Presence of advanced liver disease concurrent with initial diagnosis of Hepatitis C virus (HCV) infection among patients in the chronic hepatitis cohort study (CHECS) 2014-16: Missed opportunities for intervention.

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Background: Chronic HCV infection is typically asymptomatic until advanced liver disease has occurred, thus screening and treatment of asymptomatic persons is needed to prevent poor health outcomes. In a previous analysis, during 2006‐11, we found that 17% of new HCV infections were among persons with cirrhosis and/or end‐stage liver disease (ESLD). In this analysis we sought to reexamine the frequency of these conditions at HCV diagnosis during 2014‐16, after release of CDC “baby boomer” 1945‐65 birth cohort testing guidelines in 2012. Methods: Among persons newly diagnosed with HCV during 2014‐16 at four large US healthcare systems participating in CHeCS, we analyzed retrospective and prospective electronic health record (EHR) and administrative data through 12/31/16 using the following definitions: Date of initial HCV diagnosis‐ the earliest reported positive HCV laboratory test or related diagnostic/procedure code. Cirrhosis‐ having a liver biopsy indicating cirrhosis, FIB‐4 score >5.88, or transient elastography score>12.9 Severe liver disease – having cirrhosis or an ICD9/10 diagnosis or procedure code indicating: liver transplant, hepatocellular carcinoma, liver failure, hepatic encephalopathy, portal hypertension, esophageal varices, other gastroesophageal hemorrhage, ascites, or other sequelae of chronic liver disease. Concurrent severe liver disease‐ severe liver disease within 3 months before to 12 months after HCV diagnosis. Results: Results: Among 5,743 patients diagnosed with HCV during 2014‐16 we excluded 60 (1.0%) with HBV and 79 (1.4%) with HIV co‐infections, and 156 (2.7%) with initial HCV diagnosis prior to visiting the health system whose disease status at diagnosis could not be ascertained. We found that 1,521 (26.5%) patients had initial HCV diagnosis within their first six months in the health system, of these 831 (54.6%) had ≥12 months of follow‐up and among those 229 (27.6%) were found to have concurrent severe liver disease at diagnosis. An additional 2,348 (41.0%) persons were first HCV‐diagnosed >six months after their initial visit, of these 2,330 (99.2%) had ≥12 months of follow‐up and 492 (21.2%) had concurrent severe liver disease. Of 1,375 (23.9%) persons born 1945‐1965, 377 (27.4%) had severe liver disease concurrent with HCV diagnosis. Conclusion: About a quarter of CHeCS patients newly diagnosed with HCV during 2014‐16 had severe liver disease concurrent with their initial HCV diagnosis, an increase since 2006‐11 despite the interim initiation of age‐based screening recommendations. These data correspond with increasing national rates of HCV‐related mortality reported in the US during 2012‐2015. Our data highlight missed opportunities for diagnosis and therapeutic intervention before the onset of severe liver disease when treatment may involve high cost and diminished outcomes.



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