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

项目总结 丙型肝炎病毒感染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”中 婴儿潮一代，出生于1945-1965年(占感染者的75%)。丙型肝炎病毒对少数族裔的影响不成比例(25% 感染者中黑人；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)疗法最近成为 它可以治愈95%的丙型肝炎患者，但只有一半的人被诊断出来，而且比例要小得多。 治疗过了。疾控中心的国家病毒性肝炎行动计划(NVHAP)呼吁对所有这些患者进行识别和治疗 被感染，但由于昂贵的药品、对这些人的污名化，种族/少数民族获得机会是有问题的 对于丙型肝炎，专家的可及性不同，提供者对需要诊断和治疗的认识不一致，以及 治疗的覆盖面各不相同，特别是通过州医疗补助计划。我们建议使用探索性序列 混合方法设计分析美国婴儿潮一代的丙型肝炎检测和治疗模式，跟踪 自2014年首次获得许可以来，在全国和人口群体中推广DAA疗法，并进行 定性工作和对患者和医生的调查，以探索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医疗保险索赔数据 通过a)检查描述婴儿潮一代队列中丙型肝炎筛查和治疗的差异 不同种族/民族、社区社会经济地位(CSE)和原发病的丙型肝炎病毒筛查率的差异 护理利用情况；b)评估从丙型肝炎病毒诊断到个人开始抗病毒治疗之间的时间 有新的丙型肝炎诊断，按种族/民族和CSE；以及c)评估FDA批准 第一次DAA丙型肝炎治疗，并启动DAA治疗婴儿潮一代的流行人群 慢性丙型肝炎，按种族/民族和CSE；并根据这些发现2)评估患者的贡献 以及通过调整现有措施来形成丙型肝炎诊断和治疗差异的提供者因素 和/或开发新的措施，并通过a)将这些措施应用于丙型肝炎患者和提供者的样本 使用患者焦点小组和参与性反馈来适应健康中的污名和歧视措施 护理和其他环境，关于丙型肝炎病毒及其治疗的知识和信念，以及护理障碍(竞争 需求、抑郁、药物使用、可获得性、患者费用、距离护理)，然后将它们用于不同的丙型肝炎病毒 美国两个地区的患者；和b)制定丙型肝炎病毒知识、态度、经验和行为的衡量标准 在医生中，然后给他们初级保健，胃肠病，肝病和传染病 美国两个地区的疾病医生。我们将与社区合作伙伴分享研究工具和结果，他们 将积极参与研究的所有阶段，并与其他关键利益攸关方和调查人员合作，以促进 制定和评估干预措施，以解决本研究中确定的问题。

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.