(14) Physician Perspectives on Initiating Treatment of Hepatitis C during Hospitalization

Background & Introduction: Hepatitis C (HCV) is a chronic, prevalent disease that disproportionately affects people who use drugs in the United States (US). One strategy to decrease HCV prevalence is to start treatment while patients are hospitalized for reasons unrelated to HCV. Factors affecting the success of this approach are not well-characterized in the literature. Subspecialty providers in fields that treat substantial numbers of patients with HCV are well-positioned to describe variables affecting treatment provision. The purpose of this study was to understand barriers and facilitators of initiating treatment for hepatitis C during a hospitalization from the perspective of physicians.

Methods: In this qualitative study, we conduced semi-structured interviews with 20 subspecialty physicians (Addiction Medicine, Infectious Diseases, and Hepatology) at 12 institutions across the country. We used purposive and snowball sampling to include physicians with a range of experience treating HCV, including those at institutions that allowed for initiation of inpatient HCV treatment and those that did not. Interviews were recorded and professionally transcribed and then analyzed using a rapid matrix technique. Interviews continued until thematic saturation was achieved.

Results: Participants included seven physicians specialized in Addiction Medicine, seven physicians specialized in Infectious Diseases, three physicians specialized in both Addiction Medicine and Infectious Diseases, and three physicians specialized in Hepatology. Four major themes emerged: 1. Hospitalization can be a gateway to care for patients who otherwise might not receive HCV treatment, 2. Patients are vulnerable to being lost to follow-up in the transition from inpatient to outpatient care, 3. The inpatient payment model negatively affects widespread implementation of programs to treat HCV during hospitalization, and 4. Treatment protocols and project “champions” can support inpatient HCV treatment initiatives.

Conclusion & Discussion: Physicians view hospitalization as a potential opportunity for patients to start HCV treatment. However, they have concerns about patients becoming lost to follow-up after hospital discharge. Interviewees perceived that these concerns could be mitigated by the implementing standardized protocols for treatment with clear process ownership, as well as by dedicated funding for care navigators and systems champions. Insurance issues in the US are a major barrier to inpatient HCV treatment. Our findings are limited by potential selection bias, as participants who chose to participate in our study were likely to have a greater than average interest in treatment of hepatitis C.

References: 1. Holtzman D, Asher AK, Schillie S. The Changing Epidemiology of Hepatitis C Virus Infection in the United States During the Years 2010 to 2018. Am J Public Health. May 2021;111(5):949-955. doi:10.2105/ajph.2020.306149
2. Kapadia SN, Zhang H, Gonzalez CJ, et al. Hepatitis C Treatment Initiation Among US Medicaid Enrollees. JAMA Netw Open. Aug 1 2023;6(8):e2327326. doi:10.1001/jamanetworkopen.2023.27326
3. Midgard H, Malme KB, Pihl CM, et al. Opportunistic treatment of hepatitis C infection among hospitalized people who inject drugs (OPPORTUNI-C): A stepped wedge cluster randomized trial. Clin Infect Dis. Nov 22 2023;doi:10.1093/cid/ciad711
4. Lewinski AA, Crowley MJ, Miller C, et al. Applied Rapid Qualitative Analysis to Develop a Contextually Appropriate Intervention and Increase the Likelihood of Uptake. Med Care. Jun 1 2021;59(Suppl 3):S242-s251. doi:10.1097/mlr.0000000000001553