Patient and care profiles of under-insured hepatitis C patients in an inner city clinic setting

Hepatitis C virus (HCV) infects more than 3 million Americans and is the leading indication for liver transplantation. Patients with HCV may experience cirrhosis, hepatocellular carcinoma (HCC) and significant reductions in quality of life. Co-infection with hepatitis A or B can increase and accelerate liver disease. HCV-related morbidity and mortality can be reduced through education, risk reduction, HCC screening, and interferon-based treatment. HCV disproportionately affects racial/ethnic minorities, drug users, and individuals of low socioeconomic status. These subpopulations also confront barriers to adequate primary and specialty care. When obtained, specialty care is frequently in clinics serving the underinsured. Such clinics are understaffed and under-resourced. Little is known about the patients and care processes in these clinics; many believe that care could be improved. To improve care processes and outcomes in this population, we must first learn more about clinic patients and practices.

To identify policies, programs, and processes that could improve patient care and outcomes, we examined the HCV patient characteristics, medical histories, and clinic care profiles in an inner-city gastroenterology clinic. We abstracted data from charts of 351 (68%) patients attending clinic for HCV-related care between April 1, 2008 and March 31, 2009. Patient characteristics collected include age (m 51.4 years, SD 9.3), gender (60% male), race (generally missing from chart), and insurance status (76% Medicaid, 7% city public health supported, 6% Medicare). Health profile includes HCV genotype (88% genotype 1), HBV status (current infection 2%, previous infection 24%, evidence of immunization 24%), HAV status (51% total AB positive) and co-morbidities (including depression, bipolar disorder, other mental health issues, substance use, asthma, diabetes, and cardiovascular disease). Care profile information included appointment fidelity, relevant procedures (ultrasounds, biopsies, colonoscopies, stress tests), consultations (psychiatry and cardiology), and HCV treatment issues (candidacy, barriers, initiation, disruptions, completion, and outcomes).

Insurers' and clinic policies and practices posed impediments to optimal care, including immunization against HBV and HAV. Limited clinic hours and communication difficulties contributed to missed appointments, reducing the likelihood of HCV treatment initiation. Difficulties scheduling and completing procedures and consultations led to repeated office visits, lab tests and procedures, and delays in treatment. Social and behavioral factors, particularly alcohol use and psychological problems, impacted treatment decisions and the care process. Improved HCV care for the underinsured is possible through changes in the scheduling and communication processes in the clinic setting and sustainability of basic social support channels for patients.