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Research ArticleOriginal Research

Increasing Treatment Rates for Hepatitis C in Primary Care

Ann Stewart, Amy Craig-Neil, Kathryn Hodwitz, Rick Wang, Doret Cheng, Gordon Arbess, Caroline Jeon, Clara Juando-Prats and Tara Kiran
The Journal of the American Board of Family Medicine August 2023, 36 (4) 591-602; DOI: https://doi.org/10.3122/jabfm.2022.220427R1
Ann Stewart
From the Department of Family and Community Medicine, St. Michael’s Hospital, University of Toronto, Toronto, ON, Canada (AS, DC, GA, CJ, TK); Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada (AS, GA, CJ, TK); MAP Centre for Urban Health Solutions, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada (AC, RW, TK); Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada (KH, CJ); Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada (CJ); Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada (TK).
MD, MSc
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Amy Craig-Neil
From the Department of Family and Community Medicine, St. Michael’s Hospital, University of Toronto, Toronto, ON, Canada (AS, DC, GA, CJ, TK); Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada (AS, GA, CJ, TK); MAP Centre for Urban Health Solutions, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada (AC, RW, TK); Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada (KH, CJ); Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada (CJ); Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada (TK).
MSc
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Kathryn Hodwitz
From the Department of Family and Community Medicine, St. Michael’s Hospital, University of Toronto, Toronto, ON, Canada (AS, DC, GA, CJ, TK); Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada (AS, GA, CJ, TK); MAP Centre for Urban Health Solutions, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada (AC, RW, TK); Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada (KH, CJ); Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada (CJ); Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada (TK).
MSc
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Rick Wang
From the Department of Family and Community Medicine, St. Michael’s Hospital, University of Toronto, Toronto, ON, Canada (AS, DC, GA, CJ, TK); Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada (AS, GA, CJ, TK); MAP Centre for Urban Health Solutions, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada (AC, RW, TK); Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada (KH, CJ); Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada (CJ); Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada (TK).
MMath
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Doret Cheng
From the Department of Family and Community Medicine, St. Michael’s Hospital, University of Toronto, Toronto, ON, Canada (AS, DC, GA, CJ, TK); Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada (AS, GA, CJ, TK); MAP Centre for Urban Health Solutions, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada (AC, RW, TK); Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada (KH, CJ); Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada (CJ); Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada (TK).
BSc.Pharm, PharmD
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Gordon Arbess
From the Department of Family and Community Medicine, St. Michael’s Hospital, University of Toronto, Toronto, ON, Canada (AS, DC, GA, CJ, TK); Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada (AS, GA, CJ, TK); MAP Centre for Urban Health Solutions, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada (AC, RW, TK); Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada (KH, CJ); Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada (CJ); Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada (TK).
MD
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Caroline Jeon
From the Department of Family and Community Medicine, St. Michael’s Hospital, University of Toronto, Toronto, ON, Canada (AS, DC, GA, CJ, TK); Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada (AS, GA, CJ, TK); MAP Centre for Urban Health Solutions, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada (AC, RW, TK); Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada (KH, CJ); Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada (CJ); Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada (TK).
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Clara Juando-Prats
From the Department of Family and Community Medicine, St. Michael’s Hospital, University of Toronto, Toronto, ON, Canada (AS, DC, GA, CJ, TK); Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada (AS, GA, CJ, TK); MAP Centre for Urban Health Solutions, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada (AC, RW, TK); Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada (KH, CJ); Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada (CJ); Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada (TK).
PhD, MScN
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Tara Kiran
From the Department of Family and Community Medicine, St. Michael’s Hospital, University of Toronto, Toronto, ON, Canada (AS, DC, GA, CJ, TK); Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada (AS, GA, CJ, TK); MAP Centre for Urban Health Solutions, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada (AC, RW, TK); Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada (KH, CJ); Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada (CJ); Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada (TK).
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  • Article
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Article Figures & Data

Figures

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  • Figure 1.
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    Figure 1.

    Cohort of patient identified as being Hepatitis C Virus (HCV) RNA positive as of December 2018 and needing treatment.

  • Figure 2a.
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    Figure 2a.

    Individuals who were Hepatitis C Virus (HCV) RNA positive and untreated in December 2018 and received study outreach. Sixty-three were called twice; 54 letters and 3 emails were sent. Other reasons include mental health issues, complicated or difficult patients, pregnancy, cancer, incarceration, not engaged in care or unknown.

  • Figure 2b.
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    Figure 2b.

    Individuals who were Hepatitis C Virus (HCV) RNA positive and untreated in December 2018 but did NOT receive study outreach.

  • Figure 3.
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    Figure 3.

    Change in the number of Hepatitis C Virus (HCV) RNA positive patients who started treatment and achieved cure (Sustained Virologic Response, SVR) between December 2018 and June 2020.

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    Figure 4.

    Facilitators and barriers influencing outcomes after the intervention, summary of qualitative findings from physician focus groups and pharmacist interviews. Abbreviation: HCV, Hepatitis C Virus.

Tables

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    Table 1.

    Characteristics of Patients Included in the Intervention Who Were Hepatitis C Virus (HCV) RNA Positive for More Than 6 Months and Untreated1 as of December 2018 (n = 182)

    Demographic CharacteristicPatients Needing treatment1 as of Dec 2018
    Age, Mean (S.D.)52.4 (12.3)
    Age, N (%)
     <4028 (15.4%)
     40 to 64126 (69.2%)
     65+28 (15.4%)
    Sex, N (%)
     Female65 (35.7%)
     Male117 (64.3%)
    Neighborhood income quintile, N (%)
     No fixed address or homeless13 (14.9%)
     1 (Lowest)18 (20.7%)
     2 to 556 (64.4%)
    Chronic conditions, N (%)
     Diabetes10 (5.5%)
     HIV30 (16.5%)
    Mental health and addictions, N (%)
     Any mental health or addictions2129 (70.9%)
     Addiction36 (19.8%)
     Schizophrenia or bipolar28 (15.4%)
    Visit with any physician at the FHT within the past 2 years (December 2016-December 2018)
     Mean (S.D.)12.9 (14.5)
    Visit with any physician at the FHT within the past 2 years (December 2016-December 2018), N (%)
     025 (13.7%)
     1 to 217 (9.3%)
     3 to 523 (12.6%)
     6 to 1039 (21.4%)
     11 to 1942 (23.1%)
     20+36 (19.8%)
    • ↵1Patients who are treatment naive, have unknown treatment status, did not complete treatment or where treatment failed to clear the virus.

    • ↵2Per billing codes for depression, anxiety, addictions, schizophrenia, or bipolar disorder.

    • Abbreviations: HCV, Hepatitis C Virus; FHT, Family health team; SD, Standard deviation.

    • View popup
    Table 2.

    Characteristics of Patients Who Were Hepatitis C Virus (HCV) RNA Positive for >6 Months, by Whether or Not They Were Treated at the End of the Intervention

    Demographic CharacteristicPatients needing treatment1 as of June 2020 (n = 130)All patients treated2 as of June 2020 (n = 406)P-value
    Age, Mean (S.D.)51.1 (12.8)57.2 (10.4)<0.001
    Age, N (%)
     <4025 (19.2%)26 (6.4%)<0.001
     40 to 6489 (68.5%)273 (67.2%)
     65+16 (12.3%)107 (26.4%)
    Sex, N (%)
     Female46 (35.4%)103 (25.4%)<0.05
     Male84 (64.6%)303 (74.6%)
    Income quintile, N (%)
     No fixed address or  homeless6 (9.7%)70 (35.9%)<0.001
     1 (Lowest)15 (24.2%)8 (4.1%)
     2 to 541 (66.1%)117 (60.0%)
    Chronic conditions, N (%)
     Diabetes7 (5.4%)52 (12.8%)<0.05
     HIV22 (16.9%)94 (23.2%)0.17
    Mental health and addictions, N (%)
     Any mental health or  addictions96 (73.9%)255 (62.8%)<0.05
     Addiction22 (16.9%)60 (14.8%)0.65
     Schizophrenia or bipolar20 (15.4%)50 (12.3%)0.45
    Visit with any physician during the study period (December 2018-June 2020)
     Mean (S.D.)8.1 (12.6)10.8 ( 11.9)<0.001
    Visit with any physician at the FHT within the past 2 years (December 2016-December 2018), N (%)
     043 (33.1%)43 (10.6%)<0.001
     1 to 216 (12.3%)56 (13.8%)
     3 to 521 (16.2%)71 (17.5%)
     6 to 1017 (13.1%)82 (20.2%)
     11 to 1920 (15.4%)94 (23.2%)
     20+13 (10.0%)60 (14.8%)
    • ↵1Patients who are treatment naïve, have unknown treatment status, or where treatment failed to clear the virus.

    • ↵2Patients being treated successfully, being treated currently, or having completed treatment without a final confirmatory RNA. Five patients who cleared the infection spontaneously during the intervention are also included.

    • Abbreviations: HCV, Hepatitis C Virus; FHT, Family health team; SD, Standard deviation.

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The Journal of the American Board of Family     Medicine: 36 (4)
The Journal of the American Board of Family Medicine
Vol. 36, Issue 4
July-August 2023
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Increasing Treatment Rates for Hepatitis C in Primary Care
Ann Stewart, Amy Craig-Neil, Kathryn Hodwitz, Rick Wang, Doret Cheng, Gordon Arbess, Caroline Jeon, Clara Juando-Prats, Tara Kiran
The Journal of the American Board of Family Medicine Aug 2023, 36 (4) 591-602; DOI: 10.3122/jabfm.2022.220427R1

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Increasing Treatment Rates for Hepatitis C in Primary Care
Ann Stewart, Amy Craig-Neil, Kathryn Hodwitz, Rick Wang, Doret Cheng, Gordon Arbess, Caroline Jeon, Clara Juando-Prats, Tara Kiran
The Journal of the American Board of Family Medicine Aug 2023, 36 (4) 591-602; DOI: 10.3122/jabfm.2022.220427R1
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