Lin M, Kramer J, White D, Cao Y, Tavakoli-Tabasi S, Madu S, Smith D, Asch S M, El-Serag H B, Kanwal F
Department of Gastroenterology and Hepatology, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX, USA.
Center of Innovation, Effectiveness and Quality, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA.
Aliment Pharmacol Ther. 2017 Nov;46(10):992-1000. doi: 10.1111/apt.14328. Epub 2017 Sep 26.
Direct-acting anti-virals (DAA) are safe, effective treatment of hepatitis C virus (HCV). Suboptimal linkage to specialists and access to DAAs are the leading barriers to treatment; however, data are limited.
To determine predictors of follow-up, receipt of DAAs, and reasons for the lack thereof.
We used clinical data from retrospective cohort of HCV-infected patients with previously established HCV care in the US Department of Veterans Affairs to examine predictors of follow-up in HCV clinics and DAA treatment (during 12/1/2013-4/30/2015). We then conducted a structured review of medical charts of HCV patients to determine reasons for lack of follow-up and treatment.
We identified 84 221 veterans who were previously seen in HCV clinics during the pre-DAA era. Of these, 47 165 (56.0%) followed-up in HCV specialty clinics, 13 532 (28.7%) of whom received DAAs. Older age, prior treatment, presence of cirrhosis or HCC, HIV/HBV co-infection and psychiatric illness were predictors of follow-up. Alcohol/drug abuse and medical co-morbidity were predictors of lack of treatment. Of the 905 prospectively recruited patients, 56.2% patients had a specialist visit and 28% received DAAs. Common reasons for lack of follow-up were relocation (n = 148, 37.4%) and missed/cancelled appointments (n = 63, 15.9%). Reasons for lack of treatment included waiting for newer therapy (n = 99, 38.8%), co-morbidities (n = 66, 25.9%) and alcohol/drug abuse (n = 63, 24.7%).
Half of patients with established HCV care were followed-up in the DAA era and only 29% received DAAs. Targeted efforts focusing on patient and system-levels may improve the reach of treatment with the new DAAs.
直接抗病毒药物（DAA）是治疗丙型肝炎病毒（HCV）的安全、有效药物。与专科医生的联系欠佳以及获取DAA药物存在困难是治疗的主要障碍；然而，相关数据有限。
确定随访、接受DAA治疗的预测因素以及未接受治疗的原因。
我们使用了美国退伍军人事务部中既往已建立HCV治疗的HCV感染患者回顾性队列的临床数据，以研究HCV诊所随访及DAA治疗（2013年12月1日至2015年4月30日期间）的预测因素。然后，我们对HCV患者的病历进行了结构化审查，以确定未随访及未治疗的原因。
我们识别出84221名在DAA时代之前曾在HCV诊所就诊的退伍军人。其中，47165名（56.0%）在HCV专科诊所进行了随访，其中13532名（28.7%）接受了DAA治疗。年龄较大、既往接受过治疗、存在肝硬化或肝癌、HIV/HBV合并感染以及精神疾病是随访的预测因素。酒精/药物滥用和合并其他疾病是未接受治疗的预测因素。在905名前瞻性招募的患者中，56.2%的患者就诊于专科医生，28%的患者接受了DAA治疗。未随访的常见原因是搬迁（n = 148，37.4%）以及错过/取消预约（n = 63，15.9%）。未接受治疗的原因包括等待更新的疗法（n = 99，38.8%）、合并其他疾病（n = 66，25.9%）以及酒精/药物滥用（n = 63，24.7%）。
在DAA时代，一半既往已建立HCV治疗的患者进行了随访，只有29%的患者接受了DAA治疗。针对患者和系统层面的有针对性努力可能会提高新DAA药物的治疗可及性。
