Chronic hepatitis C (CHC) treatment is associated with major gains in health, including reduced risk of progression to end-stage liver disease and hepatocellular carcinoma. Most of our knowledge of CHC care in the VHA is based on studies of men. This is a problem because women's health-care needs differ from men's for several conditions including CHC and barriers to CHC treatment are also likely to vary by gender. Women with CHC have more mental health comorbidities-the leading modifiable barrier to antiviral treatment. Women also have much higher self-reported military sexual trauma, which often leads to mental health issues. Women's care experiences and their perception of care in the VHA are also distinct from those of men. The recent increases in the proportion of women in the VHA and the availability of more effective CHC treatment necessitate a specific focus on modifiable factors that may be contributing to missed treatment opportunities in women Veterans with CHC.
The funded project used a retrospective database design to (1) examine gender differences in access to and receipt of CHC care measured by seeing a CHC specialist and receipt of antiviral treatment, respectively, (2) identify predictors of access to and receipt of CHC care in women Veterans with CHC.
To achieve Aim 1, we used existing structured automated data to examine the rate of seeing CHC specialist and receipt of direct acting antiviral (DAA) treatment in a national cohort of Veterans who were diagnosed with CHC during 2002 and 2014 and in VHA care after the availability of new direct acting antiviral agents (DAA) defined by a visit in 2014 or 2015. To achieve Aim 2, we conducted multi-level regression analyses to identify key predictors (especially high-impact, modifiable factors) of access to and receipt of CHC DAA treatment among women Veterans with CHC. We also constructed separate multi-level regression in a parallel cohort of male Veterans with CHC for purposes of benchmarking.
Our study cohort included 145,596 patients with CHC. The mean age of patients was 60 years, 47.8% were white and 37.0% were black. A total of 4,824 (3.3%) were women. Approximately 32.7% of patients had cirrhosis. The cohort had a high burden of mental health comorbidity; 59.5% had depression, and 62.6% had a diagnosis of alcohol use disorder. Women patients were younger (55 vs. 60 years), less likely to be black, and to have a history of homelessness than men. Women were also significantly less likely to have HCV complications (cirrhosis, HCC) and history of alcohol or drug abuse, although a higher proportion had depression than men (72.4% vs. 59.0%).
A total of 42.9% of men and 41.1% of women were seen in HCV specialty clinics. Of the 145,596 patients, 17,791 (10.2%) had filled prescriptions for new DAAs during the first 16 months after release of these medications. Women were not different from men in receipt of specialty evaluation. Overall, women also were as likely to receive treatment as men (AOR = 0.99; 95% CI, 0.90-1.09). However, the odds of receiving DAAs were 29% lower for younger women compared with younger men (AOR = 0.71, 95% CI, 0.54-0.93).
A total of 47.5% of women had history of drug abuse; 46.7% had alcohol abuse, and 71.4% had depression. Women were significantly less likely to be seen in CHC specialty clinic if they had drug abuse (AOR 0.74, 95% CI, 0.63-0.88) or depression (AOR=0.81, 95% CI, 0.69-0.94); alcohol use was not associated with CHC visits. A total of 73.7% of women had a visit with a designated women heath provider (DWHP) after DAA approval. These women were 74% more likely to be seen in CHC specialty clinics than women seen by other primary care providers (AOR=1.74, 95% CI=1.46-2.07), after adjusting for demographic, clinical and other healthcare utilization factors. Among women who were seen in the CHC clinics, history of drug abuse, alcohol use, and depression were significantly associated with lower odds of receiving DAA treatment. There was no association between being seen by DWHP and DAA treatment in patients who were seen in CHC clinics. However, women who received gender concordant care in the CHC clinic (majority of CHC visits with women provider) were 2-fold (200%) more likely to receive DAA treatment than women who received gender discordant care in the CHC clinics (AOR=2.05, 95% CI=1.52-2.76). We did not find any association between history of military sexual trauma and access to and receipt of DAA treatment. Similarly, we did not find any difference in the effects of mental health conditions in women with or without military sexual trauma. The role of demographic and clinical factors on access to and receipt of DAA treatment were similar in women and men, with few exceptions. The negative effects of drug use and depression were stronger in women than in men.
Expanding health care access to women Veterans is one of the top priorities in the VHA. To date, most VHA women's health research has focused on either primary care or mental health issues. There are fewer data on women Veterans' chronic care needs for conditions traditionally managed in medical specialty clinics. Understanding how the VHA can best serve specialty care needs of the rapidly growing population of women Veterans is an important part of comprehensively addressing women's health care needs.
We found that equal proportion of men and women received the new DAA treatment overall. However, younger women were particularly vulnerable to underuse of DAAs. One possible explanation for the lower treatment rate in young women is that they have milder liver disease than men. However, the gender disparity in treatment persisted even after adjustment for underlying liver disease severity. Young women also have higher competing demands due to child rearing and elder care; these may also have contributed to our findings. We also found that women Veterans with CHC who received primary care from a designated women health provider were more likely to see CHC specialists than women cared for by other primary care physicians. Furthermore, women who received specialty care from women clinicians were more likely to receive CHC treatment than women who receive care from a gender-discordant [male] clinician. These data set the stage for development of strategies to provide patient-centered high quality care to the burgeoning group of women Veterans with CHC--a prevalent and now mostly treatable chronic problem primarily managed in specialty care settings. They also suggest that being seen by designated women health care provider and gender-concordant care may improve access to and receipt of treatments for other chronic conditions managed mostly in specialty clinics.
- Kramer JR, Puenpatom A, Erickson KF, Cao Y, Smith D, El-Serag HB, Kanwal F. Real-world effectiveness of elbasvir/grazoprevir In HCV-infected patients in the US veterans affairs healthcare system. Journal of Viral Hepatitis. 2018 Nov 1; 25(11):1270-1279.
- Kramer JR, El-Serag HB, Taylor TJ, White DL, Asch SM, Frayne SM, Cao Y, Smith DL, Kanwal F. Hepatitis C virus-related complications are increasing in women veterans: A national cohort study. Journal of Viral Hepatitis. 2017 Nov 1; 24(11):955-965.
- Kanwal F, Kramer JR, El-Serag HB, Frayne S, Clark J, Cao Y, Taylor T, Smith D, White D, Asch SM. Race and Gender Differences in the Use of Direct Acting Antiviral Agents for Hepatitis C Virus. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2016 Aug 1; 63(3):291-9.
- Lin M, Kramer JR, White DL, Tavakoli-Tabasi S, El-Serag HB, Kanwal F. Barriers to Hepatitis C Treatment for the Veteran Population in the DAA Era. Poster session presented at: Digestive Disease Week Annual Conference; 2016 May 22; San Diego, CA.
- Kanwal F, Kramer JR, Cao Y, Taylor T, Smith DL, Asch S, El-Serag HB. Demographic Predictors of Direct Acting Antiviral Receipt in Individuals with Hepatitis C Virus Infection. Presented at: American Association for the Study of Liver Diseases Annual Meeting; 2015 Nov 15; San Francisco, CA.
- Kanwal F, Kramer JR, Cao Y, Taylor T, Smith DL, Asch S, El-Serag HB. Demographic Predictors of Direct Acting Antiviral Receipt in Individuals with Hepatitis C Virus Infection. Poster session presented at: American Association for the Study of Liver Diseases Annual Meeting; 2015 Nov 13; San Francisco, CA.
Disparities, Gender Differences, HIV/AIDS, Hepatitis C, Utilization