; 95% CI, 1.01–1.34); and ≥10 visits after diagnosis (OR, 2.15; 95% CI, 1.89–2.44).

Conclusion.

 There is an opportunity to increase HCV diagnosis by testing in sites other than the OC, but this opportunity needs to be coupled with robust initiatives to improve linkage to care.