Disparities in the Diffusion of Direct-Acting Antiviral Therapy for Hepatitis C among Baby Boomers: A Mixed-Methods Study

项目摘要 丙型肝炎病毒感染（HCV）是美国慢性传染病死亡的最重要原因， 每年有200多万人感染，近2万人死亡。最大的负担;发生在“婴儿”之间 婴儿潮一代，”出生于1945-1965年（75%的感染者）。HCV不成比例地影响种族/少数民族（25%） 受感染的人是黑人;黑人死亡率为87%，西班牙裔死亡率比白人高43%）， 艾滋病毒感染者和注射吸毒者。直接作用抗病毒（DAA）治疗最近成为 它可以治愈>95%的HCV感染者，但只有一半被诊断出来，而且比例要小得多。 治疗。CDC的国家病毒性肝炎行动计划（NVHAP）呼吁识别和治疗所有这些病毒性肝炎。 感染，但少数种族/族裔的获得是有问题的，因为昂贵的药品， 对于HCV，不同的专家访问，不一致的提供者对诊断和治疗需求的认识， 治疗覆盖面可变，特别是州医疗补助计划。我们建议使用一个探索性的顺序 混合方法设计，以分析美国婴儿潮一代的HCV检测和治疗模式， 自2014年首次获得许可以来，在全国和各人口群体中推广DAA疗法，并开展 对病人和医生进行定性工作和调查，以探讨造成护理差异的因素。 具体目标是：1）使用国家和州一级公共管理的健康保险索赔数据 描述婴儿潮一代人群中HCV筛查和治疗的变化， HCV筛查率在种族/民族、社区社会经济地位（cSES）和主要 护理利用; B）评估个体中HCV诊断和抗病毒治疗开始之间的时间 根据种族/民族和cSES，新诊断为HCV的患者;以及c）评估FDA批准 第一次DAA HCV治疗，并开始DAA治疗婴儿潮一代的流行人群， 慢性HCV，按人种/种族和cSES;以及，根据这些结果2）评估患者的贡献 通过调整现有措施， 和/或开发新的措施，并将这些措施施用于HCV患者和提供者的样品，通过a） 利用病人焦点小组和参与性反馈，调整健康方面的羞辱和歧视措施 护理和其他环境，关于HCV及其治疗的知识和信念，以及护理障碍（竞争性 需要，抑郁症，药物使用，访问，患者成本，护理距离），然后将其用于不同的HCV 两个美国地区的患者;和B）制定HCV知识、态度、经验和实践的测量 在医生中，然后将其管理到初级保健，胃肠病学，肝病学和传染病 美国两个地区的医生。我们将与社区合作伙伴分享研究工具和结果， 我将积极参与研究的各个阶段，并与其他主要利益相关者和研究人员一起， 制定和评估干预措施，以解决本研究中发现的问题。

PROJECT SUMMARY Hepatitis C virus infection (HCV) is the most important cause of chronic infectious disease death in the US, with over 2 million people infected and nearly 20,000 dying annually. The greatest burden; occurs among “baby boomers,” born 1945-1965 (75% of those infected). HCV disproportionately affects racial/ethnic minorities (25% of those infected are Blacks; Black mortality is 87% and Hispanic mortality 43% higher than among Whites), persons with HIV disease and injection drug users. Direct-acting antiviral (DAA) therapy recently became available; it can cure >95% of people with HCV, but only half have been diagnosed and a much smaller proportion treated. CDC’s National Viral Hepatitis Action Plan (NVHAP) calls for identification and treatment of all those infected, but access for racial/ethnic minorities is problematic, due to costly medicines, stigmatization of those with HCV, variable access to specialists, inconsistent provider awareness of need to diagnose and treat, and variable coverage of treatment, particularly by state Medicaid plans. We propose to use an exploratory sequential mixed methods design to analyze HCV testing and treatment patterns among US baby boomers, tracking the diffusion of DAA therapy nationally and across demographic groups since initial licensing in 2014, and to conduct qualitative work and surveys of patients and physicians to explore factors contributing to disparities in care. The Specific Aims are: 1) To use national and state-level publicly-administered health insurance claims data to describe variations in HCV screening and treatment among the baby boomer cohort by a) examining differences in HCV screening rates across race/ethnicity, community socioeconomic status (cSES), and primary care utilization; b) evaluating the time between HCV diagnosis and antiviral treatment initiation among individuals with a new diagnosis of HCV, by race/ethnicity and cSES; and c) evaluating time between FDA approval of the first DAA HCV treatment, and initiation of DAA treatment for the prevalent population of baby boomers with chronic HCV, by race/ethnicity and cSES; and, informed by these findings 2) To assess the contribution of patient and provider factors to shaping disparities in diagnosis and treatment of HCV by adapting existing measures and/or developing novel measures, and administering these to samples of HCV patients and providers, by a) using patient focus groups and participatory feedback to adapt measures of stigma and discrimination in health care and other settings, knowledge and beliefs about HCV and its treatment, and barriers to care (competing needs, depression, drug use, access, patient costs, distance to care), then administering them to diverse HCV patients in two US regions; and b) developing measures of HCV knowledge, attitudes, experiences and practices among physicians, then administering them to primary care, gastroenterology, hepatology, and infectious disease physicians in two US regions. We will share study instruments and results with community partners, who will be very involved in all phases of the research, and with other key stakeholders and investigators, to facilitate the development and evaluation of interventions to address the problems identified in this study.