Department of Health Policy and Administration, The Pennsylvania State University, University Park.
Department of Public Health Sciences, College of Medicine.
J Manag Care Spec Pharm. 2019 Nov;25(11):1236-1242. doi: 10.18553/jmcp.2019.25.11.1236.
New hepatitis C virus (HCV) drugs-direct-acting antivirals (DAAs)-are highly effective but costly, which raises a concern about limited access to DAAs by vulnerable populations. Previous studies of disparities in DAA use across patient groups showed mixed results, but their generalizability was limited due to using data from commercial insurers or from 2014 only-the first year DAAs were available. Disparities in DAA use in a national cohort in the years when more DAAs were available is unknown.
To examine whether disparities in DAA use by patient race/ethnicity and socioeconomic status in Medicare changed between 2014 and 2016.
The study population was made up of chronic hepatitis C patients in fee-for-service Medicare with Part D between 2014 and 2016. We used multinomial logistic regression to estimate adjusted odds ratios (aOR) of using DAAs by patient race/ethnicity and socioeconomic status. We estimated the model separately for 2014 and 2014-2016.
Of 281,810 Medicare patients who were followed to the end of 2016, a total of 90,419 (32.1%) filled prescriptions for DAAs. In the 2014 analysis, blacks were less likely to use DAAs than whites (aOR = 0.95; 95% CI = 0.91-0.99). However, in the 2014-2016 analysis, blacks had higher odds of using DAAs than whites (aOR = 1.24; 95% CI = 1.22-1.27). No significant Hispanic-white gap existed during the study period. Income was positively associated with DAA use in both periods. Between 2014 and 2016, patients who received a Part D low-income subsidy had lower odds of using DAAs than patients who did not (aOR = 0.90; 95% CI = 0.88-0.92), and patients in areas with the higher income tertiles were more likely to initiate DAAs than those in areas with the lowest income tertile.
DAA use among Medicare patients remained far below the level needed to eradicate HCV. The black-white gap in HCV treatment was closed by 2016, but disparities by patient socioeconomic status remained. DAA use also varied by patient age and health risk, as well as across geographic regions. Continued efforts to improve DAA uptake in all HCV patients are needed to eradicate HCV.
This study was supported by the National Institute on Aging (1 R01 AG055636-01A1) and National Institute of Child Health & Human Development (R24 HD04025). The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Feldman owns stock in Gilead Sciences and Abbvie. No other potential competing interest exists.
新型丙型肝炎病毒（HCV）药物——直接作用抗病毒药物（DAAs）——具有高效性，但价格昂贵，这引发了人们对弱势群体获得 DAA 的机会有限的担忧。先前对不同患者群体使用 DAA 方面的差异的研究结果喜忧参半，但由于使用了商业保险公司或仅 2014 年的数据（即 DAA 首次可用的那一年），其普遍性受到限制。在更多 DAA 可用的情况下，全国队列中 DAA 使用的差异尚不清楚。
研究 2014 年至 2016 年间医疗保险中患者种族/族裔和社会经济地位的 DAA 使用差异是否发生变化。
研究人群由 2014 年至 2016 年期间有医疗保险和部分 D 部分的慢性丙型肝炎患者组成。我们使用多项逻辑回归来估计患者种族/族裔和社会经济地位使用 DAA 的调整后优势比（aOR）。我们分别为 2014 年和 2014-2016 年估计了模型。
在 2016 年底被跟踪的 281810 名医疗保险患者中，共有 90419 人（32.1%）开了 DAA 处方。在 2014 年的分析中，黑人使用 DAA 的可能性低于白人（aOR=0.95；95%CI=0.91-0.99）。然而，在 2014-2016 年的分析中，黑人使用 DAA 的几率高于白人（aOR=1.24；95%CI=1.22-1.27）。在此期间，西班牙裔人与白人之间没有明显的差距。收入在两个时期都与 DAA 的使用呈正相关。在 2014 年至 2016 年期间，获得部分 D 低收入补贴的患者使用 DAA 的几率低于未获得补贴的患者（aOR=0.90；95%CI=0.88-0.92），收入较高 tertile 地区的患者比收入最低 tertile 地区的患者更有可能开始使用 DAA。
医疗保险患者中 DAA 的使用仍远低于消除 HCV 所需的水平。到 2016 年，HCV 治疗中的黑白差距已经缩小，但患者社会经济地位的差异仍然存在。DAA 的使用还因患者年龄和健康风险以及地理位置而异。需要继续努力提高所有 HCV 患者对 DAA 的接受程度，以消除 HCV。
这项研究得到了美国国家老龄化研究所（1 R01 AG055636-01A1）和美国国家儿童健康与人类发展研究所（R24 HD04025）的支持。资助者在研究的设计和实施、数据的收集、管理、分析和解释、手稿的准备、审查或批准、以及提交手稿出版的决定方面没有任何作用。费尔德曼拥有吉利德科学公司和 Abbvie 的股票。没有其他潜在的竞争利益存在。
